Julie Turmel

Asthma, Airway Inflammation, and Epithelial Damage in Swimmers and Cold-air Athletes

Endurance athletes show an increased prevalence of airway hyperresponsiveness. The aim of the present study was to evaluate the long-term effects of training on airway responsiveness, inflammation and epithelial damage in swimmers and cold-air athletes. In total, 64 elite athletes (32 swimmers and 32 cold-air athletes), 32 mild asthmatic subjects and 32 healthy controls underwent allergy skin prick testing, methacholine challenge and induced sputum analysis. Overall, 69% of swimmers and 28% of cold-air athletes had airway hyperresponsiveness. Sputum neutrophil count correlated with the number of training hours per week in both swimmers and cold-air athletes. Eosinophil counts were higher in swimmers than in healthy subjects, although they were lower than in asthmatic subjects, and correlated with airway hyperresponsiveness in swimmers only. The eosinophil count in cold-air athletes was similar to that in healthy subjects. Bronchial epithelial cell count was not correlated with airway hyperresponsiveness but was significantly increased in swimmers, compared with healthy and asthmatic controls. In conclusion, the present authors observed significant airway inflammation only in competitive athletes with airway hyperresponsiveness. However, the majority of elite athletes showed evidence of bronchial epithelial damage that could possibly contribute to the development of airway hyperresponsiveness.

Relationship between atherosclerosis and the sleep apnea syndrome: an intravascular ultrasound study.

BACKGROUND Sleep apnea hypopnea syndrome (SAHS) is a predictive factor of cardiovascular disease. We hypothesized that SAHS could influence coronary atherosclerosis plaque volume as assessed by 3-dimensional intravascular ultrasound (3D-IVUS). METHODS Participating patients were identified from 2 studies assessing the progression of atherosclerosis in stable coronary artery disease using coronary 3D-IVUS. RESULTS Nineteen patients, aged 61+/-8 years, with a body mass index of 29+/-5 kg/m(2) were studied. Increased apnea-hypopnea index (AHI) >or=15 was found in 12/19 patients (63%). Patients with AHI>or=15 had larger coronary atherosclerotic plaque volume than patients with AHI<15 (238+/-69 mm(3) vs 169+/-64 mm(3), p=0.047) and the difference was even larger in patients with obstructive apnea/hypopnea episodes compared to patients without (243+/-70 mm(3) vs 170+/-59 mm(3), p=0.03). There was a significant positive correlation between obstructive AHI and coronary atherosclerotic plaque volume (r=0.6, p=0.01). A significant positive correlation was also demonstrated between respiratory arousal index and coronary atherosclerotic plaque volume (r=0.6, p=0.02) and between total arousal index and coronary atherosclerotic plaque volume (r=0.5, p=0.03). CONCLUSION In patients with stable coronary artery disease, there was a significant relationship between the frequency of obstructive sleep apnea/hypopnea episodes and sleep fragmentation and the importance of coronary atherosclerotic plaque volume. 3D-IVUS is well suited to correlate coronary atherosclerosis and sleep breathing disorders at early stages.

Airway hyperresponsiveness in elite swimmers: is it a transient phenomenon?

BACKGROUND Airway hyperresponsiveness is highly prevalent in competitive swimmers, but it is unknown whether this is transient or persistent. OBJECTIVES To document changes in airway responsiveness and airway inflammation in elite swimmers during intense training and rest. METHODS Nineteen swimmers and 16 healthy controls completed a standardized questionnaire, allergy skin prick tests, exhaled nitric oxide measurement, eucapnic voluntary hyperpnea testing, methacholine challenge, and induced sputum analysis. Testing was performed during intense swimming and after at least 2 weeks of rest. RESULTS Sixteen swimmers and 13 controls were atopic. Airway responsiveness to methacholine and eucapnic voluntary hyperpnea was significantly higher in swimmers than in controls (P < .0001). A significant decrease in airway responsiveness was observed from training to rest in swimmers only (P < .005). This occurred with both methacholine challenge--with PC(20) values of 6.0 mg/mL and 12.8 mg/mL, respectively--and eucapnic voluntary hyperpnea testing--with a maximum fall in FEV(1) after voluntary testing of 14.1 L and 10.1 L, respectively. Eight of 12 swimmers with airway hyperresponsiveness during intense training had normal airway responsiveness during rest. No airway inflammation occurred, and no significant change in this parameter was observed from training to rest. CONCLUSION Training may contribute to the development of airway hyperresponsiveness in elite swimmers, but this seems reversible in many athletes after training cessation for at least 2 weeks.

The respiratory health of swimmers.

Regular physical activity is recognized as an effective health promotion measure. Among various activities, swimming is preferred by a large portion of the population. Although swimming is generally beneficial to a person’s overall health, recent data suggest that it may also sometimes have detrimental effects on the respiratory system. Chemicals resulting from the interaction between chlorine and organic matter may be irritating to the respiratory tract and induce upper and lower respiratory symptoms, particularly in children, lifeguards and high-level swimmers. The prevalence of atopy, rhinitis, asthma and airway hyper-responsiveness is increased in elite swimmers compared with the general population. This may be related to the airway epithelial damage and increased nasal and lung permeability caused by the exposure to chlorine subproducts in indoor swimming pools, in association with airway inflammatory and remodelling processes. Currently, the recommended management of swimmers’ respiratory disorders is similar to that of the general population, apart from the specific rules for the use of medications in elite athletes. Further studies are needed to better understand the mechanisms related to the development or worsening of respiratory disorders in recreational or competitive swimmers, to determine how we can optimize treatment and possibly help prevent the development of asthma.

Seasonal variations of cough reflex sensitivity in elite athletes training in cold air environment.

BackgroundExercise-induced cough is common among athletes. Athletes training in cold air often report an increasingly troublesome cough during the winter season. Chronic airway irritation or inflammation may increase the sensory response of cough receptors. The aim of this study was to evaluate the seasonal variability of cough reflex sensitivity to capsaicin in elite athletes.MethodsFifty-three elite winter athletes and 33 sedentary subjects completed a respiratory questionnaire and a capsaicin provocation test during the summer, fall, and winter. Allergy skin prick tests, spirometry, eucapnic voluntary hyperpnea test (EVH), methacholine inhalation test (MIT), and induced sputum analysis were also performed.ResultsIn athletes, the prevalence of cough immediately after exercise was high, particularly during winter. Athletes often showed a late occurrence of cough between 2-8 h after exercise. The cough reflex sensitivity to capsaicin was unchanged through the seasons in both athletes and non-athlete subjects. No significant correlations were found in groups between cough reflex sensitivity to capsaicin and the number of years in sport training, the number of hours of training per week, EVH response (% fall in FEV1), airway responsiveness to methacholine (PC20), airway inflammation or atopy.ConclusionThe prevalence of cough immediately and a few hours after exercise is high in athletes and more frequently reported during winter. However, cough does not seem to be associated with cough reflex hypersensitivity to capsaicin, bronchoconstriction, or airway inflammation in the majority of athletes.

Cardiorespiratory Screening in Elite Endurance Sports Athletes: The Quebec Study

Abstract Background: Cardiorespiratory disorders are common in athletes. However, these conditions are often underdiagnosed, which potentially results in impaired performance and increased health risks. The aim of this study was to evaluate, in a research setting, the prevalence of cardiorespiratory disorders in athletes in order to determine the potential value of a screening program. Methods: One hundred thirty-three athletes were studied. Each subject underwent a physical examination. A eucapnic voluntary hyperventilation (EVH) test and a methacholine inhalation test were performed to confirm the diagnosis of asthma. A cardiovascular evaluation was also performed, including maximal exercise test with electrocardiogram, 24-hour ambulatory blood pressure monitoring, 24-hour Holter monitoring, and blood sampling. Results: Seventy-four (56%) athletes had airway hyperresponsiveness to EVH or the methacholine inhalation test. Among those with airway hyperresponsiveness, 45 (61%) athletes were only hyperresponsive to EVH, and 10 (14%) were only hyperresponsive to the methacholine inhalation test (using the criteria of a PC20 ≤ 4 mg/mL). Thirty-two (24%) athletes had a known diagnosis of asthma, while 34 (26%) athletes received a new asthma diagnosis. Ninety-seven (73%) athletes were sensitized to common airborne allergens. Forty-seven (35%) athletes completed the cardiovascular evaluation. Three (6%) and 7 (15%) athletes had a previous or new diagnosis of cardiovascular disease, respectively. Resting systemic hypertension was documented in 2 (4%) athletes and exaggerated blood pressure response to exercise was found in 12 (26%) athletes. Conclusion: This cardiorespiratory screening data set in athletes showed a high prevalence of exercise-induced asthma and exercise hypertension, which in many cases were not previously diagnosed.

Perception of Bronchoconstriction Following Methacholine and Eucapnic Voluntary Hyperpnea Challenges in Elite Athletes

OBJECTIVE Self-reported respiratory symptoms are poor predictors of exercise-induced bronchoconstriction (EIB) in athletes. The objective of this study was to determine whether athletes have an inadequate perception of bronchoconstriction. METHODS One hundred thirty athletes and 32 nonathletes completed a standardized questionnaire and underwent eucapnic voluntary hyperpnea (EVH) and methacholine inhalation test. Perception scores were quoted on a modified Borg scale before each spirometry measurement for cough, breathlessness, chest tightness, and wheezing. Perception slope values were also obtained by plotting the variation of perception scores before and after the challenges against the fall in FEV1 expressed as a percentage of the initial value [(perception scores after - before)/FEV1]. RESULTS Up to 76% of athletes and 68% of nonathletes had a perception score of ≤0.5 at 20% fall in FEV1 following methacholine. Athletes with EIB/airway hyperresponsiveness (AHR) had lower perception slopes to methacholine than nonathletes with asthma for breathlessness only (P=.02). Among athletes, those with EIB/AHR had a greater perception slope to EVH for breathlessness and wheezing (P=.02). Female athletes had a higher perception slope for breathlessness after EVH and cough after methacholine compared with men (P<.05). The age of athletes correlated significantly with the perception slope to EVH for each symptom (P<.05). CONCLUSIONS Minimal differences in perception of bronchoconstriction-related symptoms between athletes and nonathletes were observed. Among athletes, the presence of EIB/AHR, older age, and female sex were associated with slightly higher perception scores.

Increased exhaled breath condensate 8-isoprostane after a swimming session in competitive swimmers

Abstract Objectives: This study aimed to evaluate the levels of 8-isoprostane (8-IsoP) in the airways of competitive swimmers at baseline and after a swimming session according to their airway responsiveness. Methods: Twenty-three swimmers and six lifeguards had a baseline spirometry and bronchoprovocative challenges. During a second visit, swimmers performed a usual swimming session while lifeguards stayed in the same pool environment for the same time period. Forced expiratory volume in one second (FEV1) was measured before and 5 min after the end of the session. Exhaled breath condensate (EBC) was sampled before and 10 min after the session and EBC 8-IsoP levels were analysed by enzyme immunoassay. Change in EBC 8-IsoP from baseline to post-swimming session was calculated. Results: We observed no relationships between airway hyper-responsiveness and 8-IsoP values before or after swimming in swimmers. The levels of 8-IsoP were significantly higher after the training session (mean value 2.9, s = 0.5 pg mL−1) than at baseline (mean value 1.9, s = 0.4 pg mL−1) in swimmers only (p = .012). EBC 8-IsoP levels after the swimming session significantly correlated with the percent change in FEV1 after swimming. Conclusions: EBC 8-IsoP levels were increased after training in swimmers but not in lifeguards, suggesting that exercise-induced hyperpnoea in a chlorinated pool environment increases airways oxidative stress.

Cough in the Athlete: CHEST Guideline and Expert Panel Report

Background: Cough is a common symptom experienced by athletes, particularly after exercise. We performed a systematic review to assess the following in this population: (1) the main causes of acute and recurrent cough, either exercise‐induced or not, (2) how cough is assessed, and (3) how cough is treated in this population. From the systematic review, suggestions for management were developed. Methods: This review was performed according to the CHEST methodological guidelines and Grading of Recommendations Assessment, Development and Evaluation framework until April 2015. To be included, studies had to meet the following criteria: participants had to be athletes and adults and adolescents aged ≥ 12 years and had to complain of cough, regardless of its duration or relationship to exercise. The Expert Cough Panel based their suggestions on the data extracted from the review and final grading by consensus according to a Delphi process. Results: Only 60 reports fulfilled the inclusion criteria, and the results of our analysis revealed only low‐quality evidence on the causes of cough and how to assess and treat cough specifically in athletes. Although there was no formal evaluation of causes of cough in the athletic population, the most common causes reported were asthma, exercise‐induced bronchoconstriction, respiratory tract infection (RTI), upper airway cough syndrome (UACS) (mostly from rhinitis), and environmental exposures. Cough was also reported to be related to exercise‐induced vocal cord dysfunction among a variety of less common causes. Although gastroesophageal reflux disease (GERD) is frequent in athletes, we found no publication on cough and GERD in this population. Assessment of the causes of cough was performed mainly with bronchoprovocation tests and suspected disease‐specific investigations. The evidence to guide treatment of cough in the athlete was weak or nonexistent, depending on the cause. As data on cough in athletes were hidden in a set of other data (respiratory symptoms), evidence tables were difficult to produce and were done only for cough treatment in athletes. Conclusions: The causes of cough in the athlete appear to differ slightly from those in the general population. It is often associated with environmental exposures related to the sport training environment and occurs predominantly following intense exercise. Clinical history and specific investigations should allow identification of the cause of cough as well as targeting of the treatment. Until management studies have been performed in the athlete, current guidelines that exist for the general population should be applied for the evaluation and treatment of cough in the athlete, taking into account specific training context and anti‐doping regulations.

Symptomatic Treatment of Cough Among Adult Patients With Lung Cancer: CHEST Guideline and Expert Panel Report

Background Cough among patients with lung cancer is a common but often undertreated symptom. We used a 2015 Cochrane systematic review, among other sources of evidence, to update the recommendations and suggestions of the American College of Chest Physicians (CHEST) 2006 guideline on this topic. Methods The CHEST methodologic guidelines and the Grading of Recommendations, Assessment, Development, and Evaluation framework were used. The Expert Cough Panel based their recommendations on data from the Cochrane systematic review on the topic, uncontrolled studies, case studies, and the clinical context. Final grading was reached by consensus according to the Delphi method. Results The Cochrane systematic review identified 17 trials of primarily low‐quality evidence. Such evidence was related to both nonpharmacologic (cough suppression) and pharmacologic (demulcents, opioids, peripherally acting antitussives, or local anesthetics) treatments, as well as endobronchial brachytherapy. Conclusions Compared with the 2006 CHEST Cough Guideline, the current recommendations and suggestions are more specific and follow a step‐up approach to the management of cough among patients with lung cancer, acknowledging the low‐quality evidence in the field and the urgent need to develop more effective, evidence‐based interventions through high‐quality research.