Cough in exercise and athletes

Respiratory problems in rowers: outcomes from a systematic assessment of an elite squad

OBJECTIVES

To characterise the respiratory health of elite rowers using a systematic screening approach to assess respiratory health (SARAH) and identify the associations between SARAH findings and acute respiratory illness (ARI) and chest wall injury (CWI).

METHODS

A systematic screening approach was conducted in a cohort of elite rowers. The assessment employed validated respiratory questionnaires and multiple physiological measures. An analysis of ARI and CWI incidence and burden from the 18 months before the SARAH assessment was conducted.

RESULTS

Full respiratory surveillance was completed in 48 rowers (50% female, aged 27 [25-28] years). The incidence and burden of ARI were similar between male and female rowers. The incidence of CWI was greater in female rowers compared to males (1.6 versus 0.4 per 1000 athlete training days, respectively; incidence rate ratio of 4.3, 95% C.I. 1.5 to 12.2, p=0.005) and more common in younger rowers with greater lung function. SARAH detected at least one respiratory problem in 39 (81%) rowers, and two or more problems in 26 (54%). Sino-nasal problems (44%), allergy-related problems (42%) and breathing pattern disorder (42%) were the most prevalent problems identified. Exercise-associated cough was reported in 34 (71%) rowers, with objective evidence of asthma found in only five (10%).

CONCLUSIONS

In elite rowers, respiratory problems, including ARI and CWI, are common and impact health. A systematic screening approach identifies multiple underlying respiratory problems, presenting the opportunity to optimise athlete health and improve training availability.

Cross-country skiers often experience respiratory symptoms during and after exercise but have a low prevalence of prolonged cough

Background

Cross-country skiers train and compete during the winter for long periods of time in subfreezing conditions, which strains the airways and provokes respiratory symptoms. This study aimed to compare the prevalence of exercise-related symptoms and prolonged cough in competitive cross-country skiers versus the general population and to investigate the association between these symptoms and asthma.

Methods

A questionnaire was sent to Finnish cross-country skiers (n=1282) and a random sample of the general population (n=1754), with response rates of 26.9% and 19.0%, respectively.

Results

Both groups were mostly asymptomatic at rest, but symptoms were increased in both groups during and after exercise. Cough was more prevalent after exercise in skiers and phlegm production was more common during and after exercise in skiers. Asthma did not provoke specific symptoms, but symptom prevalence was higher in asthmatic individuals. Skiers had a higher prevalence of cough after exercise (60.6% vs 22.8%, p<0.001) compared with controls, but controls had a higher prevalence of prolonged cough (4.1% vs 9.6%, p=0.004). In participants without asthma, cold air triggered symptoms more often in skiers than controls, while strong odours triggered symptoms more often in asthmatic controls than skiers. Chronic cough lasting more than 8 weeks was rare, reported by 4.8% of controls and 2.0% of skiers.

Conclusion

Cross-country skiers, especially those with asthma, experience a higher burden of exercise-related respiratory symptoms compared with controls. However, repeated exposure to cold air does not appear to result in long-term hypersensitivity of the cough reflex arc.

Diagnosis and management of allergy and respiratory disorders in sport: An EAACI task force position paper

Allergy and respiratory disorders are common in young athletic individuals. In the context of elite sport, it is essential to secure an accurate diagnosis in order to optimize health and performance. It is also important, however, to consider the potential impact or consequences of these disorders, in recreationally active individuals engaging in structured exercise and/or physical activity to maintain health and well-being across the lifespan. This EAACI Task Force was therefore established, to develop an up-to-date, research-informed position paper, detailing the optimal approach to the diagnosis and management of common exercise-related allergic and respiratory conditions. The recommendations are informed by a multidisciplinary panel of experts including allergists, pulmonologists, physiologists and sports physicians. The report is structured as a concise, practically focussed document, incorporating diagnostic and treatment algorithms, to provide a source of reference to aid clinical decision-making. Throughout, we signpost relevant learning resources to consolidate knowledge and understanding and conclude by highlighting future research priorities and unmet needs.

Respiratory impact of a grand tour: insight from professional cycling

PURPOSE

The aim of this study was to evaluate the respiratory function and symptom perception in professional cyclists completing a Grand Tour (GT).

METHODS

Nine male cyclists completed La Vuelta or Tour de France (2018/19). At study entry, airway inflammation was measured via fractional exhaled nitric oxide (FeNO). Respiratory symptoms and pulmonary function were assessed prior to the first stage (Pre-GT), at the second rest day (Mid-GT) and prior to the final stage of the GT (Late-GT). Sniff nasal inspiratory pressure (SNIP) was assessed at pre and late-GT timepoints.

RESULTS

Seven cyclists reported respiratory symptoms during the race (with a prominence of upper airway issues). Symptom severity increased either mid or late-GT for most cyclists. A decline in FEV₁ from pre-to-mid GT (- 0.27 ± 0.24 l, - 5.7%) (P = 0.02) and pre-to-late GT (- 0.27 ± 0.13 l, - 5.7%) (P < 0.001) was observed. Similarly, a decline in FVC (- 0.22 ± 0.17 l, - 3.7%) (P = 0.01) and FEF_25-75 (- 0.49 ± 0.34 l/s, - 11%) (P = 0.02) was observed pre-to-late GT. Overall, eight (89%) and six (67%) demonstrated a clinically meaningful decline (> 200 ml) in FEV₁ and FVC during the GT follow-up, respectively. SNIP remained unchanged pre-to-late GT (n = 5), however, a positive correlation was observed between ΔSNIP and ΔFVC (r = 0.99, P = 0.002).

CONCLUSION

GT competition is associated with a high prevalence of upper respiratory symptoms and a meaningful decline in lung function in professional cyclists. Further research is now required to understand the underpinning physiological mechanisms and determine the impact on overall respiratory health and elite cycling performance and recovery.

Cardiorespiratory considerations for return-to-play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians

SARS-CoV-2 is the causative virus responsible for the COVID-19 pandemic. This pandemic has necessitated that all professional and elite sport is either suspended, postponed or cancelled altogether to minimise the risk of viral spread. As infection rates drop and quarantine restrictions are lifted, the question how athletes can safely resume competitive sport is being asked. Given the rapidly evolving knowledge base about the virus and changing governmental and public health recommendations, a precise answer to this question is fraught with complexity and nuance. Without robust data to inform policy, return-to-play (RTP) decisions are especially difficult for elite athletes on the suspicion that the COVID-19 virus could result in significant cardiorespiratory compromise in a minority of afflicted athletes. There are now consistent reports of athletes reporting persistent and residual symptoms many weeks to months after initial COVID-19 infection. These symptoms include cough, tachycardia and extreme fatigue. To support safe RTP, we provide sport and exercise medicine physicians with practical recommendations on how to exclude cardiorespiratory complications of COVID-19 in elite athletes who place high demand on their cardiorespiratory system. As new evidence emerges, guidance for a safe RTP should be updated.

The impact of a heat and moisture exchange mask on respiratory symptoms and airway response to exercise in asthma

Respiratory symptoms, including cough, are prevalent in individuals with asthma when exercising. This study investigates whether a heat and moisture exchanger (HME) face mask is effective in modulating exercise-induced bronchoconstriction (EIB) and post-exercise cough in a cold, dry environment in individuals with asthma.

Twenty-six participants diagnosed with asthma (20 males, 6 females) completed three cycling exercise challenges at 8°C and 24% relative humidity in a randomised order. Participants wore either an HME mask (MASK), sham mask (SHAM), or no mask (CONT). Following a 3-min warm-up, participants completed 6-min cycling at 80% peak power output. Before and after exercise, maximal flow-volume loops were recorded. Post-exercise cough was monitored with a Leicester Cough Monitor (LCM) for 24 h. Results were analysed using repeated-measures ANOVA and Friedman's tests and data were presented as the mean±sd or median (interquartile range (IQR)).

Eleven participants failed to demonstrate EIB (i.e. >10% fall in forced expiratory volume in 1 s after exercise) and were removed from analysis. The percentage fall in forced expiratory volume in 1 s following exercise in CONT was greater than MASK (MASK: −6% (7%), SHAM: −11% (11%), CONT: −13% (9%); p<0.01). No difference was found between exercise in cough count per hour over the 24-h monitoring period or the number of coughs in the first hour after exercise.

HME masks can attenuate EIB when exercising in cold, dry environments. The SHAM mask may not have been entirely inert, demonstrating the challenges of running randomised control trials utilising control and sham conditions.

Heat and moisture exchanger masks can reduce bronchoconstriction in individuals with exercise-induced bronchoconstriction when exercising in cold, dry environmentshttps://bit.ly/2JKeLnX

Cough in exercise and athletes

In the general population, particularly in individuals with asthma, cough is a common symptom, often reported after exertion, although regular exercise may be associated with a reduction in the prevalence of cough. In athletes, exercise-induced cough is also a particularly frequent symptom. The main etiologies of cough in athletes are somewhat similar to non-athletes, including asthma/airway hyperresponsiveness, upper airways disorders such as allergic or non-allergic rhinitis, and exercise-induced laryngeal obstruction, although these conditions are more frequently observed in athletes. In these last, this symptom can also be related to the high ventilation and heat exchange experienced during exercise, particularly during exposure to cold/dry air or pollutants. However, gastroesophageal reflux, a common cause of cough in the general population, despite being highly prevalent in athletes, has not been reported as a main cause of cough in athletes. Cough may impair quality of life, sleep and exercise performance in the general population and probably also in athletes, although there are few data on this. The causes of cough should be documented through a systematic evaluation, the treatment adapted according to identified or most probable cough etiology and pattern of presentation, while respecting sports anti-doping regulations. More research is needed on exercise-induced persistent cough in the athlete to determine its pathophysiology, optimal management and consequences.

A Machine Hearing System for Robust Cough Detection Based on a High-Level Representation of Band-Specific Audio Features

Cough is a protective reflex conveying information on the state of the respiratory system. Cough assessment has been limited so far to subjective measurement tools or uncomfortable (i.e., non-wearable) cough monitors. This limits the potential of real-time cough monitoring to improve respiratory care.

OBJECTIVE

This paper presents a machine hearing system for audio-based robust cough segmentation that can be easily deployed in mobile scenarios.

METHODS

Cough detection is performed in two steps. First, a short-term spectral feature set is separately computed in five predefined frequency bands: [0, 0.5), [0.5, 1), [1, 1.5), [1.5, 2), and [2, 5.5125] kHz. Feature selection and combination are then applied to make the short-term feature set robust enough in different noisy scenarios. Second, high-level data representation is achieved by computing the mean and standard deviation of short-term descriptors in 300 ms long-term frames. Finally, cough detection is carried out using a support vector machine trained with data from different noisy scenarios. The system is evaluated using a patient signal database which emulates three real-life scenarios in terms of noise content.

RESULTS

The system achieves 92.71% sensitivity, 88.58% specificity, and 90.69% Area Under Receiver Operating Charcteristic (ROC) curve (AUC), outperforming state-of-the-art methods.

CONCLUSION

Our research outcome paves the way to create a device for cough monitoring in real-life situations.

SIGNIFICANCE

Our proposal is aligned with a more comfortable and less disruptive patient monitoring, with benefits for patients (allows self-monitoring of cough symptoms), practitioners (e.g., assessment of treatments or better clinical understanding of cough patterns), and national health systems (by reducing hospitalizations).

Impact of detecting and treating exercise-induced bronchoconstriction in elite footballers

Our aim was to evaluate the prevalence of exercise-induced bronchoconstriction (EIB) in elite football players and assess subsequent impact of therapy on airway health and exercise performance. 97 male professional football players completed an airway health assessment with a eucapnic voluntary hyperpnoea (EVH) challenge to diagnose EIB. Players demonstrating a positive result (EVH+) were prescribed inhaler therapy depending on severity, including inhaled corticosteroids and inhaled short-acting β2-agonists, and underwent repeat assessment after 9 weeks of treatment. Eight players (EVH+ n=3, EVH- n=5) completed a peak oxygen uptake (V'O2peak) test at initial and follow-up assessment. Out of the 97 players, 27 (28%) demonstrated a positive EVH result. Of these, 10 had no prior history (37%) of EIB or asthma. EVH outcome was not predictable by respiratory symptoms. Seven (24%) of the 27 EVH+ players attended follow-up and demonstrated improved post-challenge spirometry (forced expiratory volume in 1 s pre-test -22.9±15.4%, post-test -9.0±1.6%; p=0.018). At follow-up V'O2peak improved by 3.4±2.9 mL·kg-1·min-1 in EVH+ players compared to 0.1±2.3 mL·kg-1·min-1 in EVH- players. Magnitude of inference analysis indicated treatment was possibly beneficial (74%) for exercise capacity. Elite football players have a high EIB prevalence. Treatment with inhaler therapy reduces EIB severity.