Extended diagnostic criteria used for indirect challenge testing in elite asthmatic swimmers.

The aim of the study was to investigate the prevalence of asthma with or without exercise induced symptoms among elite and elite aspiring swimmers and to compare sport specific exercise provocation with mannitol provocation. METHODS: 101 adolescent swimmers were investigated with mannitol provocation and sport specific exercise challenge test. Mannitol positivity was defined as either direct FEV(1) PD15 (ordinary criteria) or as β(2)-reversibility ≥15% after challenge (extended criteria). A direct positive exercise test was defined as a drop in FEV(1) of 10% (ordinary criteria) or a difference in FEV of ≥15% either spontaneous, variability, or with β2-agonist, reversibility (extended criteria). RESULTS: We found a high prevalence of mannitol and/or exercise positivity. Twenty-six swimmers were mannitol direct positive and 14 were direct exercise positive using ordinary criteria. Using extended criteria 43 were mannitol positive and 24 were exercise positive. When including reversibility and variability to define a positive test the sensitivity for current asthma with or without exercise induced symptoms increased while the specificity remained roughly unchanged. Direct positivity for mannitol and exercise poorly overlapped using ordinary criteria but improved using extended criteria. CONCLUSION: We found a high prevalence of asthma among elite swimmers. The use of variability and reversibility (liability) as additional criteria to define a positive test provided to our mind relevant information and should be considered

Sex differences in asthma in swimmers and tennis players

Background: Elite athletes, independent of sport, have increased risk of developing asthma, but little is known about sex difference among adolescent athletes. Objective: To investigate and compare sex-related differences according to symptoms and treatment of asthma, allergy, and health among elite athletes and a reference group. Methods: Adolescent elite swimmers (n = 101), tennis players (n = 86), and a reference group (n = 1,628) responded to a questionnaire about respiratory symptoms, allergy, health behavior, psychosomatic symptoms, self- esteem, and well-being. The athletes performed a mannitol provocation and a sport-specific exercise provocation. Atopy was assessed by skin prick tests, and fractional exhaled nitric oxide was measured. Results: The females reported more asthma symptoms than the males in both the reference group (29.1% vs 22.3%) and the athlete group (56.4% vs 40.2%). However, no significant differences were found in physician-diagnosed asthma or treatment with inhaled corticosteroids. More female athletes had a positive mannitol provocation result (48.7% vs 35.8% in male athletes), and more female swimmers had a positive exercise provocation result (15.1% vs 7.7% in male swimmers). The females in all groups had more psychosomatic symptoms compared with the respective males, and the males in the reference group reported higher self-esteem and felt more well-being compared with the reference group females. Conclusion: Overall, we found a higher prevalence of asthma symptoms in the females. However, the frequency of physician-diagnosed asthma and the prescription of inhaled corticosteroids were the same in both sexes. This finding demonstrates an insufficient diagnosis of asthma in females

Every breath you take every move you make. Studies on Asthma and Sports in Adolescent Athletes

Asthma and allergies are common diseases in adolescents and have increased during the last few decades. All elite level sports activities result in increased risk of asthma and rhinitis regardless of sport practised. Physical activity is at the same time regarded as a health-promoting factor and is recommended both for the prevention and treatment of diseases. The aim of this study was to explore the prevalence of asthma and allergy among aspiring elite athletes, swimmers and tennis players, and to compare them with a reference group. A second aim was to characterize the asthmatic presentation in both sports trying to identify factors that can help us to diagnos better. We also aimed to explore gender-related differences and factors related to life quality and physical activity in the different Groups. Methods: All groups answered a questionnaire to explore the frequency of respiratory symptom, health behaviour and life quality. To assess allergic sensitization, and airway hyper-reactivity skin-prick test, fractionated exhaled nitric oxide, mannitol provocation and exercise challenge tests were used. Clara Cell protein (CC16), 11β-prostaglandin (11-βPGF2α) and leukotriene E4 (LTE4) were measured in urine as biomarkers reflecting inflammatory reactions in the airways. Results: Respiratory symptoms and asthma were more common among the athletes and most common among the swimmers. The frequency of positive mannitol provocation test was higher among the swimmers than the tennis players while the number of positive exercise tests did not differ between the groups. There was an elevation of Clara Cell protein 16 in both groups after exercise challenge test, significantly higher among the tennis players, not seen after the mannitol provocation. Females had a higher frequency of respiratory symptoms and positive provocation tests, despite the same frequency of doctor-diagnosed asthma and asthma treatment. Physical activity led to a healthier life style and indicated better life quality most prominently among females. Conclusion: We found a high prevalence of asthma among elite swimmers and tennis players. The swimmers had a higher frequency of respiratory symptoms, current asthma and a higher rate of positive mannitol provocation tests. This may indicate an unfavorable exercise environment where trichloramine might play a role. The discrepancy between respiratory symptoms and airway hyper-reactivity on one hand and doctor-diagnosed asthma on the other could be in line with a tendency of not being sufficiently aware of the asthma diagnosis in females. Physical activity, even among athletes, seems to be a health-promoting factor

Asthma symptoms, mannitol reactivity and exercise-induced bronchoconstriction in adolescent swimmers versus tennis players

Background: Strenuous physical activity at an elite level is associated with an increased risk for asthma and, in some sports, also prevalence of allergies. The aim of this study was to investigate the prevalence of asthma and allergy among elite swimmers and tennis players and compare airway hyperreactivity to mannitol and exercise. Materials and methods: One hundred and one adolescent swimmers and 86 tennis players answered a questionnaire about respiratory symptoms and allergy and performed mannitol challenge and sport-specific exercise challenge. Atopy was assessed and fractional exhaled nitric oxide was measured. Mannitol positivity was defined as drop in FEV1 ≥15% (ordinary criteria) and/or β2-reversibility (≥15%) after provocation (extended criteria). A positive exercise test was defined as a drop in FEV1 ≥10% (ordinary criteria) and/or β2-reversibility (≥15%) after provocation (extended criteria). Club cell protein (CC16) was measured in urine before and after the challenges. Results: Asthma symptoms were common in both groups. More swimmers had exercise-induced symptoms (77% versus 50%) and current asthma symptoms (56% versus 38%), compared to the tennis players. More swimmers also had a positive mannitol challenge test both using ordinary (26% versus 6%) and extended criteria (43% versus 17%), while the number of positive exercise tests did not differ. After exercise (but not mannitol) challenge, CC16 level was increased in both groups, but to a higher extent in tennis players. There were no differences in atopy, rhinitis or fractional exhaled nitric oxide. Conclusion: We found a high prevalence of asthma among elite swimmers and tennis players and a higher frequency of current asthma and positive mannitol challenge tests among the swimmers. This indicates an unfavorable exercise environment

Asthma is more prevalent in elite swimming adolescents despite better mental and physical health.

An increased risk of developing asthma has been reported among swimmers exposed to chloramine in pool arenas. The aim of the present study was to compare the prevalence of asthma and respiratory symptoms among elite aspiring swimmers compared with age-matched controls with different degrees of physical activity. We also aimed to relate these findings to mental and psychosocial factors. One hundred and one elite swimmers and 1628 age-matched controls answered a questionnaire containing questions about respiratory symptoms, lifestyle factors, mental and physical well-being. The controls were divided into three different groups according to the degree of physical activity, no physical activity, recreational training and elite training. Swimmers reported significantly more asthma symptoms, with 36.6% having physician-diagnosed asthma, compared with 16.2% among the controls. Use of regular medication was more common (14.9% vs 8.0%) and more swimmers reported an exacerbation of their asthma during the previous 12 months (16.8%) vs (5.8%) for the controls. Despite an increased prevalence of asthma symptoms, the swimmers reported best physical performance and best mental and physical well-being. They also had a healthier lifestyle without smoking and low alcohol consumption

Asthma control in patients on fixed dose combination evaluated with mannitol challenge test

SummaryAsthma is often difficult to control and it is likely that not all patients are optimally treated.This study aimed to explore asthma control in adults receiving fixed dose combination (FDC) therapy. Control of asthma was assessed using the mannitol challenge test as a monitoring tool to see if this would give additional information compared to the asthma control test (ACT). The study was an open-label, prospective study on 98 adults prescribed with FDC therapies for at least three months.74 patients considered that their asthma was well controlled. However, 60 patients had a positive mannitol challenge test (PD15 < 635 mg), and when those with a positive response to the short-acting β2-agonist (≥15%) after the mannitol challenge test were included, this increased to 64 patients (65%). Exploratory analysis determined that the spirometry parameters; FEV1/FVC and FEV1% of predicted, were statistically significant predictors of a positive mannitol challenge test. Co-morbid conditions such as concomitant upper airway involvement or eczema did not predict mannitol reactivity.Although most patients rated their asthma as well controlled, many provided a positive mannitol challenge test, suggesting the presence of underlying inflammation, despite treatment with fixed dose combination therapy

ALMA, a new tool for the management of asthma patients in clinical practice: development, validation and initial clinical findings.

BACKGROUND: Several instruments have been developed for measuring asthma control, but there is still a need to provide a structure for primary care asthma reviews. AIMS: The Active Life with Asthma (ALMA) tool was developed with the aim of structuring patient visits and assessing asthma treatment in primary care. The ability of ALMA to map out the care of asthma patients was evaluated and validated. METHODS: ALMA was developed with patient and clinical expert input. Questions were generated in focus groups and the resulting tool was subsequently validated by factor analysis in 1779 patients (1116 females) of mean age 51 years (range 18-89) in primary care. RESULTS: The ALMA tool includes 19 questions, 14 of which belong to a subset assessing asthma control. In this subset, factor analysis revealed three domains (factors): physical, psychological, and environmental triggers. Correlation with the Asthma Control Questionnaire was 0.72 and the Cronbach's alpha was 0.88. The test-retest reliability was 0.93. Of the 1779 patients tested with ALMA in primary care, 62% reported chest tightness, 30% nightly awakenings and 45% asthma breakthrough despite medication. CONCLUSIONS: The ALMA tool is useful as a follow-up instrument in clinical practice to structure patient visits and assess asthma treatment in primary care. The breadth of the questions and the pragmatic use in clinical practice also make it useful as an outcome measure

Många överbehandlas med astmamedicin

Swedish asthma guidelines recommend treating asthma with the lowest effective dose possible. These recommendations are both hard to follow and seldom considered enough in asthma care today. As an example, combination therapy with inhaled corticosteroids (ICS) and long acting beta agonists (LABA) should only be considered if asthma control is not achieved with low to medium dose ICS daily. However, the Swedish National Board of Health and Welfare estimates that 120 000 asthma patients are overmedicated with combination therapy. Guidelines are clear in instructions of when and how to step up asthma treatment, while instructions for stepping down are not that obvious. In this article, we present an asthma treatment algorithm for step 1-3 in adults for use in clinical practice (Fig. 1), where stepping down asthma treatment is considered as an alternative. Included are also instructions of how to step down asthma treatment (Fig. 2). We conclude that stepping down is possible to do in a safe way in certain patient groups while maintaining asthma control. If possible risks are taken into consideration, stepping down asthma treatment can be done in every clinical setting