Common causes of dyspnoea in athletes: a practical approach for diagnosis and management

Preparticipation Sports Physical Evaluation in Adolescents

The purpose of the preparticipation physical evaluation (PPE) is to promote safe participation in sport and to restrict participation only when necessary for the safety of the athlete. Based on expert opinion, this tool is considered standard of care. Six stakeholder professional societies collaboratively published the Preparticipation Physical Evaluation Monograph to guide a more useful experience for both examiners and athletes. The PPE uses systems-based history-taking and physical examinations to determine medical eligibility for participation in sport.

The therapeutic role of inspiratory muscle training in the management of asthma: a narrative review

Asthma is a disorder of the airways characterized by chronic airway inflammation, hyperresponsiveness, and variable recurring airway obstruction. Treatment options for asthma include pharmacological strategies, whereas nonpharmacological strategies are limited. Established pharmacological approaches to treating asthma may cause unwanted side effects and do not always afford adequate protection against asthma, possibly because of an individual's variable response to medications. A potential nonpharmacological intervention that is most available and cost effective is inspiratory muscle training (IMT), which is a technique targeted at increasing the strength and endurance of the diaphragm and accessory muscles of inspiration. Studies examining the impact of IMT on asthma have reported increases in inspiratory muscle strength and a reduction in the perception of dyspnea and medication use. However, because of the limited number of studies and discordant methods between studies more evidence is required to elucidate in individuals with asthma the efficacy of IMT on inspiratory muscle endurance, exercise capacity, asthma control, symptoms, and quality of life as well as in adolescents with differing severities of asthma. Large randomized controlled trials would be a significant step forward in clarifying the effectiveness of IMT in individuals with asthma. Although IMT may have favorable effects on inspiratory muscle strength, dyspnea, and medication use, the current evidence that IMT is an effective treatment for asthma is inconclusive.

Exercise-Induced Dyspnea in Collegiate Athletes: Are We Missing the Diagnosis?

OBJECTIVES

Exercise-induced dyspnea (EID) can disrupt an athlete's participation and performance in their given sport. Differential diagnosis of EID is often completed using subjective report and may be inaccurate, therefore increasing the frustration and stress of the athlete. This nonexperimental research study was used to determine prevalence of EID and related respiratory symptoms in athletes at a small, Division I university.

METHODS

An anonymous survey was provided to athletes at Murray State University as they registered for participation in sports for the 2020-2021 school year. Data from this survey was analyzed as to reported physician-given diagnosis of a respiratory disorder as well as reported symptoms of EID.

RESULTS

Results showed that athletes with a physician-given diagnosis often did not report symptoms or responses to medications that support that diagnosis. Additionally, athletes frequently reported symptoms of EID without a formal diagnosis of a respiratory disorder.

CONCLUSIONS

These findings provide preliminary insight and pilot data that may be used to understand the prevalence of EID in collegiate athletes and the need for improved methods of diagnosis for etiologies of EID.

The effect of trait self-control on dyspnoea and tolerance to a CO2 rebreathing challenge in healthy males and females

BACKGROUND

High trait self-control is associated with greater tolerance of unpleasant sensations including effort and pain. Dyspnoea and pain have several commonalities and this study aimed to investigate for the first time whether trait self-control influences responses to a hypercapnic rebreathing challenge designed to induce dyspnoea. As sex also influences tolerance to dyspnoea, we also sought to investigate whether this moderated the role of trait self-control.

METHODS

Participants (n = 65, 32 females) scoring high or low for trait self-control, performed a standardised rebreathing challenge, in which inspired carbon dioxide (CO₂) gradually increased over a period of 6 min or until an intolerable level of dyspnoea. Air hunger (AH) intensity - a distinctive quality of dyspnoea, was measured every 30 s. The multidimensional dyspnoea profile (MDP) was completed after the rebreathing challenge for a more complete overview of breathing discomfort.

RESULTS

Males high in trait self-control (SCHIGH) (302 ± 42 s), tolerated the rebreathing challenge for longer than males low in self-control (SCLOW) (252 ± 66 s, P = 0.021), experienced slower increases in AH intensity during the rebreathing challenge (0.03 ± 0.01 cm^.s ^- 1 vs. 0.04 ± 0.01 cm^.s ^- 1,P = 0.045) and reported lower perceived mental effort on the MDP (4.94 ± 2.46 vs. 7.06 ± 1.60, P = 0.007). There was no difference between SCHIGH and SCLOW females for challenge duration. However, SCHIGH females (9.29 ± 0.66 cm) reported greater air hunger at the end of the challenge than SCLOW females (7.75 ± 1.75 cm, P = 0.003). It is possible that SCLOW females were unwilling to tolerate the same perceptual intensity of AH as the SCHIGH females.

CONCLUSIONS

These results indicate that individuals high in trait self-control are more tolerant of dyspnoea during a CO₂ rebreathing challenge than low self-control individuals. Tolerance of the stimulus was moderated by the sex of the participant, presenting an interesting opportunity for future research.

Regulated Monosyllabic Talk Test vs. Counting Talk Test During Incremental Cardiorespiratory Exercise: Determining the Implications of the Utterance Rate on Exercise Intensity Estimation

Purpose

When utilizing breathing for speech, the rate and volume of inhalation, as well as the rate of exhalation during the utterance, seem to be largely governed by the speech-controlling system and its requirements with respect to phrasing, loudness, and articulation. However, since the Talk Test represents a non-standardized form of assessment of exercise intensity estimation, this study aimed to compare the utterance rate and the estimated exercise intensity using a newly introduced time-controlled monosyllabic Talk Test (tMTT) versus a self-paced Counting Talk Test (CTT) across incremental exercise stages and examined their associations with the exercise physiological measures.

Methods

Twenty-four participants, 10 males and 14 females (25 ± 4.0 yr; 160 ± 10 cm; 62 ± 14.5 kg) performed two sessions of submaximal cardiorespiratory exercise at incremental heart rate reserve (HRR) stages ranging from 40 to 85% of HRR: one session was performed with a currently available CTT that was affixed to a wall in front of the participants, and the other session was conducted with a tMTT with a 1-s inter-stimulus interval that was displayed from a tablet. In each session, the participants performed six stages of exercise at 40, 50, 60, 70, 80, and 85% HRR on a treadmill and were also asked to rate their perceived exertion based on Borg's 6 to 20 Rating of Perceived Exertion (RPE) at each exercise stage.

Results

The newly designed tMTT significantly delineated all the six stages of incremental exercise (p ≤ 0.017), while CTT could only delineate exercise stages at 60, 80, and 85% HRR. However, in estimations of exercise intensity, the tMTT demonstrated only moderate associations with HRR and Borg's RPE, similarly to the CTT.

Conclusion

If the purpose of exercise monitoring is to detect the intensity of light, moderate, and vigorous exercise intensity, the tMTT could be more universally applicable. However, due to its larger variability of speech rate across exercise intensities, the time-regulated approach may alter the speech breathing characteristics of the exercising individuals in other ways that should be investigated in future research.

Breath Tools: A Synthesis of Evidence-Based Breathing Strategies to Enhance Human Running

Running is among the most popular sporting hobbies and often chosen specifically for intrinsic psychological benefits. However, up to 40% of runners may experience exercise-induced dyspnoea as a result of cascading physiological phenomena, possibly causing negative psychological states or barriers to participation. Breathing techniques such as slow, deep breathing have proven benefits at rest, but it is unclear if they can be used during exercise to address respiratory limitations or improve performance. While direct experimental evidence is limited, diverse findings from exercise physiology and sports science combined with anecdotal knowledge from Yoga, meditation, and breathwork suggest that many aspects of breathing could be improved via purposeful strategies. Hence, we sought to synthesize these disparate sources to create a new theoretical framework called “Breath Tools” proposing breathing strategies for use during running to improve tolerance, performance, and lower barriers to long-term enjoyment.

Athlete Preparticipation Physical Evaluation

Preparticipation evaluations (PPE) are both a traditional and legal requirement by many governing bodies for sport. The ideal goal of the PPE is safe participation in sport for athletes. This article provides an overview of common PPE elements and current best practice recommendations. Descriptions of every possible examination are published elsewhere and are beyond the intent of this article. Additional considerations for transgender, masters athletes, and Special Olympians are also outside the scope of this review, but are well covered in The Preparticipation Physical Evaluation, fifth edition monograph.

Accuracy and Reliability of Commercial Wrist-Worn Pulse Oximeter During Normobaric Hypoxia Exposure Under Resting Conditions

Purpose: The present study analyzed peripheral blood oxygen saturation (S_pO₂) and heart rate (HR) measurements taken on the Garmin fēnix® 5X Plus watch, comparing them to measurements taken on a standard medical-grade pulse oximeter during normobaric hypoxia exposure under resting conditions. Methods: Thirteen women (mean ± SD: Age 20 ± 1 years, height 165 ± 5 cm, mass, 67 ± 9 kg) and ten men (mean ± SD: Age 21 ± 3 years, height 177 ± 6 cm, mass 78 ± 11 kg) sat inside a customized environmental chamber while the fraction of inspired oxygen (F_IO₂) was adjusted to simulate altitudes of 12,000; 10,000; 8,000; 6,000; and 900 ft. The novel commercial device (Garmin fēnix®) and a medical-grade pulse oximeter (Nonin® 7500) were used to measure S_pO₂ and HR in triplicate at each simulated altitude. Bland-Altman analyses were used to assess differences between methods. Results: Bland-Altman analysis indicated 3.3% bias for S_pO₂ measurements taken on the Garmin fēnix® at 12,000 ft of simulated altitude (limits of agreement: -1.9-8.6%). Mean differences in S_pO₂ measurements were smaller at the remaining simulated altitudes, where bias measurements ranged from 0.7% to 0.8%. The Garmin fēnix® also underestimated heart rate, but those discrepancies were minimal (bias measurements at all simulated altitude exposures were < 1.0 bpm). Conclusions: With the exception of readings taken at 12,000 ft of simulated altitude, the Garmin fēnix® exhibits minimal overestimation of S_pO₂ and minimal underestimation of HR during simulated altitude exposure. These data suggest the Garmin fēnix® watch may be a viable method to monitor S_pO₂ and HR under most ambient environmental conditions.

The interest of rehabilitation of respiratory disorders in athletes: Myth or reality?

BACKGROUND

Healthy trained athletes generally have an "overbuilt" respiratory system in order to face the huge ventilation and gas-exchange demand imposed by strenuous exercise. Athletes frequently complain of respiratory symptoms regardless of whether they have a diagnosed respiratory disease, therefore evoking a kind of respiratory limitation during exercise. Some respiratory pathologies athletes present are closely linked to exercise and include asthma, exercise-induced bronchoconstriction (EIB) or exercise-induced laryngeal obstruction. Management of asthma and EIB are mainly based on pharmacological treatments. However, many athletes still complain of respiratory symptoms despite optimal pharmacological treatments, which highlights the need for non-pharmacological approaches including breathing retraining, inspiratory muscle training and/or laryngeal exercise performed under the guidance of a physiotherapist in this specific population.

OBJECTIVES

With this literature overview, we aimed to report evidence supporting the interest of rehabilitation for athletes with respiratory disorders and discuss whether inspiratory muscle training programs can improve performance in healthy athletes.

METHODS

We searched MEDLINE and Cochrane databases for trials, reviews and meta-analyses assessing respiratory rehabilitation and muscle training programs in athletes by using the MesH terms "athletes", "asthma", "dyspnea", "rehabilitation" and "education" published from January 2010 to March 2020. The selection of articles was based on the author's expertise to elaborate this review of the literature.

RESULTS

Major findings suggest that breathing retraining may help asthmatic athletes better control their respiratory symptoms and that inspiratory muscle training may improve respiratory symptoms of exercise-induced laryngeal obstruction in athletes. Improvement of performance by respiratory muscle training still remains controversial.

CONCLUSIONS

Respiratory rehabilitation could be of interest in the specific population of athletes but should be further evaluated to improve the level of evidence of such strategies.

Exercise-induced bronchoconstriction, temperature regulation and the role of heat shock proteins in non-asthmatic recreational marathon and half-marathon runners

Exercise is the most common trigger of bronchospasm. Heat shock protein (HSP) expression was linked to asthmatic patients. The prevalence and pathophysiology of exercise-induced bronchoconstriction (EIB) in non-professional non-asthmatic runners is unknown. We sought to investigate the frequency of EIB and cytokine changes in non-professional non-asthmatic marathon and half marathoners with and without EIB. Testing was performed before the marathon (baseline), immediately post-marathon at the finish area (peak), and 2–7 days after the marathon (recovery): immunosorbent assays for measurement of HSP70, blood count analysis, spirometry and temperature measurements. We experienced a decline in FEV1 of ≥10% in 35.29% of marathon and 22.22% of half marathon runners. Runners with EIB had significantly higher HSP70 serum concentrations at baseline than those without EIB (987.4 ± 1486.7 vs. 655.6 ± 1073.9; p = 0.014). Marathoners with EIB had significantly increased WBC before participating in the competition (7.4 ± 1.7 vs. 6.0 ± 1.5; p = 0.021). After recovery we found increased HSP70 serum concentrations in marathoners with EIB compared to those without (2539.2 ± 1692.5 vs. 1237.2 ± 835.2; p = 0.032), WBC (7.6 ± 1.8 vs. 6.4 ± 1.6; p = 0.048) and PLT (273.0 ± 43.0 vs 237.2 ± 48.3; p = 0.040). At all measured skin sites skin temperatures in runners were significantly lower immediately after participating in the competition when compared to temperature before the race (skin temperature baseline vs. peak: abdominal: 33.1 ± 0.2 vs. 30.0 ± 0.4; p < 0.001; upper arm: 31.6 ± 0.2 vs. 29.4 ± 0.3; p < 0.001; upper leg: 30.7 ± 0.3 vs. 29.4 ± 0.2; p = 0.014; lower leg: 30.6 ± 1.0 vs. 30.2 ± 1.5; p = 0.007). We found a higher than expected number of non-professional athletes with EIB. HSP70 serum concentrations and elevated WBC could indicate a predisposition to EIB.