Bronchial Challenges and Respiratory Symptoms in Elite Swimmers and Winter Sport Athletes: Airway Hyperresponsiveness in Asthma: Its Measurement and Clinical Significance

doi:10.1378/chest.09-1689

Chest

Volume 138, Issue 2, Supplement, August 2010, Pages 31S-37S

https://doi.org/10.1378/chest.09-1689 Get rights and content

This study was aimed at the following: (1) the prevalence of airway hyperresponsiveness (AHR) and exercise-induced bronchoconstriction (EIB) in swimmers and winter sport athletes according to the previously recommended regulatory sport agencies criteria, (2) the relationship between respiratory symptoms and AHR/EIB, (3) the impact of the chosen cutoff value for AHR on its prevalence, and (4) the effect on the prevalence of the positive eucapnic voluntary hyperpnea (EVH) test of using the highest vs the lowest spirometric post-EVH values to calculate the magnitude of the airway response. We compared the prevalence of respiratory symptoms with responses to methacholine challenge and EVH in 45 swimmers, 45 winter sport athletes, and 30 controls. Two methacholine challenge cutoffs for AHR were analyzed: ≤ 4 mg/mL (the sport agencies' criteria for AHR) and ≤ 16 mg/mL. Sixty percent of swimmers, 29% of winter sport athletes, and 17% of controls had evidence of EIB or AHR (with the ≤ 4 mg/mL criteria). Among athletes with a methacholine provocative concentration inducing a 20% decrease in the FEV₁ between 4 and 16 mg/mL, 43% of swimmers and 100% of winter sport athletes were symptomatic (P < .05). Prevalence of positive EVH tests were 39% in swimmers, 24% in winter sport athletes, and 13% in controls when the highest FEV₁ value measured at each time point post-EVH was used to identify maximal response for calculation of airway response, although these prevalences were higher if we used the lowest value. This study suggests that AHR/EIB is frequent in swimmers, whereas the frequently reported respiratory symptoms in winter sport athletes are often not related to AHR/EIB. Furthermore, the choice of methods for assessing methacholine challenge and EVH responses influences the prevalences of AHR and EIB.

Trial registration: clinicaltrials.gov; Identifier NCT 00686491 and NCT 00686452.

Section snippets

Study Subjects

Swimmers, winter sport athletes, and nonathlete controls were recruited. Athletes and controls had to be nonsmokers, nonobese, and free of any disease that may interfere with the study. Controls taking asthma medication were excluded. To be included, swimmers and winter sport athletes had to be active competitors and train at least 10 h per week in a chlorinated swimming pool and outside in winter, respectively. Winter sport athletes were not exposed to chlorinated environments and all athletes

Subjects' Characteristics

The characteristics of the subjects included in the study are presented in Table 1. Swimmers (11 synchronized swimmers, 32 swimmers, and two divers) and winter sport athletes (seven biathletes, 22 cross-country skiers, and 16 speed-skaters training outdoors) were competing at national to Olympic levels. Eleven percent of swimmers and 9% of winter sport athletes had asthma diagnosed during their childhood before beginning their sport career. All athletes taking ICS for > 1 month had also been

Discussion

Using the IOC-MC criteria, we found that 60% of swimmers and 29% of winter sport athletes had AHR or EIB, and therefore could be allowed to use certain types of asthma medication. Interestingly, our study underlines that the elite swimmer population is characterized by a high prevalence of symptomatic and asymptomatic AHR and/or EIB, whereas winter sport athletes often report exercise-induced cough but with a prevalence of AHR and/or EIB similar to controls. Furthermore, among athletes with a

Acknowledgments

Authors contributions: Dr Bougault: contributed to conceiving the study, performing the tests, coordinating the study, drafting the manuscript, and reading and approving the final manuscript.

Dr Turmel: contributed to conceiving the study, performing the tests, and reading and approving the final manuscript.

Dr Boulet: contributed as the main investigator of the study; he helped with the conception of the study, performed the medical examination of all subjects, helped to draft the manuscript,

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Exercise-induced bronchoconstriction (EIB) is a prevalent condition in elite athletes caused by transient airway narrowing during or after exercise. Young athletes nowadays start early to perform high level exercise, highlighting the need to screen for EIB in a younger population. The purpose of this review is to evaluate current evidence of pre-tests with high probability to predict a positive provocation test in young and adolescent athletes, aged 12–24 years and thus indicate whether a young athlete is at risk of having EIB. Up to now, there is no validated screening test available to increase the pre-test probability of a provocation test of EIB in young and adolescent athletes. We would recommend that a clinical guideline committee might consider the development of a flow chart to screen for EIB in adolescent athletes. It could be composed of a symptom-based questionnaire focusing on wheezing during exercise, atopic state, reversibility test (to exclude EIB with asthma) and completed with markers in blood/serum. However, more research is necessary.
Chlorine exposure and intensive exercise induces airway hyperreactivity in a 3-week murine exercise model
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Citation Excerpt :
In elite competitive swimmers, the prevalence of airway hyperresponsiveness (AHR) and/or exercise-induced bronchoconstriction (EIB), defined as acute narrowing of the airways during or immediately after exercise, reaches up to 76 % of the athletes with a positive provocation test (Bougault et al., 2010).
Exercise-induced bronchoconstriction (EIB) is defined as acute narrowing of the airways during or immediately after exercise. EIB has a high prevalence in elite swimmers probably due to the high ventilation rate and exposure to the chlorine by-products. It is still puzzling which pathophysiological mechanisms drive EIB.
In this study, we evaluated airway hyperreactivity, permeability, integrity and inflammation in a murine swimmers EIB model with and without chlorine exposure.
Mice performed a 3-week swimming protocol in a swimming pool with counter current. Three hours after the last swimming session, airway hyperreactivity to methacholine was assessed. Cytokine levels and cellular differential analysis was performed in BAL fluid. Airway permeability and tight junction expression was measured in serum and lung tissue. T-, B-, dendritic and innate lymphoid cells were determined in lung tissue via flow cytometry.
A significant higher airway resistance (Rn; P < 0.0001) was observed in mice swimming in chlorinated water (mean Rn = 1.26 cmH₂O.s/ml) compared to mice swimming in tap water (mean Rn = 0.76 cmH₂O.s/ml) and both inhalation groups in the absence of cellular inflammation. No significant differences were found in lung immune cell populations or in lung tight junction mRNA expression. Experiments in SCID, Rag2^−/−γc^−/− or Cpa3^cre/+ mice showed a limited involvement of the innate, adaptive immune system or the mast cells.
Our 3-week swimming murine model mimics intensive swimming in chlorinated water with the presence of airway hyperreactivity in mice swimming in chlorinated water in the absence of airway inflammation and airway epithelial damage.
Environmental factors associated with non-infective acute respiratory illness in athletes: A systematic review by a subgroup of the IOC consensus group on “acute respiratory illness in the athlete”
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The aim of this study is to review the evidence available suggesting that environmental conditions represent a risk factor associated with non-infective acute respiratory illness in athletes.
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PubMed, EBSCOhost and Web of Science (1st January 1990–31 July 2020) were searched systematically using keywords related to male and female athletes (i.e. from physically active individuals to elite athletes), aged 15–65 years and a combination of the terms (non-infective acute respiratory illness AND [pollution OR allergies OR climate] AND athletes AND prevalence/incidence/risk factors).
A total of seven papers (n = 1567 athletes) addressed our question. Among these, one focused on indoor air pollution, four on chlorinated swimming pool exposure and two on cold air conditions. None was selected for allergies, outdoor air pollution or other climatic conditions. Except rhinitis induced by swimming in chlorinated pools (n = 1), no respiratory disease due to the environment was identified specifically in athletes. The levels of chloramines in swimming pools (n = 2) and air pollutant in arenas (n = 1) were identified as risk factors for rhinitis and respiratory symptoms when exercising.
There is a paucity of data on the prevalence, incidence and risk factors of being acutely exposed to chlorine by-products, air pollution, cold air or altitude on the development of respiratory disease specifically in athletes. Noting the lack of a clear definition of environmentally induced lung disease in athletes, distinct from that of the general population, we addressed the few published management plans to protect athletes' airways for each specific environment.
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Exercise-Induced Bronchoconstriction and the Air We Breathe
2018, Immunology and Allergy Clinics of North America

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Funding/Support: Valérie Bougault was supported in part by a grant from the Groupe de recherche en santé respiratoire de l'Université Laval (GESER), Québec, QC, Canada.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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Chest

Airway Hyperresponsiveness in Asthma: Its Measurement and Clinical SignificanceBronchial Challenges and Respiratory Symptoms in Elite Swimmers and Winter Sport Athletes: Airway Hyperresponsiveness in Asthma: Its Measurement and Clinical Significance

Section snippets

Study Subjects

Subjects' Characteristics

Discussion

Acknowledgments

J Allergy Clin Immunol

Chest

Respir Med

Lancet

Chest

Asthma and the elite athlete: summary of the International Olympic Committee's consensus conference, Lausanne, Switzerland, January 22–24, 2008

J Allergy Clin Immunol

Exercise-induced bronchoconstriction and respiratory symptoms in elite athletes

Allergy

Self-reported symptoms and exercise-induced asthma in the elite athlete

Med Sci Sports Exerc

IOC: Beta2-adrenoceptor agonists and Olympic Games in Beijing

Asthma—medical information to support the decisions of TUECs

Guidelines for methacholine and exercise challenge testing-1999. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999

Am J Respir Crit Care Med

Reference values of the provocative concentrations of methacholine that cause 6% and 20% changes in forced expiratory volume in one second in a normal population

Am Rev Respir Dis

Airway Hyperresponsiveness in Asthma: Its Measurement and Clinical Significance
Bronchial Challenges and Respiratory Symptoms in Elite Swimmers and Winter Sport Athletes: Airway Hyperresponsiveness in Asthma: Its Measurement and Clinical Significance