When teenage athletes report that they cannot breathe during exertion, clinicians must look beyond traditional assumptions of asthma and investigate complex systemic disruptions tied to post-COVID effects, pediatric specialists advised at the American Academy of Pediatrics 2026 National Conference.
This clinical shift matters because long COVID operates as a systemic condition rather than a localized respiratory issue. For young competitors, respiratory distress during workouts frequently stems from underlying physiological breakdowns involving autonomic regulation, immune activation, or metabolic deficits. Treating these athletes requires identifying the precise physiological mechanism causing the symptom rather than simply applying a standard asthma protocol.
Clinicians Must Identify Specific Root Causes of Breathing Issues
- Look beyond asthma: Normal breathing tests do not rule out post-COVID complications, as many affected teens show clear symptoms despite standard spirometry results.
- Map the exact sensation: Differentiating between throat tightness, racing hearts, and true air hunger helps clinicians pinpoint specific root causes like dysautonomia or mast cell activation.
- Prevent post-exertional crashes: Overly intense training can trigger delayed, multi-system exhaustion known as post-exertional malaise, requiring carefully paced rehabilitation instead of pushing through fatigue.
Investigating Pediatric Dyspnea Beyond Traditional Spirometry
Suzanne McNulty, MD, a pediatrician based in Aliso Viejo, California, urged medical colleagues to reevaluate how they approach exertional dyspnea in adolescent patients. Speaking at the San Diego conference, McNulty emphasized that clinicians must question what specific physiology produces the sensation of breathlessness.
Standard diagnostic measures often fall short in these cases. McNulty highlighted data from a 2024 systematic review and meta-analysis encompassing eight studies and 386 pediatric patients post-COVID. While these young patients experienced genuine shortness of breath, cough, exercise intolerance, and fatigue, their pulmonary function tests and spirometry readings were generally normal.
Relying solely on standard respiratory metrics risks missing systemic drivers. McNulty outlined a comprehensive initial diagnostic workup designed to capture these hidden factors. Recommended evaluations include pulse oximetry, detailed cardiac and pulmonary exams, electrocardiograms, spirometry with bronchodilator response testing, complete blood counts, ferritin or iron studies, vitamin B12 assays, and standardized orthostatic testing.
Differential Diagnosis of Post-COVID Exertional Distress
To narrow down a diagnosis, clinicians must prompt patients to describe their exact sensations. Describing an inability to get a satisfying breath points toward different underlying pathways than reporting throat obstruction or rapid heart rates.
McNulty’s clinical differential for teen athletes includes several distinct mechanisms:
- Dysautonomia: An autonomic nervous system malfunction characterized by orthostatic or exertional tachycardia, heat intolerance, and low preload. Triggers include standing, dehydration, and menstruation.
- Mast Cell Activation Syndrome (MCAS): Involves flares across skin, gastrointestinal, neurologic, and respiratory systems, often triggered by heat, odors, stress, or exercise.
- Nutritional Deficiencies: Iron deficiency—frequently linked to menstruation—alongside vitamin B12 depletion and low energy availability.
- Post-Exertional Malaise (PEM/PESE): A delayed multi-system deterioration occurring hours or days after physical exertion, requiring carefully calibrated physical activity to avoid worsening muscle damage.
Concurrently, clinicians must still evaluate for classic conditions such as asthma and exercise-induced laryngeal obstruction (EILO). McNulty noted that an asthma diagnosis requires concrete evidence like variable airflow obstruction or a positive bronchoprovocation test, while EILO is characterized by inspiratory symptoms and audible stridor during peak exertion.
Targeted Rehabilitation Tracks Patient Responses to Treatment
Managing long COVID in young athletes requires a step-by-step approach focused on targeting specific physiological pathways. McNulty advised clinicians to track patient responses closely, noting that observing which symptoms improve—and which persist—provides critical diagnostic feedback when multiple mechanisms overlap.
This targeted rehabilitation aligns with broader clinical perspectives from specialized recovery centers. Laura A. Malone, MD, PhD, an associate professor at Johns Hopkins University School of Medicine and director of the Pediatric Post-COVID-19 Rehabilitation Clinic at the Kennedy Krieger Institute in Baltimore, noted that her clinic observes similar presentations across both athletes and non-athletic children.
Malone also said doctors must track symptom onset relative to prior infections. Because pediatric infections are frequently mild, many children and adolescents are never formally tested during the acute phase. Symptoms may emerge immediately following the acute illness or after a symptom-free recovery window lasting several weeks to 1-2 months.
Red Flag Symptoms Require Immediate Medical Triage
Adolescents experiencing exertional distress require immediate medical triage if red-flag symptoms emerge. Clinicians and caregivers must watch for danger signals including fainting during physical activity, sustained low blood oxygen saturation, progressive resting breathlessness, coughing up blood or bloody mucus, and exertion-induced chest pain.
Patients presenting with cardiac findings, persistent fever, systemic inflammation, resting anaphylaxis, or stridor—which is turbulent, high-pitched breathing—require urgent medical evaluation.
As pediatric specialists continue to refine diagnostic frameworks, guidance from organizations such as the American Heart Association offers structured insight into managing exercise intolerance and recovery responses in long COVID patients.
References
- American Academy of Pediatrics (AAP) 2026 National Conference.
- American Heart Association. 2025 statement on exercise intolerance and training responses in long COVID.
