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Letter to the Editor

Medical Care of AQUATIC Athlete — Do Not Overlook the Upper Airway

Hull, James H. PhD; Dickinson, John; Scadding, Guy; Greenwell, Jon

Author Information
doi: 10.1249/JSR.0000000000000224
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Nichols’ (6) recent article in the journal succinctly reviews a broad range of conditions that should be considered by those delivering medical care to aquatic athletes. The review covers airway disease and, more specifically, exercise-induced bronchoconstriction (EIB). However, we wish to highlight a number of important omissions relating to the assessment of the upper airway, an important aspect of care often overlooked by clinicians.

Studies have demonstrated high rates of rhinitis in elite swimmers (2,5). Both symptoms and impairment of quality of life (if not performance) are greatest during periods of intense training and appear to decrease during prolonged rest periods away from the pool (2). Although atopy is at least as common in elite swimmers as age-matched controls, both allergic and nonallergic pathologies may be relevant (4). Falls in nasal peak inspiratory flow are seen after swimming (1); swimmers also have been found to have prolonged mucociliary clearance times, and notably, rhinitis in elite swimmers is likely to be undertreated (2,5).

It is also becoming increasingly well recognized that many athletes diagnosed with EIB also have exercise-induced laryngeal obstruction (EILO), a transient narrowing of the upper airways, at the level of the voice box that develops during maximal exercise (7). This acts to generate airway turbulence and increase airflow resistance, thereby causing discomfort and impaired exercise performance. An accurate assessment of the prevalence of this condition in aquatic athletes has been hampered by the obvious difficulties in performing the gold standard test of continuous laryngoscopy during exercise in the pool environment. However, it is our experience that EILO frequently coexists with EIB in elite swimmers. Poolside assessment facilitates diagnosis, and pointers to the diagnosis include the presence of wheeze, of stridulous quality, that occurs at peak exercise and rapidly abates on exercise cessation. It is our experience that EILO in aquatic athletes responds well to work with a combination of inspiratory muscle and breathing relaxation training (3).

Overall, we urge clinicians to consider the entire airway tract when assessing respiratory health in aquatic athletes and believe this approach is vitally important to ensure that both health and performance of this group of athletes are optimized.

James H. Hull, PhD

Department of Respiratory Medicine

Royal Brompton Hospital

London, UK

[email protected]

Guy Scadding

Department of Respiratory Medicine

Royal Brompton Hospital

London, UK

John Dickinson

Endurance Research Group

School of Sport and Exercise Sciences

University of Kent

Kent, UK

Jon Greenwell

British Swimming

Loughborough, UK

The authors declare no conflicts of interest and do not have any financial disclosures.


1. Alves A, Martins C, Delgado L, et al. Exercise-induced rhinitis in competitive swimmers. Am. J. Rhinol. Allergy. 2010; 24: e114–7.
2. Bougault V, Turmel J, Boulet LP. Effect of intense swimming training on rhinitis in high-level competitive swimmers. Clin. Exp. Allergy. 2010; 40: 1238–46.
3. Dickinson JW, Whyte G, McConnell A. Inspiratory muscle training: a simple cost-effective treatment for inspiratory stridor. Br. J. Sports Med. 2007; 41: 694–5.
4. Gelardi M, Ventura MT, Fiorella R, et al. Allergic and non-allergic rhinitis in swimmers: clinical and cytological aspects. Br. J. Sports Med. 2012; 46: 54–8.
5. Katelaris CH, Carrozzi FM, Burke TV, Byth K. Patterns of allergic reactivity and disease in Olympic athletes. Clin. J. Sport Med. 2006; 16: 401–5.
6. Nichols AW. Medical care of the aquatics athlete. Curr. Sports Med. Rep. 2015; 14: 389–96.
7. Nielsen EW, Hull JH, Backer V. High prevalence of exercise-induced laryngeal obstruction in athletes. Med. Sci. Sports Exerc. 2013; 45: 2030–5.
Copyright © 2016 by the American College of Sports Medicine.