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Hostrup M, Hansen ESH, Rasmussen SM, Jessen S, Backer V. Asthma and exercise-induced bronchoconstriction in athletes: Diagnosis, treatment, and anti-doping challenges. Scand J Med Sci Sports 2024; 34:e14358. [PMID: 36965010 DOI: 10.1111/sms.14358] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/14/2023] [Accepted: 03/17/2023] [Indexed: 03/27/2023]
Abstract
Athletes often experience lower airway dysfunction, such as asthma and exercise-induced bronchoconstriction (EIB), which affects more than half the athletes in some sports, not least in endurance sports. Symptoms include coughing, wheezing, and breathlessness, alongside airway narrowing, hyperresponsiveness, and inflammation. Early diagnosis and management are essential. Not only because untreated or poorly managed asthma and EIB potentially affects competition performance and training, but also because untreated airway inflammation can result in airway epithelial damage, remodeling, and fibrosis. Asthma and EIB do not hinder performance, as advancements in treatment strategies have made it possible for affected athletes to compete at the highest level. However, practitioners and athletes must ensure that the treatment complies with general guidelines and anti-doping regulations to prevent the risk of a doping sanction because of inadvertently exceeding specified dosing limits. In this review, we describe considerations and challenges in diagnosing and managing athletes with asthma and EIB. We also discuss challenges facing athletes with asthma and EIB, while also being subject to anti-doping regulations.
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Affiliation(s)
- Morten Hostrup
- The August Krogh Section, Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Erik S H Hansen
- Centre for Physical Activity Research (CFAS), Rigshospitalet, Copenhagen, Denmark
| | - Søren M Rasmussen
- Centre for Physical Activity Research (CFAS), Rigshospitalet, Copenhagen, Denmark
- Medical Department, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Søren Jessen
- The August Krogh Section, Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Backer
- Centre for Physical Activity Research (CFAS), Rigshospitalet, Copenhagen, Denmark
- Department of Otorhinolaryngology Head & Neck Surgery and Audiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Brannan JD, Kippelen P. Bronchial Provocation Testing for the Identification of Exercise-Induced Bronchoconstriction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2156-2164. [PMID: 32620430 DOI: 10.1016/j.jaip.2020.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 01/26/2023]
Abstract
Exercise-induced bronchoconstriction (EIB) occurs in patients with asthma, children, and otherwise healthy athletes. Poor diagnostic accuracy of respiratory symptoms during exercise requires objective assessment of EIB. The standardized tests currently available are based on the assumption that the provoking stimulus to EIB is dehydration of the airway surface fluid due to conditioning large volumes of inhaled air. "Indirect" bronchial provocation tests that use stimuli to cause endogenous release of bronchoconstricting mediators from airway inflammatory cells include dry air hyperpnea (eg, exercise and eucapnic voluntary hyperpnea) and osmotic aerosols (eg, inhaled mannitol). The airway response to different indirect tests is generally similar in patients with asthma and healthy athletes with EIB. Furthermore, the airway sensitivity to these tests is modified by the same pharmacotherapy used to treat asthma. In contrast, pharmacological agents such as methacholine, given by inhalation, act directly on smooth muscle to cause contraction. These "direct" tests have been used traditionally to identify airway hyperresponsiveness in clinical asthma but are less useful to diagnose EIB. The mechanistic differences between indirect and direct tests have helped to elucidate the events leading to airway narrowing in patients with asthma and elite athletes, while improving the clinical utility of these tests to diagnose and manage EIB.
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Affiliation(s)
- John D Brannan
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton, NSW, Australia.
| | - Pascale Kippelen
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University London, Uxbridge, United Kingdom; Division of Sport, Health and Exercise Sciences, College of Health and Life Sciences, Brunel University London, Uxbridge, United Kingdom
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Rodriguez Bauza DE, Silveyra P. Asthma, atopy, and exercise: Sex differences in exercise-induced bronchoconstriction. Exp Biol Med (Maywood) 2021; 246:1400-1409. [PMID: 33794694 DOI: 10.1177/15353702211003858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Asthma is a chronic inflammatory lung disease affecting approximately 7.7% of the US population. Sex differences in the prevalence, incidence, and severity of asthma have been widely described throughout the lifespan, showing higher rates in boys than girls before puberty, but a reversed pattern in adults. Asthma is often associated with atopy, i.e. the tendency to develop allergic diseases, and can be worsened by environmental stimuli and/or exercise. While not exclusive to patients with asthma, exercise-induced bronchoconstriction (EIB) is a common complication of athletes and individuals who exercise regularly. Currently, there is limited research on sex differences in EIB and its relationship with atopy and asthma in men and women. In this minireview, we summarize the available literature on this topic. Overall, the collective knowledge supports the notion that physiological changes triggered during exercise affect males and females differently, suggesting an interaction among sex, exercise, sex hormones, and atopic status in the course of EIB pathophysiology. Understanding these differences is important to provide personalized management plans to men and women who exercise regularly and suffer from underlying asthma and/or atopy.
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Affiliation(s)
| | - Patricia Silveyra
- Biobehavioral Laboratory, The University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC 27599, USA.,Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington, IN 47405, USA
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Greiwe J, Cooke A, Nanda A, Epstein SZ, Wasan AN, Shepard KV, Capão-Filipe M, Nish A, Rubin M, Gregory KL, Dass K, Blessing-Moore J, Randolph C. Work Group Report: Perspectives in Diagnosis and Management of Exercise-Induced Bronchoconstriction in Athletes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2542-2555. [PMID: 32636147 DOI: 10.1016/j.jaip.2020.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 11/26/2022]
Abstract
Exercise-induced bronchoconstriction, otherwise known as exercise-induced bronchoconstriction with asthma or without asthma, is an acute airway narrowing that occurs as a result of exercise and can occur in patients with asthma. A panel of members from the American Academy of Allergy, Asthma & Immunology Sports, Exercise, & Fitness Committee reviewed the diagnosis and management of exercise-induced bronchoconstriction in athletes of all skill levels including recreational athletes, high school and college athletes, and professional athletes. A special emphasis was placed on the recommendations and regulations set forth by professional athletic organizations after a detailed review of their collective bargaining agreements, substance abuse policies, antidoping program manuals, and the World Anti-Doping Agency antidoping code. The recommendations in this review are based on currently available evidence in addition to providing guidance for athletes of all skill levels as well as their treating physicians to better understand which pharmaceutical and nonpharmaceutical management options are appropriate as well as which medications are permitted or prohibited, and the proper documentation required to remain compliant.
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Affiliation(s)
- Justin Greiwe
- Bernstein Allergy Group Inc, Cincinnati, Ohio; Division of Immunology/Allergy Section, Department of Internal Medicine, The University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Andrew Cooke
- Lake Allergy, Asthma & Immunology PA, Tavares, Fla
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Texas; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Kirk V Shepard
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine and James A. Haley Veterans' Hospital, Tampa, Fla
| | | | - Andy Nish
- Northeast Georgia Physician's Group Allergy and Asthma, Gainesville, Ga
| | - Mark Rubin
- Asthma and COPD Emmi Solutions, Chicago, Ill; CME Education Program Steering Committee, The France Foundation, Old Lyme, Conn
| | - Karen L Gregory
- Oklahoma Allergy and Asthma Clinic, Oklahoma City, Okla; School of Nursing and Health Studies, Georgetown University, Washington, DC
| | - Kathleen Dass
- Michigan Allergy, Asthma & Immunology Center PLLC, Oak Park, Mich; Division of Immunology/Allergy Section, Department of Internal Medicine, Oakland University William Beaumont Hospital, Rochester, Mich
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Abstract
Asthma affects approximately 300 million people worldwide and approximately 7.5% of adults in the United States. Asthma is characterized by inflammation of the airways, variable airflow obstruction, and bronchial hyperresponsiveness. The diagnosis of asthma is a clinical one with the history and physical examination being significant, but objective measures, such as pulmonary function testing, can be used to aid in the diagnosis. There are multiple associated comorbidities with asthma, including rhinitis, sinusitis, gastroesophageal reflux disease, obstructive sleep apnea, and depression. There is often an allergic component of asthma, and patient education is vital.
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Affiliation(s)
- Anil Nanda
- Asthma and Allergy Center, 724 West Main Street, Suite 160, Lewisville, TX 75067, USA; Asthma and Allergy Center, 4900 Long Prairie Road, Suite 100, Flower Mound, TX, USA; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Anita N Wasan
- Allergy and Asthma Center, 6824 Elm Street, Suite 120, McLean, VA 22101, USA
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