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Exercise induced asthma (EIA) is a concern for children and adolescents with asthma during growth and development. According to most International and National guidelines on treating asthma, one of the main objectives in children is to master EIA. Among elite athletes EIA and bronchial hyperresponsiveness (BHR) have become major problems, interfering with the performance of sports and representing a health risk. Athletes have, in the same manner as ordinary patients, the need of optimal diagnosis and treatment of their asthma. This was fully shown by Becker et al who reported deaths linked to athletic performance over a seven year period in the USA (1). Out of 263 deaths, 61 were related to asthma. Only one of the 61 athletes who died had used inhaled steroids (1). This underlines the need for optimal asthma treatment and follow-up among competitive athletes. Due to the reports of the frequent use of inhaled 2-agonists and the reasons for athletes to use these drugs, the Medical Commission of the International Olympic Committee (IOC-MC) in 1993 introduced restrictions in their use in relationship to sport. These rules have been altered several times with the introduction of the requirement to make applications to obtain approval for the use of the drugs when competing as an international athlete. Pulmonologists and allergologists considered these rules to be very restrictive, and a joint Task Force was established by the European Respiratory Society and the European Academy of Allergy and Clinical Immunology. This task force recently gave its reports in three publications (2-4). The present article focuses on the problems raised by this report as well as outlining a Pan-European study initiated to focus on asthma and bronchial hyperrepsonsiveness in top athletes. Also other allergic diseases represent a problem in elite sports. Especially exercise induced anaphylaxis is a major problem for those affected, but also allergic rhinoconjunctivitis and uritcaria of both physical and allergic types represent major problems for those affected.
Feinstein et al found EIB in nine of 48 male football players (16), whereas BHR to methacholine (PD20-methacholine < 16.3 mol) was found in 35.5% of the Norwegian national female soccer team (17). Of Canadian professional football players 56% had a positive bronchodilator test (increase in FEV1 >e; 12%) to inhaled salbutamol (18). Helenius and Haahtela reported on several studies of Finnish elite track and field athletes, showing physician diagnosed asthma in 17% of long-distance runners, 8 % of speed and power athletes and 3 % of controls (19). In another study total asthma (current asthma, physician diagnosed asthma or BHR) was found in 23% of the athletes compared to 4% of the controls, current asthma in 14% compared to 2% among controls and positive skin prick test (SPT) in 48% of the athletes compared to 36% among controls (20). High prevalence of BHR (48%) to histamine was also found among swimmers (21). Maiolo et al reported an asthma prevalence of 15% and atopy in 18% of 1060 Italian competing summer athletes (22). Higher prevalence of asthma among endurance athletes as compared to speed and power athletes was reported in a Norwegian study (23). Employing the objective criteriae for diagnosing asthma and/or bronchial hyperresponsiveness as given by the IOC Medical Comission, Dickinson reported prevalence among the British participants in the Olympic Games in 2000 and 2004 to be 21.2% and 20.7%, respectively, with a positive bronchoprovocation or bronchodilator test (24).
experimentally in exercising as compared to sedentary mice (32). Inflammatory changes have been reported in induced sputum of competitive swimmers (21). Thus, heavy and repeated physical endurance training over prolonged periods of time in combination with non-optimal environmental conditions may contribute to the development of asthma and BHR among top athletes. 3. The environment An unfavourable environment in which repeated competitions and training sessions take place is thought to contribute to the development of asthma and BHR among top athletes, as in cross country skiers exposed to cold air (8;33), competitive swimmers exposed to organic chlorine products from the water in indoor pools (21) and figure skaters and ice hockey players in ice rinks with increased levels of ultrafine particles originating from the ice freeze machines (34-36). Larsson showed that cold air inhalation increased the number of inflammatory cells in bronchoalveolar lavage (37). In children Bernard and co-workers reported that time spent in swimming pools during early childhood are related to development of asthma and signs of lung involvement by increased serum levels of surfactant proteins (38) and reduced levels of Clara cell protein (39). It has also been shown that respiratory tract infections increase bronchial responsiveness in actively training athletes (40). Thus, the combination of heavy repeated exercise with an unfavourable environmental milieu is probably important for the development of asthma among top athletes.
Clinical history of respiratory symptoms and clinical Positive clinical history examination Lung function (Spirometry or maximum expiratory Increase in FEV1 after inhaled flow volume loops). bronchodilator Reversibility to inhaled bronchodilator Exercise induced bronchoconstriction by standardised FEV1 decrease of 10% from before to after exercise test standardized exercise challenge Bronchial hyperresponsiveness to metacholine PD20 < 2 mol, PC20 < 4 mg/ml. (histamine presently not allowed by IOC-MC)) Other values when on inhaled steroids. Eucapnic hyper ventilation test or Mannitol inhalation test (Airidol test) Exercise field test Reduction in FEV1 of 15% or more. Reduction in FEV1 of 15% or more. Determination of PD15 of mannitol Reduction in FEV1 of 10% or more
EIA may be diagnosed in different ways; running provokes exercise-induced bronchoconstriction more easily than cycling. A heavy exercise load is recommended. At the University of Oslo a motor driven treadmill with an inclination of 5.5% is employed, rapidly increasing speed until a steady heart rate of approximately 95% of calculated maximum is reached and maintained for 46 minutes. The widespread use of inhaled steroids necessitates this level of exercise (43). Maximum heart rate is calculated approximately by taking 220 minus the age of the patient, and can be measured electronically. The running is performed at a room temperature of approximately 20 C and a relative humidity of approximately 40 %. Lung function is measured by FEV1 before running, immediately after stopping, then 3, 6, 10, 15 and 20 minutes after running. A fall of 10 % in FEV1 is taken as a sign of EIA. When adding an extra stimulus to the exercise test, as by combining running on a treadmill with the inhalation of dry cold air of -20C, the sensitivity of the test is markedly increased while simultaneously maintaining a high degree of specificity (44). Other tests used for the diagnosis of exercise induced bronchoconstriction and BHR are eucapnic hyperventilation (45) and mannitol bronchial provocation, determining the inhaled dose causing a 15% decrease in FEV1 (46).
Differential diagnoses
There are several differential diagnoses to EIA, including exercise induced laryngeal inspiratory stridor (also called exercise induced vocal cord dysfunction) (47;48) and hyperventilation during exercise. These conditions should be borne in mind, as many such patients have been given unnecessary drugs for treatment of asthma, including both inhaled steroids and 2-agonists, which will have no effect upon the exercise induced laryngeal stridor. Exercise induced laryngeal stridor is more common among top trained female athletes during adolescence. Marked inspiratory stridor during maximal exercise with a flattening of the maximal inspiratory flow volume curve (49), is typical, in contrast to EIA, when the dyspnoea occurs after exercise, and is expiratory due to the lower airways obstruction. Other differential diagnoses to EIB include exercise induced arterial hypoxemia (50-52) and swimming induced pulmonary edema (53) (Table 2).
Table 2. Differential diagnoses to EIA in athletes. Diagnosis EIA Presentation Symptoms occurring shortly after (sometimes during) physical exercise. If observed: Expiratory dyspnoea, expiratory rhonchi and other signs of bronchial obstruction. Gradual improvement either spontaneously or after inhaled bronchodilator Exercise induced vocal Symptoms occurring during maximum exertion. Symptoms disappear cord dysfunction after stopping exercise (unless hyperventilating) (VCD) If observed: Inspiratory stridor, audible inspiratory sounds from laryngeal area. No signs of bronchial obstruction. No effect of pretreatment with inhaled bronchodilator Poor physical fitness Related to expectations High heart rate after low grade exercise load Other chronic lung Reduced baseline lung function may reduce physical performance due to diseases limitations in air flow and lung volumes Other general disease Chronic heart diseases and others Exercise induced Occurs in well trained athletes with high max. VO2 arterial hypoxemia Primarily due to diffusion limitations and ventilation-perfusion (EIAH) inequality. Incomplete diffusion in the healthy lung may be due to a rapid red blood cell transit time through the pulmonary capillary Swimming induced Often hemoptysis after heavy swimming exercise, reduced diffusion pulmonary edema capacity (SIPE)
Allergy and Clinical Immunology (EAACI). This task force published a European Respiratory Monograph (4) viewing the topic from different angles and published a report reviewing the problem of asthma and allergy among athletes, explaining pathogenetic mechanisms and giving recommendations with regard to the diagnosis of asthma and BHR among athletes, as well as to recommended treatment (2;3). After appropriate diagnosis, the treatment of the athlete with asthma or other respiratory problems should follow the common guidelines, taking into consideration the rules set up by the doping authorities (WADA and for the Olympic Games; IOC-MC). As the regulations for the use of asthma drugs among athletes have been repeatedly changed, the physician treating asthmatic athletes and children and adolescents with asthma should keep updated on the present regulations. This may be done by going to the Web site of the World Antidoping Association (WADA) (http://www.wada-ama.org/en/t1.asp) for international sports, or to the Web site of the IOC for the Olympic Games: (http://www.olympic.org/uk/utilities/reports/level2_uk.asp?HEAD2=1&HEAD1=1). Applications for the use of asthma drugs for the Olympic Games may be submitted by filling in an electronic form on the IOC website; for other international sports by filling in the written forms for a Therapeutic Use Exemption (TUE) for submission to WADA and/or the relevant international sporting association. Beijing and further on Much concern was raised before the Summer Olympic Games in Beijing August 2008 with respect to possible harmful effects of the environmental air pollution in Beijing. The Norwegian Olympic Committee was much concerned about this problem and asked the author of the present article (Kai-Hkon Carlsen) to examine all Norwegian athletes qualifying for the Beijing Olympics for respiratory problems, to initiate treatment when needed following the regulations given by IOC-MC, and to follow the athletes up to and through the Beijing Olympics. This led to a study related to asthma and bronchial responsiveness among all athletes of different types of sports and then further to a pan-European study initiated through GA2LEN, the European Network of Centres of Excellence with participation of nine European countries. The main aim was to investigate the prevalence of asthma, bronchial responsiveness and allergy in the different types of summer sports. The results are not yet available, but it should be emphasized that during the Beijing Summer Olympic Games, 813 applications were made for the use of inhaled 2agonists, and 781 of these were approved. Of the 781 athletes with approval for the use of inhaled 2-agonists, 711 also used inhaled steroids. Inhaled steroids alone were used by 121 additional athletes (From Report of the Independent observers, XXIX Beijing Olympic Games; http://www.wadaama.org/rtecontent/document/WADA_IO_Report_Beijing_2008_FINAL_FINAL.pdf
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