Airway dysfunction in elite athletes--an occupational lung disease?

Impact of environmental air pollution on respiratory health and function

Environmental air pollution presents a considerable risk to global respiratory health. If critical levels are exceeded, inhaled pollutants can lead to the development of respiratory dysfunction and provoke exacerbation in those with pre-existing chronic respiratory disease. Over 90% of the global population currently reside in areas where environmental air pollution is considered excessive-with adverse effects ranging from acute airway irritation to complex immunomodulatory alterations. This narrative review provides an up-to-date perspective concerning the impact of environmental air pollution on respiratory health and function and describes the underpinning mechanisms that contribute to the development and progression of chronic respiratory disease.

Impact of Isolated Exercise-Induced Small Airway Dysfunction on Exercise Performance in Professional Male Cyclists

BACKGROUND

Professional cycling puts significant demands on the respiratory system. Exercise-induced bronchoconstriction (EIB) is a common problem in professional athletes. Small airways may be affected in isolation or in combination with a reduction in forced expiratory volume at the first second (FEV1). This study aimed to investigate isolated exercise-induced small airway dysfunction (SAD) in professional cyclists and assess the impact of this phenomenon on exercise capacity in this population.

MATERIALS AND METHODS

This research was conducted on professional cyclists with no history of asthma or atopy. Anthropometric characteristics were recorded, the training age was determined, and spirometry and specific markers, such as fractional exhaled nitric oxide (FeNO) and immunoglobulin E (IgE), were measured for all participants. All of the cyclists underwent cardiopulmonary exercise testing (CPET) followed by spirometry.

RESULTS

Compared with the controls, 1-FEV3/FVC (the fraction of the FVC that was not expired during the first 3 s of the FVC) was greater in athletes with EIB, but also in those with isolated exercise-induced SAD. The exercise capacity was lower in cyclists with isolated exercise-induced SAD than in the controls, but was similar to that in cyclists with EIB. This phenomenon appeared to be associated with a worse ventilatory reserve (VE/MVV%).

CONCLUSIONS

According to our data, it appears that professional cyclists may experience no beneficial impacts on their respiratory system. Strenuous endurance exercise can induce airway injury, which is followed by a restorative process. The repeated cycle of injury and repair can trigger the release of pro-inflammatory mediators, the disruption of the airway epithelial barrier, and plasma exudation, which gradually give rise to airway hyper-responsiveness, exercise-induced bronchoconstriction, intrabronchial inflammation, peribronchial fibrosis, and respiratory symptoms. The small airways may be affected in isolation or in combination with a reduction in FEV1. Cyclists with isolated exercise-induced SAD had lower exercise capacity than those in the control group.

Lung function responses to cold water ingestion: A randomised controlled crossover trial

This study tested the hypothesis that cold water ingestion would reduce lung function and thereby confound its measurement in a way that is mediated by both temperature and volume. In a randomised crossover trial, 10 healthy adults performed spirometry before and 5, 10, 15, and 30-minutes after consuming one-of-four drinks: 500 mL or 1000 mL refrigerated water (∼2 °C); identical water volumes at ambient temperature (∼18 °C). Ingesting 1000 mL cold water significantly reduced forced vital capacity (FVC) for at least 10 min (mean difference =0.28 L, p < 0.05, d=1.19) and forced expiratory volume in 1 s (FEV1) for at least 15 min (0.20-0.30 L, p < 0.05, d=1.01). Ingesting 500 mL cold water reduced FEV1 for 5 min (0.09 L, p < 0.05, d=1.05). Room-temperature water had no influence on lung function. To avoid confounding the measurement of lung function, we conclude that individuals should avoid drinking cold water, especially in large volumes, immediately prior to a given test.

Unsupervised field-based exercise challenge tests to support the detection of exercise-induced lower airway dysfunction in athletes

Background

Athletes are at risk for developing exercise-induced lower airway narrowing. The diagnostic assessment of such lower airway dysfunction (LAD) requires an objective bronchial provocation test (BPT).

Objectives

Our primary aim was to assess if unsupervised field-based exercise challenge tests (ECTs) could confirm LAD by using app-based spirometry. We also aimed to evaluate the diagnostic test performance of field-based and sport-specific ECTs, compared with established eucapnic voluntary hyperpnoea (EVH) and methacholine BPT.

Methods

In athletes with LAD symptoms, sensitivity and specificity analyses were performed to compare outcomes of (1) standardised field-based 8 min ECT at 85% maximal heart rate with forced expiratory volume in 1 s (FEV₁) measured prechallenge and 1 min, 3 min, 5 min, 10 min, 15 min and 30 min postchallenge, (2) unstandardised field-based sport-specific ECT with FEV₁ measured prechallenge and within 10 min postchallenge, (3) EVH and (4) methacholine BPT.

Results

Of 60 athletes (median age 17.5; range 16-28 years.; 40% females), 67% performed winter-sports, 43% reported asthma diagnosis. At least one positive BPT was observed in 68% (n=41/60), with rates of 51% (n=21/41) for standardised ECT, 49% (n=20/41) for unstandardised ECT, 32% (n=13/41) for EVH and methacholine BPT, while both standardised and unstandardised ECTs were simultaneously positive in only 20% (n=7/35). Standardised and unstandardised ECTs confirmed LAD with 54% sensitivity and 70% specificity, and 46% sensitivity and 68% specificity, respectively, using EVH as a reference, while EVH and methacholine BPT were both 33% sensitive and 85% specific, using standardised ECTs as reference.

Conclusion

App-based spirometry for unsupervised field-based ECTs may support the diagnostic process in athletes with LAD symptoms.

Trial registration number

NCT04275648.

Effect of Hydration on Pulmonary Function and Development of Exercise-Induced Bronchoconstriction among Professional Male Cyclists

BACKGROUND

Exercise-induced bronchoconstriction (EIB) is a common problem in elite athletes. Classical pathways in the development of EIB include the osmotic and thermal theory as well as the presence of epithelial injury in the airway, with local water loss being the main trigger of EIB. This study aimed to investigate the effects of systemic hydration on pulmonary function and to establish whether it can reverse dehydration-induced alterations in pulmonary function.

MATERIALS AND METHODS

This follow-up study was performed among professional cyclists, without a history of asthma and/or atopy. Anthropometric characteristics were recorded for all participants, and the training age was determined. In addition, pulmonary function tests and specific markers such as fractional exhaled nitric oxide (FeNO) and immunoglobulin E (IgE) were measured. All the athletes underwent body composition analysis and cardiopulmonary exercise testing (CPET). After CPET, spirometry was followed at the 3rd, 5th, 10th, 15th, and 30th min. This study was divided into two phases: before and after hydration. Cyclists, who experienced a decrease in Forced Expiratory Volume in one second (FEV₁) ≥ 10% and/or Maximal Mild-Expiratory Flow Rate (MEF_25-75) ≥ 20% after CPET in relation to the results of the spirometry before CPET, repeated the test in 15-20 days, following instructions for hydration.

RESULTS

One hundred male cyclists (n = 100) participated in Phase A. After exercise, there was a decrease in all spirometric parameters (p < 0.001). In Phase B, after hydration, in all comparisons, the changes in spirometric values were significantly lower than those in Phase A (p < 0.001).

CONCLUSIONS

The findings of this study suggest that professional cyclists have non-beneficial effects on respiratory function. Additionally, we found that systemic hydration has a positive effect on spirometry in cyclists. Of particular interest are small airways, which appear to be affected independently or in combination with the decrease in FEV₁. Our data suggest that pulmonary function improves systemic after hydration.

Exercise and asthma - Trigger or treatment?

Exercise is one of the most commonly reported symptom triggers for people with asthma. However, a growing body of evidence indicates that regular exercise and physical activity are associated with improved clinical and patient reported outcomes. In this article, we summarise and consolidate recent original studies evaluating exercise and physical activity profiles in people with asthma and provide an up-to-date perspective concerning the role of exercise training and physical activity promotion in the context of asthma management. To conclude, we identify key unmet needs and provide directions for future research.

Fractional exhaled nitric oxide in the assessment of exercise-induced bronchoconstriction: A multicenter retrospective analysis of UK-based athletes

INTRODUCTION

Exercise-induced bronchoconstriction (EIB) is not only highly prevalent in people with asthma, but can also occur independently, particularly in athletes. Fractional exhaled nitric oxide (FeNO) is an indirect biomarker of type 2 airway inflammation that has an established role in the assessment and management of asthma. The aim was to evaluate the value of FeNO in the assessment of EIB in athletes.

METHOD

Multicenter retrospective analysis. In total, 488 athletes (male: 76%) performed baseline FeNO, and spirometry pre- and post-indirect bronchial provocation via eucapnic voluntary hyperpnea (EVH). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for established FeNO thresholds-that is, intermediate (≥25 ppb) and high FeNO (≥40 ppb and ≥ 50 ppb)-and were evaluated against objective evidence of EIB (≥10% fall in FEV₁ ). The diagnostic accuracy of FeNO was calculated using receiver operating characteristics area under the curve (ROC-AUC).

RESULTS

Thirty-nine percent of the athletes had a post-EVH fall in FEV₁ consistent with EIB. FeNO values ≥25 ppb, ≥40 ppb, and ≥ 50 ppb were observed in 42%, 23%, and 17% of the cohort, respectively. The sensitivity of FeNO ≥25 ppb was 55%, which decreased to 37% and 27% at ≥40 ppb and ≥ 50 ppb, respectively. The specificity of FeNO ≥25 ppb, ≥40 ppb, and ≥ 50 ppb was 66%, 86%, and 89%, respectively. The ROC-AUC for FeNO was 0.656.

CONCLUSIONS

FeNO ≥40 ppb provides good specificity, that is, the ability to rule-in a diagnosis of EIB. However, due to the poor sensitivity and predictive values, FeNO should not be employed as a replacement for indirect bronchial provocation in athletes.

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.

Effects of airway deformation and alveolar pores on particle deposition in the lungs

The distal lung (G14-G23), which are composed of alveoli and bronchi, are responsible for almost all gas exchange and micro- and nanoparticle deposition in the lungs. In the existing research using computational fluid dynamics, the geometric modeling accuracy of the bronchial bifurcation structure is given priority, and then the alveoli are attached to bronchi as discrete spherical crowns. This method ignores the correlation between alveoli. In fact, the alveoli have a tessellated distribution, and adjacent alveoli are connected by several alveolar pores. Due to the huge number of alveoli, this seemingly small difference will be greatly amplified, which may lead to a large deviation in the prediction of the overall flow. Accordingly, the objective of this study is to construct a two-dimensional distal lung model including the bronchi, acini, and alveolar pores by using the methods of regular hexagonal tessellational subdivision, fusion, and coordinate transformation. A moving boundary is introduced to simulate the process of airflow and particle deposition in the distal lung, and the effects of bronchial deformation, respiratory frequency, and alveolar pores are obtained. The results show that there are significant differences in intrapulmonary flow patterns with and without alveolar pores. Alveolar pores can establish bypass ventilation downstream of a blockage, thus providing a pathway for particles to enter the airways downstream of the blockage. Changing the respiratory frequency and the amplitude of bronchial deformation will change the relative velocity between particles and moving wall, which, in turn, will change the particle deposition efficiency in the distal lung. To summarize this study, a geometric modeling method for the distal lung with alveolar pores is established, and the important roles of detailed characteristics of the distal lung are revealed. The findings of this study provide a reasonable hydrodynamic mechanism for the prevention of related respiratory diseases.

International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 2: non-infective acute respiratory illness

Acute respiratory illness (ARill) is common and threatens the health of athletes. ARill in athletes forms a significant component of the work of Sport and Exercise Medicine (SEM) clinicians. The aim of this consensus is to provide the SEM clinician with an overview and practical clinical approach to non-infective ARill in athletes. The International Olympic Committee (IOC) Medical and Scientific Committee appointed an international consensus group to review ARill in athletes. Key areas of ARill in athletes were originally identified and six subgroups of the IOC Consensus group established to review the following aspects: (1) epidemiology/risk factors for ARill, (2) infective ARill, (3) non-infective ARill, (4) acute asthma/exercise-induced bronchoconstriction and related conditions, (5) effects of ARill on exercise/sports performance, medical complications/return-to-sport (RTS) and (6) acute nasal/laryngeal obstruction presenting as ARill. Following several reviews conducted by subgroups, the sections of the consensus documents were allocated to 'core' members for drafting and internal review. An advanced draft of the consensus document was discussed during a meeting of the main consensus core group, and final edits were completed prior to submission of the manuscript. This document (part 2) of this consensus focuses on respiratory conditions causing non-infective ARill in athletes. These include non-inflammatory obstructive nasal, laryngeal, tracheal or bronchial conditions or non-infective inflammatory conditions of the respiratory epithelium that affect the upper and/or lower airways, frequently as a continuum. The following aspects of more common as well as lesser-known non-infective ARill in athletes are reviewed: epidemiology, risk factors, pathology/pathophysiology, clinical presentation and diagnosis, management, prevention, medical considerations and risks of illness during exercise, effects of illness on exercise/sports performance and RTS guidelines.

Influence of exercise duration on respiratory function and systemic immunity among healthy, endurance-trained participants exercising in sub-zero conditions

Background

Strenuous endurance exercise in sub-zero temperatures can cause airway damage that may lead to EIB. Prolonged exercise can also elicit greater immune perturbations than short-duration exercise. However, the influence of exercise duration on lung function and systemic immunity in sub-zero temperatures has not been established. Additionally, it is currently unknown whether atopic disposition, which is risk factor for EIB, influences respiratory responses in a sub-zero climate. The aim of this study was to compare respiratory and systemic immune responses to two cold air running trials of short and long duration, as well as to examine whether the responses differed between atopic and non-atopic subjects.

Methods

Eighteen healthy, endurance-trained subjects (males/females: 14/4; age: 29.4 ± 5.9 years old; BMI: 23.1 ± 1.7; atopic/non-atopic: 10/8) completed two moderate-intensity climate chamber running trials at − 15 °C, lasting 30 and 90 min, in a randomized, cross-over design. Lung function (spirometry and impulse oscillometry), serum CC16, respiratory symptoms, and blood leukocyte counts were examined before and after the trials.

Results

Lung function was not significantly affected by exercise or exercise duration. CC16 concentration increased after both trials (p = 0.027), but the response did not differ between trials. Respiratory symptom intensity was similar after each trial. There was a greater increase in neutrophils (p < 0.001), and a decrease in eosinophils (p < 0.001) after the 90-min bout. The 90-min protocol increased X5 compared to the 30-min protocol only in atopic subjects (p = 0.015) while atopy increased lower airway symptoms immediately after the 90-min session (p = 0.004).

Conclusions

Our results suggest that a 90-min bout of moderate-intensity exercise at − 15 °C does not cause substantial lung function decrements, airway epithelial damage or respiratory symptoms compared to 30 min running in the same environment, despite a heightened redistribution of white blood cells. However, exercise at − 15 °C may cause airway injury and evoke respiratory symptoms, even at moderate intensity. Atopic status may lead to greater peripheral bronchodilation and higher frequency of respiratory symptoms after long-duration exercise in cold.

Trial registration: 01/02/2022 ISRCTN13977758. This trial was retrospectively registered upon submission to satisfy journal guidelines. The authors had not initially registered the study, as the intervention was considered to be a controlled simulation of exercise in a naturally occurring environment (i.e. sub-zero air) for healthy volunteers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02029-2.

Prevalence of lower airway dysfunction in athletes: a systematic review and meta-analysis by a subgroup of the IOC consensus group on 'acute respiratory illness in the athlete'

OBJECTIVE

To report the prevalence of lower airway dysfunction in athletes and highlight risk factors and susceptible groups.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EBSCOhost and Web of Science (1 January 1990 to 31 July 2020).

ELIGIBILITY CRITERIA

Original full-text studies, including male or female athletes/physically active individuals/military personnel (aged 15-65 years) who had a prior asthma diagnosis and/or underwent screening for lower airway dysfunction via self-report (ie, patient recall or questionnaires) or objective testing (ie, direct or indirect bronchial provocation challenge).

RESULTS

In total, 1284 studies were identified. Of these, 64 studies (n=37 643 athletes) from over 21 countries (81.3% European and North America) were included. The prevalence of lower airway dysfunction was 21.8% (95% CI 18.8% to 25.0%) and has remained stable over the past 30 years. The highest prevalence was observed in elite endurance athletes at 25.1% (95% CI 20.0% to 30.5%) (Q=293, I²=91%), those participating in aquatic (39.9%) (95% CI 23.4% to 57.1%) and winter-based sports (29.5%) (95% CI 22.5% to 36.8%). In studies that employed objective testing, the highest prevalence was observed in studies using direct bronchial provocation (32.8%) (95% CI 19.3% to 47.2%). A high degree of heterogeneity was observed between studies (I²=98%).

CONCLUSION

Lower airway dysfunction affects approximately one in five athletes, with the highest prevalence observed in those participating in elite endurance, aquatic and winter-based sporting disciplines. Further longitudinal, multicentre studies addressing causality (ie, training status/dose-response relationship) and evaluating preventative strategies to mitigate against the development of lower airway dysfunction remain an important priority for future research.

Asthma medication in athletes: a qualitative investigation of adherence, avoidance and misuse in competitive sport

OBJECTIVES

The purpose of this qualitative study was to utilize the Capability, Opportunity, Motivation - Behavior model (COM-B) to: (1) evaluate athlete knowledge and understanding of current asthma-related anti-doping regulations, (2) explore the impact of environmental and societal influences on athletes with asthma, and (3) examine athlete perception of asthma medication use in competitive sport.Methods: Semi-structured interviews were conducted with ten competitive endurance athletes (five athletes with asthma and five without asthma). Interviews were guided by the COM-B model and transcripts were analyzed inductively and deductively using reflexive thematic analysis.Results: Mapping the experiences and perceptions of athletes against an established behavioral framework identified that: (1) athletes' possess limited knowledge and understanding of the World Anti-Doping Agency (WADA) Prohibited List and Therapeutic use exemption (TUE) policy with respect to asthma medication; (2) the use of sub-optimal diagnostic methods is commonplace and increases the risk of misdiagnosis and unnecessary inhaler therapy; (3) negative media portrayal of high-profile asthma-related doping allegations impacts public opinion and contributes to the perception of wrongdoing within the sporting community.Conclusion: The novel application of behavioral science highlights several factors that may contribute to asthma medication avoidance and promote misuse in competitive sport. The findings from this study provide a foundation for the development and implementation of targeted education programmes, and it is hoped that employing this approach will ultimately improve overall perceptions of asthma treatment in athletes, which is necessary to maintain respiratory health, optimize performance and protect the integrity of sport.

© 2021 The Author(s). Published with license by Taylor & Francis Group, LLC.

Exercise-induced bronchoconstriction and bronchodilation: investigating the effects of age, sex, airflow limitation and FEV1

Exercise-induced bronchoconstriction (EIBc) is a recognised response to exercise in asthmatic subjects and athletes but is less well understood in an unselected broad population. Exercise-induced bronchodilation (EIBd) has received even less attention. The objective of this study was to investigate the effects of age, sex, forced expiratory volume in 1 s (FEV₁) and airflow limitation (FEV₁/forced vital capacity (FVC) <0.7) on the prevalence of EIBc and EIBd.This was a retrospective study based on incremental cardiopulmonary exercise testing on cycle ergometry to symptom limitation performed between 1988 and 2012. FEV₁ was measured before and 10 min after exercise. EIBc was defined as a percentage fall in FEV₁ post-exercise below the 5th percentile, while EIBd was defined as a percentage increase in FEV₁ above the 95th percentile.35 258 subjects aged 6-95 years were included in the study (mean age 53 years, 60% male) and 10.3% had airflow limitation (FEV₁/FVC <0.7). The lowest 5% of subjects demonstrated a ≥7.6% fall in FEV₁ post-exercise (EIBc), while the highest 5% demonstrated a >11% increase in FEV₁ post-exercise (EIBd). The probability of both EIBc and EIBd increased with age and was highest in females across all ages (OR 1.76, 95% CI 1.60-1.94; p<0.0001). The probability of EIBc increased as FEV₁ % pred declined (<40%: OR 4.38, 95% CI 3.04-6.31; p<0.0001), with a >2-fold increased likelihood in females (OR 2.31, 95% CI 1.71-3.11; p<0.0001), with a trend with airflow limitation (p=0.06). The probability of EIBd increased as FEV₁ % pred declined, in the presence of airflow limitation (OR 1.55, 95% CI 1.24-1.95; p=0.0001), but sex had no effect.EIBc and EIBd can be demonstrated at the population level, and are influenced by age, sex, FEV₁ % pred and airflow limitation.

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.

Is the healthy respiratory system built just right, overbuilt, or underbuilt to meet the demands imposed by exercise?

In the healthy, untrained young adult, a case is made for a respiratory system (airways, pulmonary vasculature, lung parenchyma, respiratory muscles, and neural ventilatory control system) that is near ideally designed to ensure a highly efficient, homeostatic response to exercise of varying intensities and durations. Our aim was then to consider circumstances in which the intra/extrathoracic airways, pulmonary vasculature, respiratory muscles, and/or blood-gas distribution are underbuilt or inadequately regulated relative to the demands imposed by the cardiovascular system. In these instances, the respiratory system presents a significant limitation to O₂ transport and contributes to the occurrence of locomotor muscle fatigue, inhibition of central locomotor output, and exercise performance. Most prominent in these examples of an "underbuilt" respiratory system are highly trained endurance athletes, with additional influences of sex, aging, hypoxic environments, and the highly inbred equine. We summarize by evaluating the relative influences of these respiratory system limitations on exercise performance and their impact on pathophysiology and provide recommendations for future investigation.

Anti-doping Policy, Therapeutic Use Exemption and Medication Use in Athletes with Asthma: A Narrative Review and Critical Appraisal of Current Regulations

Asthma is prevalent in athletes and when untreated can impact both respiratory health and sports performance. Pharmacological inhaler therapy currently forms the mainstay of treatment; however, for elite athletes competing under the constraints of the World Anti-Doping Code (Code), a number of established therapies are prohibited both in and/or out of competition and/or have a maximum permitted dose. The recent release of medical information detailing inhaler therapy in high-profile athletes has brought the legitimacy and utilisation of asthma medication in this setting into sharp focus. This narrative review critically appraises recent changes to anti-doping policy and the Code in the context of asthma management, evaluates the impact of asthma medication use on sports performance and employs a theory of behaviour to examine perceived determinants and barriers to athletes adhering to the anti-doping rules of sport when applied to asthma.

Diagnosis of Exercise-induced Bronchoconstriction in Swimmers: Context Matters

Swimmers have a high prevalence of exercise-induced bronchoconstriction (EIB), which may be associated with repeated exposure to chlorinated pool water. The eucapnic voluntary hyperpnea (EVH) test is used to diagnose EIB; however, it fails to replicate the environmental conditions experienced by swimmers. The relationship between the composition of the EVH inspired gas and the development of EIB from swim exercise remains unclear.

PURPOSE

This study aimed to compare the bronchoconstrictive effect of a chlorinated inspirate EVH test and swim test to a laboratory-based EVH test in swimmers.

METHODS

Fifteen collegiate swimmers (n = 5 male, n = 10 female; 21 ± 2 yr) completed 3 d of testing in pseudorandom order; a standard EVH test (EVHL), a pool air EVH test (EVHCl), and a swimming test (Swim). Spirometry was measured at baseline, and 3, 5, 10, 15, and 20 min after each test.

RESULTS

EVHL elicited a forced expired volume in 1 s (FEV1) fall index of -9.7% ± 6.4% compared with -6.6% ± 9.2% and -3.0% ± 7.5% after EVHCl and Swim, respectively (P < 0.05). Using Bland-Altman analysis, we found good agreement between EVHL and EVHCl (bias = -2.8, r = 0.79; P < 0.05) with poor agreement between EVHL and Swim (bias = -6.7, r = 0.20) and between EVHCl and Swim (bias = -3.9, r = 0.50; both P < 0.05). Forced expired flow between 25% and 75% lung volume and peak expired flow were significantly reduced by the EVHL compared with the EVHCl and Swim tests (P < 0.05).

CONCLUSIONS

EVHL elicits a greater forced expired volume in 1-s fall index compared with EVHCl and Swim. The unique aquatic environment of swimmers potentially protects against bronchoconstriction and should be considered in the determination of EIB.

Health effects of physical activity as predicted by particle deposition in the human respiratory tract

Although health benefits of physical activity are well known, the risk of physical activity in polluted air is unclear. Our objective is to investigate health effects resulting from physical activity in polluted air by looking at particle deposition in human tracheobronchial (TB) airways. Airflow and particle deposition in TB airways were investigated using a computational fluid dynamics (CFD) method. We chose three regional airways: upper (G3-G5), central (G9-G11) and lower (G14-G16). Physical activity was described by breathing rate at the mouth, for three levels of activity: sedentary (15 l/min), moderate (30 l/min) and intense (60 l/min). We found that particle deposition was strongly affected by physical activity. Particles are deposited in greater number in the lower airways (G14-G16) during sedentary activity, more in the upper airways (G3-G5) during intense activity, and uniformly in the airways during moderate activity. The difference in the deposition pattern was due to the reason that physical activity increased the airflow which increased inertial impaction. Our modeling of particle deposition in the human respiratory airways shows that there are different health effects for different activity levels: sedentary activity leads to chronic health effects, intense activity results in acute effects, and moderate activity minimizes the adverse health effects of physical activity in polluted air.

Exercise-Induced Dyspnea in Children and Adolescents: Differential Diagnosis

Exercise-induced dyspnea in children and adolescents can occur for many reasons. Although asthma is the common cause, failure to prevent exercise-induced asthma by pretreatment with a bronchodilator, such as albuterol, indicates that other etiologies should be considered. Other causes of exercise-induced dyspnea include exercise-induced vocal cord dysfunction, exercise-induced laryngomalacia, exercise-induced hyperventilation, chest wall restrictive abnormalities, cardiac causes, and normal physiologic limitation. When exercise-induced dyspnea is not from asthma, cardiopulmonary exercise testing with reproduction of the patient's dyspnea is the means to identify the other causes. Cardiopulmonary exercise testing monitors oxygen use, carbon-dioxide production, end-tidal pCO₂ (partial pressure of carbon dioxide), and electrocardiogram. Additional components to testing are measurement of blood pH and pCO₂ when symptoms are reproduced, and selective flexible laryngoscopy when upper airway obstruction is observed to specifically identify vocal cord dysfunction or laryngomalacia. This approach is a highly effective means to identify exercise-induced dyspnea that is not caused by asthma. [Pediatr Ann. 2019;48(3):e121-e127.].

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.

Mechanisms of exercise-induced bronchoconstriction in athletes: Current perspectives and future challenges

The evidence of exercise-induced bronchoconstriction (EIB) without asthma (EIBw_A ) occurring in athletes led to speculate about different endotypes inducing respiratory symptoms within athletes. Classical postulated mechanisms for bronchial obstruction in this population include the osmotic and the thermal hypotheses. More recently, the presence of epithelial injury and inflammation in the airways of athletes was demonstrated. In addition, neuronal activation has been suggested as a potential modulator of bronchoconstriction. Investigation of these emerging mechanisms is of major importance as EIB is a significant problem for both recreational and competitive athletes and is the most common chronic condition among Olympic athletes, with obvious implications for their competing performance, health and quality of life. Hereby, we summarize the latest achievements in this area and identify the current gaps of knowledge so that future research heads toward better defining the etiologic factors and mechanisms involved in development of EIB in elite athletes as well as essential aspects to ultimately propose preventive and therapeutic measures.

Phenotypic analysis of asthma in Japanese athletes

BACKGROUND

Asthma in athlete populations such as Olympic athletes has various pathogeneses. However, few reports are available on the features of asthma in the athlete population in clinical practice. In this study, we focused on classifying asthma in Japanese athlete population.

METHODS

We performed a cluster analysis of data from pulmonary function tests and clinical biomarkers before administering inhaled corticosteroids (ICS) therapy in athlete population of individuals diagnosed with asthma (n = 104; male, 76.9%; median age, 16.0 years), based on respiratory symptoms and positive data on methacholine provocation tests. We also compared backgrounds, sports types, and treatments between clusters.

RESULTS

Three clusters were identified. Cluster 1 (32%) comprised athletes with a less atopic phenotype and normal pulmonary function. Cluster 2 (44%) comprised athletes with a less atopic phenotype and lower percent predicted forced expiratory volume in 1 s (%FEV₁) values, despite less symptomatic state. Cluster 3 (24%) comprised athletes with a strong atopic phenotype such as high eosinophil count in the blood and total serum immunoglobulin E level. After treatment with ICS or ICS plus long-acting β-adrenergic receptor agonist for 6-12 months, %FEV₁ values were significantly improved in Cluster 2 athletes, whereas Cluster 3 athletes had a significant decrease in the fraction of exhaled nitric oxide compared to pretreatment values.

CONCLUSIONS

These data suggest three clusters exist in Japanese athlete population with asthma. Between the clusters, the characteristics differed with regard to symptoms, atopic features, and lower %FEV₁ values. The pathogeneses between clusters may vary depending on the inflammation type and airway hyperresponsiveness.

The training type influence on male elite athletes' ventilatory function

Background/aim

To assess and compare measured ventilatory volumes (forced expiratory volume in 1 s (FEV₁), peak expirium flow (PEF) and maximal voluntary ventilation (MVV)), ventilatory function capacities (forced vital capacity (FVC) and vital capacity (VC)) and FEV₁/VC ratio in a sample of power and endurance elite athletes and their age-matched and sex-matched sedentary control group.

Methods

A cross-sectional study was applied on male elite athletes (n=470) who were classified according to the type of the predominantly performed exercise in the following way: group 1: endurance group (EG=270), group 2: power athletes group (SG=200) and group 3: sedentary control group (CG=100). The lung VC, FVC, FEV₁, FEV₁/FVC ratio, PEF and MVV were measured in all of the observed subjects, who were also classified with regard to body mass index (BMI) and the percentage of the body fat (BF%).

Results

The CG had the highest BF% value, while the endurance group had the lowest BMI and BF% value, which is significantly different from the other two groups (p<0.05). The observed values of VC, FVC and FEV₁ in the EG were significantly higher than those from the other two groups (p<0.05). There were no differences concerning the observed FEV₁/FVC ratio.

Conclusions

A continued endurance physical activity leads to adaptive changes in spirometric parameters (VC, FVC and FEV₁), highlighting the fact that there is a need for specific consideration of different respiratory ‘pattern’ development in different types of sport, which also has to be further evaluated.

Eucapnic Voluntary Hyperpnea: Gold Standard for Diagnosing Exercise-Induced Bronchoconstriction in Athletes?

In athletes, a secure diagnos is of exercise-induced bronchoconstriction (EIB) is dependent on objective testing. Evaluating spirometric indices of airflow before and following an exercise bout is intuitively the optimal means for the diagnosis; however, this approach is recognized as having several key limitations. Accordingly, alternative indirect bronchoprovocation tests have been recommended as surrogate means for obtaining a diagnosis of EIB. Of these tests, it is often argued that the eucapnic voluntary hyperpnea (EVH) challenge represents the ‘gold standard’. This article provides a state-of-the-art review of EVH, including an overview of the test methodology and its interpretation. We also address the performance of EVH against the other functional and clinical approaches commonly adopted for the diagnosis of EIB. The published evidence supports a key role for EVH in the diagnostic algorithm for EIB testing in athletes. However, its wide sensitivity and specificity and poor repeatability preclude EVH from being termed a ‘gold standard’ test for EIB.

Hyperoside attenuates OVA-induced allergic airway inflammation by activating Nrf2

Allergic airways disease (AAD) is one of the most common medical illnesses that is associated with an increased allergic airway inflammation. Hyperoside, an active compound isolated from Rhododendron brachycarpum G. Don, has been reported to have anti-inflammatory effect. The aim of this study was to analyze the protective effect of hyperoside on OVA-induced allergic airway inflammation in mice. In the present study, the mouse asthma model was induced by given OVA and hyperoside was administrated 1h before OVA challenge. The levels of IL-4, IL-5, IL-13, and IgE were detected by ELISA. H&E staining was used to assess lung histopathological changes. The expression of NF-κB p65, IκB, HO-1, and Nf-E2 related factor 2 (Nrf2) were measured by western blot analysis. The results showed that hyperoside significantly reduced the inflammatory cells infiltration and the levels of IL-4, IL-5, IL-13, and IgE. Hyperoside significantly inhibited OVA-induced oxidative stress as demonstrated by decreased MDA, and increased GSH and SOD levels. Treatment of hyperoside also inhibited OVA-induced airway hyperresponsiveness (AHR). Furthermore, the results showed that treatment of hyperoside significantly inhibited LPS-induced NF-κB activation. In addition, hyperoside was found to activate Nrf2/HO-1 signaling pathway. In conclusion, these results suggest that hyperoside ameliorates OVA-induced allergic airway inflammation by activating Nrf2 signaling pathway.

Exercise-induced bronchoconstriction in athletes - A qualitative assessment of symptom perception

BACKGROUND

A poor relationship between perceived respiratory symptoms and objective evidence of exercise-induced bronchoconstriction (EIB) in athletes is often reported; however, the reasons for this disconnect remain unclear. The primary aim of this study was to utilise a qualitative-analytical approach to compare respiratory symptoms in athletes with and without objectively confirmed EIB.

METHODS

Endurance athletes who had previously undergone bronchoprovocation test screening for EIB were divided into sub-groups, based on the presence or absence of EIB ± heightened self-report of dyspnoea: (i) EIB-Dys- (ii) EIB + Dys+ (iii) EIB + Dys- (iv) EIB-Dys+. All athletes underwent a detailed semi-structured interview.

RESULTS

Twenty athletes completed the study with an equal distribution in each sub-group (n = 5). Thematic analysis of individual narratives resulted in four over-arching themes: 1) Factors aggravating dyspnoea, 2) Exercise limitation, 3) Strategies to control dyspnoea, 4) Diagnostic accuracy. The anatomical location of symptoms varied between EIB + Dys + athletes and EIB-Dys + athletes. All EIB-Dys + reported significantly longer recovery times following high-intensity exercise in comparison to all other sub-groups. Finally, EIB + Dys + reported symptom improvement following beta-2 agonist therapy, whereas EIB-Dys + deemed treatment ineffective.

CONCLUSION

A detailed qualitative approach to the assessment of breathlessness reveals few features that distinguish between EIB and non-EIB causes of exertional dyspnoea in athletes. Important differences that may provide value in clinical work-up include (i) location of symptoms, (ii) recovery time following exercise and (iii) response to beta-2 agonist therapy. Overall these findings may inform clinical evaluation and development of future questionnaires to aid clinic-based assessment of athletes with dyspnoea.

Environmental influence on the prevalence and pattern of airway dysfunction in elite athletes

BACKGROUND AND OBJECTIVE

Elite swimming and boxing require athletes to achieve relatively high minute ventilation. The combination of a sustained high ventilation and provocative training environment may impact the susceptibility of athletes to exercise-induced bronchoconstriction (EIB). The purpose of this study was to evaluate the prevalence of EIB in elite Great British (GB) boxers and swimmers.

METHODS

Boxers (n = 38, mean age: 22.1 ± 3.1 years) and swimmers (n = 44, mean age: 21.1 ± 2.6 years) volunteered for the study. Athletes completed an exercise-induced respiratory symptom questionnaire, baseline assessment of fraction of exhaled nitric oxide (FeNO), maximal spirometry manoeuvres and a eucapnic voluntary hyperpnoea (EVH) challenge. EIB was confirmed if forced expiratory volume in 1 s (FEV₁ ) reduced by ≥10% from baseline at two time points post-EVH challenge.

RESULTS

The prevalence of EIB was greater in elite swimmers (30 of 44; 68%) than in boxers (3 of 38; 8%) (P < 0.001). Twenty-two out of the 33 (67%) EVH-positive athletes had no prior diagnosis of asthma/EIB. Moreover, 12% (6 of 49) of the EVH-negative athletes had a previous diagnosis of asthma/EIB. We found a correlation between FeNO and FEV₁ change in lung function post-EVH challenge in swimmers (r = 0.32; P = 0.04) but not in boxers (r = 0.24; P = 0.15).

CONCLUSION

The prevalence of EIB was ninefold greater in swimmers when compared with boxers. Athletes who train and compete in provocative environments at sustained high ventilation may have an increased susceptibility to EIB. It is not entirely clear whether increased susceptibility to EIB affects elite sporting performance and long-term airway health in elite athletes.

Endurance training: is it bad for you?

Educational aims

Endurance exercise training exerts many positive effects on health, including improved metabol­ism, reduction of cardiovascular risk, and reduced all-cause and cardiovascular mortality. Intense endurance exercise causes mild epithelial injury and inflammation in the airways, but does not appear to exert detrimental effects on respiratory health or bronchial reactivity in recreational/non-elite athletes. Conversely, elite athletes of both summer and winter sports show increased susceptibility to development of asthma, possibly related to environmental exposures to allergens or poor conditioning of inspired air, so that a distinct phenotype of “sports asthma” has been proposed to characterise such athletes, who more often practise aquatic and winter sports. Overall, endurance training is good for health but may become deleterious when performed at high intensity or volume.

Endurance training is good for health but may become deleterious when performed at high intensity or volumehttp://ow.ly/4n9jR4

The World Anti-Doping Code: can you have asthma and still be an elite athlete?

KEY POINTS

The World Anti-Doping Code (the Code) does place some restrictions on prescribing inhaled β2-agonists, but these can be overcome without jeopardising the treatment of elite athletes with asthma.While the Code permits the use of inhaled glucocorticoids without restriction, oral and intravenous glucocorticoids are prohibited, although a mechanism exists that allows them to be administered for acute severe asthma.Although asthmatic athletes achieved outstanding sporting success during the 1950s and 1960s before any anti-doping rules existed, since introduction of the Code's policies on some drugs to manage asthma results at the Olympic Games have revealed that athletes with confirmed asthma/airway hyperresponsiveness (AHR) have outperformed their non-asthmatic rivals.It appears that years of intensive endurance training can provoke airway injury, AHR and asthma in athletes without any past history of asthma. Although further research is needed, it appears that these consequences of airway injury may abate in some athletes after they have ceased intensive training. The World Anti-Doping Code (the Code) has not prevented asthmatic individuals from becoming elite athletes. This review examines those sections of the Code that are relevant to respiratory physicians who manage elite and sub-elite athletes with asthma. The restrictions that the Code places or may place on the prescription of drugs to prevent and treat asthma in athletes are discussed. In addition, the means by which respiratory physicians are able to treat their elite asthmatic athlete patients with drugs that are prohibited in sport are outlined, along with some of the pitfalls in such management and how best to prevent or minimise them.

Safety evaluation of MP29-02 (a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate) for allergic rhinitis

INTRODUCTION

As a chronic disease, allergic rhinitis (AR) requires regular use of allergy medications for the effective management of symptoms. It is therefore imperative that AR treatments not only provide adequate symptom control but are also well tolerated.

AREAS COVERED

MP29-02 (Dymista, Meda, Solna, Sweden) is the first new class of AR medication (WHO ATC R01AD58) since the introduction of intranasal corticosteroids (INS) almost 50 years ago. It is a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate delivered in a single spray. Here we review all the safety information relevant to MP29-02, from the initial phase I bioavailability and disposition data, to the phase III 14-day and 52-week data and finally to phase IV safety data collected during MP29-02 use in routine clinical practice.

EXPERT OPINION

MP29-02 is the first real therapeutic advance in AR since the introduction of INS and has the potential to change the way this disease is managed, simplifying AR treatment regimens to a single puff in each nostril twice a day. Patients will benefit from superior symptom relief MP29-02 compared to INS with the added assurance that the safety of MP29-02 has been confirmed in the short term and long term as well as in real life.

Exercise and asthma: an overview

The terms 'exercise-induced asthma' (EIA) and 'exercise-induced bronchoconstriction' (EIB) are often used interchangeably to describe symptoms of asthma such as cough, wheeze, or dyspnoea provoked by vigorous physical activity. In this review, we refer to EIB as the bronchoconstrictive response and to EIA when bronchoconstriction is associated with asthma symptoms. EIB is a common occurrence for most of the asthmatic patients, but it also affects more than 10% of otherwise healthy individuals as shown by epidemiological studies. EIA and EIB have a high prevalence also in elite athletes, especially within endurance type of sports, and an athlete's asthma phenotype has been described. However, the occurrence in elite athletes shows that EIA/EIB, if correctly managed, may not impair physical activity and top sports performance. The pathogenic mechanisms of EIA/EIB classically involve both osmolar and vascular changes in the airways in addition to cooling of the airways with parasympathetic stimulation. Airways inflammation plays a fundamental role in EIA/EIB. Diagnosis and pharmacological management must be carefully performed, with particular consideration of current anti-doping regulations, when caring for athletes. Based on the demonstration that the inhaled asthma drugs do not improve performance in healthy athletes, the doping regulations are presently much less strict than previously. Some sports are at a higher asthma risk than others, probably due to a high environmental exposure while performing the sport, with swimming and chlorine exposure during swimming as one example. It is considered very important for the asthmatic child and adolescent to master EIA/EIB to be able to participate in physical activity on an equal level with their peers, and a precise early diagnosis with optimal treatment follow-up is vital in this aspect. In addition, surprising recent preliminary evidences offer new perspectives for moderate exercise as a potential therapeutic tool for asthmatics.

Exercise and asthma: an overview

The terms 'exercise-induced asthma' (EIA) and 'exercise-induced bronchoconstriction' (EIB) are often used interchangeably to describe symptoms of asthma such as cough, wheeze, or dyspnoea provoked by vigorous physical activity. In this review, we refer to EIB as the bronchoconstrictive response and to EIA when bronchoconstriction is associated with asthma symptoms. EIB is a common occurrence for most of the asthmatic patients, but it also affects more than 10% of otherwise healthy individuals as shown by epidemiological studies. EIA and EIB have a high prevalence also in elite athletes, especially within endurance type of sports, and an athlete's asthma phenotype has been described. However, the occurrence in elite athletes shows that EIA/EIB, if correctly managed, may not impair physical activity and top sports performance. The pathogenic mechanisms of EIA/EIB classically involve both osmolar and vascular changes in the airways in addition to cooling of the airways with parasympathetic stimulation. Airways inflammation plays a fundamental role in EIA/EIB. Diagnosis and pharmacological management must be carefully performed, with particular consideration of current anti-doping regulations, when caring for athletes. Based on the demonstration that the inhaled asthma drugs do not improve performance in healthy athletes, the doping regulations are presently much less strict than previously. Some sports are at a higher asthma risk than others, probably due to a high environmental exposure while performing the sport, with swimming and chlorine exposure during swimming as one example. It is considered very important for the asthmatic child and adolescent to master EIA/EIB to be able to participate in physical activity on an equal level with their peers, and a precise early diagnosis with optimal treatment follow-up is vital in this aspect. In addition, surprising recent preliminary evidences offer new perspectives for moderate exercise as a potential therapeutic tool for asthmatics.

Two distinct phenotypes of asthma in elite athletes identified by latent class analysis

INTRODUCTION

Clusters of asthma in athletes have been insufficiently studied. Therefore, the present study aimed to characterize asthma phenotypes in elite athletes using latent class analysis (LCA) and to evaluate its association with the type of sport practiced.

METHODS

In the present cross-sectional study, an analysis of athletes' records was carried out in databases of the Portuguese National Anti-Doping Committee and the Norwegian School of Sport Sciences. Athletes with asthma, diagnosed according to criteria given by the International Olympic Committee, were included for LCA. Sports practiced were categorized into water, winter and other sports.

RESULTS

Of 324 files screened, 150 files belonged to asthmatic athletes (91 Portuguese; 59 Norwegian). LCA retrieved two clusters: "atopic asthma" defined by allergic sensitization, rhinitis and allergic co-morbidities and increased exhaled nitric oxide levels; and "sports asthma", defined by exercise-induced respiratory symptoms and airway hyperesponsiveness without allergic features. The risk of developing the phenotype "sports asthma" was significantly increased in athletes practicing water (OR = 2.87; 95% CI [1.82-4.51]) and winter (OR = 8.65; 95% CI [2.67-28.03]) sports, when compared with other athletes.

CONCLUSION

Two asthma phenotypes were identified in elite athletes: "atopic asthma" and "sports asthma". The type of sport practiced was associated with different phenotypes: water and winter sport athletes had three- and ninefold increased risk of "sports asthma". Recognizing different phenotypes is clinically relevant as it would lead to distinct targeted treatments.

The role of impulse oscillometry in detecting airway dysfunction in athletes

BACKGROUND

Impulse oscillometry (IOS) has previously been proposed to provide greater sensitivity than spirometry when employed with indirect bronchoprovocation testing for the diagnosis of airway dysfunction in athletes. However, this recommendation is based on a highly selected population of symptomatic patients.

OBJECTIVE

To compare IOS, spirometry and respiratory symptoms following indirect bronchoprovocation in a screened cohort of athletes.

METHODS

One hundred and one recreational athletes were recruited. Respiratory symptoms were assessed via the Dyspnoea-12 questionnaire. Spirometry and IOS were performed pre and post a eucapnic voluntary hyperpnoea (EVH) challenge.

RESULTS

Ninety-four athletes completed the study. Sixteen athletes (17%) were positive for airway dysfunction based on spirometry (i.e. ≥ 10% fall in FEV1) and 17 athletes (18%) based on IOS (i.e. ≥ 50% increase in R5). Only nine athletes (10%) met both diagnostic thresholds. A poor relationship was observed between respiratory symptoms (i.e. Dyspnoea-12 score) and all spirometry and IOS variables. A direct relationship was observed between percentage change in R5 (r = 0.65), Z5 (r = 0.68), RF (r = 0.65), AX (r = 0.69) and the maximum fall in FEV1 (ΔFEV1max; p < 0.001). A weak relationship was observed between R20 (r = 0.27), X5 (r = 0.37) and ΔFEV1max (p < 0.01).

CONCLUSION

Impulse oscillometry and spirometry do not concur precisely following indirect bronchoprovocation. However, IOS detects additional cases of airway dysfunction in athletes and therefore may provide diagnostic value in this population. Further work is required to establish diagnostic thresholds and fully determine the place of IOS in screening athletes for airway dysfunction.

Escaping the trap of allergic rhinitis

Rhinitis is often the first symptom of allergy but is frequently ignored and classified as a nuisance condition. Ironically it has the greatest socioeconomic burden worldwide caused by its impact on work and on daily life.

However, patients appear reticent to seek professional advice, visiting their doctor only when symptoms become ‘intolerable’ and often when their usual therapy proves ineffective.

Clearly, it’s time for new and more effective allergic rhinitis treatments.

MP29-02 (Dymista®; Meda, Solna, Sweden) is a new class of medication for moderate to severe seasonal and perennial allergic rhinitis if monotherapy with either intranasal antihistamine or intranasal corticosteroids is not considered sufficient.

MP29-02 is a novel formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP). It benefits not only from the incorporation of two active agents, but also from a novel formulation; its lower viscosity, smaller droplet size, larger volume (137 μl) and wider spray angle ensure optimal coverage of, and retention on the nasal mucosa and contribute to its clinical efficacy.

In clinical trials, patients treated with MP29-02 experienced twice the symptom relief as those treated with FP and AZE, who in turn exhibited significantly greater symptom relief than placebo-patients. Indeed, the advantage of MP29-02 over FP was approximately the same as that shown for FP over placebo. The advantage of MP29-02 was particularly evident in those patients for whom nasal congestion is predominant, with MP29-02 providing three times the nasal congestion relief of FP (p = 0.0018) and five times the relief of AZE (p = 0.0001). Moreover, patients treated with MP29-02 achieved each and every response up to a week faster than those treated with FP or AZE alone and in real life 1 in 2 patients reported the perception of well-controlled disease after only 3 days. MP29-02’s superiority over FP was also apparent long-term in patients with perennial allergic rhinitis or non-allergic rhinitis, with statistical significance noted from the first day of treatment, with treatment difference maintained for a full year.

Taken together, these data suggest that MP29-02 may improve the lives of many of our patients, enabling them to finally escape the allergic rhinitis trap.

The impact of exercise-induced bronchoconstriction on athletic performance: a systematic review

BACKGROUND

Exercise-induced bronchoconstriction (EIB) describes the phenomenon of transient airway narrowing in association with physical activity. Although it may seem likely that EIB would have a detrimental impact on athletic performance, this has yet to be established.

OBJECTIVES

The aim of this review is to provide a systematic appraisal of the current status of knowledge regarding EIB and exercise performance and to highlight potential mechanisms by which performance may be compromised by EIB.

DATA SOURCES AND STUDY SELECTION

PubMed/Medline and EBSCO databases were searched up to May 2014 using the search parameter: [('exercise' OR 'athlete') AND ('asthma' OR 'bronchoconstriction' OR 'hypersensitivity') AND 'performance']. This search string returned 243 citations. After systematically reviewing all of the abstracts, 101 duplicate papers were removed, with 132 papers excluded for not including an exercise performance outcome measure.

RESULTS

The remaining ten studies that met the initial criteria were included in this review; six evaluated the performance of physically active individuals with asthma and/or EIB while four assessed the effects of medication on performance in a comparable population.

CONCLUSION

The evidence concludes that whilst it is reasonable to suspect that EIB does impact athletic performance, there is currently insufficient evidence to provide a definitive answer.

Exercise-induced bronchoconstriction: new evidence in pathogenesis, diagnosis and treatment

The acute airway narrowing that occurs as a result of exercise is defined exercise-induced bronchoconstriction (EIB). Most recent guidelines recommend distinguishing EIB with underlying clinical asthma (EIB_A) from the occurrence of bronchial obstruction in subjects without other symptoms and signs of asthma (EIBw_A). EIB has been in fact reported in up to 90 % of asthmatic patients, reflecting the level of disease control, but it may develop even in subjects without clinical asthma, particularly in children, athletes, patients with atopy or rhinitis and following respiratory infections. Both EIB_A and EIBw_A have peculiar pathogenic mechanisms, diagnostic criteria and responses to treatment and prevention. The use of biomarkers, proteomic approaches and innovative technological procedures will hopefully contribute to better define peculiar phenotypes and to clarify the role of EIB as risk factor for the development of asthma, as well as an occupational disease.

Vitamin D and omega-3 polyunsaturated fatty acid supplementation in athletes with exercise-induced bronchoconstriction: a pilot study

OBJECTIVE

The aim of this pilot study was to determine the combined effect of vitamin D and omega-3 polyunsaturated fatty acid (PUFA) supplementation on airway function and inflammation in recreational athletes with exercise-induced bronchoconstriction (EIB).

METHODS

Ten recreational athletes with EIB participated in a single-blind, placebo-controlled trial over six consecutive weeks. All subjects attended the laboratory on three occasions. Each visit was separated by a period of 3 weeks: visit 1 (usual diet), visit 2 (placebo) and visit 3 (SMARTFISH® NutriFriend 2000; 30 µg vitamin D3-3000 mg eicosapentaenoic acid, 3000 mg docosahexaenoic acid) consumed once daily for a period of 3 weeks. Venous blood was collected at the beginning of each trial to determine vitamin D status. Spirometry was performed pre- and post-eucapnic voluntary hyperpnoea (EVH).

RESULTS

The Maximum fall in FEV1 (ΔFEV1max) post-EVH was not different between visits (usual diet: -15.9 ± 3.6%, placebo: -16.1 ± 6.1%, vitamin D + omega-3 PUFA: -17.8 ± 7.2%). Serum vitamin D remained unchanged between visits.

CONCLUSION

Vitamin D and omega-3 PUFA supplementation does not attenuate the reduction in lung function post-EVH. This finding should be viewed as preliminary until the results of randomised controlled trials are made available.