Exercise and asthma: an overview

Thoracoabdominal Asynchrony Contributes to Exercise Limitation in Mild Asthmatic Subjects

This study aimed to better understand how subjects with stable asthma and without exercise-induced bronchoconstriction respond to mild exercise. Breathing pattern, chest wall compartmental and operational volumes, and thoracoabdominal asynchrony were assessed in 11 stable asthmatic subjects and 10 healthy subjects at rest and during exercise in a cycle-ergometer through optoelectronic plethysmography. Dyspnea and sensation of leg effort were assessed through Borg scale. During exercise, with similar minute ventilation, a significant lower chest wall tidal volume (p = 0.003) as well as a higher respiratory rate (p < 0.05) and rapid shallow breathing (p < 0.05) were observed in asthmatic when compared to healthy subjects. Asthmatic subjects exhibited a significantly lower inspiratory (p < 0.05) and expiratory times (p < 0.05). Intergroup analysis found a significant higher end-expiratory chest wall volume in asthmatic subjects, mainly due to a significant increase in volume of the pulmonary ribcage (RCp; 170 ml, p = 0.002), indicating dynamic hyperinflation (DH). Dyspnea and sensation of leg effort were both significantly greater (p < 0.0001) in asthmatic when compared to healthy subjects. In addition to a higher thoracoabdominal asynchrony found between RCp and abdominal (AB) (p < 0.005) compartments in asthmatic subjects, post-inspiratory action of the inspiratory ribcage and diaphragm muscles were observed through the higher expiratory paradox time of both RCp (p < 0.0001) and AB (p = 0.0002), respectively. Our data suggest that a different breathing pattern is adopted by asthmatic subjects without exercise-induced bronchoconstriction during mild exercise and that this feature, associated with DH and thoracoabdominal asynchrony, contributes significantly to exercise limitation.

Aronia-citrus juice (polyphenol-rich juice) intake and elite triathlon training: a lipidomic approach using representative oxylipins in urine

In the present study, we examined whether particular urinary oxylipins (isoprostanes (IsoPs), leukotrienes (LTs), prostaglandins (PGs), and thromboxanes (TXs)) in 16 elite triathletes could alter during 145 days of training. Within this time span, 45 days were dedicated to examining the effects of the intake of a beverage rich in polyphenols (one serving: 200 mL per day) supplemented in their diet. The beverage was a mixture of citrus juice (95%) and Aronia melanocarpa juice (5%) (ACJ). Fifty-two oxylipins were analyzed in the urine. The quantification was carried out using solid-phase extraction, liquid chromatography coupled with triple quadrupole mass spectrometry. The physical activity decreased the excretion of some PG, IsoP, TX, and LT metabolites from arachidonic acid, γ-dihomo-linolenic acid, and eicosapentaenoic acid. The ACJ also reduced the excretion of 2,3-dinor-11β-PGF_2α and 11-dehydro-TXB₂, although the levels of other metabolites increased after juice supplementation (PGE₂, 15-keto-15-F_2t-IsoP, 20-OH-PGE₂, LTE₄, and 15-epi-15-E_2t-IsoP), compared to the placebo. The metabolites that increased in abundance have been related to vascular homeostasis and smooth muscle function, suggesting a positive effect on the cardiovascular system. In conclusion, exercise influences mainly the decrease in oxidative stress and the inflammation status in elite triathletes, while ACJ supplementation has a potential benefit regarding the cardiovascular system that is connected in a synergistic manner with elite physical activity.

Atopy in Elite Endurance Athletes

OBJECTIVE

To assess the frequency of atopy (specific IgE levels), to evaluate the allergic symptoms using the Allergy Questionnaire for Athletes (AQUA), and to determine whether atopy is associated with allergic symptoms in elite endurance athletes.

DESIGN

Cross-sectional study.

SETTING

Assessments were performed at Hospital das Clinicas-São Paulo University Medical School.

PARTICIPANTS

Fifty-nine elite endurance athletes (triathletes and runners).

MAIN OUTCOME MEASURES

Allergic symptoms were assessed by a validated self-report AQUA questionnaire and atopy by specific IgE level.

RESULTS

The frequency of atopy (specific IgE to at least one inhalant allergen) and allergic symptoms was 57.6% and 54.2%, respectively. In addition, no association was observed between atopy and allergic symptoms.

CONCLUSIONS

A possible implication from our results is that atopy screening in elite athletes should be performed using AQUA questionnaire and measuring specific IgE simultaneously.

Asthma and exercise-induced respiratory symptoms in the athlete: new insights

PURPOSE OF REVIEW

Asthma and exercise-induced bronchoconstriction (EIB) are common in the athlete and can interfere with sport performances. In this review, we report recent findings on the prevalence, diagnosis and evaluation of these conditions, in addition to specific issues regarding their treatment and antidoping regulations.

RECENT FINDINGS

Recent studies confirmed the high prevalence of exercise-induced respiratory symptoms, asthma and EIB, in athletes and showed that these conditions are still underdiagnosed and undertreated. Recent studies highlight the suboptimal use of asthma medication in asthmatic and allergic athletes. Regarding the diagnosis and treatment, questions about the role and criteria for positivity of eucapnic voluntary hyperpnea test were raised. It was confirmed that there is a subgroup of athletes with poor response to asthma medication. Finally, regarding antidoping regulations, new methods and changes in criteria for urinary bronchodilator thresholds were suggested.

SUMMARY

Recent publications confirm that exercise-induced respiratory symptoms, asthma and EIB are common in athletes but often unrecognized and not optimally or successfully treated. It was suggested that current criteria for diagnostic bronchoprovocation test responses could be reassessed, as well as antidoping criteria for β2-agonists urinary levels. There is a need for more research on prevention of airways dysfunction in athletes, identification of different asthma phenotypes and the benefits of standard asthma medication in this population.

Asthma Control and Asthma Medication Use among Swedish Elite Endurance Athletes

Background

Asthma is common in elite athletes. In this study, we examined the use of asthma medication and asthma control in endurance athletes in Sweden and compared the findings with those in a reference group of patients with asthma.

Methods

The Asthma Control Test (ACT) and a questionnaire on asthma, respiratory symptoms, and medication use were posted to endurance athletes (n=711) and the reference group of patients with asthma (n=1026). Four hundred and sixty-nine athletes (66%) responded, of whom 141 (20%) reported physician-diagnosed asthma. In the reference group, 397 (39%) responded.

Results

Seventy-seven percent of the athletes with asthma reported using asthma medication during the previous year; 39% used short/long-acting β2-agonists, 31% used inhaled corticosteroids, and 31% used both daily. According to the ACT scores, 19%, 24%, and 58% of athletes with asthma had uncontrolled, partially controlled, or well-controlled asthma, respectively. After adjustment, there was no difference in ACT scores or daily use of asthma medication between the study groups.

Conclusions

Many endurance athletes had uncontrolled or partially controlled asthma, and one-third used inhaled corticosteroids and long-acting β2-agonists daily. Their adjusted ACT scores and use of asthma medication were similar to the values in the reference population.

Swimming pool exposure is associated with autonomic changes and increased airway reactivity to a beta-2 agonist in school aged children: A cross-sectional survey

Background

Endurance swimming exercises coupled to disinfection by-products exposure has been associated with increased airways dysfunction and neurogenic inflammation in elite swimmers. However, the impact of swimming pool exposure at a recreational level on autonomic activity has never been explored. Therefore, this study aimed to investigate how swimming pool attendance is influencing lung and autonomic function in school-aged children.

Methods

A total of 858 children enrolled a cross sectional survey. Spirometry and airway reversibility to beta-2 agonist, skin-prick-tests and exhaled nitric oxide measurements were performed. Pupillometry was used to evaluate autonomic nervous function. Children were classified as current swimmers (CS), past swimmers (PS) and non-swimmers (NS), according to the amount of swimming practice.

Results

Current swimmers group had significantly lower maximum and average pupil constriction velocities when compared to both PS and NS groups (3.8 and 5.1 vs 3.9 and 5.3 vs 4.0 and 5.4 mm/s, p = 0.03 and p = 0.01, respectively). Moreover, affinity to the beta-2 agonist and levels of exhaled nitric oxide were significantly higher in CS when compared to NS (70 vs 60 mL and 12 vs 10 ppb, p<0.01 and p = 0.03, respectively). A non-significant trend for a higher risk of asthma, atopic eczema and allergic rhinitis was found with more years of swimming practice, particularly in atopic individuals (β = 1.12, 1.40 and 1.31, respectively). After case-case analysis, it was possible to observe that results were not influenced by the inclusion of individuals with asthma.

Conclusions

Concluding, swimming pool attendance appears to be associated with autonomic changes and increased baseline airway smooth muscle constriction even in children without asthma.

A Systematic Review of Associations of Physical Activity and Sedentary Time with Asthma Outcomes

BACKGROUND

Physical inactivity and high sedentary time are associated with adverse health outcomes in several diseases. However, their impact in asthma is less clear.

OBJECTIVE

We aimed to synthesize the literature characterizing physical activity and sedentary time in adults with asthma, to estimate activity levels using meta-analysis, and to evaluate associations between physical activity and sedentary time and the clinical and physiological characteristics of asthma.

METHODS

Articles written in English and addressing the measurement of physical activity or sedentary time in adults ≥18 years old with asthma were identified using 4 electronic databases. Meta-analysis was used to estimate steps/day in applicable studies.

RESULTS

There were 42 studies that met the inclusion criteria. Physical activity in asthma was lower compared with controls. The pooled mean (95% confidence interval) steps/day for people with asthma was 8390 (7361, 9419). Physical activity tended to be lower in females compared with males, and in older people with asthma compared with their younger counterparts. Higher levels of physical activity were associated with better measures of lung function, disease control, health status, and health care use. Measures of sedentary time were scarce, and indicated a similar engagement in this behavior between participants with asthma and controls. High sedentary time was associated with higher health care use, and poorer lung function, asthma control, and exercise capacity.

CONCLUSIONS

People with asthma engage in lower levels of physical activity compared with controls. Higher levels of physical activity may positively impact on asthma clinical outcomes. Sedentary time should be more widely assessed.

Exercise-Induced Bronchoconstriction: Background, Prevalence, and Sport Considerations

The transient airway narrowing that occurs as a result of exercise is defined as exercise-induced bronchoconstriction (EIB). The prevalence of EIB has been reported to be up to 90% in asthmatic patients, reflecting the level of disease control. However, EIB may develop even in subjects without clinical asthma, particularly in children, athletes, patients with atopy or rhinitis, and following respiratory infections. The intensity, duration, and type of training have been associated with the occurrence of EIB. In athletes, EIB seems to be only partly reversible, and exercise seems to be a causative factor of airway inflammation and symptoms.

A similar pro/anti-inflammatory cytokine balance is present in the airways of competitive athletes and non-exercising asthmatics

PURPOSE

Intensive exercise modifies airway inflammation and infection susceptibility. We aimed to determine the effect of exercise on pro- and anti-inflammatory cytokine (TNF-α, IL-1ra, IL-10) and innate immunity protein (HSPA1, sCD14) levels in exhaled breath condensate (EBC) and nasal secretions of competitive athletes, non-exercising asthmatics and healthy controls (HC).

MATERIAL AND METHODS

The study group consisted of 15 competitive athletes (five speed skaters and ten swimmers) aged 15-25. The control groups comprised 10 mild-to-moderate asthmatics (AC) and seven HC. Athletes were assessed in- and off-training while asthmatics and controls at one time point. Nasal lavages and EBC were collected before and after a treadmill exercise challenge. Protein levels were assessed using ELISA.

RESULTS

TNF-α levels in EBC were significantly higher in athletes than HC, but similar to asthmatic patients. In contrast, IL-1ra EBC concentrations were significantly lower in athletes than in HC, but again similar to asthmatics. Significant positive correlations were seen between baseline concentrations of TNF-α in EBC and fall in FEV1 following exercise challenge in athletes during training period (R=0.74, p<0.01) and in asthmatics (R=0.64, p<0.05). In nasal secretions, baseline IL-1ra levels were significantly higher in athletes and asthmatics than in HC. Exercise caused a slight, yet significant, increase in EBC HSPA1 in athletes (p=0.02). The exercise challenge did not considerably influence TNF-α, IL-1ra, HSPA1 and sCD14 in EBC or nasal secretions.

CONCLUSIONS

Dysregulation of the TNF-α/IL-1ra balance in EBC and nasal secretions from athletes may reflect the presence of airway inflammation induced by repeated strenuous exercise.

Mechanisms, measurement and management of exertional dyspnoea in asthma: Number 5 in the Series "Exertional dyspnoea" Edited by Pierantonio Laveneziana and Piergiuseppe Agostoni

Asthma is a heterogeneous condition, with dyspnoea during exercise affecting individuals to a variable degree. This narrative review explores the mechanisms and measurement of exertional dyspnoea in asthma and summarises the available evidence for the efficacy of various interventions on exertional dyspnoea. Studies on the mechanisms of dyspnoea in asthma have largely utilised direct bronchoprovocation challenges, rather than exercise, which may invoke different physiological mechanisms. Thus, the description of dyspnoea during methacholine challenge can differ from what is experienced during daily activities, including exercise. Dyspnoea perception during exercise is influenced by many interacting variables, such as asthma severity and phenotype, bronchoconstriction, dynamic hyperinflation, respiratory drive and psychological factors. In addition to the intensity of dyspnoea, the qualitative description of dyspnoea may give important clues as to the underlying mechanism and may be an important endpoint for future interventional studies. There is currently little evidence demonstrating whether pharmacological or non-pharmacological interventions specifically improve exertional dyspnoea, which is an important area for future research.

Exercise-Induced Bronchospasm and Allergy

Sport is an essential part of childhood, with precious and acknowledged positive health effects but the impact of exercise-induced bronchoconstriction (EIB) significantly reduces participation in physical activity. It is important to recognize EIB, differentiating EIB with or without asthma if the transient narrowing of the airways after exercise is associated with asthmatic symptoms or not, in the way to select the most appropriate treatment among the many treatment options available today. Therapy is prescribed based on symptoms severity but diagnosis of EIB is established by changes in lung function provoked by exercise evaluating by direct and indirect tests. Sometimes, in younger children it is difficult to obtain the registration of difference between the preexercise forced expiratory volume in the first second (FEV1) value and the lowest FEV1 value recorded within 30 min after exercise, defined as the gold standard, but interrupter resistance, in association with spirometry, has been showed to be a valid alternative in preschool age. Atopy is the main risk factor, as demonstrated by epidemiologic data showing that among the estimated pediatric population with EIB up to 40% of them have allergic rhinitis and 30% of these patients may develop adult asthma, according with atopic march. Adopting the right treatment and prevention, selecting sports with no marked hyperventilation and excessive cooling of the airways, children with EIB can be able to take part in physical activity like all others.

Prevalence of cough throughout childhood: A cohort study

Background

Cough in children is a common reason for medical consultations and affects quality of life. There are little population-based data on the epidemiology of recurrent cough in children and how this varies by age and sex, or between children with and without wheeze. We determined the prevalence of cough throughout childhood, comparing several standardised cough questions. We did this for the entire population and separately for girls and boys, and for children with and without wheeze.

Methods

In a population-based prospective cohort from Leicestershire, UK, we assessed prevalence of cough with repeated questionnaires from early childhood to adolescence. We asked whether the child usually coughed more than other children, with or without colds, had night-time cough or cough triggered by various factors (triggers, related to increased breathing effort, allergic or food triggers). We calculated prevalence from age 1 to 18 years using generalised estimating equations for all children, and for children with and without wheeze.

Results

Of 7670 children, 10% (95% CI 10–11%) coughed more than other children, 69% (69–70%) coughed usually with a cold, 34% to 55% age-dependently coughed without colds, and 25% (25–26%) had night-time cough. Prevalence of coughing more than peers, with colds, at night, and triggered by laughter varied little throughout childhood, while cough without colds and cough triggered by exercise, house dust or pollen became more frequent with age. Cough was more common in boys than in girls in the first decade of life, differences got smaller in early teens and reversed after the age of 14 years. All symptoms were more frequent in children with wheeze.

Conclusions

Prevalence of cough in children varies with age, sex and with the questions used to assess it, suggesting that comparisons between studies are only valid for similar questions and age groups.

Advances in the Evaluation of Respiratory Pathophysiology during Exercise in Chronic Lung Diseases

Dyspnea and exercise limitation are among the most common symptoms experienced by patients with various chronic lung diseases and are linked to poor quality of life. Our understanding of the source and nature of perceived respiratory discomfort and exercise intolerance in chronic lung diseases has increased substantially in recent years. These new mechanistic insights are the primary focus of the current review. Cardiopulmonary exercise testing (CPET) provides a unique opportunity to objectively evaluate the ability of the respiratory system to respond to imposed incremental physiological stress. In addition to measuring aerobic capacity and quantifying an individual's cardiac and ventilatory reserves, we have expanded the role of CPET to include evaluation of symptom intensity, together with a simple "non-invasive" assessment of relevant ventilatory control parameters and dynamic respiratory mechanics during standardized incremental tests to tolerance. This review explores the application of the new advances in the clinical evaluation of the pathophysiology of exercise intolerance in chronic obstructive pulmonary disease (COPD), chronic asthma, interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). We hope to demonstrate how this novel approach to CPET interpretation, which includes a quantification of activity-related dyspnea and evaluation of its underlying mechanisms, enhances our ability to meaningfully intervene to improve quality of life in these pathologically-distinct conditions.

Lack of desensitization of the cough reflex in ovalbumin-sensitized rabbits during exercise

Introduction

Cough is a major symptom of asthma frequently experienced during exercise but little is known about interactions between cough and exercise. The goal of our study was to clarify the potential modulation of the cough reflex (CR) by exercise in a spontaneously breathing anaesthetized animal model of airway eosinophilic inflammation.

Materials & methods

Ten ovalbumin (OVA) sensitized adult rabbits and 8 controls were studied. The ventilatory response to direct tracheal stimulation, performed both at rest and during exercise was determined to quantify the incidence and the sensitivity of the CR.

Broncho-alveolar lavages (BAL) and cell counts were performed to assess the level of the airway inflammation following OVA-induced sensitization. Exercise was mimicked by Electrically induced hindlimb Muscular Contractions (EMC).

Results

Among 494 tracheal stimulations, 261 were performed at rest and 233 at exercise. OVA challenges in sensitized rabbits caused a significant increase in the percentage of eosinophils (p = 0.008) in BAL. EMC increased minute ventilation by 36% and 35% in OVA and control rabbits respectively, compared to rest values. The sensitivity of the CR decreased during exercise compared to baseline in control rabbits (p = 0.0313) while it remained unchanged in OVA rabbits.

Conclusion

The desensitization of the CR during exercise in control rabbits was abolished in OVA rabbits. The precise role of airway inflammation in this lack of CR desensitization needs to be further investigated but it might contribute to the exercise-induced cough in asthmatics.

Exercise inducible laryngeal obstruction: diagnostics and management

Obstruction of the central airways is an important cause of exercise-induced inspiratory symptoms (EIIS) in young and otherwise healthy individuals. This is a large, heterogeneous and vastly understudied group of patients. The symptoms are too often confused with those of asthma. Laryngoscopy performed as symptoms evolve during increasing exercise is pivotal, since the larynx plays an important role in symptomatology for the majority. Abnormalities vary between patients, and laryngoscopic findings are important for correct treatment and handling. The simplistic view that all EIIS is due to vocal cord dysfunction [VCD] still hampers science and patient management. Causal mechanisms are poorly understood. Most treatment options are based on weak evidence, but most patients seem to benefit from individualised information and guidance. The place of surgery has not been settled, but supraglottoplasty may cure well-defined severe cases. A systematic clinical approach, more and better research and randomised controlled treatment trials are of utmost importance in this field of respiratory medicine.

Asthma phenotypes in children and stratified pharmacological treatment regimens

INTRODUCTION

Asthma is the most common inflammatory disease in childhood. The interaction of genetic, environmental and host factors may contribute to the development of childhood asthma and defines its progress, including persistence and severity. Until now, various classifications of childhood asthma phenotypes have been suggested based on patient's age during onset of symptoms, type of inflammatory cells, response to treatment and disease severity. Many efforts have been carried out to identify childhood asthma phenotypes and to clarify which are the risk factors that define asthma prediction and the response to therapy. The identification of asthma phenotypes has not only prognostic but also therapeutic role. However, the classification of asthma phenotypes is complex due to the heterogeneity of the disease. Areas covered: The current childhood asthma phenotypes and the new therapeutic strategies for each phenotype are reviewed. Expert commentary: There are multiple phenotypes in childhood asthma and it is crucial to define them before the initiation of personalized treatment. Both the therapeutic strategy and monitoring should follow the recent guidelines.

Physical Activity, Air Pollution, and the Risk of Asthma and Chronic Obstructive Pulmonary Disease

RATIONALE

Physical activity enhances uptake of air pollutants in the lung, possibly augmenting their harmful effects on chronic lung disease during exercise.

OBJECTIVES

To examine whether benefits of physical activity with respect to the risk of asthma and chronic obstructive pulmonary disease (COPD) are moderated by exposure to high air pollution levels in an urban setting.

METHODS

A total of 53,113 subjects (50-65 yr) from the Danish Diet, Cancer, and Health cohort reported physical activity at recruitment (1993-1997) and were followed until 2013 in the National Patient Register for incident hospitalizations for asthma and COPD. Levels of nitrogen dioxide (NO₂) were estimated at subject residences at the time of recruitment. We used Cox regression to associate physical activities and NO₂ (high/medium/low) with asthma and COPD, and then introduced an interaction term between each physical activity and NO₂.

MEASUREMENTS AND MAIN RESULTS

A total of 1,151 subjects were hospitalized for asthma and 3,225 for COPD during 16 years. We found inverse associations of participation in sports (hazard ratio [95% confidence interval]: 0.85 [0.75-0.96]) and cycling (0.85 [0.75-0.96]) with incident asthma, and of participation in sports (0.82 [0.77-0.89]), cycling (0.81 [0.76-0.87]), gardening (0.88 [0.81-0.94]), and walking (0.85 [0.75-0.95]) with incident COPD admissions. We found positive associations between NO₂ and incident asthma (1.23 [1.04-1.47]) and COPD (1.15 [1.03-1.27]) hospitalizations (comparing ≥21.0 μg/m³ to <14.3 μg/m³). We found no interaction between associations of any physical activity and NO₂ on incident asthma or COPD hospitalizations.

CONCLUSIONS

Increased exposure to air pollution during exercise does not outweigh beneficial effects of physical activity on the risk of asthma and COPD.

Exercise, Asthma and the Olympics: A 2000-year-old tale

Two separated phenotypes of Exercise-Induced-Asthma existOlympic Athletes have won more medals than their non-asthmatic peersCompetitive swimmers show an increased asthma prevalenceAsthmatics have no limitations in sports practice if they receive adequate medical treatmentAerobic exercise programs are beneficial for asthmatics and should be included in asthma action plans.