What is the best course of treatment for a patient in their late 40s with a history of childhood asthma, now presenting with increasing sputum production after swimming?

Treatment for Swimming-Related Respiratory Symptoms in Adult with Childhood Asthma History

This patient requires immediate assessment for chlorine-induced airway irritation and potential asthma reactivation, with initiation of short-acting bronchodilator therapy (albuterol 2.5 mg via nebulizer) if any evidence of bronchospasm exists, followed by avoidance of chlorinated pool exposure until symptoms resolve. 1, 2

Immediate Clinical Assessment

The presentation of increasing sputum after swimming in a patient with childhood asthma history strongly suggests either:

• Chloramine-induced airway irritation - Swimming pool disinfection byproducts (DBPs), particularly trichloramine, cause dose-dependent respiratory symptoms including increased sputum production, cough, and airway inflammation 1
• Reactivation of underlying asthma - Adults with childhood asthma history remain at risk for symptom recurrence, particularly when exposed to respiratory irritants 1

Key clinical features to assess immediately:

• Presence of wheezing, dyspnea, or chest tightness indicating bronchospasm 1
• Timing of symptom onset relative to pool exposure (symptoms typically occur during or immediately after exposure) 1
• Character of sputum (clear vs. purulent) to differentiate irritant response from infection 1
• Measurement of peak expiratory flow or spirometry if available to document airflow obstruction 1

Primary Treatment Algorithm

Step 1: Bronchodilator Therapy if Airflow Obstruction Present

Administer albuterol 2.5 mg (one 3 mL vial of 0.083% solution) via nebulizer over 5-15 minutes if any evidence of bronchospasm exists (wheezing, reduced peak flow, dyspnea) 2. This can be repeated three to four times daily as needed 2.

• Onset of improvement typically occurs within 5 minutes, with maximum effect at 1 hour and duration of 3-6 hours 2
• If previously effective bronchodilator therapy fails to provide relief, this indicates seriously worsening asthma requiring immediate reassessment 2

Step 2: Complete Pool Exposure Avoidance

Immediately discontinue swimming in chlorinated pools until symptoms completely resolve 1. The evidence is clear that:

• Chloramine exposure causes an exposure-response relationship with respiratory symptoms in swimmers and pool workers 1
• Adult swimmers show increased airway hyperresponsiveness and inflammatory markers compared to non-swimmers 1
• Continued exposure perpetuates epithelial damage and symptom progression 1, 3

Step 3: Consider Inhaled Corticosteroid Initiation

If symptoms persist beyond 48 hours or if spirometry confirms airflow obstruction, initiate inhaled corticosteroid therapy (e.g., fluticasone 250 mcg twice daily) 1, 4. The rationale:

• Chloramine exposure causes oxidative stress and inflammatory changes in airways that may require anti-inflammatory treatment 1
• Patients with childhood asthma history who develop symptoms should be treated as having asthma reactivation until proven otherwise 1
• A trial of controller medication with documented response supports the diagnosis of asthma 1

Diagnostic Workup

Perform spirometry with bronchodilator response testing to confirm or exclude asthma reactivation 1:

• Document baseline FEV₁ and FEV₁/FVC ratio 1
• Assess for ≥12% improvement in FEV₁ after albuterol administration, which confirms reversible airflow obstruction 1
• If spirometry is normal but symptoms persist, consider methacholine challenge testing to assess for bronchial hyperresponsiveness 1

Measure exhaled nitric oxide (eNO) if available as an objective marker of airway inflammation, though this is supplemental rather than diagnostic 1

Critical Pitfalls to Avoid

Do not dismiss symptoms as "just irritation" - The distinction between irritant-induced symptoms and true asthma reactivation is clinically important but often overlapping, as chloramine exposure can trigger both immediate irritant effects and longer-term airway hyperresponsiveness 1. When in doubt, treat as asthma.

Do not recommend returning to chlorinated pools even if symptoms improve - Elite swimmers show persistently elevated airway inflammation markers despite being asymptomatic between training sessions 1, 5. If the patient wishes to continue swimming, recommend:

• Well-maintained pools with proper ventilation and lower chloramine levels 1, 6
• Outdoor pools where DBP concentrations are lower due to air circulation 1
• Alternative exercise options that don't involve chlorinated water exposure 1

Do not assume childhood asthma that "went away" is truly resolved - Many adults with childhood asthma history have persistent airway hyperresponsiveness that becomes clinically apparent only with significant irritant exposure 1

Evidence Quality Considerations

The evidence linking swimming pool exposure to respiratory symptoms is robust, with consistent findings across multiple studies showing dose-response relationships between chloramine exposure and respiratory symptoms in swimmers, lifeguards, and pool workers 1. However, the evidence specifically addressing treatment of swimming-related symptoms in adults with childhood asthma history is limited, requiring extrapolation from general asthma management principles 1 and occupational exposure data 1.

The recommendation to avoid chlorinated pool exposure is based on strong evidence of causation 1, while the specific pharmacologic treatment recommendations follow standard asthma management guidelines 1, 2.