Airway dysfunction in elite swimmers: prevalence, impact, and challenges

Figures & data

Table 1 $\dot{V}{O}_2$ peak, ${\dot{V}}_{\mathrm{E}}$ breathing frequency, and tidal volume measured during all-out front crawl, back stroke, or breast stroke swimming in trained swimmers

Parameter	Range	References
Breathing frequency (breaths/min)	39–57	^Citation21b, ^Citation22b, ^Citation37a, ^Citation74a
Tidal volume (L)	1.43–3.53	^Citation21b, ^Citation22b, ^Citation23c, ^Citation37a, ^Citation74a
${\dot{V}}_{\mathrm{E}}$(L/min)	68–152	^Citation20a, ^Citation21b, ^Citation22b, ^Citation23c, ^Citation37a, ^Citation74a
$\dot{V}{O}_2$ peak (L/min)	2.49–5.08	^Citation19a, ^Citation20a, ^Citation21b, ^Citation22b, ^Citation23c, ^Citation37a, ^Citation74a, ^Citation75c, ^Citation76a, ^Citation77a, ^Citation78a, ^Citation79a
$\dot{V}{O}_2$ peak (mL/kg/min)	49.8–69.9	^Citation19a, ^Citation23c, ^Citation24a, ^Citation37a, ^Citation76a, ^Citation78a, ^Citation79a

Notes: Measured during:

a progressive intensity swimming;

b all-out swimming until exhaustion;

c all-out 400 m or 400 yard swim.

Abbreviations:, $\dot{V}{O}_2$ oxygen uptake; ${\dot{V}}_{\mathrm{E}}$, minute ventilation.

Table 2 Overview of respiratory disorders observed in endurance-based athletes

Disorder	Explanation
Bronchial tone disorders
Asthma	Reversible narrowing of the airways. Manifested by inflammation and widespread narrowing.
AHR	Allergen exposure enhances the response to exercise in asthmatics and increases the responsiveness to pharmacological agents. The airways over-respond to various stimuli causing reversible airway obstruction.
BHR	Positive response to direct (eg, methacholine or histamine) and indirect (eg, exercise, EVH, or hypertonic aerosols) stimuli.
EIA	Occurs in individuals who have underlying asthma and exercise is an exacerbation trigger.
EIB	Transient narrowing of the airways (bronchospasm) that follows vigorous exercise in individuals with no history of asthma.
Other disorders
EFL	Occurs in nonasthmatics when the tidal flow-to-volume envelope loop encroaches on the maximal loop. A ${\dot{V}}_{\mathrm{E}}$ in excess of 120–130 L/min is required. More prevalent in females.
Rhinitis	Prevalence of rhinitis in competitive swimmers is high and thought to reflect irritation of nasal mucosa by chlorinated water. Symptoms include nasal obstruction, rhinorrhea, nasal burning, sneezing, and nasal itching.
Swimming-induced pulmonary	Occurs in response to a single heavy swimming session. More prevalent than nonaquatic pulmonary edema.
edema	Reflects pulmonary capillary stress failure brought about by immersion.
VCD	Associated with inspiratory wheeze. Occurs during maximal exercise. Symptoms disappear once hyperpnea or hyperventilation stops. Often misdiagnosed as asthma or EIB. More prevalent in females.

Note: Adapted from references.^{2,48,51,52,65,80–86}

Abbreviations: AHR, airway hyperresponsiveness; BHR, bronchial hyperresponsiveness; EIA, exercise-induced asthma; EIB, exercise-induced bronchoconstriction; EFL, expiratory flow limitation; EVH, eucapnic voluntary hyperpnea; ${\dot{V}}_{\mathrm{E}}$, minute ventilation; VCD, vocal cord dysfunction.

Table 3 Positive test criteria for some common bronchial provocation tests: WADA guidelines

Test	Positive criteria
EVH	≥10% fall of FEV1
Exercise challenge	≥10% fall of FEV1
Histamine challenge	≥20% fall of FEV1 at a histamine concentration of 8 mg/mL or less during a graded test of 2 minutes1
Mannitol inhalation	≥15% fall in FEV1 after challenge
Methacholine challenge	≥20% fall in FEV1 If steroid naïve PC20 should be <4 mg/mL. If taking inhaled glucocorticoids for more than 1 month,PD20 should be ≤1,600 µg or PC20 ≤16.0 mg/mL

Note: WADA guidelines.⁶⁸

Abbreviations: WADA, World Anti-Doping Agency; EVH, eucapnic voluntary hyperpnea; FEV_1, forced expired volume in the first second of exhalation; PC₂₀, concentration of the agonist in the inhaled aerosol leading to a fall in FEV₁ of 20%; PD₂₀, administered dose of an inhaled aerosol which causes FEV₁ to fall by 20%.

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