SAN DIEGO — In the era of long COVID, it’s not enough to automatically assume a teenage athlete has asthma when they say “I can’t breathe,” a pediatrician advised colleagues at the American Academy of Pediatrics (AAP) 2026 National Conference.

Instead, “when an athlete presents with dyspnea, I’m going to always ask what physiology is producing that symptom,” said Suzanne McNulty, MD, of Aliso Viejo, California, in a presentation about breathing problems in the context of post-COVID effects. “What does ‘I can’t breathe’ actually mean?”

She asks the question because long COVID is a systemic disease, she said. According to McNulty, young athletes with the condition can struggle to breathe because of a number of mechanisms other than traditional causes such as asthma and exercise-induced laryngeal obstruction (EILO).

“The goal is not simply to get an athlete through a workout,” she said. “It’s to understand the physiology well enough that they can actually exercise, recover, and ultimately return safely to their sport.”

McNulty offered these step-by-step tips for helping these athletes:

Focus on Red Flags First

Ask yourself, McNulty said, “Is the athlete safe?” Do they require immediate care?

Danger signals include fainting on exertion, sustained low blood oxygen, progressive resting dyspnea, coughing up blood or bloody mucus, chest pain on exertion, cardiac findings, persistent fever or systemic inflammation, resting anaphylaxis, and stridor (turbulent, high-pitched breathing).

Launch an Extensive Workup

McNulty recommends:

• Pulse oximetry and cardiac or pulmonary examination
• ECG
• Spirometry with bronchodilator response
• Complete blood count plus ferritin or complete iron studies and vitamin B₁₂ testing
• Standardized orthostatic testing
• Imaging or echo or rhythm monitoring when indicated

Don’t Relax if Spirometry Is Normal

“Normal pulmonary testing does not end the evaluation,” McNulty said. She highlighted a 2024 systematic review and meta-analysis of eight studies examining 386 children post-COVID. While some had dyspnea, cough, exercise intolerance, and fatigue, spirometry was generally normal.

Pinpoint the Type of Breathing Problem

McNulty doesn’t accept “shortness of breath” as the full explanation of what a teen athlete is feeling. Instead, she asks the patient to describe the sensation, when it happens, what triggers it, what else happens, and how they recover.

“‘I can’t get a satisfying breath’ is different from ‘chest pain.’ ‘My throat is blocked’ is different from ‘my heart races, and I can’t breathe,’” she said.

As she explained, this matters because the patient’s experience can help narrow the diagnosis. Mast cell activation syndrome (MCAS), for example, can present with air hunger or chest tightness, while exertional dyspnea can be a sign of iron deficiency or deconditioning related to long COVID.

Consider a Range of Causes

Once McNulty gets enough information, she considers a full differential that includes these potential causes:

• Dysautonomia (autonomic nervous system malfunction). Look for orthostatic or exertional tachycardia, heat intolerance, and low preload.

  “Dysautonomia is one of the easiest conditions to miss when the presenting complaint is respiratory because the athlete may not come in saying, ‘I get dizzy when I stand up,’” McNulty said.

  Triggers include standing, heat, dehydration, low fluid or sodium intake, illness, and menstruation. Treatments include fluids, sodium, compression, planning around heat and exercise, and adjustment of medication.

• MCAS. Look for flares in the skin and disruptions of the gastrointestinal, neurologic, autonomic, genitourinary, and respiratory systems, she said. Consider triggers such as heat, odors, infection, stress, and exercise. Consult the Global Consensus-2 Framework for help with next steps.
• Nutritional deficiency. Look for iron deficiency (which can be related to menstruation), vitamin B₁₂ deficiency, low energy availability, and restricted food intake.
• Deconditioning. “Exercise limitation is expected and should gradually improve with appropriate progressive training,” she said.

• Post-exertional malaise, also known as post-exertional symptom exacerbation (PEM/PESE). It is believed to be common in long COVID.

  In patients with this condition following exercise, “deterioration comes later in the day and the next day and may involve multiple systems,” she said. “Recovery may take days rather than hours.”

  Exercise is helpful but be aware, as a 2025 compendium statement highlighted by McNulty advises, “Overly intense activity can trigger PEM/PESE and worsen muscle damage.”

Confirm Asthma or EILO With Positive Evidence

As for asthma and EILO, “You can have both of those or either one in these kids,” she said. “The point is that shortness of breath does not establish either diagnosis.”

According to McNulty, these findings make an asthma diagnosis more convincing: expiratory cough or wheeze, variable airflow obstruction, bronchodilator response, or a positive exercise or bronchoprovocation test.

These make an EILO diagnosis more likely: inspiratory symptoms during high-intensity or peak exercise, stridor or noisy inspiration, and obstruction demonstrated during continuous laryngoscopy during exercise testing.

In Treatment, Do Things in Sequential Order

During treatment, McNulty advised, start by targeting physiology. Track response and reassess with an eye toward remaining symptoms, she said. “If I target the suspected pathway, what improves? More importantly, what doesn’t improve? If one domain improves, but then another one doesn’t, then that’s useful information. It may be that there’s more than one mechanism operating.”

She pointed to a 2025 statement from the American Heart Association that offers guidance regarding exercise intolerance and response to training in patients with long COVID.

Another Perspective: It’s Not Just Athletes

In an interview, Laura A. Malone, MD, PhD, said McNulty’s recommendations reflect her clinic’s approach. 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, she noted that while McNulty focuses on teen athletes, “we see similar symptoms in younger children and those that are not necessarily athletes.”

Malone added that it’s helpful to ask about the timing of symptom onset in relation to infections that were identified — or not identified — as COVID. “Children and adolescents frequently have mild COVID-19 illnesses and may not always be tested to identify a cause,” she said. “We know that some patients will have symptoms that start during or immediately following their COVID-19 acute symptoms, whereas others might have a recovery for a few weeks or 1-2 months before developing symptoms. Both these patterns can be seen in long COVID.”

McNulty and Malone reported having no disclosures.