Shortness of Breath in a Runner


Adrian Western, Cayuga Medical Center, Ithaca NY; Andrew Getzin, Cayuga Medical Center, Ithaca, NY

Email: awestern@cayugamed.org

HISTORY: A 17 year old female high school runner presented for evaluation of dyspnea with exercise. She had been diagnosed with EIA (exercise-induced asthma). She was treated with albuterol which did not seem to help. Symptoms occurred within a couple minutes around half a mile into her runs, and typically would last for about five minutes if she stopped and walked. During symptoms she felt as though she is not able to get enough air into her lungs. The location of her restriction was in her throat and she described the feeling of her throat “closing”. She did not have a cough but did report breathing loudly. She did have seasonal allergies that affected her more in the fall. She perceived her level of fitness as high compared to others (8/10). She is a 4.0 student and described her level of stress as being “high by choice.”

PHYSICAL EXAMINATION: Patient presents in the office with complaining of shortness of breath at high levels of exertion. She is a normal appearing 17 year old female with no symptoms at rest. BMI 19.7, weight 136 lbs, Heart Rate 65, Respiration 10 bpm. She has a history of asthma, seasonal allergies, and anemia. On 12/21/12 patient was tested with a methacholine challenge which was negative. She has no history of any other chronic disorder. Patient has a healthy diet that focuses on fruits and vegetables and limits processed food. Current medications include Vitamin D, and Iron supplementation.

DIFFERENTIAL DIAGNOSIS: 1) Asthma 2) Vocal Cord Dysfunction 3) Lack of Fitness/unreasonable expectations


Pre and Post Beta Agonist testing revealed no change in FEV1, a 1% decrease in FVC, and a 1% increase in FEV1/FVC. This testing revealed a slight flattening of her inspiration loop with difficulty exhaling after 1 second. ECG revealed a sinus arrhythmia, but was otherwise normal. Blood work included Hemoglobin of 13.5 g/dL and Hematocrit of 41%. Chest X-rays were within normal limits. Shortness of breath testing revealed a maximum drop of 9% for FVC, 7% for FEV1, and 1% for FEV1/FVC ratio. Maximum heart rate during testing was recorded at 200 bpm (98% of age predicted max). VO2 response to work load was 57.4 ml/kg/min, 3.57 L/min (99% for women 20-29 age, ACSM’s Guideline for Exercise Testing and Prescription, Ninth Edition). Pulse ox revealed a drop from 98%-88% during exercise. Heart rate response to exercise was normal. Post-exercise lung exam was clear throughout. Post exercise flexible fiberoptic laryngoscopy showed significant adduction throughout membranous vocal cords on inspiratory effort with posterior glottis opening; however, full abduction with expiration. The patient exhibited and audible stridor during the last stage of testing.


TREATMENT AND OUTCOMES: Patient had enrolled in speech therapy prior to testing because of pretest suspicion for VCD. Patient was instructed to continue speech therapy to help treat her vocal cord dysfunction by working to maintain vocal cord abduction and airway patency near VO2max. She continues to compete in her cross country season with intermittent symptoms.

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