International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 2: non-infective acute respiratory illness.

Acute respiratory illness (ARill) is common and threatens the health of athletes. ARill in athletes forms a significant component of the work of Sport and Exercise Medicine (SEM) clinicians. The aim of this consensus is to provide the SEM clinician with an overview and practical clinical approach to non-infective ARill in athletes. The International Olympic Committee (IOC) Medical and Scientific Committee appointed an international consensus group to review ARill in athletes. Key areas of ARill in athletes were originally identified and six subgroups of the IOC Consensus group established to review the following aspects: (1) epidemiology/risk factors for ARill, (2) infective ARill, (3) non-infective ARill, (4) acute asthma/exercise-induced bronchoconstriction and related conditions, (5) effects of ARill on exercise/sports performance, medical complications/return-to-sport (RTS) and (6) acute nasal/laryngeal obstruction presenting as ARill. Following several reviews conducted by subgroups, the sections of the consensus documents were allocated to 'core' members for drafting and internal review. An advanced draft of the consensus document was discussed during a meeting of the main consensus core group, and final edits were completed prior to submission of the manuscript. This document (part 2) of this consensus focuses on respiratory conditions causing non-infective ARill in athletes. These include non-inflammatory obstructive nasal, laryngeal, tracheal or bronchial conditions or non-infective inflammatory conditions of the respiratory epithelium that affect the upper and/or lower airways, frequently as a continuum. The following aspects of more common as well as lesser-known non-infective ARill in athletes are reviewed: epidemiology, risk factors, pathology/pathophysiology, clinical presentation and diagnosis, management, prevention, medical considerations and risks of illness during exercise, effects of illness on exercise/sports performance and RTS guidelines.

International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 1: acute respiratory infections.

Acute illnesses affecting the respiratory tract are common and form a significant component of the work of Sport and Exercise Medicine (SEM) clinicians. Acute respiratory illness (ARill) can broadly be classified as non-infective ARill and acute respiratory infections (ARinf). The aim of this consensus is to provide the SEM clinician with an overview and practical clinical approach to ARinf in athletes. The International Olympic Committee (IOC) Medical and Scientific Commission appointed an international consensus group to review ARill (non-infective ARill and ARinf) in athletes. Six subgroups of the IOC Consensus group were initially established to review the following key areas of ARill in athletes: (1) epidemiology/risk factors for ARill, (2) ARinf, (3) non-infective ARill including ARill due to environmental exposure, (4) acute asthma and related conditions, (5) effects of ARill on exercise/sports performance, medical complications/return-to-sport and (6) acute nasal/vocal cord dysfunction presenting as ARill. Several systematic and narrative reviews were conducted by IOC consensus subgroups, and these then formed the basis of sections in the consensus documents. Drafting and internal review of sections were allocated to 'core' members of the consensus group, and an advanced draft of the consensus document was discussed during a meeting of the main consensus core group in Lausanne, Switzerland on 11 to 12 October 2021. Final edits were completed after the meeting. This consensus document (part 1) focusses on ARinf, which accounts for the majority of ARill in athletes. The first section of this consensus proposes a set of definitions and classifications of ARinf in athletes to standardise future data collection and reporting. The remainder of the consensus paper examines a wide range of clinical considerations related to ARinf in athletes: epidemiology, risk factors, pathology/pathophysiology, clinical presentation and diagnosis, management, prevention, medical considerations, risks of infection during exercise, effects of infection on exercise/sports performance and return-to-sport guidelines.

Glucocorticoid prescribing habits of sports medicine physicians working in high-performance sport: a 30-nation survey.

OBJECTIVES: Glucocorticoids are commonly prescribed in medicine. When administered via certain routes, glucocorticoids are prohibited for incompetition use by WADA. The glucocorticoid prescribing habits of sports medicine doctors have not been reported. METHODS: An online survey was distributed internationally to physicians working in high-performance sports. The survey queried the doctors about their use of glucocorticoids with athletes and their understanding of WADA's regulations regarding glucocorticoid use in competition. RESULTS: 603 sports medicine doctors from 30 different countries participated. The majority (>85%) routinely injected glucocorticoids and/or prescribed glucocorticoids by other routes. There were substantial differences in the common routes of injection as well as types of glucocorticoid used among the physicians from various countries. A relatively small percentage of sports doctors (<25%) accurately identified which routes of glucocorticoid administration are prohibited in competition by WADA. There was a great variation in how long before competition the use of glucocorticoids would cause the doctor to consider applying for a therapeutic use exemption (TUE). A better understanding of the clearance rates of glucocorticoids from athletes' bodies would greatly aid sports medicine doctors' decisions on how and when to apply for a TUE. A small number of doctors had observed side effects of glucocorticoid administration, with the majority of side effects being minor in nature. CONCLUSION: Glucocorticoids are widely prescribed by sports physicians. There is a need to better educate sports physicians on the current WADA regulations in relation to glucocorticoid administration.

Glucocorticoids at the Olympic Games: state-of-the-art review.

In this state-of-the-art review, the author discusses the history of prohibiting glucocorticoids (GCs) and how this has occurred over nearly three decades at the Olympic Games. He relates how prohibiting systemic GCs in sport was a major factor in the development of therapeutic use exemptions and the fluctuating status of non-systemic GCs (banned, not banned). Concern is expressed that for 2017, the World Anti-Doping Agency (WADA) is proposing to prohibit injecting GCs shortly prior to competition. The author notes that in 1986, when GCs were first prohibited, analytical chemistry techniques could not distinguish the route of GC administration from its urinary concentration. Thirty years later, this remains the case. Importantly, this article discusses how the desired pharmacological effects of injecting GCs locally and intra-articularly can be achieved and why exercising vigorously immediately or shortly after a GC injection is therapeutically unsound. The review concludes by agreeing that injecting GCs shortly prior to strenuous training or competition is medically unwise but stresses that this is a clinical matter that sport-not WADA-needs to address. Cycling and rowing have managed this successfully for the past 5 years.

Prevalence and characteristics of asthma in the aquatic disciplines.

BACKGROUND: Despite the health benefits of swimming as a form of exercise, evidence exists that both the swimming pool environment and endurance exercise are etiologic factors in the development of asthma. The prevalence of asthma in swimmers is high compared with that in participants in other Olympic sport disciplines. There are no publications comparing the prevalence of asthma in the 5 aquatic disciplines. OBJECTIVE: The purpose of this study is to examine and compare the prevalence of asthma in the aquatic disciplines and in contrast with other Olympic sports. METHODS: Therapeutic Use Exemptions containing objective evidence of athlete asthma/airway hyperresponsiveness (AHR) were collected for all aquatic athletes participating in swimming, diving, synchronized swimming, water polo, and open water swimming for major events during the time period from 2004-2009. The prevalence of asthma/AHR in the aquatic disciplines was analyzed for statistical significance (with 95% CIs) and also compared with that in other Olympic sports. RESULTS: Swimming had the highest prevalence of asthma/AHR in comparison with the other aquatic disciplines. The endurance aquatic disciplines have a higher prevalence of asthma/AHR than the aquatic nonendurance disciplines. Asthma/AHR is more common in Oceania, Europe, and North America than in Asia, Africa, and South America. In comparison with other Olympic sports, swimming, synchronized swimming, and open water swimming were among the top 5 sports for asthma/AHR prevalence. CONCLUSION: Asthma/AHR in the endurance aquatic disciplines is common at the elite level and has a varied geographic distribution. Findings from this study demonstrate the need for development of aquatic discipline-specific prevention, screening, and treatment regimens.

Proscribed drugs at the Olympic Games: permitted use and misuse (doping) by athletes.

Athletes have always sought to outperform their competitors and regrettably some have resorted to misuse of drugs or doping to achieve this. Stimulants were taken by the first Olympic athletes to be disqualified in 1972. Although undetectable until 1975, from the 1950s androgenic anabolic steroids were administered for increased strength and power followed in the 1990s by erythropoietin for enhanced endurance. Both are highly effective doping agents. As analytical science validated improved techniques to identify these drugs, Olympic athletes, including many medallists were caught and disqualified. When the International Olympic Committee (IOC) prohibited beta blockers (beneficial in shooting), diuretics (assist weight classified athletes) and glucocorticosteroids, some athletes with genuine medical conditions were denied legitimate medical therapy. To overcome this, in 1992 the IOC introduced a system known now as Therapeutic Use Exemption (TUE). This paper discusses Olympic athletes who have been known to dope at past Games and some medical indications and pitfalls in the TUE process.

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".

OBJECTIVES: 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. DESIGN: Systematic review. METHODS: 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). RESULTS: 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. DISCUSSIONS: 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.

The innovative role of Olympic sports and exercise in the promotion of health, gender equality and sustainability: past achievements and future challenges.

Olympic sports represent, through their athletes, an iconic source of inspiration and ambition for everyone. During every Olympiad we are reminded of the astonishing achievements that can be reached through hard work and dedication. Nevertheless, these performances are very far from the reality of those being physically active to improve their health and fitness. The technological development that humanity has gone through in the last couple of centuries, has engineered physical activity out of our lives and dramatically altered our lifestyle, leading to the development of diseases that were not so prevalent. Exercise has become an integral part of our lives and it is now regarded as a medicine to prevent and counteract chronic conditions that are associated with a sedentary lifestyle. In this context Olympic sports can play a key role in attracting people to be physically active as well as leveraging on city governments to allow, not only sport participation, but a global active lifestyle. Therefore, International Sports Federations (ISF) have a central position in ensuring sports are in line with the changes occurring in society as well as fostering its natural evolution. Examples of this evolution are gender equality and sustainability, topics that finally are becoming central in ISFs as they have been in society for decades. Therefore, Olympic sports should acknowledge the prominent role they have in society and contribute to its further development by promoting socially relevant actions.

The enigma of inhaled salbutamol and sport: unresolved after 45 years.

During the past 45 years, there have been more changes on the World Anti-Doping Agency's (WADA) Prohibited List (the List) to the status of inhaled salbutamol than any other substance. With 658 athletes, 6.1% of all participating athletes approved to inhale salbutamol at the 2008 Beijing Games, it is one of the medications used most frequently by Olympic athletes. Nevertheless, since the 2008 Games, WADA has made numerous changes to inhaled salbutamol on the List including prohibiting its use, then a year later permitting it without prior notification and recommending a pharmacokinetic study if an athlete exceeds the urinary threshold of 1000 ng/mL. Recently, an elite athlete undertook two pharmacokinetic studies and the results have raised several questions. These include whether WADA should continue to permit nebulized salbutamol as an acceptable method of inhalation and there is some justification for nebulized salbutamol to be prohibited in sport. Another question is whether the modified advisory on salbutamol in the 2017 List appropriately informs athletes of the risks of exceeding the urinary threshold and the recent changes may not inform athletes optimally. Finally, concern is expressed at the persistent failure of WADA to apply a correction down to a specific gravity of 1.020 when an exogenous substance is identified in the urine of a dehydrated athlete. It is recommended that this should be implemented. Copyright © 2017 John Wiley & Sons, Ltd.

The World Anti-Doping Code: can you have asthma and still be an elite athlete?

KEY POINTS: The World Anti-Doping Code (the Code) does place some restrictions on prescribing inhaled ß2-agonists, but these can be overcome without jeopardising the treatment of elite athletes with asthma.While the Code permits the use of inhaled glucocorticoids without restriction, oral and intravenous glucocorticoids are prohibited, although a mechanism exists that allows them to be administered for acute severe asthma.Although asthmatic athletes achieved outstanding sporting success during the 1950s and 1960s before any anti-doping rules existed, since introduction of the Code's policies on some drugs to manage asthma results at the Olympic Games have revealed that athletes with confirmed asthma/airway hyperresponsiveness (AHR) have outperformed their non-asthmatic rivals.It appears that years of intensive endurance training can provoke airway injury, AHR and asthma in athletes without any past history of asthma. Although further research is needed, it appears that these consequences of airway injury may abate in some athletes after they have ceased intensive training. The World Anti-Doping Code (the Code) has not prevented asthmatic individuals from becoming elite athletes. This review examines those sections of the Code that are relevant to respiratory physicians who manage elite and sub-elite athletes with asthma. The restrictions that the Code places or may place on the prescription of drugs to prevent and treat asthma in athletes are discussed. In addition, the means by which respiratory physicians are able to treat their elite asthmatic athlete patients with drugs that are prohibited in sport are outlined, along with some of the pitfalls in such management and how best to prevent or minimise them.

Air pollution, athletic health and performance at the Olympic Games.

The objective of this study was to briefly review air pollution and its effects on athletes' health and performance and to examine air quality (AQ) at specific Olympic Summer Games between 1964 and 2008. It will focus on any attempts made by the cities hosting these Olympics to improve AQ for the Games and if undertaken, how successful these were. The author had a medical role at five of the seven Olympic Games that will be examined and hence has personal experiences. Information was obtained from the readily accessible official reports of the Olympic Games, relevant published papers and books and the internet. For each of these seven Olympic Games, monitoring AQ was far below current acceptable standards and for the majority, minimal or no data on major pollutants was available. From what can be ascertained, at these Games, AQ varied but was less than optimal in most if not all. Nevertheless, there were few reported or known unfavorable effects on the health of Olympic athletes. To date, there have been few reported consequences of sub-optimal AQ at Olympic Games. The focus on AQ at Olympic Games has gradually increased over the past five decades and is expected to continue into the future.

Bronchial challenges in athletes applying to inhale a beta2-agonist at the 2004 Summer Olympics.

BACKGROUND: The International Olympic Committee Medical Commission required a medical justification for athletes to inhale a beta2-agonist before an event at the Summer Games in Athens in 2004. OBJECTIVE: We sought to establish the percentage of athletes applying to use an inhaled beta2-agonist on the basis of the results of objective tests to establish a diagnosis of asthma or exercise-induced bronchoconstriction. We also sought to compare this percentage with the percentage of athletes simply notifying the intention to use a beta2-agonist at the previous Summer Games in Sydney in 2000. METHODS: An analysis was made of tests that measured the change in FEV1 in response to a bronchodilator or in response to a provoking stimulus, such as exercise, eucapnic voluntary hyperpnea, hypertonic saline, or methacholine. RESULTS: Ten thousand six hundred fifty-three athletes competed in Athens; 4.2% were approved to use a beta2-agonist, and 0.4% were rejected. This approval rate was 26% less than the notifications in 2000 in Sydney (5.7%). Compared with Sydney 2000, there was a significant reduction of submissions and approvals for athletes from the United States, New Zealand, Australia, and Canada and in triathlon and swimming sports. CONCLUSION: The need to provide objective testing has resulted in a reduction in the number of athletes seeking approval to use an inhaled beta2-agonist. Objective evidence has provided information for the doctor that is likely to improve the health of the athlete because many athletes appeared to be undertreated at the time of testing. CLINICAL IMPLICATIONS: We show that documentation of airway narrowing in athletes, particularly in response to exercise or surrogate stimuli for exercise, aids in the diagnosis and management of asthma by providing evidence of bronchial hyperresponsiveness that will respond to treatment with inhaled corticosteroids and is usually associated with a reduction in respiratory symptoms on exercise.