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Bronchospasm

Bronchospasm is the sudden tightening or constriction of the smooth muscles lining the bronchi and bronchioles in the lungs, which narrows the airways and restricts airflow, often leading to wheezing and breathing difficulties.^[1] This physiological response can occur acutely or as part of chronic conditions, potentially progressing to respiratory distress if untreated.^[1] Bronchospasm is a common feature of underlying respiratory disorders such as asthma and chronic obstructive pulmonary disease (COPD); asthma alone affects approximately 300 million people worldwide.^[2] Common triggers include allergens (e.g., pollen, dust mites), respiratory infections, exercise, cold air, irritants (e.g., smoke, chemical fumes), and certain medications.^[1] In some cases, it arises from anaphylaxis, foreign body aspiration, or even during anesthesia induction.^[3] Symptoms typically manifest as wheezing (a high-pitched whistling sound during exhalation), shortness of breath, chest tightness, persistent coughing, and fatigue, with severe episodes potentially causing cyanosis, rapid breathing, or use of accessory respiratory muscles.^[1] With prompt intervention, most episodes resolve quickly, but unmanaged bronchospasm can lead to life-threatening complications like hypoxia or status asthmaticus.^[1]

Overview

Definition

Bronchospasm is defined as the sudden and involuntary contraction of the smooth muscle layers lining the walls of the bronchi and bronchioles, resulting in a transient narrowing of the airways and increased resistance to airflow. This physiological response obstructs the passage of air into and out of the lungs, often producing a characteristic wheezing sound due to turbulent airflow through the constricted passages.^[4]^[1] Anatomically, the bronchi serve as the primary conduits branching from the trachea into the lungs, further dividing into smaller bronchioles that terminate in alveoli; bronchospasm primarily affects these structures by elevating airway resistance, which can significantly impair ventilation even if the contraction is brief. This differs from general bronchoconstriction, a broader term encompassing any sustained or gradual narrowing of the airways often associated with chronic conditions like chronic obstructive pulmonary disease, whereas bronchospasm specifically denotes an acute, spasmodic event. In contrast, asthma represents a chronic inflammatory disorder of the airways characterized by recurrent episodes of bronchospasm, though bronchospasm itself is not synonymous with asthma and can arise in isolation from various triggers.^[5]^[6] The concept of bronchospasm emerged in early 20th-century respiratory physiology studies, with the term first appearing in medical literature around 1901, reflecting advances in understanding smooth muscle dynamics in airway obstruction. These foundational investigations shifted focus from earlier vague descriptions of breathing difficulties to precise mechanisms of bronchial muscle contraction.^[7]^[8]

Epidemiology

Bronchospasm, a key feature of asthma and other respiratory conditions such as chronic obstructive pulmonary disease (COPD), exhibits a global prevalence closely tied to these disorders. According to the Global Burden of Disease study, there were approximately 455 million prevalent cases of asthma and 212 million of COPD worldwide in 2021 (as of 2021 estimates), with age-standardized prevalence of asthma at about 3.4% overall and higher rates in children (typically 5-10% depending on region).^[9] Among asthmatic children, the prevalence of exercise-induced bronchospasm, a common manifestation, ranges from 40% to 90%, underscoring elevated risk in this subgroup.^[10] Incidence rates of bronchospasm vary by population risk, escalating significantly among those with asthma or COPD, particularly during triggers like exercise or infections. In the United States, for instance, 39.4% of individuals with current asthma reported at least one attack in the past year in 2021, many involving bronchospasm.^[11] Bronchospasm is strongly associated with asthma, where it represents a recurrent symptom in affected individuals.^[12] Demographic patterns reveal higher bronchospasm occurrence in urban environments, where air pollution exacerbates risks, and among children under 5 years, who face up to 20% prevalence of exercise-induced forms.^[13] Allergies, such as rhinitis and conjunctivitis, further elevate susceptibility, with affected schoolchildren showing increased rates.^[14] Gender differences emerge post-puberty, with a slight female predominance in asthma-related bronchospasm due to hormonal and environmental interactions.^[15] Over the 2020s, bronchospasm cases have trended upward, driven by environmental pollution, with nearly 2 million annual new pediatric asthma incidences worldwide attributable to traffic-related pollutants, particularly in developing regions where exposure is intensifying.^[16] Data from low- and middle-income countries indicate rising prevalence linked to urbanization and poor air quality, contrasting with stable or declining rates in some high-income areas.^[9]

Clinical Features

Signs and Symptoms

Bronchospasm manifests primarily through respiratory symptoms, including wheezing, shortness of breath, chest tightness, and cough, which arise due to the sudden narrowing of the airways.^[1]^[4] Wheezing is often the most prominent audible sign, presenting as a high-pitched whistling sound during exhalation, while shortness of breath and chest tightness reflect the subjective sensation of restricted airflow.^[1]^[17] The severity of bronchospasm episodes varies widely, graded from mild to severe based on symptom intensity and physiological impact.^[18] Mild cases may involve only nocturnal cough or minimal discomfort without significant disruption to daily activities.^[19] In contrast, severe episodes can progress to cyanosis—a bluish discoloration of the skin due to low oxygen levels—and marked respiratory distress, potentially requiring immediate medical attention.^[20]^[4] Acute bronchospasm typically has a rapid onset, developing within minutes following exposure to a trigger, such as allergens or exercise.^[4] Without intervention, episodes often last 20 to 60 minutes in milder forms, though duration can extend longer in persistent cases.^[21]^[1] Associated features during bronchospasm include an increased respiratory rate (tachypnea), visible use of accessory muscles for breathing, such as intercostal retractions or nasal flaring, and evidence of reversible airflow limitation on spirometry, where obstruction improves post-bronchodilator.^[4]^[17] These signs underscore the dynamic nature of the condition, distinguishing it from fixed airway obstructions.

Complications

Untreated or severe episodes of bronchospasm can lead to acute complications such as hypoxemia, where inadequate oxygen reaches the tissues due to impaired gas exchange in the constricted airways.^[22] This hypoxemia may progress to respiratory failure, characterized by hypercarbia and the need for mechanical ventilation, particularly in cases of status asthmaticus, a refractory form of bronchospasm unresponsive to initial therapies.^[23] Status asthmaticus often requires intubation to maintain airway patency and support ventilation, as the persistent airway obstruction exacerbates respiratory distress.^[24] Chronic or recurrent bronchospasm contributes to long-term airway remodeling, involving structural changes like subepithelial fibrosis and smooth muscle hypertrophy, which perpetuate airway narrowing.^[25] These alterations result in progressive reduction of lung function, as evidenced by declines in forced expiratory volume and overall pulmonary capacity over time.^[26] Additionally, the ongoing inflammation and impaired mucociliary clearance associated with chronic bronchospasm increase susceptibility to respiratory infections, such as viral exacerbations that further compromise lung health.^[27] Rare complications include pneumothorax, which can arise from forceful coughing during intense bronchospasm episodes, leading to alveolar rupture and air leakage into the pleural space.^[28] In severe, prolonged cases, cor pulmonale may develop due to sustained pulmonary hypertension from chronic hypoxemia and vascular changes, straining the right ventricle of the heart.^[29] Overall mortality from bronchospasm episodes remains low, with asthma-related death rates approximately 1.0 per 100,000 population as of 2021, though status asthmaticus carries a higher risk of fatality around 10% in adults requiring intensive care (below 1% in children).^[30]^[31] Rates are elevated among elderly patients and those with comorbidities, where factors like reduced physiological reserve amplify the lethality of acute episodes.^[31]

Pathophysiology

Mechanisms of Airway Constriction

Bronchospasm involves the constriction of bronchial smooth muscle, primarily mediated by neural pathways of the parasympathetic nervous system. The vagus nerve provides efferent parasympathetic innervation to the airways, releasing acetylcholine from postganglionic nerve endings onto M3 muscarinic receptors located on airway smooth muscle cells. This binding activates a signaling cascade that promotes muscle contraction, leading to increased airway tone and bronchoconstriction.^[32]^[33] An inflammatory cascade further contributes to airway constriction through the activation and degranulation of mast cells. Upon exposure to allergens or irritants, IgE cross-linking on mast cell surfaces triggers rapid degranulation, releasing preformed mediators such as histamine and newly synthesized lipid mediators including cysteinyl leukotrienes. Histamine binds to H1 receptors on smooth muscle, inducing contraction, while leukotrienes (particularly LTC4, LTD4, and LTE4) act via CysLT1 receptors to potentiate bronchospasm and enhance vascular permeability.^[34]^[35] The smooth muscle response to these stimuli culminates in contraction driven by intracellular calcium dynamics. Acetylcholine and inflammatory mediators increase calcium influx through voltage-gated and receptor-operated channels, elevating cytosolic calcium levels that bind to calmodulin, activating myosin light chain kinase and promoting actin-myosin cross-bridging for muscle shortening. This reduces airway radius, dramatically elevating resistance to airflow, as described by the simplified form of Poiseuille's law:

\text{Airway Resistance} = \frac{\text{Length} \times \text{Viscosity}}{\text{Radius}^4}

where resistance is inversely proportional to the fourth power of the radius, meaning even minor reductions in diameter cause substantial increases in resistance.^[36]^[37]^[38] In susceptible individuals, feedback loops involving airway hyperresponsiveness amplify these constrictive mechanisms. Initial constriction triggers reflex neural activation and release of additional endogenous spasmogens, creating a positive feedback cycle that exacerbates narrowing and perpetuates bronchospasm beyond the initial stimulus. This hyperresponsiveness involves heightened sensitivity of smooth muscle to contractile agonists and impaired bronchodilatory responses, sustaining elevated airway resistance. Non-allergic triggers, such as exercise or cold air, can also induce bronchospasm through osmolality changes or neurogenic pathways involving bradykinin release, independent of type 2 inflammation.^[39]^[40]^[4]

Cellular and Molecular Processes

Bronchospasm involves intricate cellular and molecular processes that lead to airway smooth muscle contraction and inflammation. A primary mediator is IgE-mediated hypersensitivity, where allergens bind to IgE antibodies on the surface of mast cells in the airways, triggering degranulation and release of inflammatory mediators such as histamine and leukotrienes, which directly contribute to bronchoconstriction.^[41] This process is central to allergic bronchospasm, as inhaled allergens interact with IgE to initiate rapid mast cell activation and subsequent airway narrowing.^[42] Cytokine release further amplifies these events, with interleukin-4 (IL-4) and interleukin-13 (IL-13) playing pivotal roles in promoting type 2 inflammation. IL-4 and IL-13 drive eosinophil recruitment, mucus hypersecretion, and bronchial hyperresponsiveness by signaling through shared receptor complexes on airway epithelial and smooth muscle cells, enhancing the inflammatory milieu that sustains bronchospasm.^[43] These cytokines are particularly prominent in type 2 responses, where they exacerbate airway reactivity.^[44] Prostanoids, including prostaglandin D2 (PGD2), also contribute as key mediators; PGD2 induces bronchoconstriction primarily through activation of the thromboxane prostanoid (TP) receptor on airway smooth muscle, rather than its own DP receptor, leading to potent contraction in sensitized airways.^[45] At the receptor level, activation of muscarinic M3 receptors on airway smooth muscle cells mediates bronchoconstriction via G-protein-coupled signaling that increases intracellular calcium and promotes myosin light chain phosphorylation for contraction.^[46] This effect is counterbalanced by beta-2 adrenergic receptors, which, when stimulated, activate adenylate cyclase to elevate cyclic AMP levels, inducing smooth muscle relaxation and mitigating spasm.^[46] Partial agonists at M3 receptors, such as certain muscarinic agents, can induce bronchospasm that is functionally antagonized by endogenous beta-2 receptor activation through sympathetic pathways.^[46] Genetic factors influence susceptibility and severity, notably polymorphisms in the ADRB2 gene encoding the beta-2 adrenergic receptor. Common variants like Arg16Gly and Gln27Glu are associated with altered receptor function, leading to reduced bronchodilator responsiveness and increased asthma severity, including more frequent bronchospasm episodes.^[47] The Arg/Arg genotype at position 16, for instance, correlates with heightened allergic asthma severity by impairing beta-2 agonist efficacy in reversing constriction.^[48] Recent advances in the 2020s highlight the role of the airway microbiome in modulating these processes, with dysbiosis promoting inflammation through altered microbial metabolites that enhance Th2 cytokine production and eosinophil activation in airway cells.^[49] Concurrently, epigenetic modifications, such as DNA methylation and histone acetylation in airway smooth muscle and epithelial cells, perpetuate chronic inflammation and hyperresponsiveness by silencing anti-inflammatory genes or upregulating pro-contractile pathways, as evidenced in asthma models.^[50] These mechanisms underscore the interplay between environmental factors and cellular processes in sustaining bronchospasm.

Etiology

Associated Medical Conditions

Bronchospasm is a primary feature of asthma, the most common associated condition, where sudden constriction of airway smooth muscle leads to episodic airflow obstruction and wheezing.^[39] In chronic obstructive pulmonary disease (COPD), bronchospasm often occurs during exacerbations, contributing to acute worsening of airflow limitation through inflammatory responses and increased sputum production.^[51] Patients with cystic fibrosis frequently experience bronchospasm due to airway hyperresponsiveness, which can manifest as wheezing and requires bronchodilator intervention to improve lung function.^[52] In allergic conditions, bronchospasm is a hallmark of anaphylaxis, presenting as acute respiratory distress alongside hypotension and urticaria in severe allergic reactions.^[53] Allergic rhinitis is linked to bronchospasm through shared mechanisms of airway hyperreactivity, increasing the risk of lower respiratory symptoms even without overt asthma.^[54] Other associations include exercise-induced bronchospasm, prevalent in 20% to 50% of elite athletes, where high-intensity physical activity triggers transient airway narrowing.^[55] Foreign body aspiration can acutely trigger bronchospasm by mechanically irritating or obstructing the airways, often presenting as sudden respiratory distress.^[4] In children, post-viral bronchospasm commonly follows lower respiratory infections like bronchiolitis, leading to prolonged wheezing and hyperresponsiveness.^[4] Comorbidities such as obesity elevate the risk of bronchospasm, particularly in asthmatic individuals, by promoting exercise-induced episodes and slower recovery from airway constriction.^[56] Gastroesophageal reflux disease (GERD) is associated with bronchospasm through vagal reflex mechanisms or microaspiration, exacerbating respiratory symptoms in affected patients.^[57]

Triggers and Risk Factors

Bronchospasm can be precipitated by various environmental factors that irritate or sensitize the airways. Common allergens such as pollen and dust mites are well-established triggers, particularly in individuals with underlying airway hyperreactivity, as these inhaled particles provoke inflammatory responses leading to airway constriction.^[58] Cold air exposure is another significant environmental trigger, where sudden inhalation of cold, dry air can cause rapid cooling of the airway mucosa, resulting in bronchospasm in susceptible individuals.^[59] Air pollution, including fine particulate matter like PM2.5, exacerbates bronchospasm by promoting oxidative stress and inflammation in the respiratory tract, with studies showing adverse effects on asthma outcomes in both children and adults.^[60] Iatrogenic factors, often related to medications, can induce bronchospasm in sensitive populations. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) trigger bronchospasm in approximately 10-20% of adults with asthma, particularly those with aspirin-exacerbated respiratory disease, through inhibition of cyclooxygenase-1 and subsequent alteration in arachidonic acid metabolism.^[61] Beta-blockers, used for cardiovascular conditions, can provoke bronchospasm by blocking beta-2 adrenergic receptors in the airways, increasing the risk in patients with preexisting respiratory issues.^[62] Sulfite preservatives, found in certain foods, beverages, and medications, are known to cause bronchospasm in sulfite-sensitive individuals, often via a non-IgE-mediated mechanism, with symptoms appearing shortly after exposure.^[63] Bronchospasm may also occur during anesthesia induction due to airway irritation from intubation or hypersensitivity reactions to anesthetic agents.^[4] Behavioral factors also play a key role in precipitating bronchospasm. Exercise-induced bronchospasm occurs during or after physical activity, especially in cool or dry conditions, due to increased respiratory rate and airway dehydration, affecting up to 90% of individuals with asthma and 10-20% of the general athletic population.^[64] Psychological stress can trigger bronchospasm through autonomic nervous system activation, leading to heightened airway responsiveness and breathlessness, as observed in clinical studies of stress-exposed asthma patients.^[65] Smoking, both active and passive, irritates the airways and induces immediate bronchospasm by releasing irritants that cause mucus hypersecretion and smooth muscle contraction.^[66] Occupational exposures represent important risk modifiers for bronchospasm, particularly in industrial settings involving chemicals like isocyanates, which are used in polyurethane production and automotive painting. These low-molecular-weight compounds sensitize the airways over time, leading to occupational asthma with bronchospastic episodes, and remain a leading cause of work-related respiratory disease despite regulatory efforts as of 2025.^[67] Certain underlying medical conditions, such as chronic rhinosinusitis, can amplify susceptibility to these triggers.^[68]

Diagnosis

Clinical Evaluation

The clinical evaluation of suspected bronchospasm begins with a thorough medical history to identify key features suggestive of airway constriction, such as the timing of onset, which is often sudden and may occur during exercise or exposure to irritants.^[69] Patients are questioned about potential triggers, including allergens, viral infections, tobacco smoke, or environmental factors like cold air, as these can precipitate episodes.^[69] A family history of asthma or allergic diseases in first-degree relatives is elicited, as it increases the likelihood of recurrent bronchospasm.^[69] Inquiry into prior episodes of wheezing or shortness of breath helps establish patterns of recurrence and assess the chronicity of the condition.^[69] Physical examination focuses on respiratory assessment, starting with auscultation of the lungs to detect expiratory wheezing, a hallmark sign of bronchospasm due to narrowed airways, though it may be absent in severe cases with minimal airflow.^[69] Signs of increased work of breathing, such as use of accessory muscles or prolonged expiration, are noted to gauge acuity.^[69] Peak expiratory flow (PEF) measurement is performed using a peak flow meter, with the highest of three attempts recorded; average daily diurnal variability exceeding 10% in adults or 13% in children over 1-2 weeks supports the diagnosis of variable airflow limitation associated with bronchospasm.^[69] Differential diagnosis is essential to exclude mimics of bronchospasm, such as pneumonia, which may present with focal findings on exam and fever, or heart failure, characterized by bilateral crackles and orthopnea rather than polyphonic wheezes.^[70] A detailed history and exam help differentiate these by evaluating for infectious symptoms or cardiac risk factors, respectively. In non-asthma causes like chronic obstructive pulmonary disease (COPD), airflow limitation is less reversible; guidelines like GOLD 2025 recommend post-bronchodilator forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ratio <0.70 for COPD diagnosis.^[71]^[4] Severity and control are assessed using validated scoring systems, such as the Asthma Control Test (ACT), a patient-reported questionnaire evaluating symptoms over the past four weeks with scores ranging from 5 (poor control) to 25 (well-controlled); a score of 20 or higher indicates good control, while lower scores prompt further evaluation for uncontrolled bronchospasm.^[69]^[72] For children aged 4-11, the Childhood Asthma Control Test (C-ACT) is used similarly, with scores below 20 signaling inadequate control.^[69] These tools integrate symptom frequency, nighttime awakenings, and activity limitations to guide initial management decisions.^[72]

Laboratory and Imaging Tests

Spirometry serves as a cornerstone for objectively assessing airway obstruction in bronchospasm, measuring forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). A reduced pre-bronchodilator FEV1/FVC ratio (below the lower limit of normal, approximately <70% or 0.70) indicates airflow obstruction, while post-bronchodilator testing assesses reversibility, with an increase in FEV1 of greater than 12% and at least 200 mL confirming bronchospasm's reversible nature.^[69]^[73] These metrics help differentiate bronchospasm from fixed obstructions, guiding diagnosis when clinical symptoms suggest episodic wheezing.^[74] Peak expiratory flow (PEF) monitoring provides a portable method for tracking bronchospasm variability over time, particularly in ambulatory settings. Patients perform twice-daily measurements, typically morning and evening, to calculate average daily diurnal variability; values exceeding 10% in adults or 13% in children over 1-2 weeks support a diagnosis of asthma-associated bronchospasm.^[69]^[75] This tool is especially useful for confirming variable airflow limitation in suspected cases.^[76] Imaging modalities play a supportive role in evaluating bronchospasm, primarily to exclude complications or alternative diagnoses rather than directly confirming the condition. Chest X-rays are routinely used during acute episodes to identify hyperinflation, atelectasis, or secondary infections like pneumonia that may mimic or exacerbate bronchospasm.^[77]^[1] High-resolution computed tomography (CT) scans, though not first-line due to radiation exposure, reveal structural abnormalities such as bronchial wall thickening or air trapping in persistent cases.^[78]^[79] Biomarkers offer insights into the inflammatory underpinnings of bronchospasm, aiding in phenotyping for targeted management. Fractional exhaled nitric oxide (FeNO) measurement, a non-invasive test, detects eosinophilic airway inflammation; levels greater than 50 parts per billion (ppb) in adults who are ICS-naïve suggest type 2 inflammation consistent with asthmatic bronchospasm, per updated 2025 guidelines.^[80]^[81] Blood eosinophil counts have gained prominence in recent assessments, with levels ≥150 cells/µL indicating elevated risk for eosinophil-driven bronchospasm and guiding biologic therapies.^[82]^[83] These markers complement pulmonary function tests by quantifying inflammation non-invasively.^[84]

Management

Acute Interventions

The primary intervention for reversing acute bronchospasm involves the administration of short-acting beta-2 agonists (SABAs), such as albuterol, delivered via metered-dose inhaler (MDI) or nebulizer to rapidly relax bronchial smooth muscle.^[72] Standard dosing for adults is 4 to 8 puffs of albuterol MDI (90 mcg per puff) every 20 minutes for up to three doses in the first hour, or equivalent nebulized doses of 2.5 to 5 mg, with reassessment after each administration to gauge response.^[85] This approach is supported by guidelines emphasizing repetitive dosing to achieve bronchodilation while minimizing systemic side effects.^[72] Adjunctive therapies enhance SABA efficacy in moderate to severe episodes. In moderate to severe episodes, ipratropium bromide (0.5 mg nebulized) is added to the initial three doses of SABA to enhance bronchodilation.^[72] Systemic corticosteroids, such as oral prednisone at 40 to 60 mg as a single dose, are recommended to reduce airway inflammation and prevent relapse, typically initiated within the first hour of treatment.^[86] Oxygen supplementation is provided via nasal cannula or mask to maintain oxygen saturation above 90% to 92%, addressing hypoxemia without routine use of high-flow methods unless indicated.^[72] In severe or refractory cases, additional agents are employed. Intravenous magnesium sulfate, dosed at 2 g over 20 minutes, serves as a bronchodilator by antagonizing calcium influx in smooth muscle cells, particularly when initial SABA and corticosteroid responses are inadequate.^[87] For bronchospasm associated with anaphylaxis, intramuscular epinephrine (1:1000 concentration, 0.3 to 0.5 mg) is administered in the anterolateral thigh to counteract mediator release and stabilize mast cells, with repeat dosing every 5 to 15 minutes if needed.^[88] Response to therapy is monitored through serial peak expiratory flow (PEF) measurements or forced expiratory volume in one second (FEV1), performed before and 15 to 30 minutes after bronchodilator doses to track improvement in airflow.^[72] Hospital admission is warranted if post-treatment FEV1 remains below 40% predicted, persistent symptoms occur despite maximal therapy, or risk factors for deterioration are present, ensuring close observation and further intervention.^[89]

Long-Term Strategies

Long-term strategies for managing bronchospasm vary by underlying condition; for asthma-associated bronchospasm (a common cause), they focus on achieving sustained control to minimize recurrent episodes, primarily through structured pharmacologic escalation and supportive measures tailored to individual patient needs. The Global Initiative for Asthma (GINA) 2025 guidelines recommend a stepwise approach for adults and adolescents, beginning with as-needed low-dose inhaled corticosteroid (ICS)-formoterol for mild symptoms to reduce inflammation and bronchoconstriction from the outset.^[90] As control is assessed, therapy escalates: Step 2 involves low-dose ICS-formoterol maintenance with as-needed use of the same (MART); Step 3 uses low-dose ICS-long-acting beta-agonist (LABA) MART; Step 4 uses medium-dose ICS-LABA MART; and Step 5 incorporates high-dose ICS-LABA MART with add-ons such as leukotriene receptor antagonists or tiotropium.^[90] For severe uncontrolled cases at Step 5, referral for biologic therapies is advised, such as omalizumab for patients with allergic asthma characterized by high IgE levels and perennial allergens, which targets IgE to prevent mediator release and airway hyperresponsiveness.^[91] For bronchospasm associated with chronic obstructive pulmonary disease (COPD), long-term management follows the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2025 guidelines, emphasizing initial long-acting muscarinic antagonist (LAMA) or LABA monotherapy, with ICS added selectively based on exacerbation history or eosinophil levels.^[92] Non-pharmacologic interventions complement pharmacotherapy by empowering patients to maintain control. Patient education on personalized asthma action plans is essential, outlining daily management, early recognition of worsening symptoms, and appropriate responses to prevent escalation to acute bronchospasm.^[90] Education also emphasizes trigger avoidance strategies, such as minimizing exposure to known irritants, to reduce the frequency of bronchospasm episodes over time.^[90] Ongoing monitoring ensures therapy effectiveness and guides adjustments. Regular spirometry, including forced expiratory volume in 1 second (FEV1) measurements at treatment initiation, after 3-6 months of ICS therapy, and periodically thereafter, helps track lung function and personal best values.^[90] Symptom diaries or validated tools like the Asthma Control Test are recommended for self-reporting symptoms and adherence, facilitating timely step-up or step-down in treatment.^[90] In special populations, strategies require cautious adaptation to balance efficacy and safety. For pregnant individuals, continuation of pre-pregnancy controller therapy with low-to-medium dose ICS is preferred, with regular reviews every 4-6 weeks to optimize control and minimize risks to mother and fetus, avoiding high-dose oral corticosteroids unless necessary.^[90] In elderly patients, lower steroid doses are often prioritized to mitigate side effects like osteoporosis, while accounting for comorbidities such as cardiovascular disease that may influence LABA or biologic selection.^[90]

Prevention

Lifestyle Modifications

Lifestyle modifications play a crucial role in reducing the frequency and severity of bronchospasm episodes by minimizing exposure to environmental irritants and supporting overall respiratory health. Individuals prone to bronchospasm, often linked to conditions like asthma, can implement practical changes in their daily routines to create a safer living environment and promote better airway function. These strategies focus on non-medical interventions that complement professional medical advice. Environmental controls are essential for limiting exposure to common airborne triggers such as dust mites, pollen, and pollutants. Using allergen-proof bedding covers on mattresses, pillows, and duvets reduces contact with dust mite allergens, which can provoke bronchospasm in sensitized individuals, although evidence for clinical benefits in reducing symptoms is mixed.^[93] Installing high-efficiency particulate air (HEPA) purifiers in bedrooms and living areas helps filter out fine particles and allergens, thereby improving indoor air quality and potentially decreasing asthma-related symptoms that include bronchospasm.^[94] Additionally, complete avoidance of tobacco smoke, both active and secondhand, is critical, as it irritates airways and exacerbates bronchospasm risk; maintaining smoke-free homes and vehicles is a key recommendation.^[95] For those experiencing exercise-induced bronchospasm, incorporating warm-up routines before physical activity can precondition the airways and reduce the likelihood of constriction. A gradual 10-15 minute warm-up involving light aerobic exercise, such as walking or cycling, allows the body to adapt and minimizes sudden airway narrowing during more intense efforts.^[96] Adopting an anti-inflammatory diet, such as the Mediterranean diet rich in fruits, vegetables, whole grains, fish, and olive oil, has been associated with lower asthma incidence and symptom severity, including reduced bronchospasm, due to its antioxidant and anti-inflammatory properties.^[97] Maintaining a healthy weight through balanced nutrition further supports lung function by decreasing the mechanical burden on the respiratory system.^[98] Behavioral adjustments, including stress management techniques like mindfulness-based stress reduction (MBSR), can help mitigate bronchospasm by lowering psychological triggers that worsen airway hyperresponsiveness. Regular mindfulness practices, such as guided meditation or deep breathing exercises for 20-30 minutes daily, have shown improvements in asthma control and reduced inflammatory markers in clinical trials.^[99] Staying current with vaccinations against respiratory viruses is another vital behavioral step; as of 2025, annual influenza vaccination, the updated COVID-19 vaccine, pneumococcal vaccine, and RSV vaccine (for eligible adults and high-risk children) are strongly recommended for individuals with asthma to prevent viral and bacterial infections that could trigger bronchospasm.^[100]^[101] In occupational settings with potential irritant exposure, such as those involving chemicals, dust, or fumes, using personal protective equipment like respirators or masks is a fundamental modification to safeguard against work-related bronchospasm. Employers and workers should prioritize engineering controls alongside gear like N95 respirators in high-risk industries, such as manufacturing or cleaning, to minimize inhalation of triggering agents.^[102] These measures address common environmental triggers without relying on medication.^[103]

Prophylactic Therapies

Prophylactic therapies for bronchospasm primarily involve controller medications administered regularly to reduce airway inflammation and prevent episodes, particularly in conditions like asthma where bronchospasm is a hallmark feature. These therapies target underlying mechanisms to maintain long-term control and minimize the risk of acute attacks.^[104] According to the 2025 Global Initiative for Asthma (GINA) guidelines, low-dose inhaled corticosteroid-formoterol (ICS-formoterol) is the preferred controller for adults and adolescents with persistent asthma, used as both maintenance therapy and reliever medication (Track 1 approach) due to its proven reduction in severe exacerbations compared to other regimens. Inhaled corticosteroids (ICS), such as budesonide, remain a key component, binding to glucocorticoid receptors in airway epithelial cells and inflammatory cells to suppress inflammatory genes, cytokines, and eosinophil recruitment, thereby decreasing airway hyperresponsiveness. For patients requiring additional control, fixed-dose ICS/LABA combinations like budesonide/formoterol provide synergistic effects, with the LABA relaxing airway smooth muscle via beta-2 receptors. These are recommended in moderate persistent cases.^[105]^[69]^[106]^[107] In persistent cases uncontrolled by preferred Track 1 therapy, long-acting muscarinic antagonists like tiotropium serve as an effective add-on. Tiotropium, delivered via soft-mist inhaler, blocks M3 muscarinic receptors in airway smooth muscle for sustained bronchodilation. GINA 2025 endorses its use in adults and children aged 6 years and older at step 4, enhancing lung function and control.^[69]^[108] For severe allergic subtypes of bronchospasm, biologics targeting specific immune pathways offer targeted prophylaxis. Omalizumab, an anti-IgE monoclonal antibody, binds free IgE to prevent mast cell activation and allergen-induced bronchospasm in patients with high IgE levels, reducing exacerbation rates by about 25%. Approved for patients aged 6 years and older, it is used in step 5 for severe allergic asthma. Similarly, mepolizumab, an anti-IL-5 antibody, depletes eosinophils by blocking IL-5 signaling in severe eosinophilic cases with blood eosinophils ≥150/µL; it reduces exacerbations and oral corticosteroid dependence, approved for ages 6 and older, with 2025 data confirming sustained efficacy. These biologics are reserved for step 5 after standard controllers fail, guided by biomarkers.^[109]^[110]^[111]

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The resultant physiological and functional changes include the reduction in lung elasticity of lung tissue, forced expiratory volume (FEV), forced vital ...
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Mini Review: Neural Mechanisms Underlying Airway ...
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The anatomic substrate of irreversible airway obstruction and ...
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Prostaglandin D2-induced bronchoconstriction is mediated only in ...
PGD2 causes vasodilation acting via the prostaglandin (DP) receptor on vascular smooth muscle, and myocontraction acting via the thromboxane (TP) receptor on ...
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Compensation of Muscarinic Bronchial Effects of Talsaclidine by ...
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GINA 2025 Asthma Update: T2 Biomarkers & Young Children
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Managing Asthma Exacerbations in the Emergency Department
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FEV1 values corresponding to PRAM and AAIRS severity score ...
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The 2025 update of the Global Strategy for Asthma Management and Prevention incorporates new scientific information about asthma.
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[PDF] DIFFICULT-TO-TREAT & SEVERE ASTHMA
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Update on House Dust Mite Allergen Avoidance Measures for Asthma
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The Efficacy of the Dyson Air Purifier in Improving Asthma Control
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Mediterranean-Type Diets as a Protective Factor for Asthma and Atopy
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Asthma diet: Does what you eat make a difference? - Mayo Clinic
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Clinically relevant effects of Mindfulness-Based Stress Reduction in ...
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Vaccines that Protect Against Infectious Respiratory Diseases
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Induction of Asthma and the Environment: What We Know and Need ...
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Environmental triggers and avoidance in the management of asthma
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This activity describes the mode of action of inhaled corticosteroids, including mechanism of action, pharmacology, adverse event profiles, eligible patient ...
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[PDF] Summary Guide for Asthma Management and Prevention
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Tiotropium for the Treatment of Asthma: Patient Selection and ... - NIH
The incorporation of tiotropium at Step 4 in recent iterations of the GINA guidelines targets the unmet need for optimal disease control in those with ...
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Biologic Therapies for Severe Asthma: Current Insights and Future ...
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Biologics for the Management of Severe Asthma
Omalizumab is approved for patients as young as 6 years old, while all the other biologics except for reslizumab are approved for patients as young as 12 years ...