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Grandinetti R, Mussi N, Rossi A, Zambelli G, Masetti M, Giudice A, Pilloni S, Deolmi M, Caffarelli C, Esposito S, Fainardi V. Exercise-Induced Bronchoconstriction in Children: State of the Art from Diagnosis to Treatment. J Clin Med 2024; 13:4558. [PMID: 39124824 PMCID: PMC11312884 DOI: 10.3390/jcm13154558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/17/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Exercise-induced bronchoconstriction (EIB) is a common clinical entity in people with asthma. EIB is characterized by postexercise airway obstruction that results in symptoms such as coughing, dyspnea, wheezing, chest tightness, and increased fatigue. The underlying mechanism of EIB is not completely understood. "Osmotic theory" and "thermal or vascular theory" have been proposed. Initial assessment must include a specific work-up to exclude alternative diagnoses like exercise-induced laryngeal obstruction (EILO), cardiac disease, or physical deconditioning. Detailed medical history and clinical examination must be followed by basal spirometry and exercise challenge test. The standardized treadmill running (TR) test, a controlled and standardized method to assess bronchial response to exercise, is the most adopted exercise challenge test for children aged at least 8 years. In the TR test, the goal is to reach the target heart rate in a short period and maintain it for at least 6 min. The test is then followed by spirometry at specific time points (5, 10, 15, and 30 min after exercise). In addition, bronchoprovocation tests like dry air hyperpnea (exercise and eucapnic voluntary hyperpnea) or osmotic aerosols (inhaled mannitol) can be considered when the diagnosis is uncertain. Treatment options include both pharmacological and behavioral approaches. Considering medications, the use of short-acting beta-agonists (SABA) just before exercise is the commonest option strategy, but daily inhaled corticosteroids (ICS) can also be considered, especially when EIB is not controlled with SABA only or when the patients practice physical activity very often. Among the behavioral approaches, warm-up before exercise, breathing through the nose or face mask, and avoiding polluted environments are all recommended strategies to reduce EIB risk. This review summarizes the latest evidence published over the last 10 years on the pathogenesis, diagnosis using spirometry and indirect bronchoprovocation tests, and treatment strategies, including SABA and ICS, of EIB. A specific focus has been placed on EIB management in young athletes, since this condition can not only prevent them from practicing regular physical activity but also competitive sports.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43125 Parma, Italy; (R.G.); (N.M.); (A.R.); (G.Z.); (M.M.); (A.G.); (S.P.); (M.D.); (C.C.); (S.E.)
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2
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Ora J, De Marco P, Gabriele M, Cazzola M, Rogliani P. Exercise-Induced Asthma: Managing Respiratory Issues in Athletes. J Funct Morphol Kinesiol 2024; 9:15. [PMID: 38249092 PMCID: PMC10801521 DOI: 10.3390/jfmk9010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/19/2023] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Asthma is a complex respiratory condition characterized by chronic airway inflammation and variable expiratory airflow limitation, affecting millions globally. Among athletes, particularly those competing at elite levels, the prevalence of respiratory conditions is notably heightened, varying between 20% and 70% across specific sports. Exercise-induced bronchoconstriction (EIB) is a common issue among athletes, impacting their performance and well-being. The prevalence rates vary based on the sport, training environment, and genetics. Exercise is a known trigger for asthma, but paradoxically, it can also improve pulmonary function and alleviate EIB severity. However, athletes' asthma phenotypes differ, leading to varied responses to medications and challenges in management. The unique aspects in athletes include heightened airway sensitivity, allergen, pollutant exposure, and temperature variations. This review addresses EIB in athletes, focusing on pathogenesis, diagnosis, and treatment. The pathogenesis of EIB involves complex interactions between physiological and environmental factors. Airway dehydration and cooling are key mechanisms, leading to osmotic and thermal theories. Airway inflammation and hyper-responsiveness are common factors. Elite athletes often exhibit distinct inflammatory responses and heightened airway sensitivity, influenced by sport type, training, and environment. Swimming and certain sports pose higher EIB risks, with chlorine exposure in pools being a notable factor. Immune responses, lung function changes, and individual variations contribute to EIB in athletes. Diagnosing EIB in athletes requires objective testing, as baseline lung function tests can yield normal results. Both EIB with asthma (EIBA) and without asthma (EIBwA) must be considered. Exercise and indirect bronchoprovocation tests provide reliable diagnoses. In athletes, exercise tests offer effectiveness in diagnosing EIB. Spirometry and bronchodilation tests are standard approaches, but the diagnostic emphasis is shifting toward provocation tests. Despite its challenges, achieving an optimal diagnosis of EIA constitutes the cornerstone for effective management, leading to improved performance, reduced risk of complications, and enhanced quality of life. The management of EIB in athletes aligns with the general principles for symptom control, prevention, and reducing complications. Non-pharmacological approaches, including trigger avoidance and warming up, are essential. Inhaled corticosteroids (ICS) are the cornerstone of asthma therapy in athletes. Short-acting beta agonists (SABA) are discouraged as sole treatments. Leukotriene receptor antagonists (LTRA) and mast cell stabilizing agents (MCSA) are potential options. Optimal management improves the athletes' quality of life and allows them to pursue competitive sports effectively.
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Affiliation(s)
- Josuel Ora
- Division of Respiratory Medicine, University Hospital “Tor Vergata”, 00133 Rome, Italy
| | - Patrizia De Marco
- Division of Respiratory Medicine, University Hospital “Tor Vergata”, 00133 Rome, Italy
| | - Mariachiara Gabriele
- Division of Respiratory Medicine, University Hospital “Tor Vergata”, 00133 Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Paola Rogliani
- Division of Respiratory Medicine, University Hospital “Tor Vergata”, 00133 Rome, Italy
- Department of Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
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3
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Anderson SD, Kippelen P. A proposal to account for the stimulus, the mechanism, and the mediators released in exercise-induced bronchoconstriction. FRONTIERS IN ALLERGY 2023; 4:1004170. [PMID: 38026130 PMCID: PMC10657894 DOI: 10.3389/falgy.2023.1004170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
Exercise induced bronchoconstriction (EIB) describes the transient narrowing of the airways that follows vigorous exercise. It commonly occurs in children and adults who have asthma and in elite athletes. The primary stimulus is proposed to be loss of water, by evaporation, from the airway surface due to conditioning inspired air. The mechanism, whereby this evaporative loss of water provokes contraction of the bronchial smooth muscle, is thought to be an increase in osmolarity of the airway surface liquid. The increase in osmolarity causes mast cells to release histamines, prostaglandins, and leukotrienes. It is these mediators that contract smooth muscle causing the airways to narrow.
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Affiliation(s)
- Sandra D. Anderson
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Pascale Kippelen
- Division of Sport, Health and Exercise Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
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4
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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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5
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Schwellnus M, Adami PE, Bougault V, Budgett R, Clemm HH, Derman W, Erdener U, Fitch K, Hull JH, McIntosh C, Meyer T, Pedersen L, Pyne DB, Reier-Nilsen T, Schobersberger W, Schumacher YO, Sewry N, Soligard T, Valtonen M, Webborn N, Engebretsen L. International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 2: non-infective acute respiratory illness. Br J Sports Med 2022; 56:bjsports-2022-105567. [PMID: 35623888 DOI: 10.1136/bjsports-2022-105567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Martin Schwellnus
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- SEMLI, IOC Research Centre, Pretoria, Gauteng, South Africa
| | - Paolo Emilio Adami
- Health & Science Department, World Athletics, Monaco, Monaco Principality
| | - Valerie Bougault
- Laboratoire Motricité Humaine Expertise Sport Santé, Université Côte d'Azur, Nice, Provence-Alpes-Côte d'Azu, France
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Wayne Derman
- Institute of Sport and Exercise Medicine (ISEM), Department of Sport Science, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- ISEM, IOC Research Center, South Africa, Stellenbosch, South Africa
| | - Uğur Erdener
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Ken Fitch
- School of Human Science; Sports, Exercise and Health, The University of Western Australia, Perth, Western Australia, Australia
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Institute of Sport, Exercise and Health (ISEH), University College London (UCL), London, UK
| | - Cameron McIntosh
- Dr CND McIntosh INC, Edge Day Hospital, Port Elizabeth, South Africa
| | - Tim Meyer
- Institute of Sports and Preventive Medicine, Saarland University, Saarbrucken, Germany
| | - Lars Pedersen
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - David B Pyne
- Research Institute for Sport and Exercise, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Tonje Reier-Nilsen
- Oslo Sports Trauma Research Centre, The Norwegian Olympic Sports Centre, Oslo, Norway
- Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Wolfgang Schobersberger
- Insitute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), Kliniken Innsbruck and Private University UMIT Tirol, Hall, Austria
| | | | - Nicola Sewry
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- SEMLI, IOC Research Centre, Pretoria, Gauteng, South Africa
| | - Torbjørn Soligard
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, Calgary, Alberta, Canada
| | - Maarit Valtonen
- KIHU, Research Institute for Olympic Sports, Jyväskylä, Finland
| | - Nick Webborn
- Centre for Sport and Exercise Science and Medicine, University of Brighton, Brighton, UK
| | - Lars Engebretsen
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
- Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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6
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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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Päivinen M, Keskinen K, Tikkanen H. Swimming-induced changes in pulmonary function: special observations for clinical testing. BMC Sports Sci Med Rehabil 2021; 13:55. [PMID: 34016179 PMCID: PMC8139112 DOI: 10.1186/s13102-021-00277-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/03/2021] [Indexed: 11/10/2022]
Abstract
Background A special improvement in pulmonary function is found in swimmers. In clinical testing the airway reactivity is observed at certain exercise intensity and target ventilation. However, in highly trained swimmers exercising in water the reactions may not function the same way. The aim was to study the combined effects of the water environment and swimming on pulmonary function and the associations with perceived symptoms. Methods First, 412 competitive swimmers completed questionnaires concerning respiratory symptoms at different swimming intensities. Then, pulmonary function testing was performed in 14 healthy elite swimmers. Spirometry and maximal voluntary ventilation (MVV) were measured on land and in water before and after swimming. While swimming, minute ventilation (VE) tidal volume (VT) and breathing frequency (fb) were measured during competition speed swimming. Results Swimmers reported the most symptoms at competition speed intensity swimming. In the transition from the land into the water swimming body position, the ratio of forced expiratory volume in one second (FEV1) and forced expiratory capacity (FVC) (FEV1/FVC) decreased by a mean (SD) 5.3% (3) in females and by 2.2% (5) in males. During competition speed intensity swimming, the minute ventilation (VE) had a mean of 72 and 75% of calculated maximal voluntary ventilation (cMVV) in females and in males, respectively. Conclusions Spirometry showed sex differences in water compared to land measurements. These differences should be considered when the effects of swimming are observed. During the intensity that triggered the symptoms the most, the VE was approximately 20% higher than the target ventilations for clinical testing. These findings encourages specific modifications of clinical testing protocols for elite swimmers.
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Affiliation(s)
- Marja Päivinen
- University of Turku, Turku, Finland. .,University of Helsinki, Helsinki, Finland.
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8
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Kennedy MD, Lenz E, Niedermeier M, Faulhaber M. Are Respiratory Responses to Cold Air Exercise Different in Females Compared to Males? Implications for Exercise in Cold Air Environments. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186662. [PMID: 32933124 PMCID: PMC7559764 DOI: 10.3390/ijerph17186662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 11/24/2022]
Abstract
Research has shown that cold air exercise causes significant respiratory dysfunction, especially in female athletes. However, how female and male athletes respond to cold air exercise is not known. Thus, we aimed to compare acute respiratory responses (function, recovery and symptoms) in males and females after high-intensity cold air exercise. Eighteen (nine female) athletes completed two environmental chamber running trials at 0 °C and −20 °C (humidity 34 ± 5%) on different days in a randomized starting order. Spirometry was performed pre, 3, 6, 10, 15 and 20 min post. Respiratory symptoms were measured posttrial and heart rate and rating of perceived exertion were assessed during each trial. No significant differences in delta change (pre to post) were found at either temperature between sexes for FEV1, FVC, FEF50% and FEF25–75%. At −20 °C, FEV1 decreased similarly in both sexes (males: 7.5%, females: 6.3%) but not at 0 °C, p = 0.003. Postexertion respiratory function recovery and reported symptoms were not different between sexes at either temperature. These results indicate no sex-based differences in acute respiratory responses (function, recovery and symptoms) to cold air exercise. However, intense exercise at −20 °C is challenging to the respiratory system in both sexes and may lead to altered respiratory responses compared to mild winter conditions like 0 °C.
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Affiliation(s)
- Michael D. Kennedy
- Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, AB T6G 2H9, Canada;
| | - Elisabeth Lenz
- Department of Sport Science, University of Innsbruck, 6020 Innsbruck, Austria; (E.L.); (M.F.)
| | - Martin Niedermeier
- Department of Sport Science, University of Innsbruck, 6020 Innsbruck, Austria; (E.L.); (M.F.)
- Correspondence:
| | - Martin Faulhaber
- Department of Sport Science, University of Innsbruck, 6020 Innsbruck, Austria; (E.L.); (M.F.)
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9
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Leahy MG, Peters CM, Geary CM, Koehle MS, McKenzie DC, Brotherhood J, Sheel AW. Diagnosis of Exercise-induced Bronchoconstriction in Swimmers: Context Matters. Med Sci Sports Exerc 2020; 52:1855-1861. [PMID: 32175977 DOI: 10.1249/mss.0000000000002335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Michael George Leahy
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, CANADA
| | - Carli M Peters
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, CANADA
| | - Caitlin M Geary
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, CANADA
| | | | | | | | - A William Sheel
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, CANADA
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10
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Exercise-induced bronchoconstriction in elite or endurance athletes:: Pathogenesis and diagnostic considerations. Ann Allergy Asthma Immunol 2020; 125:47-54. [PMID: 32035936 DOI: 10.1016/j.anai.2020.01.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To review the pathogenesis and evaluation of exercise-induced bronchoconstriction pertaining to the elite or endurance athlete, as well as propose a diagnostic algorithm based on the current literature. DATA SOURCES Studies were identified using Ovid MEDLINE and reference lists of key articles. STUDY SELECTIONS Randomized controlled trials were selected when available. Systematic reviews and meta-analyses of peer-reviewed literature were included, as were retrospective studies and observational studies of clinical interest. RESULTS Exercise-induced bronchoconstriction (EIB) is the physiologic entity in which exercise induces acute narrowing of the airways and occurs in patients both with and without asthma. It may present with or without respiratory symptoms, and the underlying cause is likely attributable to environment stressors to the airway encountered during exercise. These include the osmotic effects of inhaled dry air, temperature variations, autonomic nervous system dysregulation, sensory nerve reactivity, and airway epithelial injury. Deposition of allergens, particulate matter, and gaseous pollutants into the airway also contribute. Elite and endurance athletes are exposed to these stressors more frequently and in greater duration than the general population. CONCLUSION A greater awareness of EIB among elite and endurance athletes is needed, and a thorough evaluation should be performed if EIB is suspected in this population. We propose an algorithm to aid in this evaluation. Symptoms should not be solely relied on for diagnosis but should be taken into the context of bronchoprovocative challenges, which should replicate the competitive environment as closely as possible. Further research is needed to validate these tests' predictive values.
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11
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Sandnes A, Hilland M, Vollsæter M, Andersen T, Engesæter IØ, Sandvik L, Heimdal JH, Halvorsen T, Eide GE, Røksund OD, Clemm HH. Severe Exercise-Induced Laryngeal Obstruction Treated With Supraglottoplasty. Front Surg 2019; 6:44. [PMID: 31417908 PMCID: PMC6684966 DOI: 10.3389/fsurg.2019.00044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/16/2019] [Indexed: 01/29/2023] Open
Abstract
Introduction: Exercise induced laryngeal obstruction (EILO) is relatively common in adolescents, with symptoms often confused with exercise induced asthma. EILO often starts with medial or inward rotation of supraglottic structures of the larynx, whereas glottic adduction appears as a secondary phenomenon in a majority. Therefore, surgical treatment (supraglottoplasty) is used in thoroughly selected and highly motivated patients with pronounced symptoms and severe supraglottic collapse. Aim: To investigate efficacy and safety of laser supraglottoplasty as treatment for severe supraglottic EILO by retrospective chart reviews. Methods: The EILO register at Haukeland University Hospital, Bergen, Norway was used to identify patients who had undergone laser supraglottoplasty for severe supraglottic EILO, verified by continuous laryngoscopy exercise (CLE) test, during 2013–2015. Laser incision in both aryepiglottic folds anterior to the cuneiform tubercles and removal of the mucosa around the top was performed in general anesthesia. Outcomes were questionnaire based self-reported symptoms, and laryngeal obstruction scored according to a defined scheme during a CLE-test performed before and after surgery. Results: Forty-five of 65 eligible patients, mean age 15.9 years, were included. Post-operatively, 38/45 (84%) patients reported less symptoms, whereas CLE-test scores had improved in all, of whom 16/45 (36%) had no signs of obstruction. Most improvements were at the supraglottic level, but 21/45 (47%) also improved at the glottic level. Two of 65 patients had complications; self-limiting vocal fold paresis and scarring/shortening of plica ary-epiglottica. Conclusion: Supraglottoplasty improves symptoms and decreases laryngeal obstruction in patients with severe supraglottic EILO, and appears safe in highly selected cases.
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Affiliation(s)
- Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - Tiina Andersen
- Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway.,Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway
| | | | - Lorentz Sandvik
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ola Drange Røksund
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege H Clemm
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
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12
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Gaston AF, Marti Peiro A, Hapkova I, Durand F. Exploring physiological parameters in ski mountaineering during world cup races. INT J PERF ANAL SPOR 2019. [DOI: 10.1080/24748668.2019.1597399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Anne-Fleur Gaston
- Laboratoire Européen Performance Santé Altitude, Université de Perpignan Via Domitia, Font-Romeu, France
- Unité de Physiologie des Exercices et Activités en Conditions Extrêmes, Institut de Recherche Biomédicale des Armées, Brétigny-sur-Orge, France
| | - Adrià Marti Peiro
- Laboratoire Européen Performance Santé Altitude, Université de Perpignan Via Domitia, Font-Romeu, France
- Nässjö Basket, Nässjö, Sweden
| | - Ilona Hapkova
- Laboratoire Européen Performance Santé Altitude, Université de Perpignan Via Domitia, Font-Romeu, France
- ECOWAS Campus, Lomé, Togo
| | - Fabienne Durand
- Laboratoire Européen Performance Santé Altitude, Université de Perpignan Via Domitia, Font-Romeu, France
- Catedra de Medicina de Muntanya i del Medi Natural i de Simulacio Clinica, Universitat de Girona, Girona, Spain
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13
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Asthma and exercise-induced respiratory disorders in athletes. The position paper of the Polish Society of Allergology and Polish Society of Sports Medicine. Postepy Dermatol Alergol 2019; 36:1-10. [PMID: 30858772 PMCID: PMC6409872 DOI: 10.5114/ada.2019.82820] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 01/19/2019] [Indexed: 11/27/2022] Open
Abstract
Exercise-induced respiratory symptoms describe acute airway narrowing that occurs as a result of exercise. It includes exercise-induced bronchoconstriction (EIB) and exercise-induced asthma (EIA) issues. To provide clinicians with practical guidelines, a multidisciplinary panel of stakeholders was convened to review the pathogenesis of EIB/EIA and to develop evidence-based guidelines for the diagnosis and treatment. Recommendations for the diagnosis and treatment of EIB were developed. High-intensity exercise in polluted environment (cold air, humidity, contamination, allergens) may increase the risk of EIB and asthma symptoms in athletes. Diagnostic procedures should include history taking, physical examination, atopy assessment and functional tests of the respiratory system. A strong recommendation was made for regular use of inhaled glucocorticosteroids and avoidance of short-acting β2-agonists as the only treatment. The treatment of asthma in athletes should always take into account current anti-doping regulations. This position paper reflects the currently available evidence.
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14
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Sandnes A, Andersen T, Clemm HH, Hilland M, Vollsæter M, Heimdal JH, Eide GE, Halvorsen T, Røksund OD. Exercise-induced laryngeal obstruction in athletes treated with inspiratory muscle training. BMJ Open Sport Exerc Med 2019; 5:e000436. [PMID: 30792880 PMCID: PMC6350751 DOI: 10.1136/bmjsem-2018-000436] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 02/04/2023] Open
Abstract
Background Exercise-induced laryngeal obstruction (EILO) is common in athletes and presents with dyspnoea, chest tightness, inspiratory stridor and sometimes panic reactions. The evidence for conservative treatment is weak, but case reports suggest effects from inspiratory muscle training (IMT). We aimed to explore effects from IMT used in athletes with EILO. Method Twenty-eight athletes, mean age 16.4 years, diagnosed with EILO at our clinic, participated in a 6-week treatment programme, using a resistive flow-dependent IMT device (Respifit S). Four athletes competed at international level, 13 at national and 11 at regional levels. Video-recorded continuous transnasal flexible laryngoscopy was performed from rest to peak exercise (continuous laryngoscopy exercise (CLE) test) and scored before and 2–4 weeks after the training period. Ergospirometric variables were obtained from this CLE set-up. Lung function was measured according to guidelines. Symptom scores and demographic variables were obtained from a questionnaire. Results After the treatment period, symptoms had decreased in 22/28 (79%) participants. Mean overall CLE score had improved after treatment (p<0.001), with the scores becoming normal in five athletes but worse in two. Most of the improvement was explained by changes at the glottic laryngeal level (p=0.009). Ergospirometric variables revealed significantly higher peak minute ventilation explained by higher tidal volumes and were otherwise unchanged. Conclusion This explorative study underlines the heterogeneous treatment response of EILO and suggests that IMT may become an efficient conservative treatment tool in subgroups, possibly contributing to better control of the vocal folds. The signals from this study should be tested in future controlled interventional studies.
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Affiliation(s)
- Astrid Sandnes
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tiina Andersen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Thoracic Department, Norwegian Advisory Unit on Home Mechanical Ventilation, Bergen, Norway.,Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway
| | - Hege Havstad Clemm
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Thoracic Department, Norwegian Advisory Unit on Home Mechanical Ventilation, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ola Drange Røksund
- Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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15
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Combes A, Dekerle J, Dumont X, Twomey R, Bernard A, Daussin F, Bougault V. Continuous exercise induces airway epithelium damage while a matched-intensity and volume intermittent exercise does not. Respir Res 2019; 20:12. [PMID: 30654798 PMCID: PMC6337858 DOI: 10.1186/s12931-019-0978-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While continuous exercise (CE) induces greater ventilation ([Formula: see text]E) when compared to intermittent exercise (IE), little is known of the consequences on airway damage. Our aim was to investigate markers of epithelial cell damage - i.e. serum levels of CC16 and of the CC16/SP-D ratio - during and following a bout of CE and IE of matched work. METHODS Sixteen healthy young adults performed a 30-min continuous (CE) and a 60-min intermittent exercise (IE; 1-min work: 1-min rest) on separate occasions in a random order. Intensity was set at 70% of their maximum work rate (WRmax). Heart rate (HR) and [Formula: see text]E were measured throughout both tests. Blood samples were taken at rest, after the 10th min of the warm-up, at the end of both exercises, half way through IE (matched time but 50% work done for IE) as well as 30- and 60-min post-exercise. Lactate and CC16 and SP-D were determined. RESULTS Mean [Formula: see text]E was higher for CE compared to IE (85 ± 17 l.min- 1 vs 50 ± 8 l.min- 1, respectively; P < 0.001). Serum-based markers of epithelial cell damage remained unchanged during IE. Interaction of test × time was observed for SP-D (P = 0.02), CC16 (μg.l- 1) (P = 0.006) and CC16/SP-D ratio (P = 0.03). Maximum delta CC16/SP-D was significantly correlated with mean [Formula: see text]E sustained (r = 0.83, P < 0.001) during CE but not during IE. CONCLUSION The 30-min CE performed at 70% WRmax induced mild airway damage, while a time- or work-matched IE did not. The extent of the damage during CE was associated with the higher ventilation rate.
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Affiliation(s)
- Adrien Combes
- URePSSS, Unité de Recherche Pluridisciplinaire Sport, Santé, Société, Lille, France
| | - Jeanne Dekerle
- Fatigue and Exercise Laboratory, Centre for Sport Exercise Science and Medicine (SESAME), University of Brighton, Eastbourne, UK
| | - Xavier Dumont
- Louvain Center of Toxicology and Applied Pharmacology, Catholic University of Louvain, Brussels, Belgium
| | - Rosie Twomey
- Fatigue and Exercise Laboratory, Centre for Sport Exercise Science and Medicine (SESAME), University of Brighton, Eastbourne, UK
| | - Alfred Bernard
- Louvain Center of Toxicology and Applied Pharmacology, Catholic University of Louvain, Brussels, Belgium
| | - Frédéric Daussin
- URePSSS, Unité de Recherche Pluridisciplinaire Sport, Santé, Société, Lille, France
| | - Valérie Bougault
- URePSSS, Unité de Recherche Pluridisciplinaire Sport, Santé, Société, Lille, France. .,LAMHESS, Université Côte d'Azur, Nice, France. .,Eurasport, 413 Avenue Eugène Avinée, 59120, Loos, France.
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16
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Hallstrand TS, Leuppi JD, Joos G, Hall GL, Carlsen KH, Kaminsky DA, Coates AL, Cockcroft DW, Culver BH, Diamant Z, Gauvreau GM, Horvath I, de Jongh FHC, Laube BL, Sterk PJ, Wanger J. ERS technical standard on bronchial challenge testing: pathophysiology and methodology of indirect airway challenge testing. Eur Respir J 2018; 52:13993003.01033-2018. [PMID: 30361249 DOI: 10.1183/13993003.01033-2018] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/20/2018] [Indexed: 12/20/2022]
Abstract
Recently, this international task force reported the general considerations for bronchial challenge testing and the performance of the methacholine challenge test, a "direct" airway challenge test. Here, the task force provides an updated description of the pathophysiology and the methods to conduct indirect challenge tests. Because indirect challenge tests trigger airway narrowing through the activation of endogenous pathways that are involved in asthma, indirect challenge tests tend to be specific for asthma and reveal much about the biology of asthma, but may be less sensitive than direct tests for the detection of airway hyperresponsiveness. We provide recommendations for the conduct and interpretation of hyperpnoea challenge tests such as dry air exercise challenge and eucapnic voluntary hyperpnoea that provide a single strong stimulus for airway narrowing. This technical standard expands the recommendations to additional indirect tests such as hypertonic saline, mannitol and adenosine challenge that are incremental tests, but still retain characteristics of other indirect challenges. Assessment of airway hyperresponsiveness, with direct and indirect tests, are valuable tools to understand and to monitor airway function and to characterise the underlying asthma phenotype to guide therapy. The tests should be interpreted within the context of the clinical features of asthma.
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Affiliation(s)
- Teal S Hallstrand
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Joerg D Leuppi
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, and Medical Faculty University of Basel, Basel, Switzerland
| | - Guy Joos
- Dept of Respiratory Medicine, University of Ghent, Ghent, Belgium
| | - Graham L Hall
- Children's Lung Health, Telethon Kids Institute, School of Physiotherapy and Exercise Science, Curtin University, and Centre for Child Health Research University of Western Australia, Perth, Australia
| | - Kai-Håkon Carlsen
- University of Oslo, Institute of Clinical Medicine, and Oslo University Hospital, Division of Child and Adolescent Medicine, Oslo, Norway
| | - David A Kaminsky
- Pulmonary and Critical Care, University of Vermont College of Medicine, Burlington, VT, USA
| | - Allan L Coates
- Division of Respiratory Medicine, Translational Medicine, Research Institute-Hospital for Sick Children, University of Toronto, ON, Canada
| | - Donald W Cockcroft
- Division of Respirology, Critical Care and Sleep Medicine, Royal University Hospital, Saskatoon, SK, Canada
| | - Bruce H Culver
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Zuzana Diamant
- Dept of Clinical Pharmacy and Pharmacology and QPS-Netherlands, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Dept of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Gail M Gauvreau
- Division of Respirology, Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ildiko Horvath
- Dept of Pulmonology, National Korányi Institute of Pulmonology, Budapest, Hungary
| | - Frans H C de Jongh
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Beth L Laube
- Division of Pediatric Pulmonology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter J Sterk
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jack Wanger
- Pulmonary Function Testing and Clinical Trials Consultant, Rochester, MN, USA
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17
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Bonini M, Silvers W. Exercise-Induced Bronchoconstriction: Background, Prevalence, and Sport Considerations. Immunol Allergy Clin North Am 2018; 38:205-214. [PMID: 29631730 DOI: 10.1016/j.iac.2018.01.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Matteo Bonini
- Airways Disease Section, National Heart and Lung Institute (NHLI), Royal Brompton Hospital, Imperial College London, Dovehouse Street, London SW3 6LY, UK.
| | - William Silvers
- University of Colorado School of Medicine, 13001 E 17th Place, Aurora, CO 80045, USA
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18
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Kennedy MD, Faulhaber M. Respiratory Function and Symptoms Post Cold Air Exercise in Female High and Low Ventilation Sport Athletes. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2018; 10:43-51. [PMID: 29178677 PMCID: PMC5705483 DOI: 10.4168/aair.2018.10.1.43] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/19/2017] [Accepted: 07/31/2017] [Indexed: 12/04/2022]
Abstract
Purpose Cold weather exercise is common in many regions of the world; however, it is unclear whether respiratory function and symptom worsen progressively with colder air temperatures. Furthermore, it is unclear whether high-ventilation sport background exacerbates dysfunction and symptoms. Methods Seventeen active females (measure of the maximum volume of oxygen [VO2max]: 49.6±6.6 mL·kg-1·min-1) completed on different days in random order 5 blinded running trials at 0℃, -5℃, -10℃, -15℃, and -20℃ (humidity 40%) in an environmental chamber. Distance, heart rate, and rating of perceived exertion (RPE) were measured within each trial; forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), forced expiratory flow at 25%-75% (FEF25-75), and forced expiratory flow at 50% (FEF50) were measured pre- and post-test (3, 6, 10, 15, and 20 minutes). Respiratory symptoms and global effort were measured post-test spirometry. Results Mean decreases were found in FEV1 (4%-5% at 0℃, -5℃, -10℃, and -15℃; 7% at -20℃). FEF25-75 and FEF50 decreased 7% and 11% at -15℃ and -20℃, respectively. Post-exertion spirometry results were decreased most at 3 to 6 minutes, recovering back to baseline at 20 minutes. Respiratory symptoms and global effort significantly increased at -15℃ and -20℃ with decreased heart rate. High-ventilation sports decreased function more than low-ventilation participants but had fewer symptoms. Conclusions These results indicate that intense exercise at cold air temperatures up to -20℃ is achievable; however, greater effort along with transient acute bronchoconstriction and symptoms of cough after exercising in temperatures colder than -15℃ are likely. It is recommended that individuals cover their mouth and reduce exercise intensity to ameliorate the effects of cold weather exercise.
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Affiliation(s)
- Michael D Kennedy
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada.
| | - Martin Faulhaber
- Department of Sport Science, Medical Section, University of Innsbruck, Innsbruck, Austria
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19
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Eucapnic Voluntary Hyperpnea: Gold Standard for Diagnosing Exercise-Induced Bronchoconstriction in Athletes? Sports Med 2017; 46:1083-93. [PMID: 27007599 PMCID: PMC4963444 DOI: 10.1007/s40279-016-0491-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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20
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Compact Eucapnic Voluntary Hyperpnoea Apparatus for Exercise-Induced Respiratory Disease Detection. SENSORS 2017; 17:s17051139. [PMID: 28509868 PMCID: PMC5470815 DOI: 10.3390/s17051139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/03/2017] [Accepted: 05/11/2017] [Indexed: 11/29/2022]
Abstract
Eucapnic voluntary hyperpnoea (EVH) challenge provides objective criteria for exercise-induced asthma (EIA) or exercise-induced bronchoconstriction (EIB), and it was recommended to justify the use of inhaled β2-agonists by athletes for the Olympics. This paper presents the development of a compact and easy-to-use EVH apparatus for assessing EIB in human subjects. The compact apparatus has been validated on human subjects and the results have been compared to the conventional EVH system. Twenty-two swimmers, including eleven healthy subjects and eleven subjects who had been physician-diagnosed with asthma, were recruited from sport and recreation centers throughout Auckland, New Zealand. Each subject performed two EVH challenge tests using the proposed breathing apparatus and the conventional Phillips EVH apparatus on separate days, respectively. Forced expiratory volume in one second (FEV1) was measured before and after the challenges. A reduction in FEV1 of 10% or more was considered positive. Of the eleven subjects who were previously diagnosed with asthma, EIB was present in all subjects (100%) in the compact EVH group, while it was presented in ten subjects (90.91%) in the conventional EVH challenge group. Of the eleven healthy subjects, EIB was present in one subject (4.55%) in the compact EVH group, while it was not present in the conventional EVH group. Experimental results showed that the compact EVH system has potential to become an alternative tool for EIB detection.
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21
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Inci D, Guggenheim R, Altintas DU, Wildhaber JH, Moeller A. Reported Exercise-Related Respiratory Symptoms and Exercise-Induced Bronchoconstriction in Asthmatic Children. J Clin Med Res 2017; 9:410-415. [PMID: 28392861 PMCID: PMC5380174 DOI: 10.14740/jocmr2935w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2017] [Indexed: 11/20/2022] Open
Abstract
Background Unlimited physical activity is one of the key issues of asthma control and management. We investigated how reliable reported exercise-related respiratory symptoms (ERRS) are in predicting exercise-induced bronchoconstriction (EIB) in asthmatic children. Methods In this prospective study, 179 asthmatic children aged 7 - 15 years were asked for specific questions on respiratory symptoms related to exercise and allocated into two groups according to whether they complained about symptoms. Group I (n = 134) consisted of children answering “yes” to one or more of the questions and group II (n = 45) consisted of children answering “no” to all of the questions. Results Sixty-four of 179 children showed a positive exercise challenge test (ECT). There was no difference in the frequency of a positive test between children in group I (n = 48) and group II (n = 12) (P = 0.47). The sensitivity of a positive report for ERRS to predict a positive ECT was only 37%, with a specificity of 0.72. Conclusion According to current guidelines, the report or lack of ERRS has direct consequences on treatment decisions. However, the history of ERRS did not predict EIB and one-third of asthmatic children without complaints of ERRS developed EIB during the ECT. This raises the question of the need for objective measures of bronchial hyperresponsiveness (BHR) in pediatric asthma management.
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Affiliation(s)
- Demet Inci
- Division of Respiratory Medicine, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Refoel Guggenheim
- Division of Respiratory Medicine, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Derya Ufuk Altintas
- Division of Paediatric Allergy and Immunology, Faculty of Medicine, University of Cukurova, 01330 Balcali, Saricam/Adana, Turkey
| | - Johannes H Wildhaber
- Department of Paediatrics, Cantonal Hospital Fribourg, HFR 1708 Freiburg, Switzerland
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
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22
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Westergren T, Berntsen S, Lødrup Carlsen KC, Mowinckel P, Håland G, Fegran L, Carlsen KH. Perceived exercise limitation in asthma: The role of disease severity, overweight, and physical activity in children. Pediatr Allergy Immunol 2017; 28:86-92. [PMID: 27734537 DOI: 10.1111/pai.12670] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Children with asthma may be less physically active than their healthy peers. We aimed to investigate whether perceived exercise limitation (EL) was associated with lung function or bronchial hyper-responsiveness (BHR), socioeconomic factors, prenatal smoking, overweight, allergic disease, asthma severity, or physical activity (PA). METHODS The 302 children with asthma from the 10-year examination of the Environment and Childhood Asthma birth cohort study underwent a clinical examination including perceived EL (structured interview of child and parent(s)), measure of overweight (body mass index by sex and age passing through 25 kg/m2 or above at 18 years), exercise-induced bronchoconstriction (forced expiratory volume in one-second (FEV1 ) pre- and post-exercise), methacholine bronchial challenge (severe BHR; provocative dose causing ≥20% decrease in FEV1 ≤ 1 μmol), and asthma severity score (dose of controller medication and exacerbations last 12 months). Multivariate logistic regression analyses were conducted to assess associations with perceived EL. RESULTS In the final model explaining 30.1%, asthma severity score (OR: 1.49, (1.32, 1.67)) and overweight (OR: 2.35 (1.14, 4.82)) only were significantly associated with perceived EL. Excluding asthma severity and allergic disease, severe BHR (OR: 2.82 (1.38, 5.76)) or maximal reduction in FEV1 post-exercise (OR: 1.48 (1.10, 1.98)) and overweight (OR: 2.15 (1.13, 4.08) and 2.53 (1.27, 5.03)) explained 9.7% and 8.4% of perceived EL, respectively. CONCLUSIONS Perceived EL in children with asthma was independently associated with asthma severity and overweight, the latter doubling the probability of perceived EL irrespectively of asthma severity, allergy status, socioeconomic factors, prenatal smoking, or PA.
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Affiliation(s)
- Thomas Westergren
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Sveinung Berntsen
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Karin C Lødrup Carlsen
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Petter Mowinckel
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Geir Håland
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Liv Fegran
- Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Kai-Håkon Carlsen
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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23
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Weiler JM, Brannan JD, Randolph CC, Hallstrand TS, Parsons J, Silvers W, Storms W, Zeiger J, Bernstein DI, Blessing-Moore J, Greenhawt M, Khan D, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Schuller DE, Tilles SA, Wallace D. Exercise-induced bronchoconstriction update-2016. J Allergy Clin Immunol 2016; 138:1292-1295.e36. [PMID: 27665489 DOI: 10.1016/j.jaci.2016.05.029] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/13/2016] [Accepted: 05/25/2016] [Indexed: 12/26/2022]
Abstract
The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.
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24
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Riiser A. Bronchial hyperresponsiveness in childhood: A narrative review. World J Respirol 2016; 6:63-68. [DOI: 10.5320/wjr.v6.i2.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/02/2016] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Bronchial hyperresponsiveness (BHR) is an important but not asthma-specific characteristic and can be assessed by direct and indirect methods, based on the stimulus causing airway obstruction. BHR has been proposed as a prognostic marker of asthma severity and persistence, and may also be used to control pharmacological management of asthma. The most recent data on the prevalence and development of BHR in childhood and its predictive value for subsequent asthma development in late adolescence and adulthood is discussed in this review. According to the BHR-related scientific articles written in the English language and indexed in the publicly searchable PubMed database, the prevalence of BHR varies based upon the methods used to assess it and the population examined. In general, however, BHR prevalence is reduced as children grow older, in both healthy and asthmatic populations. While asthma can be predicted by BHR, the predictive value is limited. Reduced lung function, allergic sensitization, female sex, and early respiratory illness have been identified as risk factors for BHR. The collective studies further indicate that BHR is a dynamic feature related to asthma, but asymptomatic BHR is also common. Ultimately, the prevalence of BHR varies depending on the population, the environment, and the evaluation methods used. While both the methacholine challenge and the exercise test may predict asthma in adolescence or early adulthood, the predictive value is higher for the methacholine challenge compared to the exercise test. The collective data presented in the present study demonstrate how BHR develops through childhood and its relation to bronchial asthma.
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25
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Vigorous Exercise Can Cause Abnormal Pulmonary Function in Healthy Adolescents. Ann Am Thorac Soc 2016; 12:872-7. [PMID: 25909448 DOI: 10.1513/annalsats.201411-520oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Although exercise-induced bronchoconstriction is more common in adolescents with asthma, it also manifests in healthy individuals without asthma. The steady-state exercise protocol is widely used and recommended by the American Thoracic Society (ATS) as a method to diagnose exercise-induced bronchoconstriction. Airway narrowing in response to exercise is thought to be related to airway wall dehydration secondary to hyperventilation. More rigorous exercise protocols may have a role in detecting exercise-induced bronchoconstriction in those who otherwise have a normal response to steady-state exercise challenge. OBJECTIVES The objective of this study was to determine the effect of two different exercise protocols--a constant work rate protocol and a progressive ramp protocol--on pulmonary function testing in healthy adolescents. We hypothesized that vigorous exercise protocols would lead to reductions in lung function in healthy adolescents. METHODS A total of 56 healthy adolescents (mean age, 15.2 ± 3.3 [SD] years) were recruited to perform two exercise protocols: constant work rate exercise test to evaluate for exercise-induced bronchoconstriction (as defined by ATS) and standardized progressive ramp protocol. Pulmonary function abnormalities were defined as a decline from baseline in FEV1 of greater than 10%. MEASUREMENTS AND MAIN RESULTS Ten participants (17.8%) had a significant drop in FEV1. Among those with abnormal lung function after exercise, three (30%) were after the ATS test only, five (50%) were after the ramp test only, and two (20%) were after both ATS and ramp tests. CONCLUSION Healthy adolescents demonstrate subtle bronchoconstriction after exercise. This exercise-induced bronchoconstriction may be detected in healthy adolescents via constant work rate or the progressive ramp protocol. In a clinical setting, ramp testing warrants consideration in adolescents suspected of having exercise-induced bronchoconstriction and who have normal responses to steady-state exercise testing.
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26
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Evjenth B, Hansen TE, Holt J. Exhaled nitric oxide decreases during exercise in non-asthmatic children. CLINICAL RESPIRATORY JOURNAL 2016; 7:121-7. [PMID: 22521142 DOI: 10.1111/j.1752-699x.2012.00292.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Exhaled nitric oxide (FENO) measurements are recommended to be performed before spirometry and exercise challenge tests because forced breathing might influence FENO values. Information on the effect of exercise on FENO is lacking in non-asthmatic children. AIM To investigate the effect on FENO of a standardized exercise challenge test on a treadmill in non-asthmatic children with and without allergic rhinoconjunctivitis (AR) symptoms. METHODS From the case-control study 'Asthma and allergy among school children in Nordland', 330 non-asthmatic pupils age 8-16 years were enrolled. FENO was measured at baseline and at 1 min and 30 min after exercise challenge test by the single breath technique with EcoMedics Exhalazer® (Eco Physics, Duernten, Switzerland). RESULTS Pair-wise comparison of FENO from baseline demonstrated a highly significant reduction in FENO post-exercise for all children at 1 min (27.4%) and at 30 min (16.1%) (P < 0.001). The AR group had a significantly higher decline in FENO value at 1 min post-exercise compared to the non-AR group, 4.2 parts per billion (ppb) vs 2.6 ppb (P < 0.001). Decline in FENO immediately post-exercise was more significant if baseline FENO was ≥ 20 ppb; mean reduction 9.9 (95% CI: 8.7-11.4) ppb. CONCLUSION FENO is reduced by 27.4% immediately after a standardized treadmill exercise test in non-asthmatic children. Pupils reporting AR symptoms demonstrate a larger decline in FENO value at 1 min post-exercise compared to pupils without AR symptoms. These findings confirm that children should refrain from physical activity before FENO measurement.
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Affiliation(s)
- Bjørg Evjenth
- Department of Pediatrics, Division of Pediatrics, Obstetrics and Women's Health, Nordland Hospital, Bodø, Norway.
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27
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Moeller A, Carlsen KH, Sly PD, Baraldi E, Piacentini G, Pavord I, Lex C, Saglani S. Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation. Eur Respir Rev 2016; 24:204-15. [PMID: 26028633 DOI: 10.1183/16000617.00003914] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
This review focuses on the methods available for measuring reversible airways obstruction, bronchial hyperresponsiveness (BHR) and inflammation as hallmarks of asthma, and their role in monitoring children with asthma. Persistent bronchial obstruction may occur in asymptomatic children and is considered a risk factor for severe asthma episodes and is associated with poor asthma outcome. Annual measurement of forced expiratory volume in 1 s using office based spirometry is considered useful. Other lung function measurements including the assessment of BHR may be reserved for children with possible exercise limitations, poor symptom perception and those not responding to their current treatment or with atypical asthma symptoms, and performed on a higher specialty level. To date, for most methods of measuring lung function there are no proper randomised controlled or large longitudinal studies available to establish their role in asthma management in children. Noninvasive biomarkers for monitoring inflammation in children are available, for example the measurement of exhaled nitric oxide fraction, and the assessment of induced sputum cytology or inflammatory mediators in the exhaled breath condensate. However, their role and usefulness in routine clinical practice to monitor and guide therapy remains unclear, and therefore, their use should be reserved for selected cases.
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Affiliation(s)
- Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kai-Hakon Carlsen
- Dept of Paediatrics, Women and Children's Division, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Peter D Sly
- Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Australia
| | - Eugenio Baraldi
- Women's and Children's Health Department, Unit of Respiratory Medicine and Allergy, University of Padova, Padova, Italy
| | - Giorgio Piacentini
- Paediatric Section, Dept of Life and Reproduction Sciences, University of Verona, Verona, Italy
| | - Ian Pavord
- Dept of Respiratory Medicine, University of Oxford, NDM Research Building, Oxford, UK
| | - Christiane Lex
- Dept of Paediatric Cardiology and Intensive Care Medicine, Division of Paediatric Respiratory Medicine, University Hospital Goettingen, Goettingen, Germany
| | - Sejal Saglani
- Leukocyte Biology and Respiratory Paediatrics, National Heart and Lung Institute, Imperial College London, London, UK
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28
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Anderson SD. 'Indirect' challenges from science to clinical practice. Eur Clin Respir J 2016; 3:31096. [PMID: 26908255 PMCID: PMC4764958 DOI: 10.3402/ecrj.v3.31096] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/25/2016] [Indexed: 12/17/2022] Open
Abstract
Indirect challenges act to provoke bronchoconstriction by causing the release of endogenous mediators and are used to identify airway hyper-responsiveness. This paper reviews the historical development of challenges, with exercise, eucapnic voluntary hyperpnoea (EVH) of dry air, wet hypertonic saline, and with dry powder mannitol, that preceded their use in clinical practice. The first challenge developed for clinical use was exercise. Physicians were keen for a standardized test to identify exercise-induced asthma (EIA) and to assess the effect of drugs such as disodium cromoglycate. EVH with dry air became a surrogate for exercise to increase ventilation to very high levels. A simple test was developed with EVH and used to identify EIA in defence force recruits and later in elite athletes. The research findings with different conditions of inspired air led to the conclusion that loss of water by evaporation from the airway surface was the stimulus to EIA. The proposal that water loss caused a transient increase in osmolarity led to the development of the hypertonic saline challenge. The wet aerosol challenge with 4.5% saline, provided a known osmotic stimulus, to which most asthmatics were sensitive. To simplify the osmotic challenge, a dry powder of mannitol was specially prepared and encapsulated. The test pack with different doses and an inhaler provided a common operating procedure that could be used at the point of care. All these challenge tests have a high specificity to identify currently active asthma. All have been used to assess the benefit of treatment with inhaled corticosteroids. Over the 50 years, the methods for testing became safer, less complex, and less expensive and all used forced expiratory volume in 1 sec to measure the response. Thus, they became practical to use routinely and were recommended in guidelines for use in clinical practice.
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Affiliation(s)
- Sandra D Anderson
- Sydney Medical School, Central Clinical School, University of Sydney, Sydney, NSW, Australia;
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29
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Rundell KW, Anderson SD, Sue-Chu M, Bougault V, Boulet LP. Air quality and temperature effects on exercise-induced bronchoconstriction. Compr Physiol 2016; 5:579-610. [PMID: 25880506 DOI: 10.1002/cphy.c130013] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is exaggerated constriction of the airways usually soon after cessation of exercise. This is most often a response to airway dehydration in the presence of airway inflammation in a person with a responsive bronchial smooth muscle. Severity is related to water content of inspired air and level of ventilation achieved and sustained. Repetitive hyperpnea of dry air during training is associated with airway inflammatory changes and remodeling. A response during exercise that is related to pollution or allergen is considered EIB. Ozone and particulate matter are the most widespread pollutants of concern for the exercising population; chronic exposure can lead to new-onset asthma and EIB. Freshly generated emissions particulate matter less than 100 nm is most harmful. Evidence for acute and long-term effects from exercise while inhaling high levels of ozone and/or particulate matter exists. Much evidence supports a relationship between development of airway disorders and exercise in the chlorinated pool. Swimmers typically do not respond in the pool; however, a large percentage responds to a dry air exercise challenge. Studies support oxidative stress mediated pathology for pollutants and a more severe acute response occurs in the asthmatic. Winter sport athletes and swimmers have a higher prevalence of EIB, asthma and airway remodeling than other athletes and the general population. Because of fossil fuel powered ice resurfacers in ice rinks, ice rink athletes have shown high rates of EIB and asthma. For the athlete training in the urban environment, training during low traffic hours and in low traffic areas is suggested.
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Affiliation(s)
- Kenneth W Rundell
- Department of The Basic Sciences, The Commonwealth Medical College, Scranton, PA, USA
| | - Sandra D Anderson
- Clinical Professor Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Malcolm Sue-Chu
- Department of Thoracic Medicine, St Olavs Hospital, Trondheim University Hospital, Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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30
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Chateaubriand do Nascimento Silva Filho MJ, Gonçalves AV, Tavares Viana M, Peixoto DM, Cavalcanti Sarinho ES, Rizzo JÂ. Exercise-induced bronchoconstriction diagnosis in asthmatic children: comparison of treadmill running and eucapnic voluntary hyperventilation challenges. Ann Allergy Asthma Immunol 2015; 115:277-81. [PMID: 26238422 DOI: 10.1016/j.anai.2015.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/02/2015] [Accepted: 07/12/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Exercise-induced bronchoconstriction (EIB) occurs in up to 90% of young people with asthma and can be diagnosed using serial measurements of forced expiratory volume in 1 second (FEV1) after standardized exercise, usually treadmill running (TR). Eucapnic voluntary hyperventilation (EVH) is a guideline-recommended alternative challenge for EIB diagnosis. The 2 methods have not been compared for EIB diagnosis in this population. OBJECTIVE To compare 2 methods of EIB diagnosis in children and adolescents with asthma. METHODS Thirty-four children 8 to 18 years of age attending the allergy clinic of the Hospital das Clínicas (Recife, Brazil) from September through December 2013 were examined. All underwent a basal FEV1 determination followed by TR for 8 minutes or EVH for 6 minutes on consecutive days. The first challenge was chosen at random. Serial FEV1 determinations were obtained at 3, 5, 7, 10, 15, and 30 minutes after the challenge and the test result was considered positive if at least 2 consecutive FEV1 measurements decreased at least 10% below the basal value. RESULTS Thirteen patients responded to the 2 challenges, 6 only after TR and 4 exclusively after EVH (agreement 71%, κ = 0.41). The 95% limits of agreement of FEV1 decreasing after the challenges were widely spread (mean 0.1%, limits 19.8% to -19.6%). CONCLUSION The 2 tests cannot be used interchangeably and the reproducibility of the FEV1 response to the EVH challenge has to be properly evaluated to better understand its role in EIB diagnosis.
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Affiliation(s)
| | - Adriana Velozo Gonçalves
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Marcelo Tavares Viana
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Décio Medeiros Peixoto
- Departments of Pediatrics and Allergy, Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | - José Ângelo Rizzo
- Departments of Pneumology and Allergy, Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
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31
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Bonini M, Palange P. Exercise-induced bronchoconstriction: new evidence in pathogenesis, diagnosis and treatment. Asthma Res Pract 2015; 1:2. [PMID: 27965757 PMCID: PMC4970375 DOI: 10.1186/s40733-015-0004-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 05/07/2015] [Indexed: 11/10/2022] Open
Abstract
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 (EIBA) from the occurrence of bronchial obstruction in subjects without other symptoms and signs of asthma (EIBwA). 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 EIBA and EIBwA 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.
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Affiliation(s)
- Matteo Bonini
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Viale dell'Universita', 37, 00185 Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Viale dell'Universita', 37, 00185 Rome, Italy
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32
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Stensrud T, Stang J, Thorsen E, Bråten V. Exhaled nitric oxide concentration in the period of 60 min after submaximal exercise in the cold. Clin Physiol Funct Imaging 2014; 36:85-91. [PMID: 25302764 DOI: 10.1111/cpf.12196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Fractional expired nitric oxide (FENO ) is decreased after exercise. The effect of exercise in the cold upon FENO is unknown. PURPOSE To examine changes in FENO after a short, high intensive exercise test in a cold and in a temperate environment. METHODS Twenty healthy well-trained subjects (eight females) aged 18-28 years performed an 8-min exercise test at 18°C (SD = 1.0) and -10°C (SD = 1.2) ambient temperature. The tests were performed in a climate chamber in random order. The workload corresponded to 90-95% of peak heart rate (HRpeak ) during the last 4 min. FENO was measured offline. Exhaled gas was sampled in Mylar(®) bags using a collector kit with a flow restrictor and analysed within 2 h. FENO was measured before exercise and repeatedly during the first hour after. ANOVA for repeated measures was used to compare differences in FENO after exercise between environments. RESULTS There was no difference in baseline FENO . A significant difference in FENO between environments was found after warm-up and from 20 to 30 min after exercise, with FENO being lower after exercise in the cold (P<0.05). The maximal reduction in FENO was seen 5 min after exercise and was not different between environments. CONCLUSION Recovery of FENO was slower after exercising in -10°C compared with 18°C.
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Affiliation(s)
- Trine Stensrud
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Julie Stang
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Einar Thorsen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Veslemøy Bråten
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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Westergren T, Ommundsen Y, Lødrup Carlsen KC, Carlsen KH, Mowinckel P, Fegran L, Berntsen S. A nested case-control study: personal, social and environmental correlates of vigorous physical activity in adolescents with asthma. J Asthma 2014; 52:155-61. [PMID: 25134784 DOI: 10.3109/02770903.2014.955190] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Physical activity (PA) is associated with health benefits. Children and adolescents with asthma may be limited in their PA, particularly at vigorous intensity due to asthma symptoms or poor psychological adjustment to asthma. We aimed to investigate if self-perceived competence, enjoyment, support from others and social-physical environment were associated with vigorous physical activity (VPA) and secondarily to assess if such associations were modified by asthma and asthma severity. METHODS Data from a nested case-control study at 13 years of age within the birth-cohort Environment and Childhood Asthma Study were compiled from 95 participants with and 79 without asthma. The participants completed a questionnaire designed to capture self-perceived competence, enjoyment, support from others and social-physical environment. VPA, defined as ≥ 6 Metabolic Equivalents, was recorded objectively by SenseWear™ Pro2 Armband. Asthma severity was assessed pragmatically by lung function and use of inhaled glucocorticosteroids and β2-agonists and incidence of exacerbations in the last 14 days. Data were analysed using linear regression analysis. RESULTS No significant differences between adolescents with and without asthma were identified in terms of VPA, competence-enjoyment, support from others and social-physical environment. Peer support (b = 0.29 (0.05-0.52)) and competence-enjoyment (b = 0.23 (0.01-0.44)) were significantly and positively associated with VPA, and teacher support (b = -0.26 (-0.50 to -0.02)) were inversely associated. The model explained 25% of the variance in VPA. CONCLUSIONS Peer support and competence-enjoyment were positively associated with increased VPN in adolescents irrespectively of asthma and asthma severity.
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Affiliation(s)
- Thomas Westergren
- Faculty of Health and Sport Sciences, University of Agder , Grimstad/Kristiansand , Norway
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34
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Perpiñá Tordera M, García Río F, Álvarez Gutierrez FJ, Cisneros Serrano C, Compte Torrero L, Entrenas Costa LM, Melero Moreno C, Rodríguez Nieto MJ, Torrego Fernández A. Guidelines for the Study of Nonspecific Bronchial Hyperresponsiveness in Asthma. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.arbr.2013.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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35
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Laslovich SM, Laslovich JM. Exercise and Asthma. Strength Cond J 2013. [DOI: 10.1519/ssc.0b013e31829d232f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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36
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Perpiñá Tordera M, García Río F, Álvarez Gutierrez FJ, Cisneros Serrano C, Compte Torrero L, Entrenas Costa LM, Melero Moreno C, Rodríguez Nieto MJ, Torrego Fernández A. Guidelines for the study of nonspecific bronchial hyperresponsiveness in asthma. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). Arch Bronconeumol 2013; 49:432-46. [PMID: 23896599 DOI: 10.1016/j.arbres.2013.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 05/10/2013] [Accepted: 05/13/2013] [Indexed: 11/20/2022]
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Parsons JP, Hallstrand TS, Mastronarde JG, Kaminsky DA, Rundell KW, Hull JH, Storms WW, Weiler JM, Cheek FM, Wilson KC, Anderson SD. An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction. Am J Respir Crit Care Med 2013; 187:1016-27. [DOI: 10.1164/rccm.201303-0437st] [Citation(s) in RCA: 370] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Godfrey S, Fitch KD. Exercise-induced bronchoconstriction: celebrating 50 years. Immunol Allergy Clin North Am 2013; 33:283-97, vii. [PMID: 23830125 DOI: 10.1016/j.iac.2013.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article examines in detail the history of more than half a century of investigations into elucidating the causation of exercise-induced bronchoconstriction. Despite earnest attempts by many researchers from many countries, answers to some pivotal questions await the next generation of investigators into exercise-induced bronchoconstriction.
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Anderson SD, Kippelen P. Assessment of EIB: What you need to know to optimize test results. Immunol Allergy Clin North Am 2013; 33:363-80, viii. [PMID: 23830130 DOI: 10.1016/j.iac.2013.02.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Respiratory symptoms and asthma control questionnaires are poor predictors of the presence or severity of exercise-induced bronchoconstriction (EIB), and objective measurement is recommended. To optimize the chance of a positive test result, there are several factors to consider when exercising patients for EIB, including the ventilation achieved and sustained during exercise, water content of the inspired air, and the natural variability of the response. The high rate of negative exercise test results has led to the development of surrogates to identify EIB in laboratory or office settings, including eucapnic voluntary hyperpnea of dry air and inhalation of hyperosmolar aerosols.
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Affiliation(s)
- Sandra D Anderson
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales 2050, Missenden road, Australia.
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Wuestenfeld JC, Wolfarth B. Special considerations for adolescent athletic and asthmatic patients. Open Access J Sports Med 2013; 4:1-7. [PMID: 24379703 PMCID: PMC3871903 DOI: 10.2147/oajsm.s23438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Asthma is defined as a chronic inflammatory disorder of the airways with bronchial hyperresponsiveness and variable bronchoconstriction, and is one of the most common diseases in childhood and adolescence. Exercise-induced asthma-like symptoms and asthma are also frequently seen in highly trained athletes. Exercise-induced asthma (EIA) and exercise-induced bronchoconstriction (EIB) are found in 8%–10% of healthy school-aged children and in 35% of children with asthma. Highly increased ventilation, inhalation of cold, dry air and air pollutants (eg, chlorine) are thought to be important triggers for EIA and EIB. EIA is often experienced concurrently with vocal cord dysfunction, which needs to be considered during the differential diagnosis. The pharmacological treatment of EIA is similar to the treatment of asthma in nonexercising adolescents. The therapy is based on anti-inflammatory drugs (eg, inhaled glucocorticosteroids) and bronchodilators (eg, β2-agonists). The treatment of EIB is comparable to the treatment of EIA and leukotriene modifiers offer a new and promising treatment option, particularly in EIB. Generally, athletes may not use β2-agonists according to the prohibited list of the World Anti-Doping Agency (WADA). However, the WADA list contains specific β2-agonistic substances that are permitted to be used by inhalation.
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Affiliation(s)
- Jan C Wuestenfeld
- Department of Preventive and Rehabilitative Sports Medicine, Technical University Munich (TUM), Munich, Germany ; Institute for Applied Training Science (IAT), Leipzig, Germany
| | - Bernd Wolfarth
- Department of Preventive and Rehabilitative Sports Medicine, Technical University Munich (TUM), Munich, Germany ; Institute for Applied Training Science (IAT), Leipzig, Germany
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Petsky HL, Kynaston JA, McElrea M, Turner C, Isles A, Chang AB. Cough and exhaled nitric oxide levels: what happens with exercise? Front Pediatr 2013; 1:30. [PMID: 24400276 PMCID: PMC3864220 DOI: 10.3389/fped.2013.00030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 10/11/2013] [Indexed: 11/30/2022] Open
Abstract
Cough associated with exertion is often used as a surrogate marker of asthma. However, to date there are no studies that have objectively measured cough in association with exercise in children. Our primary aim was to examine whether children with a pre-existing cough have an increase in cough frequency during and post-exercise. We hypothesized that children with any coughing illness will have an increase in cough frequency post-exercise regardless of the presence of exercise-induced broncho-constriction (EIB) or atopy. In addition, we hypothesized that Fractional exhaled nitric oxide (FeNO) levels decreases post-exercise regardless of the presence of EIB or atopy. Children with chronic cough and a control group without cough undertook an exercise challenge, FeNO measurements and a skin prick test, and wore a 24-h voice recorder to objectively measure cough frequency. The association between recorded cough frequency, exercise, atopy, and presence of EIB was tested. We also determined if the change in FeNO post exercise related to atopy or EIB. Of the 50 children recruited (35 with cough, 15 control), 7 had EIB. Children with cough had a significant increase in cough counts (median 7.0, inter-quartile ranges, 0.5, 24.5) compared to controls (2.0, IQR 0, 5.0, p = 0.028) post-exercise. Presence of atopy or EIB did not influence cough frequency. FeNO level was significantly lower post-exercise in both groups but the change was not influenced by atopy or EIB. Cough post-exertion is likely a generic response in children with a current cough. FeNO level decreases post-exercise irrespective of the presence of atopy or EIB. A larger study is necessary confirm or refute our findings.
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Affiliation(s)
- Helen L Petsky
- Queensland Children's Medical Research Institute, Queensland University of Technology , Brisbane, QLD , Australia ; Queensland Children's Respiratory Centre, Royal Children's Hospital , Brisbane, QLD , Australia ; School of Nursing and Midwifery, The University of Queensland , Brisbane, QLD , Australia
| | | | - Margaret McElrea
- Queensland Children's Respiratory Centre, Royal Children's Hospital , Brisbane, QLD , Australia
| | - Catherine Turner
- School of Nursing and Midwifery, The University of Queensland , Brisbane, QLD , Australia
| | - Alan Isles
- Queensland Children's Medical Research Institute, Queensland University of Technology , Brisbane, QLD , Australia ; Queensland Children's Respiratory Centre, Royal Children's Hospital , Brisbane, QLD , Australia
| | - Anne B Chang
- Queensland Children's Medical Research Institute, Queensland University of Technology , Brisbane, QLD , Australia ; Queensland Children's Respiratory Centre, Royal Children's Hospital , Brisbane, QLD , Australia ; Child Health Division, Menzies School of Health , Darwin, NT , Australia
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Bertelsen RJ, Longnecker MP, Løvik M, Calafat AM, Carlsen KH, London SJ, Lødrup Carlsen KC. Triclosan exposure and allergic sensitization in Norwegian children. Allergy 2013; 68:84-91. [PMID: 23146048 DOI: 10.1111/all.12058] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Exposure to the synthetic antimicrobial chemical, triclosan, used in personal care products, has been hypothesized to lead to allergic disease. We investigated whether triclosan exposure was associated with allergic sensitization and symptoms in 10-year-old Norwegian children. METHODS Urinary concentrations of triclosan were measured in one first morning void from 623 children, collected during 2001-2004. Logistic regression models, controlling for urine specific gravity, parental allergic disease, maternal education, and household income, were fitted for allergic sensitization (either skin prick test positivity or serum-specific IgE ≥ 0.35 kU/l to at least one of 15 evaluated inhalant and food allergens), current rhinitis, and current asthma (questionnaire and exercise challenge test). RESULTS The adjusted odds ratio (aOR) for allergic sensitization among those in the fourth quartile of triclosan concentration was 2.0 [95% confidence interval (CI): 1.1, 3.4] compared with the reference group (<the limit of detection), and the aOR per log(10) unit increase in triclosan was 1.2 (95% CI: 1.0, 1.4). The aOR for current rhinitis was 1.9 (95% CI: 1.1, 3.4) for the fourth quartile and 1.2 (95% CI: 0.97, 1.4) per log(10) unit increase in triclosan. CONCLUSION Triclosan concentrations were associated with allergic sensitization, especially inhalant and seasonal allergens, rather than food allergens. Current rhinitis was associated with the highest levels of triclosan, whereas no association was seen for current asthma. These results are consistent with recent findings in other studies and provide additional evidence for an association between triclosan and allergy.
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Affiliation(s)
| | - M. P. Longnecker
- Department of Health and Human Services; Epidemiology Branch; National Institute of Environmental Health Sciences; National Institute of Health; RTP; NC; USA
| | - M. Løvik
- Department of Food, Water and Cosmetics; Division of Environmental Medicine; Norwegian Institute of Public Health; Oslo; Norway
| | - A. M. Calafat
- National Center for Environmental Health; Centers for Disease Control and Prevention; Atlanta; GA; USA
| | | | - S. J. London
- Department of Health and Human Services; Epidemiology Branch; National Institute of Environmental Health Sciences; National Institute of Health; RTP; NC; USA
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Fitch KD. Pharmacotherapy for exercise-induced asthma: allowing normal levels of activity and sport. Expert Rev Clin Pharmacol 2012; 3:139-52. [PMID: 22111539 DOI: 10.1586/ecp.09.52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is experienced by the majority of an estimated 300 million individuals who have asthma, a condition that affects all ages and is increasing globally. Respiratory water loss with dehydration of the airways causing mediator release and airway narrowing is considered the cause of EIB, the severity of which will be increased if the inhaled air is cold or polluted. Adequate control of asthma is essential to minimize or prevent EIB and permit normal levels of physical activity and sport. This is important because exercise is a necessary component of daily living, assists in obtaining and maintaining a healthy body and has been demonstrated to benefit asthmatics. Inhaled glucocorticosteroids and inhaled β(2)-adrenoceptor agonists (IβA) are the pharmacological agents of choice to manage asthma and minimize EIB, assisted when necessary, by other drugs including leukotriene receptor antagonists and chromones. Tolerance from daily use of IβA is of concern and more flexible drug therapy needs to be considered. Optimal use of inhalers to deliver drugs effectively requires closer attention. Pharmacogenetics may hold the key to future drug therapy.
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Affiliation(s)
- Kenneth D Fitch
- Department of Sports Science, Exercise and Health, Faculty of Life Sciences, University of Western Australia, M408 35 Stirling Highway, Crawley 6009, WA, Australia.
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Maurer M, Simonett D, Brutsche MH. Challenge of exercise-induced asthma and exercise-induced bronchoconstriction. Expert Rev Respir Med 2012; 3:13-9. [PMID: 20477279 DOI: 10.1586/17476348.3.1.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Exertional dyspnea is a common clinical problem seen with different etiologies in different clinical situations and may even be found in healthy individuals. Approximately 90% of asthmatic patients suffer from shortness of breath in the context of exercise. Dyspnea, occurring during or after exercise, can be the only clinical manifestation of asthma. On the other hand, bronchoconstriction may occur in the absence of asthma - so-called exercise-induced bronchoconstriction. In elite athletes and persons performing sports with high ventilatory demand, bronchospasm in the context of exercise may appear without the presence of asthma. In these circumstances, bronchoconstriction is characterized by neutrophilic inflammation in the bronchial epithelium. Exercise-induced bronchoconstriction in the absence of asthma is difficult to diagnose and to treat. Diagnostic tests are often complex to handle, infrequently performed and the majority miss well-defined cut-off points. Diagnosis is confirmed either by performing direct or indirect bronchial challenge tests for classical asthma or through indirect tests for exercise-induced bronchoconstriction. Therapy for both diseases is based on short-acting beta-agonists used 15 min before exercise. Daily basic therapy is different for asthmatics and nonasthmatics - where basic therapy consists of inhaled corticosteroids in asthmatics, leukotriene antagonists play a more important role in exercise-induced bronchoconstriction. In general, treatment of exercise-induced asthma follows the Global Initiative of Asthma guidelines.
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Affiliation(s)
- Marc Maurer
- Department of Pneumology, Kantonsspital Aarau, CH-5000 Aarau, Switzerland.
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Riiser A, Hovland V, Carlsen KH, Mowinckel P, Lødrup Carlsen KC. Does bronchial hyperresponsiveness in childhood predict active asthma in adolescence? Am J Respir Crit Care Med 2012; 186:493-500. [PMID: 22798318 DOI: 10.1164/rccm.201112-2235oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Bronchial hyperresponsiveness (BHR) is an important, but not specific, asthma characteristic. OBJECTIVES We aimed to assess the predictive value of BHR tested by methacholine and exercise challenge at age 10 years for active asthma 6 years later. METHODS From a Norwegian birth cohort, 530 children underwent methacholine challenge and exercise-induced bronchoconstriction (EIB) test (n = 478) at 10 years and structured interview and clinical examination at age 16 years. The methacholine dose causing 20% reduction in FEV(1) (PD(20)) and the reduction in FEV(1) (%) after a standardized treadmill test were used for BHR assessment. Active asthma was defined with at least two criteria positive: doctor's diagnosis of asthma, symptoms of asthma, and/or treatment for asthma in the last year. MEASUREMENTS AND MAIN RESULTS PD(20) and EIB at 10 years of age increased the risk of asthma (β = 0.94 [95% confidence interval (CI), 0.92-0.96] per μmol methacholine and β = 1.10 [95% CI, 1.06-1.15] per %, respectively). Separately the tests explained 10 and 7%, respectively, and together 14% of the variation in active asthma 6 years later. The predicted probability for active asthma at the age of 16 years increased with decreasing PD(20) and increasing EIB. The area under the curve (receiver operating characteristic curves) was larger for PD(20) (0.69; 95% CI, 0.62-0.75) than for EIB (0.60; 95% CI, 0.53-0.67). CONCLUSIONS BHR at 10 years was a significant but modest predictor of active asthma 6 years later, with methacholine challenge being superior to exercise test.
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Affiliation(s)
- Amund Riiser
- Department of Paediatrics, Oslo University Hospital, NO-0407 Oslo, Norway.
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Ansley L, Kippelen P, Dickinson J, Hull JHK. Misdiagnosis of exercise-induced bronchoconstriction in professional soccer players. Allergy 2012; 67:390-5. [PMID: 22175650 DOI: 10.1111/j.1398-9995.2011.02762.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Physicians typically rely heavily on self-reported symptoms to make a diagnosis of exercise-induced bronchoconstriction (EIB). However, in elite sport, respiratory symptoms have poor diagnostic value. In 2009, following a change in international sports regulations, all elite athletes suspected of asthma and/or EIB were required to undergo pulmonary function testing (PFT) to permit the use of inhaled β(2)-agonists. The aim of this study was to examine the diagnostic accuracy of physician diagnosis of asthma/EIB in English professional soccer players. METHODS Sixty-five players with a physician diagnosis of asthma/EIB were referred for pulmonary function assessment. Medication usage and respiratory symptoms were recorded by questionnaire. A bronchial provocation test with dry air was conducted in 42 players and a mannitol challenge in 18 players. Five players with abnormal resting spirometry performed a bronchodilator test. RESULTS Of the 65 players assessed, 57 (88%) indicated regular use of asthma medication. Respiratory symptoms during exercise were reported by 57 (88%) players. Only 33 (51%) of the players tested had a positive bronchodilator or bronchial provocation test. Neither symptoms nor the use of inhaled corticosteroids were predictive of pulmonary function tests' outcome. CONCLUSION A high proportion of English professional soccer players medicated for asthma/EIB (a third with reliever therapy only) do not present reversible airway obstruction or airway hyperresponsiveness to indirect stimuli. This underlines the importance of objective PFT to support a symptoms-based diagnosis of asthma/EIB in athletes.
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Affiliation(s)
- L. Ansley
- Department of Sport and Exercise Sciences; University of Northumbria; Newcastle; UK
| | - P. Kippelen
- Centre for Sports Medicine and Human Performance; Brunel University; Uxbridge; UK
| | - J. Dickinson
- Research Institute for Sport and Exercise Sciences; Liverpool John Moore's University; Liverpool; UK
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Abstract
This article reviews the diagnostic challenge methods-both exercise and surrogate-for diagnosis of exercise-induced bronchoconstriction (EIB) and EIB with known asthma. Indirect challenges that release the entire repertoire of mediators representative of EIB and asthma are more specific for diagnosis and are recommended over direct challenges such as methacholine challenge, which are sensitive but nonspecific. Self-reported history and empiric therapeutic trials are not adequate for diagnosis of EIB with or without known asthma. Objective pulmonary function documentation with bronchodilator reversibility or exercise or surrogate challenge are optimal for diagnosis of EIB or EIB with known asthma. Such objective pulmonary function documentation is optimal for the proper management and healthy lifestyle of the exercising athlete or individual.
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Affiliation(s)
- Christopher Randolph
- Department of Pediatrics/Medicine, Division of Allergy/Immunology Center for Allergy, Asthma, and Immunology, Yale University, Waterbury, CT 06708, USA.
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Abstract
Physical activity is beneficial for children with positive outcomes for mental and physical well-being. Allergic conditions unique to the sporting arena may serve as an impediment to participation in physical activity for allergic children. A common example is exercise-induced asthma; less common activity-related allergic conditions include food-dependent exercise-induced anaphylaxis, exercise-induced anaphylaxis, and exercise-induced urticaria. Allergic children may also be at risk of allergic reactions when exposed to allergens that are more commonly found in the sports environment, e.g., latex, sports drinks, and medications such as NSAIDs. Recent advances in our understanding of the patho-physiological and immunologic mechanisms that may account for these conditions have facilitated more effective and safer management strategies. There are also important immunologic lessons to be learnt with respect to specific physical factors that may result in diminished allergen tolerance; indeed, these lessons may facilitate safer allergen desensitisation regimens. The role of the immune system in exercise-induced immunoallergic syndromes, clinical aspects, and diagnostic and therapeutic approaches are discussed in this review.
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Affiliation(s)
- Stefano R Del Giacco
- Department of Medical Sciences M. Aresu, University of Cagliari, Cagliari, Italy.
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Leão da Silva P, de Mello MT, Cheik NC, Sanches PL, Munhoz da Silveira Campos R, Carnier J, Inoue D, do Nascimento CMO, Oyama LM, Tock L, Tufik S, Dâmaso AR. Reduction in the leptin concentration as a predictor of improvement in lung function in obese adolescents. Obes Facts 2012. [PMID: 23207491 DOI: 10.1159/000345840] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess the effects of weight loss on adipokines, asthma-related symptoms, exercise-induced bronchospasm (EIB) and lung function, and to evaluate the role of leptin and adiponectin levels on lung function after treatment in obese adolescents. METHODS 84 postpubertal obese adolescents were enrolled and distributed in quartiles according to weight loss (low (<2.5 kg), low to moderate (>2.5 and <8 kg), moderate (<8 and <14 kg) and massive (<14 kg)). Body composition was measured by plethysmography, and visceral and subcutaneous fat were detected by ultrasound. Serum levels of adiponectin and leptin were analyzed. Lung function, asthma and EIB were evaluated according to the American Thoracic Society criteria. Patients were submitted to 1 year of interdisciplinary intervention consisting of physiotherapy, medical, nutritional, exercise, and psychological therapy. RESULTS After treatment the moderate and massive weight loss promoted an increase in adiponectin and adiponectin/leptin (A/L) ratio as well as a decrease in leptin levels and a reduction in EIB frequency and asthma-related symptoms. Furthermore, the reduction in leptin levels was a predictor factor to improvement in lung function. CONCLUSION Interdisciplinary therapy was able to decrease EIB and asthma-related symptoms and to improve pro/anti-inflammatory adipokines. Additionally, the leptin concentration was a predictor factor to explain changes in lung function.
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Affiliation(s)
- Patrícia Leão da Silva
- Post Graduate Program of Nutrition, Universidade Federal de São Paulo, São Paulo, Brazil
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Riiser A, Hovland V, Mowinckel P, Carlsen KH, Carlsen KL. Bronchial hyperresponsiveness decreases through childhood. Respir Med 2011; 106:215-22. [PMID: 22015380 DOI: 10.1016/j.rmed.2011.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 09/23/2011] [Accepted: 09/30/2011] [Indexed: 01/09/2023]
Abstract
Limited knowledge exists about development of bronchial hyperresponsiveness (BHR) through adolescence. We aimed to assess changes in and risk factors for BHR in adolescence. From a Norwegian birth cohort 517 subjects underwent clinical examinations, structured interviews and methacholine challenges at age 10 and 16. BHR was divided into four categories: no BHR (cumulative methacholine dose required to reduce FEV(1) by 20% (PD(20)) >16 μmol), borderline BHR (PD(20) ≤16 and >8 μmol), mild to moderate BHR (PD(20) ≤8 and >1 μmol), and severe BHR (PD(20) ≤ 1 μmol). Logistic regression analysis was used to assess risk factors and possible confounders. The number of children with PD(20) ≤ 8 decreased from 172 (33%) to 79 (15%) from age 10-16 (p < 0.001). Most children (n = 295, 57%) remained in the same BHR (category) from age 10-16 (50% with no BHR), whereas the majority 182 (82%) of the 222 children who changed BHR category, had decreased severity at age 16. PD(20) ≤ 8 at age 10 was the major risk factor for PD(20) ≤ 8 6 years later (odds ratio 6.3), without significant confounding effect (>25% change) of gender, active rhinitis, active asthma, height, FEV(1)/FVC, or allergic sensitization. BHR decreased overall in severity through adolescence, was stable for the majority of children and only a minority (8%) had increased BHR from age 10 to 16. Mild to moderate and severe BHR at age 10 were major risk factors for PD(20) ≤ 8 at 16 years and not modified by asthma or body size.
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Affiliation(s)
- Amund Riiser
- Oslo University Hospital, Department of Paediatrics, Oslo, Norway.
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