BTS clinical statement for the assessment and management of respiratory problems in athletic individuals

INTRODUCTION This British Thoracic Society (BTS) Clinical Statement addresses the diagnosis, evaluation and management of respiratory problems in athletic individuals. The overall recommendations issued in this document are built on a synthesis of the best available published evidence, where available and appropriate, but are largely based on expert opinion, with emphasis on providing readers with pragmatic clinical advice, when faced with respiratory problems in exercising individuals. Participation in vigorous exercise or sport plays an important role in many people’s lifestyle and is associated with a broad range of benefits, including for cardiovascular, metabolic and mental health. For some individuals, however, the ability to participate in and enjoy sporting activities may be curtailed by the presence of respiratory symptoms. Indeed, it is estimated that at least one in four individuals report troublesome exerciserelated respiratory issues, such as breathlessness, cough and/or wheeze. Moreover, in competitive athletes, asthma is the most prevalent medical condition and encountered in approximately a quarter of those partaking in endurance sport. 3 Although athletic individuals can develop any cardiorespiratory illness and thus general clinical guideline documents are broadly applicable, studies over the past three decades have highlighted issues that are particularly relevant when assessing respiratory problems in athletic individuals or in certain sporting scenarios. For example, in the sports medicine world, it is now widely accepted that a clinicalbased diagnosis of exerciseinduced bronchoconstriction (EIB) in athletic individuals is often inaccurate and that symptoms of EIB poorly relate to objective test findings, such as from bronchoprovocation testing. 5 This may be explained by the presence of ‘sportspecific’ differential diagnoses, including highly prevalent conditions, such as exerciseinduced laryngeal obstruction (EILO) and breathing pattern disorder (BPD). This highlights the need for a modified approach to ensure a robust and accurate diagnosis and thus appropriate treatment. There are also some clinical presentations and scenarios that are unique and specific to sport, for example, swimminginduced pulmonary oedema (SIPE). Thus, while the broad principles of clinical assessment of the respiratory system apply, there are several caveats and considerations when assessing the athletic population. Scope The purpose of this document was to provide concise and pragmatic guidance to help clinicians from all aspects of the multidisciplinary team (ie, including doctors, physiotherapists, speech and language therapists, pharmacists, physiologists, psychologists and specialist nurses), in both primary and secondary care settings, in assessing and managing respiratory problems in athletic individuals. While it is important to acknowledge that symptoms in many common cardiorespiratory conditions (eg, heart disease) will be exacerbated by vigorous exercise, the intent of the document is to largely provide guidance regarding the clinical approach to an individual presenting with sportassociated respiratory symptoms. The statement does not address exertional breathlessness, wheeze on exertion or other symptoms in the nonathletic, general population, where the differential is broad and beyond the scope of this work. The statement also does not cover high altitude or extreme sport, given the CSG felt these issues would typically necessitate experienced and highly specialist input and as such would be beyond the scope of this general guidance document. For the purposes of this document, an athlete (paediatric or adult) is defined as an individual who regularly partakes in physical activity that could be classified as sport. When relevant, we further classify athletic status, based on level of competition, as either amateur, national or international (elite)±professional. The statement, however, aims to be inclusive of ‘athletes’ of all levels of aptitude, and while some issues will be particularly pertinent in the elite or professional setting (section 5), the approach to any specific issue is broadly applicable across all athletic individuals. This acknowledged, some of the diagnoses described in the statement will be relevant, even in this context. When appropriate, reference is made to cardiac diagnoses, and other clinical conditions in athletes and readers are signposted to other sources of information. A supplementary file with tables is available online, including details on recommended areas for future research (online supplemental table S4).