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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

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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 Tom 1 • numer 1 • styczeń-kwiecień 2014 • ISSN: 0000-0000 Alergologia Polska – Polish Journal of Allergology 2019; 6, 1: 13–23 DOI: https://doi.org/10.5114/pja.2019.84261 Otrzymano: 19.08.2018, zaakceptowano: 19.01.2019. WYTYCZNE/GUIDELINES ! Asthma and exercise-induced respiratory disordersalergologia_cover_bez-u.indd 1 6/14/17 4:26:33 PM in athletes. The position paper of the Polish Society of Allergology and Polish Society of Sports Medicine Radoslaw Gawlik1, Marcin Kurowski2, Marek Kowalski2, Ziemowit Ziętkowski3, Andrzej Pokrywka4,5, Hubert Krysztofiak5,6, Jarosław Krzywański5,7, Andrzej Bugajski5,8, Zbigniew Bartuzi9 1Department of Internal Diseases, Allergy and Clinical Immunology, Medical University of Silesia, Katowice, Poland 2Department of Immunology and Allergy, Medical University of Lodz, Lodz, Poland 3Department of Allergology and Internal Medicine, University of Bialystok, Bialystok, Poland 4 Department of Applied and Clinical Physiology, Faculty of Medicine and Health Sciences, University of Zielona Gora, Zielona Gora, Poland 5Polish Society of Sports Medicine 6Department of Applied Physiology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland 7National Centre for Sports Medicine, Warsaw, Poland 8Higher School of Physiotherapy, Wroclaw, Poland 9 Department of Allergy, Clinical Immunology and Internal Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland Reprint: Gawlik R, Kurowski M, Kowalski M, Ziętkowski Z, Pokrywka A, Krysztofiak H, Krzywański J, Bugajski A, Bartuzi Z. Asthma and exercise-induced respiratory disorders in athletes. The position paper of the Polish Society of Allergology and Polish Society of Sports Medicine. Adv Dermatol Allergol 2019; 36: 1-10. DOI: https://doi.org/10.5114/ada.2019.82820. ABSTRACT Exercise-induced respiratory symptoms describe acute airway narrowing that occurs as a result of ex- ercise. It includes exercise-induced bronchoconstriction (EIB) and exercise-induced asthma (EIA) is- sues. 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 di- agnosis and treatment. Recommendations for the diagnosis and treatment of EIB were developed. High-intensity exercise in polluted environment (cold air, humidity, contamination, allergens) may in- crease the risk of EIB and asthma symptoms in athletes. Diagnostic procedures should include his- tory 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. KEY WORDS: exercise-induced bronchoconstriction, diagnosis, treatment. 13 R. Gawlik, M. Kurowski, M. Kowalski, Z. Ziętkowski, A. Pokrywka, H. Krysztofiak, J. Krzywański, A. Bugajski, Z. Bartuzi ADDRESS FOR CORRESPONDENCE: Radoslaw Gawlik, Department of Internal Diseases, Allergy and Clinical Immunology, Medical University of Silesia, 35 Ceglana St, 40-514 Katowice, Poland, phone: +48 601 464 786, e-mail: [email protected] EPIDEMIOLOGY OF EXERCISE-INDUCED The examination of the Olympic athletes representing ASTHMA/EXERCISE-INDUCED BRONCHO Norway, Germany and Spain in Beijing showed an incre- CONSTRICTION ased risk of symptoms typical of asthma as well as asthma diagnosis by a medical specialist in endurance and water Exercise-induced respiratory symptoms are most sports athletes [11]. frequently referred to as: Swimmers represent a group of athletes with a hi- • exercise-induced bronchoconstriction (EIB) or gher risk of the development of exercise-induced asthma • exercise-induced asthma (EIA). symptoms [11–15]. Although swimming is recommended Both terms were often used interchangeably in the for asthma sufferers to improve their respiratory system past. Currently it is recommended to describe exercise- functioning, regular swimming may increase the proba- induced symptoms in people without coexisting asthma bility of asthma in healthy people. Theoretically, humid and allergies as exercise-induced bronchoconstriction and warm environment of most swimming pools should whereas exercise-induced asthma should be referred to prevent the airway mucosa from drying and cooling. We as post-exercise bronchoconstriction in asthma sufferers. should bear in mind, however, that exposure to chlori- Bronchoconstriction is a form of bronchial hyperreac- ne compounds, mites and mould spores is associated tivity which is defined as increased readiness of the bron- with potential asthma. Skating and cross-country skiing chi to constrict in response to a variety of external factors. are the kinds of winter sports which are connected with Bronchial hyperreactivity is the basic feature of bronchial a higher incidence of such symptoms as coughing and asthma and it occurs more often in athletes than in gene- dyspnoea. These symptoms are ascribed to the exposure ral population, especially in swimmers and winter sports of the airways to adverse conditions or irritating chemical athletes [1, 2]. compounds released from the ice [16–21]. There is an extensive literature on the prevalence of asthma or EIB symptoms in competitive athletes. Exerci- PATHOGENESIS se-induced asthma symptoms were identified in over 11% of the USA representatives at the Summer Olympic Ga- Asthma is a heterogeneous disease typically associated mes in Los Angeles (1984). The observation was confir- with a chronic respiratory inflammation which is defined med by the studies conducted 12 years later at the Olym- as a syndrome of such respiratory symptoms as wheezing, pic Games in Atlanta [3]. In the USA team at the Winter dyspnoea, chest tightening and coughing which differ Olympic Games in Nagano (1998), as many as 22% of in time and intensity and are connected with variable the athletes had previously been diagnosed with asthma airways obstruction. and over 18% had used antiasthmatic medications before Currently discussed pathogenic mechanisms poten- [4, 5]. European studies carried out since 2000 have re- tially responsible for exercise-induced bronchoconstric- ported a gradual increase in the incidence of asthma and tion in people who practice high-intensity exercise on allergy symptoms in athletes [6–9]. a regular basis include [22]: When Polish athletes participating in the Olympic • osmotic and thermal changes in airways mucosa cau- Games in Beijing (2008) responded to a questionnaire, sed by exercise-induced hyperventilation (osmotic 28.4% of them reported at least one symptom of exerci- and thermal hypothesis); se-induced asthma (coughing, shortness of breath, tighte- • damage to respiratory epithelium; ning of the chest or wheezing). No differences in asthma • increasing severity of the airway inflammation; symptoms incidence were observed between endurance • neural activation. and non-endurance sports. Clinical evaluation confir- Osmotic and thermal changes to bronchial mucosa med the diagnosis of asthma in 11.3% of the examined are the rationale behind the osmotic and thermal hy- athletes. It is noteworthy that prior to the study inclusion, potheses which are considered as ‘classical’ ones in the asthma was diagnosed in 5.9% of the athletes only and attempts to explain the pathogenesis of EIB in athletes. 8.6% declared ever taking anti-asthmatic medication, Increased water evaporation from the mucosa during β either 2-agonists or glucocorticosteroids or leukotriene exercise leads to the increase in the osmolarity of the receptor antagonists [10]. fluid covering the respiratory epithelium. The changes 14 Alergologia Polska – Polish Journal of Allergology, January–March 2019 Asthma and exercise-induced respiratory disorders in athletes. The position paper of the Polish Society of Allergology and Polish Society of Sports Medicine to osmotic relations result in the lysis of the cells and Neurogenic inflammation is also considered in the the release of the mediators including cysteinyl leukotrie- investigation of EIB pathogenesis [31]. High-intensity nes which have strong bronchoconstrictive properties. exercise elevates the concentration of substance P which Furthermore, the airway cooling activates cholinergic is one of the key mediators of neurogenic inflammation. receptors, which causes increased tension of bronchial Acetylcholine and nerve growth factor (NGF) have also smooth muscles and enhanced fluid secretion in airways. been put forward as potentially involved in the develop- Directly after exercise completion the respiratory tract ment of the EIB-provoking inflammation. warming commences and leads to secondary hyperaemia Since none of the aforementioned mechanisms fully and increased capillary permeability in the bronchial explains the pathogenesis of EIB, potential interaction of wall. several mechanisms should be taken into account while A rise in the number of inflammatory cells (eosino- assessing individual predisposition to exercise-induced phils, neutrophils, epithelial cells) has been observed in respiratory symptoms. The identification of the athletes the respiratory tract of athletes. A large body of evidence susceptible to EIB appears to be the key issue here as it may has already proven that damage to respiratory epithelium contribute to the improvement of preventive
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