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Dickinson J, Gowers W, Sturridge S, Williams N, Kippelen P, Simpson A, Jackson A, Hull JH, Price OJ. Fractional exhaled nitric oxide in the assessment of exercise-induced bronchoconstriction: A multicenter retrospective analysis of UK-based athletes. Scand J Med Sci Sports 2023. [PMID: 37051807 DOI: 10.1111/sms.14367] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/03/2023] [Accepted: 03/25/2023] [Indexed: 04/14/2023]
Abstract
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.
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Affiliation(s)
- John Dickinson
- School of Sport and Exercise Sciences, University of Kent, Canterbury, UK
| | - William Gowers
- School of Sport and Exercise Sciences, University of Kent, Canterbury, UK
| | - Savannah Sturridge
- School of Sport and Exercise Sciences, University of Kent, Canterbury, UK
| | - Neil Williams
- SHAPE Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, UK
| | - Pascale Kippelen
- Centre for Physical Activity in Health and Disease, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK
| | - Andrew Simpson
- School of Sport, Exercise and Rehabilitation Sciences, University of Hull, Hull, UK
| | | | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
- Institute of Sport, Exercise and Health (ISEH), Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Oliver J Price
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Reier-Nilsen T, Sewry N, Chenuel B, Backer V, Larsson K, Price OJ, Pedersen L, Bougault V, Schwellnus M, Hull JH. Diagnostic approach to lower airway dysfunction in athletes: a systematic review and meta-analysis by a subgroup of the IOC consensus on 'acute respiratory illness in the athlete'. Br J Sports Med 2023; 57:481-489. [PMID: 36717213 DOI: 10.1136/bjsports-2022-106059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To compare the performance of various diagnostic bronchoprovocation tests (BPT) in the assessment of lower airway dysfunction (LAD) in athletes and inform best clinical practice. DESIGN Systematic review with sensitivity and specificity meta-analyses. DATA SOURCES PubMed, EBSCOhost and Web of Science (1 January 1990-31 December 2021). ELIGIBILITY CRITERIA Original full-text studies, including athletes/physically active individuals (15-65 years) who underwent assessment for LAD by symptom-based questionnaires/history and/or direct and/or indirect BPTs. RESULTS In 26 studies containing data for quantitative meta-analyses on BPT diagnostic performance (n=2624 participants; 33% female); 22% had physician diagnosed asthma and 51% reported LAD symptoms. In athletes with symptoms of LAD, eucapnic voluntary hyperpnoea (EVH) and exercise challenge tests (ECTs) confirmed the diagnosis with a 46% sensitivity and 74% specificity, and 51% sensitivity and 84% specificity, respectively, while methacholine BPTs were 55% sensitive and 56% specific. If EVH was the reference standard, the presence of LAD symptoms was 78% sensitive and 45% specific for a positive EVH, while ECTs were 42% sensitive and 82% specific. If ECTs were the reference standard, the presence of LAD symptoms was 80% sensitive and 56% specific for a positive ECT, while EVH demonstrated 65% sensitivity and 65% specificity for a positive ECT. CONCLUSION In the assessment of LAD in athletes, EVH and field-based ECTs offer similar and moderate diagnostic test performance. In contrast, methacholine BPTs have lower overall test performance. PROSPERO REGISTRATION NUMBER CRD42020170915.
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Affiliation(s)
- Tonje Reier-Nilsen
- The Norwegian Olympic Sports Centre, Norwegian Olympic and Paralympic Committee and Confederation of Sports, Oslo, Norway .,Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Nicola Sewry
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,International Olympic Committee (IOC) Research Centre of South Africa, University of Pretoria, Pretoria, South Africa
| | - Bruno Chenuel
- Centre Hospitalier Régional Universitaire de Nancy, Department of Lung function and Exercise Physiology - University Center of Sports Medicine and Adapted Physical Activity, Université de Lorraine, Nancy, France.,Université de Lorraine, DevAH, Nancy, France
| | - Vibeke Backer
- Department of ENT, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.,CFAS, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Kjell Larsson
- Integrative Toxicology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Oliver J Price
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Lars Pedersen
- Department of Respiratory Medicine and Infectious Diseases, Bispebjerg Hospital, Copenhagen, Denmark
| | - Valerie Bougault
- Laboratoire Motricité Humaine Expertise Sport Santé, Université Côte d'Azur, Nice, France
| | - Martin Schwellnus
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,International Olympic Committee (IOC) Research Centre of South Africa, University of Pretoria, Pretoria, South Africa
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,Institute of Sport, Exercise and Health (ISEH), Division of surgery and Interventional science, University College London, London, UK
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Price OJ, Sewry N, Schwellnus M, Backer V, Reier-Nilsen T, Bougault V, Pedersen L, Chenuel B, Larsson K, Hull JH. 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'. Br J Sports Med 2021; 56:213-222. [PMID: 34872908 DOI: 10.1136/bjsports-2021-104601] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Oliver J Price
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Nicola Sewry
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,IOC Research Centre, Pretoria, South Africa
| | - Martin Schwellnus
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,IOC Research Centre, Pretoria, South Africa
| | - Vibeke Backer
- Centre for Physical Activity Research, Rigshopitalet, Copenhagen University, Denmark, Copenhagen, Denmark
| | | | - Valerie Bougault
- Laboratoire Motricité Humaine Expertise Sport Santé, Université Côte d'Azur, Nice, France
| | - Lars Pedersen
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Bruno Chenuel
- Centre Hospitalier Régional Universitaire de Nancy, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, Service des Explorations de la Fonction Respiratoire, Université de Lorraine, Nancy, France.,Medical Physiology, Université de Lorraine, Nancy, France
| | - Kjell Larsson
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK .,Division of Surgery and Interventional Science, Institute of Sport, Exercise and Health (ISEH), University College London, London, UK
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