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Exercise-induced asthma screening of elite athletes: field versus laboratory exercise challenge


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Sport Science and Technology Division, United States Olympic Committee, Lake Placid, NY 12946

Submitted for publication September 1999.

Accepted for publication November 1999.

Address for correspondence: Dr. Kenneth W. Rundell, Sport Science & Technology Division, United States Olympic Committee at Lake Placid, Lake Placid, NY 12946. E-mail:

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RUNDELL, K. W., R. L. WILBER, L. SZMEDRA, D. M. JENKINSON, L. B. MAYERS, and J. IM. Exercise-induced asthma screening of elite athletes: field versus laboratory exercise challenge. Med. Sci. Sports Exerc., Vol. 32, No. 2, pp. 309–316, 2000.

Purpose: The purpose of this study was to compare a laboratory based exercise challenge (LBC) to a field based exercise challenge (FBC) for pulmonary function test (PFT) exercise-induced asthma (EIA) screening of elite athletes.

Methods: Twenty-three elite cold weather athletes (14 men, 9 women) PFT positive for EIA (FBC screened) served as subjects. Twenty-three gender and sport matched controls (nonasthmatics) were randomly selected to establish PFT reference values for normal elite athletes. Before FBC, athletes completed a medical history questionnaire for EIA symptoms. FBC evaluations consisted of baseline spirometry, actual or simulated competition, and 5, 10, and 15 min postexercise spirometry. PFT positive athletes were evaluated in the laboratory using an exercise challenge simulating race intensity (ambient conditions: 21°C, 60% relative humidity). PFT procedures were identical to FBC.

Results: 91% of PFT positive and 48% of PFT normal athletes reported at least one symptom of EIA, with postrace cough most frequent. Baseline spirometry was the same for PFT positives and normal controls. Lower limit reference range (MN - 2 SD) of FEV1 for controls suggests that postexercise decrements of greater than ∼−7% indicate abnormal airway response in this population. Exercise time duration did not effect bronchial reactivity; 78% of FBC PFT positives were PFT normal post-LBC. Conclusion: Self-reported symptoms by elite athletes are not reliable in identifying EIA. Reference range criterion for FEV1 decrement in the elite athlete postexercise contrasts current recommended guidelines. Moreover, a large number of false negatives may occur in this population if EIA screening is performed with inadequate exercise and environmental stress.

The prevalence of exercise-induced asthma (EIA) among elite athletes has been found to be higher for cold weather athletes than for warm weather athletes. The prevalence of EIA reported for elite Finnish runners (9%) (14), the 1984 United States Summer Olympic Team (11%) (35), and the 1996 U.S. Summer Olympic Team (20%) (37) is similar to the general population (12–15%) (27,28). In contrast, 30–35% of figure skaters had postexercise pulmonary function deficits consistent with EIA (20,24), and the reported incidence of EIA in Scandinavian cross-country skiers has ranged from 14% (11) to 55% (17). We have recently observed a 23% prevalence of EIA (defined as a >10% postexercise decrement in FEV1) among 1998 Winter Olympic athletes from seven different sports (38).

Exercise at high ventilation rates in a cold, dry ambient environment has been implicated in the observed high incidence of EIA among cold weather athletes (4,6,8,10,12,23,30,31,38). The precise mechanism responsible for initiating this reaction is not well understood, but it is clear that airway cooling and/or airway drying exacerbates the condition. Other factors that may influence bronchial hyperresponsiveness include chronic exposure to poorly ventilated wax rooms in Nordic sport and exposure to high NO2 concentrations (approaching 3000 ppb) in ice arenas (18). Asthmatics experience significant increases in airway resistance with short-term NO2 exposures of 500 ppb and nonasthmatics react to 1000 ppb (7). This exposure may affect hockey players, figure skaters, and speed skaters who spend several hours a day training and competing at high ventilation rates in this environment. Whatever the precise perturbation is, the winter sport athlete is at significantly higher risk for developing EIA than the warm weather athlete.

Diagnosis and treatment of EIA by the physician is frequently based on self-reported symptoms (chest tightness, dyspnea out of proportion to the exercise intensity, coughing, wheezing, and/or excess sputum) without pulmonary function testing (11,19). While studying U.S. National Team cold weather athletes, we found that 45% pulmonary function test normal athletes (N = 87) reported symptoms and 61% of 41 pulmonary function test positive athletes (N = 41) also reported symptoms (26). The lack of statistical significance between these two groups implies that the diagnosis of EIA based on history alone is unreliable within the elite athlete population and that appropriate pulmonary function testing should accompany self-reported symptoms for accurate diagnosis.

However, pulmonary function testing of elite cold weather athletes is challenging. In some cases, athletes who are clearly symptomatic postexercise and/or exhibit performance decrements in cold conditions demonstrate normal postexercise FEV1 when exercise challenged, even in a cold environment (34). Additionally, the exercise capacity of the elite athlete may be underestimated by the clinician so that the diagnostic exercise challenge may lack the appropriate intensity or cold environment to initiate bronchoconstriction. General guidelines for EIA pulmonary function testing include an exercise challenge in ambient laboratory conditions of 6–8 min duration at an intensity of ∼85% of predicted peak heart rate (2,5,9,16,19). Personal communication with asthmatic athletes suggests that, in many cases, symptoms do not appear unless the exercise intensity approaches race pace (90–100% HRmax) and the ambient air temperature is “cold.” We believe that the exercise challenge for evaluating elite athletes for EIA should be sport and environment specific at a competitive effort intensity. We hypothesized that a “field-based” sport/intensity specific exercise challenge in a cold environment would be a more valid assessment of EIA in the elite cold weather athlete than the traditional laboratory based exercise challenge.

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Twenty-three elite athletes (age: 20 ± 4.5 yr, height: 173 ± 8.7 cm, weight: 67 ± 9.9 kg, 14 men and 9 women) identified as EIA positive were selected as subjects and provided written informed consent to participate in this study. Experimental procedures were approved by the Institutional Review Board of the Sport Science and Technology Division of the United States Olympic Committee (USOC). Six subjects were Olympians, 10 others had participated on World Championship Teams and the remaining 7 were top developmental athletes. Subject sports were: biathlon (6), cross-country skiing (6), Nordic combined (3), short-track speed skating (5), and kayaking (3). Fifteen subjects were from outdoor cold-weather sport, five from cold-weather indoor sport, and three from paddling sport. The athletes were selected from a larger pool of approximately 160 athletes who were evaluated for the presence of EIA by using a sport/environment specific “field” exercise challenge (race or race simulation) in a prior study. All subjects selected for this study demonstrated postexercise challenge decrements in pulmonary function consistent with EIA. Seven subjects had been previously diagnosed with EIA as children, but none were currently using oral or inhaled medication before exercise or competition. Before the field exercise challenge pulmonary function tests (PFT), each subject completed a questionnaire for four common symptoms of EIA: coughing, wheezing, excessive mucus formation, and chest tightness/trouble breathing. An additional gender and sport matched subpopulation of 23 athletes from the EIA screened athlete pool with normal postexercise challenge spirometry were randomly selected to establish references for PFT normal cold weather athletes.

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Our study consisted of two series of EIA evaluations. The first involved a sport-specific exercise challenge of either actual competition or simulated competition (FBC). Time duration ranged from approximately 1 min 20 s for speed skaters to over 1 h for cross-country skiers. Subjects who demonstrated postexercise PFT decrements consistent with EIA from this evaluation were asked to perform a second exercise challenge in the laboratory (LBC; 21°C, 60% relative humidity). This involved treadmill running for 8 min at a speed and elevation that elicited approximately 95% of peak heart rate (an exercise challenge that closely mimicked competition level intensity). The rational for this intensity was based on competition specificity and the superior fitness level of this elite athlete population. In addition, verbal communication with symptomatic athletes indicated that symptoms did not occur at lower exercise intensities (e.g., <90% maximal heart rate).

Standard spirometry evaluations were performed preexercise and at 5, 10, and 15 min postexercise challenge using a calibrated computerized 10 L rolling dry-seal spirometer (Model 2130, Sensormedics, Yorba Linda, CA). Before each exercise challenge, baseline spirometry was performed by obtaining three consistent trials that involved the following procedure: 1) three normal tidal volume breaths; 2) maximal inhalation; 3) forced maximal exhalation; and 4) maximal inhalation. The best-of-three trials was used for analysis. The athletes performed preexercise baseline spirometry for FBC before any warm-up. After baseline spirometry was obtained, the athletes followed their usual warm-up schedule, completed their competition, and reported for postexercise pulmonary function tests (PFT). This procedure was the same for LBC except that no warm-up was done before the exercise challenge. Postexercise PFT were done at 5, 10, and 15 min post exercise challenge for both FBC and LBC. Pulmonary function decrements were determined by subtracting each postexercise value of FVC, FEV1, FEF25–75%, and PEF from best-of-three preexercise baseline values, dividing by baseline values and multiplying by 100. Decrements of greater than 10% in FEV1, and/or 15% in FEF25–75%, and/or 10% in PEF from baseline values were considered as positive indications of airway flow restriction. Nineteen of the 23 subjects demonstrated decrements in FEV1 greater than 10%. The remaining four subjects were FEV1 compromised by 8.7 ± 0.9% (outside of the −6.4% criteria established by our population of asymptomatics, see results), but values for FEF25–75% and PEF were consistent with EIA and exceeded the above established criteria, and were thus included in the study population.

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Statistical analysis.

Statistical comparisons between field and laboratory exercise challenge based spirometry were made by ANOVA. Pearson product moment correlations were used to evaluate relationships between pulmonary function deficits. For all statistical comparisons, the level of significance was set as P < 0.05.

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Table 1 lists self-reported symptoms that occurred during or after high exertion exercise. Twenty-one (91%) of 23 PFT+ athletes reported at least one symptom, whereas 11 (48%) of 23 PFT normal athletes reported at least one symptom (P < 0.05). Eighteen (78%) PFT+ athletes and 8 (35%) PFT-normal athletes reported two or more symptoms (P < 0.05). For the PFT+ athletes, a postrace cough/hack was the most prevalent symptom reported, followed by excess mucus, chest constriction, and wheezing and was significantly higher than other symptoms (P < 0.05). For PFT normal athletes, the post race cough/hack was the most reported symptom, followed by chest constriction, wheezing and excess mucus. The PFT positive group reported more than twice as many symptoms as the PFT normal group.

Table 1
Table 1
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Table 2 provides baseline spirometry values for FBC, LBC, and for 23 PFT normal controls. As expected for this elite athlete population, mean values were above predicted values. No group or gender differences for any pulmonary function variables (as percent of predicted value) were noted. Four men and 4 women recorded baseline values below 100% predicted for at least one PFT variable (∼35% of the PFT+ population). Of those, two men and one woman (∼13% of the study population) had been previously diagnosed with asthma as children but did not use medication. PFT values for these eight were 102 ± 9.6, 101 ± 5.7, 96 ± 10.6, and 90 ± 15.4 for FVC, FEV1, FEF25–75%, and PEF, respectively.

Table 2
Table 2
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Twenty-three gender and sport matched PFT normal controls who demonstrated no differences between pre- and post-FBC pulmonary function test values were used to determine a PFT reference range for an elite cold weather athlete population (Table 3). The mean maximal exercise induced change after FBC (in FVC, FEV1, FEF25–75%, and PEF) minus 2 SD was established as the lower limit reference range (Table 3). FEV1 and FEF25–75% lower limits determined with this group were less rigorous than the previously established cut-off criteria of 10–20% for FEV1 (1,2,4,7,27,36) and 15–25% for FEF25–75% (1,19).

Table 3
Table 3
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Figure 1 shows post-FBC pulmonary functions of the study population grouped according to FBC exercise duration, <2 min (I), 6–7 min (II), and >25 min (III). No significant differences existed between groups for any pulmonary function at any time point.

Figure 1
Figure 1
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Eighteen (78%) of the 23 post-FBC PFT positive subjects had normal spirometry post-LBC. Figure 2 depicts pulmonary function decrements from FBC and LBC for those 18 subjects. Significant differences between FBC and LBC pulmonary functions were apparent for all values (P < 0.05) except 10 and 15 min FVC and 15 min PEF. For FBC, 5 and 10 min FVC decrements were significantly greater than 15 min FVC (P < 0.05), whereas 10 min FEV1 and FEF 25–75% decrements were significantly greater than 15 min values (P < 0.05) but not different than those at 5 min. No differences were apparent between PEF decrements for FBC. For LBC, no differences between values at 5, 10, and 15 min postexercise were apparent for FVC, FEV1, or PEF, but 5 min was different than 10 and 15 min FEF25–75% post exercise values (P < 0.05).

Figure 2
Figure 2
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Of the five FBC PFT positive athletes who demonstrated post LBC pulmonary decrements consistent with EIA positive criteria, no differences were evident between FBC and LBC values at any time point. No significant differences existed for postexercise challenge pulmonary decrements between time points for FVC, FEV1, FEF25–75%, or PEF (Fig. 3).

Figure 3
Figure 3
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It is generally accepted that inhaling cold dry air at high ventilation rates causes EIA. Never the less, many authors (2,5,9,16,19,21,28) recommend that pulmonary function testing be performed in the laboratory environment using an exercise challenge with an intensity at or below lactate threshold (50% to 85% of maximal aerobic capacity) and a duration of 4–8 min. The rational for this intensity level is based on the assumption that catecholamine release at higher intensities may produce bronchodilation, resulting in false negative diagnoses. However, Warren et al. (36) states that withdrawal of vagal tone and not circulating catecholamines is responsible for bronchodilation during exercise. The recommended test duration is primarily based on studies done with asthmatic children (9) or a nonelite athletic population (2). These procedures may not apply to the elite athlete population.

In this study, we examined the efficacy of sport/environment-specific field based exercise challenge of varying duration (but at maximal effort specific to the duration) compared to a standardized laboratory based exercise challenge for EIA diagnosis in elite cold weather athletes. “Field” evaluations were done in conjunction with actual competitions (e.g., U.S. Olympic Trials, World Cup competition) or mock competitions specific to each athlete’s sport. Laboratory evaluations were done at a specific duration (8 min) and intensity (≥95% of maximal heart rate) in controlled environmental conditions (22°C, 60% RH).

The findings of our study are critical to effective diagnosis of EIA in the elite cold weather athlete. We demonstrated that resting pulmonary functions of this PFT positive population are 10–20% above predicted normative values for the nonathlete and are not different from those of PFT normal elite cold weather athletes. We have established a lower limit reference range (MN –2 SD) for postexercise pulmonary function variables from a subpopulation of PFT normal elite cold weather athletes which we believe provides appropriate cut-off criteria for these athletes. Furthermore, these values agree with other reference ranges determined in elite runners (14). Moreover, we found that among this population, duration of the exercise perturbation (1.5 min to ∼1 h) is not as important as exercise intensity and environmental condition. We have clearly demonstrated that cold dry air and near maximal exercise intensity are critical components of the exercise challenge for EIA evaluation. Our data suggests that the laboratory environment, even at race pace intensity, does not provide appropriate conditions to assess cold weather athletes for EIA and will yield a high percentage of “false negatives” (>78%).

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Self-reported symptoms.

The questionnaire responses from the limited number of subjects (N = 46) in our study suggests that the majority of athletes who are PFT positive will report symptoms (91%); however, 48% of those athletes who have normal PFT will also report symptoms. This suggests that diagnosis based upon reported symptoms without pulmonary function testing may result in about one third of the symptom reporting population being treated unnecessarily. Other survey data on Nordic skiers (17) show that about 39% will report symptoms consistent with EIA. In the study by Rice et al. (25), intercollegiate athletes were referred for pulmonary function tests based on a reported medical history consistent with EIA. Among the 41 referred athletes in that study (25), 46% were positive for EIA based on a greater than 10% drop in FEV1. This number was substantially lower than we found in this study with elite cold weather athletes where 66% (21 of 32 subjects) of those who reported at least one symptom were PFT positive for EIA. This discrepancy was probably the result of differences in the exercise challenge. An alternative explanation would be an effect of the small “N ” in our study. More recently, we (26) examined a larger population of elite athletes (N = 158) and found that 61% of PFT positive and 45% of PFT normal athletes reported symptoms (cough, excess mucus, chest constriction, and wheezing).

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Baseline pulmonary functions of elite athletes.

Normative resting pulmonary function data for the elite athlete population is limited. In a study of 58 elite Finnish runners, Helenius et al. (14) found FVC and FEV1 to approximate 100% predicted values, whereas PEF was 110% predicted. In our study, no difference in percent predicted baseline values was noted between FVC, FEV1, FEF25–75%, or PEF, and all criterion variables were between 109% and 123% of predicted, independent of gender or broncho-responsiveness. In support of this finding, Helenius et al. (13) examined 32 nonasthmatic Finnish runners and found no difference in preexercise FEV1 (expressed as percent predicted) between nonatopic and atopic subjects. Heir and Oseid (11) reported values for FVC, FEV1, FEF25%−75%, and PEF for male Norwegian cross-country skiers that were similar to our values. Baseline spirometry in our study, or in the above cited studies (11,13,14,20), was not sufficient to provide insight to the tendency for bronchial hyperreactivity.

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“Normal range” postexercise pulmonary functions for elite athletes.

Definitive EIA has been defined most frequently as a >10% postexercise fall in FEV1 or PEF (2,5,31,32). Others have suggested that a 15–20% postexercise reduction in FEV1 or PEF is appropriate (4,27). Further recommendations include decrements in FEF25–75% ranging from 15% to 25% to be representative of EIA (1,19). More recently a normal range for pulmonary functions has been established for elite runners by defining the lower limit of normal bronchial flow rate for symptom-free nonatopic runners as mean maximal exercise induced change in FEV1 and PEF minus 2 SD (13,14,33). Postexercise reductions in FEV1 and/or PEF of 6.5% and 17% (or greater), respectively, were considered abnormal (13,14,33). We have extended this concept to include a reference range for FVC, FEV1, FEF25–75%, and PEF for cold weather athletes. The lower limit (mean postexercise change from baseline spirometry minus 2 SD) for FEV1 of −6.4% in our PFT normal control group is in agreement with values for elite runners (13,14,33), but the PEF lower limit in our study was less than that defined by Tikkanen et al. (−12% vs –17%) (33). Still, these lower limit PEF values are greater than recommended cut-off criteria of 10% (2,8,27) and are probably a consequence of the effort dependency of PEF. In another study (35) (N = 87 nonasthmatic athletes) we found lower limit reference ranges for FEV1 and PEF to be −7.1% and 18.1%, respectively.

By using the lower limit for FEV1 (−6.4% postexercise decrement) defined by our control group, an additional four athletes would be considered probable for EIA from the laboratory exercise-challenge. This is still only 39% of those identified positive for definitive EIA (>10% decrement in FEV1) from the field based exercise-challenge. If the control group defined lower limit for PEF (−12%) was used in addition to FEV1 to evaluate the efficacy of LBC, the reliability improves to 57% of FBC identified EIA positive athletes. Of the 18 athletes PFT positive post-FBC who were PFT normal post-LBC, all were above the control group established lower limit of −13.5% for FEF25–75% post-LBC.

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Field versus laboratory exercise challenge.

The remarkable differences in postexercise pulmonary functions between FBC and LBC provide strong evidence for the efficacy of a field based cold weather exercise challenge for EIA diagnosis. Control of the exercise challenge and ambient conditions (except for speed skaters) during FBC was limited, since testing was done according to the race or athlete’s training schedule. Baseline spirometry was done before any warm-up or prolonged exposure to cold air. However, after baseline spirometry was completed, the athlete assumed his/her usual prerace strategy, including a warm-up. Several authors (6,15,19,21,29) have suggested a “refractory period” whereby a warm-up before exercise decreases postexercise bronchoconstriction. However, this data may not apply to our elite athlete subject pool. Using FBC for broncho-provocation and allowing for a warm-up period of the athletes’ choice, we have reported EIA incidence consistent with others that evaluated cold weather athletes (17,20,24,38). These included, cross-country skiers using a methacholine challenge (33%) (17) and figure skaters using an on-ice high intensity protocol (30%−35%) (20,24). Therefore, our data does not support the existence of a refractory period that significantly attenuates broncho-responsiveness for elite cold weather athletes. This finding is in agreement with Beck et al. (3) who found no evidence of a refractory period during interval type exercise by EIA patients. Moreover, the LBC did not allow for a warm-up period, yet only 5 of 23 PFT positive athletes (post-FBC) were positive post-LBC.

Several studies (4,10,22,23,30) have examined bronchial responsiveness to temperature and humidity. Our study is the first to provide strong evidence that among elite winter athletes, cold dry ambient air and near maximal exercise effort are key to diagnosing bronchospasm while exercise duration is not important. Exercise intensity during FBC and LBC was at or near race pace for our subjects, whereas exercise duration during FBC ranged from 1.5 min to over 60 min and was held constant during LBC (8 min). FBC data (cf., Fig. 1) demonstrates that exercise challenge duration per se is unimportant in provoking broncho-responsiveness, implying that intensity (high ventilation rates and not total ventilation during the exercise) and ambient conditions determine the occurrence of bronchospasm. No difference in pulmonary response relative to FBC duration was found. We did not examine a control FBC group where intensity was manipulated, but verbal communication with our elite athlete subjects indicated that the onset of symptoms was coincident with cold ambient temperatures coupled with high intensity (above 90% maximum heart rate) exercise. Even in cold ambient temperatures, the athletes stated that they were typically asymptomatic unless exercise intensity was at or near race pace. The primary difference between FBC and LBC tests was ambient air temperature and humidity.

Medical questionnaires/interviews do not provide accurate information concerning the prevalence or severity of EIA. Likewise, a laboratory exercise challenge at room temperature and 50% relative humidity is not appropriate for assessment of EIA in elite cold weather athletes and it will likely result in false negative evaluations. Our results suggest that broncho-responsiveness is strongly related to high ventilation rates (not total ventilation during exercise) in cold-dry air, and time duration of the exercise challenge seems to be unimportant. The lower limit reference range established from our PFT normal control group implies that among elite cold weather athletes, previously recommended cut-off criteria for establishing EIA diagnosis may be too stringent. In conclusion, to appropriately diagnose EIB in elite cold weather athletes, we suggest a sport/environment specific field based exercise challenge using postexercise decrement lower limits of −8.3% for FVC, −6.5% for FEV1, −13.5% for FEF25–75%, and −12% for PEF.

This study was supported by the United States Olympic Committee.

The views, opinions, and findings contained in this report are those of the authors and should not be construed as an official United States Olympic Committee position.

The authors would like to express gratitude to the athletes participating in this study.

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American Journal of Respiratory and Critical Care Medicine
An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction
Parsons, JP; Hallstrand, TS; Mastronarde, JG; Kaminsky, DA; Rundell, KW; Hull, JH; Storms, WW; Weiler, JM; Cheek, FM; Wilson, KC; Anderson, SD
American Journal of Respiratory and Critical Care Medicine, 187(9): 1016-1027.
Journal of Sports Medicine and Physical Fitness
Recurrent childhood wheezing and exercise induced asthma in later life
Rosenhagen, A; Vogt, L; Thiel, C; Bernhorster, M; Banzer, W
Journal of Sports Medicine and Physical Fitness, 52(6): 661-664.

Allergy and sports
Del Giacco, SR; Manconi, PE; Del Giacco, GS
Allergy, 56(3): 215-223.

Inspiratory stridor in elite athletes
Rundell, KW; Spiering, BA
Chest, 123(2): 468-474.

Applied Physiology Nutrition and Metabolism-Physiologie Appliquee Nutrition Et Metabolisme
The effect of a competitive season and environmental factors on pulmonary function and aerobic power in varsity hockey players
Game, AB; Bell, GJ
Applied Physiology Nutrition and Metabolism-Physiologie Appliquee Nutrition Et Metabolisme, 31(2): 95-100.
International Journal of Sports Medicine
Comparative Effects of Caffeine and Albuterol on the Bronchoconstrictor Response to Exercise in Asthmatic Athletes
VanHaitsma, TA; Mickleborough, T; Stager, JM; Koceja, DM; Lindley, MR; Chapman, R
International Journal of Sports Medicine, 31(4): 231-236.

Journal of Pediatrics
Effectiveness of screening examinations to detect unrecognized exercise-induced bronchoconstriction
Hallstrand, TS; Curtis, JR; Koepsell, TD; Martin, DP; Schoene, RB; Sullivan, SD; Yorioka, GN; Aitken, ML
Journal of Pediatrics, 141(3): 343-349.
Clinical and Experimental Allergy
Increased airway inflammatory cells in endurance athletes: what do they mean?
Bonsignore, MR; Morici, G; Vignola, AM; Riccobono, L; Bonanno, A; Profita, M; Abate, P; Scichilone, N; Amato, G; Bellia, V; Bonsignore, G
Clinical and Experimental Allergy, 33(1): 14-21.

Journal of Asthma
Dietary omega-3 polyunsaturated fatty acid supplementation and airway hyperresponsiveness in asthma
Mickleborough, TD
Journal of Asthma, 42(5): 305-314.
Clinical Reviews in Allergy & Immunology
Medical screening of the athlete - How does asthma fit in?
Hong, G; Mahamitra, N
Clinical Reviews in Allergy & Immunology, 29(2): 97-111.

Immunology and Allergy Clinics of North America
Asthma associated with exercise
Storms, WW
Immunology and Allergy Clinics of North America, 25(1): 31-+.
Iranian Journal of Allergy Asthma and Immunology
The prevalence of exercise-induced bronchospasm in soccer player children, ages 7 to 16 years
Ziaee, V; Yousefi, A; Movahedi, M; Mehrkhani, F; Noorian, R
Iranian Journal of Allergy Asthma and Immunology, 6(1): 33-36.

Journal of Allergy and Clinical Immunology
Why must Olympic athletes prove that they have asthma to be permitted to take inhaled beta(2)-agonists?
Weiler, JM
Journal of Allergy and Clinical Immunology, 111(1): 36-37.

Clinical Reviews in Allergy & Immunology
Methods for "indirect" challenge tests including exercise, eucapnic voluntary hyperpnea, and hypertonic aerosols
Anderson, SD; Brannan, JD
Clinical Reviews in Allergy & Immunology, 24(1): 27-54.

Clinical Reviews in Allergy & Immunology
Exercise-induced bronchospasm in children
Randolph, C
Clinical Reviews in Allergy & Immunology, 34(2): 205-216.
Journal of Athletic Training
National Athletic Trainers' Association position statement: Management of asthma in athletes
Miller, MG; Weiler, JM; Baker, R; Collins, J; D'Alonzo, G
Journal of Athletic Training, 40(3): 224-245.

Predictive value of allergy and pulmonary function tests for the diagnosis of asthma in elite athletes
Bonini, M; Lapucci, G; Petrelli, G; Todaro, A; Pamich, T; Rasi, G; Bonini, S
Allergy, 62(): 1166-1170.
Exercise-induced asthma, respiratory and allergic disorders in elite athletes: epidemiology, mechanisms and diagnosis: Part I of the report from the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA(2)LEN
Carlsen, KH; Anderson, SD; Bjermer, L; Bonini, S; Brusasco, V; Canonica, W; Cummiskey, J; Delgado, L; Del Giacco, SR; Drobnic, F; Haahtela, T; Larsson, K; Palange, P; Popov, T; van Cauwenberge, P
Allergy, 63(4): 387-403.
Journal of Allergy and Clinical Immunology
Responses to bronchial challenge submitted for approval to use inhaled beta(2)-agonists before an event at the 2002 Winter Olympics
Anderson, SD; Fitch, K; Perry, CP; Sue-Chu, M; Crapo, R; McKenzie, D; Magnussen, H
Journal of Allergy and Clinical Immunology, 111(1): 45-50.
Airway narrowing measured by spirometry and impulse oscillometry following room temperature and cold temperature exercise
Evans, TM; Rundell, KW; Beck, KC; Levine, AM; Baumann, JM
Chest, 128(4): 2412-2419.

Clinical role of rapid-incremental tests in the evaluation of exercise-induced bronchoconstriction
De Fuccio, MB; Nery, LE; Malaguti, C; Taguchi, S; Dal Corso, S; Neder, JA
Chest, 128(4): 2435-2442.

Monatsschrift Kinderheilkunde
Sports examination for children and adolescents
Rosenhagen, A; Vogt, L; Banzer, W
Monatsschrift Kinderheilkunde, 156(1): 14-+.
International Journal of Food Sciences and Nutrition
Modification of blood antioxidant status and lipid profile in response to high-intensity endurance exercise after low doses of omega-3 polyunsaturated fatty acids supplementation in healthy volunteers
Poprzecki, S; Zajac, A; Chalimoniuk, M; Waskiewicz, Z; Langfort, J
International Journal of Food Sciences and Nutrition, 60(): 67-79.
Medicine and Science in Sports and Exercise
Exercise-induced bronchospasm prevalence in collegiate cross-country runners
Thole, RT; Sallis, RE; Rubin, AL; Smith, GN
Medicine and Science in Sports and Exercise, 33(): 1641-1646.

Journal of Allergy and Clinical Immunology
Exercise in elite summer athletes: Challenges for diagnosis
Holzer, K; Anderson, SD; Douglass, J
Journal of Allergy and Clinical Immunology, 110(3): 374-380.
Journal of Allergy and Clinical Immunology
American Academy of Allergy, Asthma & Immunology Work Group Report: Exercise-induced asthma
Weiler, JM; Bonini, S; Coifman, R; Craig, T; Delgado, L; Capao-Filipe, M; Passali, D; Randolph, C; Storms, W
Journal of Allergy and Clinical Immunology, 119(6): 1349-1358.
Physician and Sportsmedicine
IOC asks athletes for asthma proof - Request raises complex issues
Schnirring, L
Physician and Sportsmedicine, 30(1): 15-16.

Journal of Allergy and Clinical Immunology
Exercise-induced asthma: Is it the right diagnosis in elite athletes?
Anderson, SD; Holzer, K
Journal of Allergy and Clinical Immunology, 106(3): 419-428.
Respiratory Physiology & Neurobiology
The effects of cycle racing on pulmonary diffusion capacity and left ventricular systolic function
Stickland, MK; Petersen, SR; Haykowsky, MJ; Taylor, DA; Jones, RL
Respiratory Physiology & Neurobiology, 138(): 291-299.
Annals of Allergy Asthma & Immunology
Effect of lycopene supplementation on lung function after exercise in young athletes who complain of exercise-induced bronchoconstriction symptoms
Falk, B; Gorev, R; Zigel, L; Ben-Amotz, A; Neuman, I
Annals of Allergy Asthma & Immunology, 94(4): 480-485.

Impact of changes in the IOC-MC asthma criteria: a British perspective
Dickinson, JW; Whyte, GP; McConnell, AK; Harries, MG
Thorax, 60(8): 629-632.
British Journal of Sports Medicine
Screening elite winter athletes for exercise induced asthma: a comparison of three challenge methods
Dickinson, JW; Whyte, GP; McConnell, AK; Harries, MG
British Journal of Sports Medicine, 40(2): 179-182.
Current Allergy and Asthma Reports
Sideline management of asthma
Allen, TW
Current Allergy and Asthma Reports, 6(3): 252-255.

International Journal of Sports Medicine
Exercise-induced changes in pulmonary function of healthy, elite long-distance runners in cold air and pollen season exercise challenge tests
Helenlus, I; Tikkanen, HO; Helenius, M; Lumme, A; Remes, V; Haahtela, T
International Journal of Sports Medicine, 23(4): 252-261.

Science & Sports
Prevalence of asthma in athletes, influence of sport and environmental exposure
Michalak, T; Flore, P; Bouvat, E; Verges, S; Samuel, MJ; Favre-Juvin, A
Science & Sports, 17(6): 278-285.
PII S0765-1597(02)00178-8
American Journal of Respiratory and Critical Care Medicine
Fish oil supplementation reduces severity of exercise-induced bronchoconstriction in elite athletes
Mickleborough, TD; Murray, RL; Ionescu, AA; Lindley, MR
American Journal of Respiratory and Critical Care Medicine, 168(): 1181-1189.
Exercise-induced bronchoconstriction in athletes
Parsons, JP; Mastronarde, JG
Chest, 128(6): 3966-3974.

International Sportmed Journal
A workload equation for a bicycle ergometer is not sufficient to elicit exercise-induced bronchoconstriction in athletes
Dal, U; Erdogan, AT; Helvaci, I
International Sportmed Journal, 11(1): 226-234.

Nursing Clinics of North America
Exercise-induced asthma
Brooks, EG; Hayden, ML
Nursing Clinics of North America, 38(4): 689-+.
Sports Medicine
Exercise-induced bronchospasm in the elite athlete
Rundell, KW; Jenkinson, DM
Sports Medicine, 32(9): 583-600.

Medicine and Science in Sports and Exercise
Montelukast has no ergogenic effect on cycle ergometry in cold temperature
Rundell, KW; Spiering, BA; Baumann, JM; Evans, TM
Medicine and Science in Sports and Exercise, 36(): 1847-1851.
European Journal of Clinical Nutrition
Dietary polyunsaturated fatty acids in asthma- and exercise-induced bronchoconstriction
Mickleborough, TD; Rundell, KW
European Journal of Clinical Nutrition, 59(): 1335-1346.
Journal of Asthma
Impulse oscillometry is sensitive to bronchoconstriction after eucapnic voluntary hyperventilation or exercise
Evans, TM; Rundell, KW; Beck, KC; Levine, AM; Baumann, JM
Journal of Asthma, 43(1): 49-55.
Allergy and Asthma Proceedings
Exercise-induced bronchospasm among students of Tehran University of Medical Sciences in 2004
Mansournia, MA; Jamali, M; Mansournia, N; Yunesian, M; Moghadam, KG
Allergy and Asthma Proceedings, 28(3): 348-352.

Medicina Dello Sport
Exercise induced bronchospasm in recreational athletes: prevalence and effects on physical performance
Yildiz, Y; Saka, T; Hazneci, B; Sekir, U; Aydin, T
Medicina Dello Sport, 61(2): 167-177.

Mid-expiratory flow versus FEV1 measurements in the diagnosis of exercise induced asthma in elite athletes
Dickinson, JW; Whyte, GP; McConnell, AK; Nevill, AM; Harries, MG
Thorax, 61(2): 111-114.
Journal of Sports Medicine and Physical Fitness
Testing of pulmonary function in a professional cycling team
Medelli, J; Lounana, J; Messan, F; Menuet, JJ; Petitjean, M
Journal of Sports Medicine and Physical Fitness, 46(2): 298-306.

British Journal of Sports Medicine
Provocation by eucapnic voluntary hyperpnoea to identify exercise induced bronchoconstriction
Anderson, SD; Argyros, GJ; Magnussen, H; Holzer, K
British Journal of Sports Medicine, 35(5): 344-347.

Revue Des Maladies Respiratoires
Asthma in athletes
Kippelen, P; Friemel, F; Godard, P
Revue Des Maladies Respiratoires, 20(3): 385-397.

British Journal of Sports Medicine
Effects of montelukast on airway narrowing from eucapnic voluntary hyperventilation and cold air exercise
Rundell, KW; Spiering, BA; Baumann, JM; Evans, TM
British Journal of Sports Medicine, 39(4): 232-236.
Journal of Allergy and Clinical Immunology
Exercise and other indirect challenges to demonstrate asthma or exercise-induced bronchoconstriction in athletes
Rundell, KW; Slee, JB
Journal of Allergy and Clinical Immunology, 122(2): 238-246.
Journal of Asthma
An evaluation of standardizing target ventilation for eucapnic voluntary hyperventilation using FEV1
Spiering, BA; Judelson, DA; Rundell, KW
Journal of Asthma, 41(7): 745-749.
Inhalation Toxicology
Bronchoconstriction provoked by exercise in a high-particulate-matter environment is attenuated by montelukast
Rundell, KW; Spiering, BA; Baumann, JM; Evans, TM
Inhalation Toxicology, 17(2): 99-105.
Sports Medicine
Asthma, airway inflammation and treatment in elite athletes
Helenius, I; Lumme, A; Haahtela, T
Sports Medicine, 35(7): 565-574.

Protective effect of fish oil supplementation on exercise-induced bronchoconstriction in asthma
Mickleborough, TD; Lindley, MR; Ionescu, AA; Fly, AD
Chest, 129(1): 39-49.

Journal of Pediatrics
Screening for exercise-induced asthma
Bokulic, RE
Journal of Pediatrics, 141(3): 306-308.
Prevalence of exercise-induced bronchospasm in long distance runners trained in cold weather
Ucok, K; Dane, S; Gokbel, H; Akar, S
Lung, 182(5): 265-270.
Field exercise vs laboratory eucapnic voluntary hyperventilation to identify airway hyperresponsiveness in elite cold weather athletes
Rundell, KW; Anderson, SD; Spiering, BA; Judelson, DA
Chest, 125(3): 909-915.

Postgraduate Medical Journal
Exercise induced bronchoconstriction and sports
Billen, A; Dupont, L
Postgraduate Medical Journal, 84(): 512-517.
Annals of Saudi Medicine
Prevalence of exercise-induced bronchoconstriction in teenage football players in Tunisia
Aissa, I; Frikha, A; Ghedira, H
Annals of Saudi Medicine, 29(4): 299-303.

Irish Journal of Medical Science
Prevalence of obstructive airflow limitation in Irish collegiate athletes
Smith, E; Mahony, N; Donne, B; O'Brien, M
Irish Journal of Medical Science, 171(4): 202-205.

Clinical Reviews in Allergy & Immunology
Making the diagnosis of asthma in the athlete
Randolph, C
Clinical Reviews in Allergy & Immunology, 29(2): 113-123.

Annals of Allergy Asthma & Immunology
Asthma screening of high school athletes: identifying the undiagnosed and poorly controlled
Hammerman, SI; Becker, JM; Rogers, J; Quedenfeld, TC; D'Alonzo, GE
Annals of Allergy Asthma & Immunology, 88(4): 380-384.

Inhalation Toxicology
Pulmonary function decay in women ice hockey players: Is there a relationship to ice rink air quality?
Rundell, KW
Inhalation Toxicology, 16(3): 117-123.
Journal of Allergy and Clinical Immunology
Asthma and the elite athlete: Summary of the International Olympic Committee's Consensus Conference, Lausanne, Switzerland, January 22-24, 2008
Fitch, KD; Sue-Chu, M; Anderson, SD; Boulet, LP; Hancox, RJ; McKenzie, DC; Backer, V; Rundell, KW; Alonso, JM; Kippelen, P; Cummiskey, JM; Garnier, A; Ljungqvist, A
Journal of Allergy and Clinical Immunology, 122(2): 254-260.
Respiratory Medicine
The relation between age and time to maximal bronchoconstriction following exercise in children
Vilozni, D; Szeinberg, A; Barak, A; Yahav, Y; Augarten, A; Efrati, O
Respiratory Medicine, 103(): 1456-1460.
Exercise-induced bronchoconstriction
Gotshall, RW
Drugs, 62(): 1725-1739.

Inhalation Toxicology
High levels of airborne ultrafine and fine particulate matter in indoor ice arenas
Rundell, KW
Inhalation Toxicology, 15(3): 237-250.
American Journal of Respiratory and Critical Care Medicine
Mannitol as a challenge test to identify exercise-induced bronchoconstriction in elite athletes
Holzer, K; Anderson, SD; Chan, HK; Douglass, J
American Journal of Respiratory and Critical Care Medicine, 167(4): 534-537.
Immunology and Allergy Clinics of North America
Assessment of EIB What You Need to Know to Optimize Test Results
Anderson, SD; Kippelen, P
Immunology and Allergy Clinics of North America, 33(3): 363-+.
Medicine & Science in Sports & Exercise
Bronchoconstriction during Cross-Country Skiing: Is There Really a Refractory Period?
Medicine & Science in Sports & Exercise, 35(1): 18-26.

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Cold Air Inhalation Does Not Affect the Severity of EIB after Exercise or Eucapnic Voluntary Hyperventilation
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