Diagnosis and management of allergy and respiratory disorders in sport: An EAACI task force position paper.

Allergy and respiratory disorders are common in young athletic individuals. In the context of elite sport, it is essential to secure an accurate diagnosis in order to optimize health and performance. It is also important, however, to consider the potential impact or consequences of these disorders, in recreationally active individuals engaging in structured exercise and/or physical activity to maintain health and well-being across the lifespan. This EAACI Task Force was therefore established, to develop an up-to-date, research-informed position paper, detailing the optimal approach to the diagnosis and management of common exercise-related allergic and respiratory conditions. The recommendations are informed by a multidisciplinary panel of experts including allergists, pulmonologists, physiologists and sports physicians. The report is structured as a concise, practically focussed document, incorporating diagnostic and treatment algorithms, to provide a source of reference to aid clinical decision-making. Throughout, we signpost relevant learning resources to consolidate knowledge and understanding and conclude by highlighting future research priorities and unmet needs.

Clinical patterns, recovery time and prolonged impact of COVID-19 illness in international athletes: the UK experience.

OBJECTIVES: To report COVID-19 illness pattern, symptom duration and time loss in UK elite athletes. METHODS: Observational, clinical and database review of athletes with symptomatic COVID-19 illness managed within the UK Sports Institutes. Athletes were classified as confirmed (positive SARS-CoV-2 PCR or antibody tests) or probable (consistent clinical features) COVID-19. Clinical presentation was characterised by the predominant symptom focus (eg, upper or lower respiratory illness). Time loss was defined as days unavailable for full sport participation and comparison was made with a 2016-2019 respiratory illness dataset from the same surveillance system. RESULTS: Between 24 February 2020 and 18 January 2021, 147 athletes (25 Paralympic (17%)) with mean (SD) age 24.7 (5.2) years, 37% female, were diagnosed with COVID-19 (76 probable, 71 confirmed). Fatigue was the most prevalent symptom (57%), followed by dry cough (50%) and headache (46%). The median (IQR) symptom duration was 10 (6-17) days but 14% reported symptoms >28 days. Median time loss was 18 (12-30) days, with 27% not fully available >28 days from initial date of infection. This was greater than our historical non-COVID respiratory illness comparator; 6 days, 0-7 days (p<0.001) and 4% unavailable at 28 days. A lower respiratory phenotype (ie, including dyspnoea±chest pain±cough±fever) was present in 18% and associated with a higher relative risk of prolonged symptoms risk ratio 3.0 (95% CI: 1.4 to 6.5) and time loss 2.1 (95% CI: 1.2 to 3.5). CONCLUSIONS: In this cohort, COVID-19 largely resulted in a mild, self-limiting illness. The presence of lower respiratory tract features was associated with prolonged illness and a delayed return to sport.

Characteristics and impact of exercise-induced laryngeal obstruction: an international perspective.

BACKGROUND: Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathlessness and wheeze yet is frequently misdiagnosed as asthma. Insight regarding the demographic characteristics, laryngeal abnormalities and impact of EILO is currently limited, with data only available from individual centre reports. The aim of this work was to provide a broader perspective from a collaboration between multiple international expert centres. METHODS: Five geographically distinct clinical paediatric and adult centres (3 Denmark, 1 UK, 1 USA) with an expertise in assessing unexplained exertional breathlessness completed database entry of key characteristic features for all cases referred with suspected EILO over a 5-year period. All included cases completed clinical asthma workup and continuous laryngoscopy during exercise (CLE) testing for EILO. RESULTS: Data were available for 1007 individuals (n=713 female (71%)) with a median (range) age of 24 (8-76) years, and of these 586 (58%) were diagnosed with EILO. In all centres, EILO was frequently misdiagnosed as asthma; on average there was a 2-year delay to diagnosis of EILO, and current asthma medication was discontinued in 20%. Collapse at the supraglottic level was seen in 60%, whereas vocal cord dysfunction (VCD) was only detected/visualised in 18%. Nearly half (45%) of individuals with EILO were active participants in recreational-level sports, suggesting that EILO is not simply confined to competitive/elite athletes. CONCLUSION: Our findings indicate that key clinical characteristics and the impact of EILO/VCD are similar in globally distinct regions, facilitating improved awareness of this condition to enhance recognition and avoid erroneous asthma treatment.

Clinical Utility of Measuring Inspiratory Neural Drive During Cardiopulmonary Exercise Testing (CPET).

Cardiopulmonary exercise testing (CPET) has traditionally included ventilatory and metabolic measurements alongside electrocardiographic characterization; however, research increasingly acknowledges the utility of also measuring inspiratory neural drive (IND) through its surrogate measure of diaphragmatic electromyography (EMGdi). While true IND also encompasses the activation of non-diaphragmatic respiratory muscles, the current review focuses on diaphragmatic measurements, providing information about additional inspiratory muscle groups for context where appropriate. Evaluation of IND provides mechanistic insight into the origins of dyspnea and exercise limitation across pathologies; yields valuable information reflecting the integration of diverse mechanical, chemical, locomotor, and metabolic afferent signals; and can help assess the efficacy of therapeutic interventions. Further, IND measurement during the physiologic stress of exercise is uniquely poised to reveal the underpinnings of physiologic limitations masked during resting and unloaded breathing, with important information provided not only at peak exercise, but throughout exercise protocols. As our understanding of IND presentation across varying conditions continues to grow and methods for its measurement become more accessible, the translation of these principles into clinical settings is a logical next step in facilitating appropriate and nuanced management tailored to each individual's unique physiology. This review provides an overview of the current state of understanding of IND measurement during CPET: its origins, known patterns of behavior and links with dyspnea in health and major respiratory diseases, and the possibility of expanding this approach to applications beyond exercise.

High prevalence of exercise-induced stridor during Parkrun: a cross-sectional field-based evaluation.

BACKGROUND AND OBJECTIVE: The differential diagnosis for exercise-associated breathlessness is broad, however, when a young athletic individual presents with respiratory symptoms, they are most often prescribed inhaler therapy for presumed exercise-induced asthma (EIA). The purpose of this study was therefore to use a novel sound-based approach to assessment to evaluate the prevalence of exertional respiratory symptoms and characterise abnormal breathing sounds in a large cohort of recreationally active individuals. METHODS: Cross-sectional field-based evaluation of individuals completing Parkrun. PHASE 1: Prerace, clinical assessment and baseline spirometry were conducted. At peak exercise and immediately postrace, breathing was monitored continuously using a smartphone. Recordings were analysed retrospectively and coded for signs of the predominant respiratory noise. PHASE 2: A subpopulation that reported symptoms with at least one audible sign of respiratory dysfunction was randomly selected and invited to attend the laboratory on a separate occasion to undergo objective clinical workup to confirm or refute EIA. RESULTS: Forty-eight participants (22.6%) had at least one audible sign of respiratory dysfunction; inspiratory stridor (9.9%), expiratory wheeze (3.3%), combined stridor+wheeze (3.3%), cough (6.1%). Over one-third of the cohort (38.2%) were classified as symptomatic. Ten individuals attended a follow-up appointment, however, only one had objective evidence of EIA. CONCLUSIONS: The most common audible sign, detected in approximately 1 in 10 individuals, was inspiratory stridor, a characteristic feature of upper airway closure occurring during exercise. Further work is now required to further validate the precision and feasibility of this diagnostic approach in cohorts reporting exertional breathing difficulty.

Listening to music prior to bronchoscopy reduces anxiety - a randomised controlled trial.

Background: Listening to music as a means of relieving anxiety before and during endoscopy has been examined in several studies but results so far are contradictory and inconclusive. Aims: We aimed to determine whether listening to music could reduce anxiety prior to and during bronchoscopy, and whether it is influenced by the patient's preference in music. Methods: 300 patients undergoing bronchoscopy for suspected lung cancer were randomly assigned to: self-selected music, specially-designed music (MusiCureTM), or control (no sound). Spielberger's State-Trait Anxiety Inventory (STAI) was administered three times: at admission, after 20 min with or without music (preceding bronchoscopy), and shortly before discharge. The primary outcome was STAI state score after 20 min, with or without exposure to music prior to bronchoscopy. Results: On average, music reduced the STAI score by 2.5 points (95% CI, 1.1 to 4.0; p < 0.001) compared with the control group. This reduction was largest in the self-selected music group (3.4; 95% CI, 1.5 to 5.3; p < 0.001). In contrast, specially designed music did not significantly reduce STAI score (1.7; 95% CI, -0.3 to 3.6; p = 0.1). Conclusion: Listening to music reduces anxiety in patients undergoing bronchoscopy, provided that the music complies with the patient's preferences.

Feasibility of portable continuous laryngoscopy during exercise testing.

Exercise-induced laryngeal obstruction (EILO) is a prevalent problem causing exertional breathlessness and wheeze. This report demonstrates the feasibility and safety of a diagnostic approach to EILO, using a portable laryngoscope during exercise. http://ow.ly/eM6L30njDst.

Quantification and Analysis of Laryngeal Closure From Endoscopic Videos.

OBJECTIVE: At present, there are no objective techniques to quantify and describe laryngeal obstruction, and the reproducibility of subjective manual quantification methods is insufficient, resulting in diagnostic inaccuracy and a poor signal-to-noise ratio in medical research. In this work, a workflow is proposed to quantify laryngeal movements from laryngoscopic videos, to facilitate the diagnosis procedure. METHODS: The proposed method analyses laryngoscopic videos, and delineates glottic opening, vocal folds, and supraglottic structures, using a convolutional neural networks (CNNs) based algorithm. The segmentation is divided into two steps: A bounding box which indicates the region of interest (RoI) is found, followed by segmentation using fully convolutional networks (FCNs). The segmentation results are statistically quantified along the temporal dimension and processed using singular spectrum analysis (SSA), to extract clear objective information that can be used by the clinicians in diagnosis. RESULTS: The segmentation was validated on 400 images from 20 videos acquired using different endoscopic systems from different patients. The results indicated significant improvements over using FCN only in terms of both processing speed (16 FPS vs. 8 FPS) and segmentation result statistics. Five clinical cases on patients have also been provided to showcase the quantitative analysis results using the proposed method. CONCLUSION: The proposed method guarantees a robust and fast processing of laryngoscopic videos. Measurements of glottic angles and supraglottic index showed distinctive patterns in the provided clinical cases. SIGNIFICANCE: The proposed automated and objective method extracts important temporal laryngeal movement information, which can be used to aid laryngeal closure diagnosis.

Novel assessment tool to detect breathing pattern disorder in patients with refractory asthma.

BACKGROUND AND OBJECTIVE: Breathing pattern disorder (BPD) can co-exist with and mimic asthma, acting to amplify symptoms and confound assessment of disease control, resulting in inappropriate treatment escalation. The aim of this research was to report the utility of a novel breathing pattern assessment tool (BPAT) to detect BPD in treatment-refractory asthma. METHODS: As a component of a multidisciplinary assessment, adult patients referred with treatment-refractory asthma underwent respiratory physiotherapy assessment to diagnose BPD. Based on this assessment, patients were classified as having asthma, asthma + BPD or BPD alone. BPAT data were collected in addition to questionnaire data (Asthma Quality of Life Questionnaire (AQLQ) and Nijmegen Questionnaire (NQ)), pulmonary function and an assessment of exercise capacity. RESULTS: Data were retrospectively analysed for 150 (female; 69%) patients, mean (SD) age of 43 (14) years; characterized as asthma-only (n = 54, 36%), asthma + BPD (n = 63, 42%) and BPD-only (n = 33, 22%). Of the total population, 113 (76%) had an NQ score ≥23, but of these only 68% had physiotherapy evidence of BPD. Exercise capacity and AQLQ were lower in the asthma + BPD group than in the asthma-only group (P < 0.05), whilst lung function was similar between groups. Sensitivity analysis indicated that a BPAT score of ≥4 corresponded to a sensitivity of 0.92 and a specificity of 0.75 for diagnosis of BPD in this cohort. CONCLUSION: Breathing pattern irregularities are highly prevalent in individuals referred with treatment-refractory asthma and can be characterized using the BPAT. Further work is needed to determine inter-observer and within-subject variability and ensure the BPAT is a robust clinical tool. Watch the video abstract.

Increased respiratory neural drive and work of breathing in exercise-induced laryngeal obstruction.

Exercise-induced laryngeal obstruction (EILO), a phenomenon in which the larynx closes inappropriately during physical activity, is a prevalent cause of exertional dyspnea in young individuals. The physiological ventilatory impact of EILO and its relationship to dyspnea are poorly understood. The objective of this study was to evaluate exercise-related changes in laryngeal aperture on ventilation, pulmonary mechanics, and respiratory neural drive. We prospectively evaluated 12 subjects (6 with EILO and 6 healthy age- and gender-matched controls). Subjects underwent baseline spirometry and a symptom-limited incremental exercise test with simultaneous and synchronized recording of endoscopic video and gastric, esophageal, and transdiaphragmatic pressures, diaphragm electromyography, and respiratory airflow. The EILO and control groups had similar peak work rates and minute ventilation (V̇e) (work rate: 227 ± 35 vs. 237 ± 35 W; V̇e: 103 ± 20 vs. 98 ± 23 l/min; P > 0.05). At submaximal work rates (140-240 W), subjects with EILO demonstrated increased work of breathing ( P < 0.05) and respiratory neural drive ( P < 0.05), developing in close temporal association with onset of endoscopic evidence of laryngeal closure ( P < 0.05). Unexpectedly, a ventilatory increase ( P < 0.05), driven by augmented tidal volume ( P < 0.05), was seen in subjects with EILO before the onset of laryngeal closure; there were however no differences in dyspnea intensity between groups. Using simultaneous measurements of respiratory mechanics and diaphragm electromyography with endoscopic video, we demonstrate, for the first time, increased work of breathing and respiratory neural drive in association with the development of EILO. Future detailed investigations are now needed to understand the role of upper airway closure in causing exertional dyspnea and exercise limitation. NEW & NOTEWORTHY Exercise-induced laryngeal obstruction is a prevalent cause of exertional dyspnea in young individuals; yet, how laryngeal closure affects breathing is unknown. In this study we synchronized endoscopic video with respiratory physiological measurements, thus providing the first detailed commensurate assessment of respiratory mechanics and neural drive in relation to laryngeal closure. Laryngeal closure was associated with increased work of breathing and respiratory neural drive preceded by an augmented tidal volume and a rise in minute ventilation.

Laryngoscopy during swimming: A novel diagnostic technique to characterize swimming-induced laryngeal obstruction.

Exercise-induced laryngeal obstruction (EILO) is a key differential diagnosis for respiratory symptoms in athletes and is particularly prevalent in aquatic athletes. A definitive diagnosis of EILO is dependent on laryngoscopy, performed continuously, while an athlete engages in the sport that precipitates their symptoms. This report provides the first description of the feasibility of performing continuous laryngoscopy during exercise in a swimming environment. The report describes the methodology and safety of the use of continuous laryngoscopy while swimming. Laryngoscope, 127:2298-2301, 2017.

Music does not alter anxiety in patients with suspected lung cancer undergoing bronchoscopy: a randomised controlled trial.

BACKGROUND: The use of music to relieve anxiety has been examined in various studies, but the results are inconclusive. METHODS: From April to October 2015, 160 patients undergoing examination of pulmonary nodules were randomly assigned to MusiCure or no music. MusiCure was administered through earplugs to ensure blinding of the staff and was played from admission to the operating theatre to the end of the bronchoscopy. Spielberger's State-Trait Anxiety Inventory (STAI) was administered on admission, immediately before bronchoscopy, and on discharge. Secondary outcomes were p-cortisol, physiological variables, dosage of sedatives, movements measured by Actigraph, bronchoscopy duration, number of re-examinations, and overall perception of the sounds in the operating theatre measured by Visual analogue scale. RESULTS: The STAI scores were similar on admission, but after a 10-min wait in the operating theatre, scores varied significantly between patients with and without music, with lower scores in the music group [median (interquartile range, IQR) 35 (18) vs. 43 (25); p=0.03]. Post hoc multiple regression revealed treatment group as insignificant when adjusting for sex and baseline anxiety. However, there was a significantly more positive perception of the sounds in the operating theatre in the music group (median (IQR) 8.2 (1.8) vs. 5.4 (6.8); p<0.0001) and fewer re-examinations in the music group (19.2% vs. 7.7%, p<0.032). CONCLUSIONS: Ten minutes with MusiCure does not alter anxiety when adjusting for baseline anxiety and sex. The current study indicates that this field of research has many confounders.