John Dickinson – Optimising Care for Asthma and Disordered Breathing Patterns in Athletes – Injury Rehab Network Event

The April 2023 Injury Rehab Network event with BASRaT featured John Dickinson, Professor of Sport and Exercise Sciences at the University of Kent. The online event took place on the evening of 20th April, with over 115 sports rehabilitation professionals in attendance.

John has 20 years’ of experience supporting the care athletes receive to optimise respiratory health. Professor Dickinson’s presentation explored optimal care from practitioners for asthma and exercise-induced respiratory problems.

The recording of John’s presentation is available to watch here.

John Dickinson, Professor in Sport & Exercise Sciences (University of Kent)

John is a Professor of Sport and Exercise Sciences and Head of the Exercise Respiratory Clinic at the University of Kent. He has 20 years of experience supporting the care athletes receive to optimise respiratory health.

John established the University of Kent Exercise Respiratory Clinic in 2013, which has supported Olympic and professional athletes as well as recreational athletes to overcome respiratory issues such as asthma, exercise-induced bronchoconstriction and breathing pattern disorders.

He also runs a clinic at the Marylebone Health Group (formerly CHHP) in Harley Street, London and is Chair of the BASES Outreach Panel.

Optimising care for asthma, exercise-induced bronchoconstriction and disordered breathing patterns in athletes

Professor Dickinson’s presentation, “Optimising care for asthma, exercise-induced bronchoconstriction and disordered breathing patterns in athletes” explored optimal care from practitioners for asthma and exercise-induced respiratory problems.

John works primarily with athletes with breathing problems but also supports the general population. His presentation covered the following:

• Introduction to respiratory symptoms in athletes
• Asthma and exercise-induced bronchoconstriction (EIB) explanation
• Management strategies for asthma and EIB in athletes
• Explain what breathing pattern disorder is
• How to identify breathing pattern disorder
• Management toolbox for breathing pattern disorder

Exercise Respiratory Symptoms

John discussed symptoms associated with respiratory issues in exercise.

• Wheezing
• Tight Chest
• Coughing
• Difficulty in Breathing – cannot get enough air

John noted that the symptoms are non-specific and require specific criteria to assess objectively.

Causes of Exercise Respiratory Symptoms

John described the causes of respiratory symptoms in exercise:

• Asthma/ Exercise-Induced Bronchoconstriction
• Breathing Pattern Disorders (BPD)
• Exercise Induced Laryngeal Obstruction (EILO)

Other causes may include cardiovascular disorders, physical limitations (fitness/ obesity) and anxiety/ stress.

A systematic assessment as part of a research study identified that up to 80% of athletes had a respiratory issue, with 60% having two or more issues. John noted that practitioners should therefore consider all possibilities and assess for a range of issues.

Exercise Induced Bronchoconstriction (EIB)

Professor Dickinson described the definition of EIB as ‘narrowing of the airways, limiting expiration, following a bout of exercise.’ EIB usually occurs following exercise, symptoms do not have to be present, and it is estimated that 80-90% of asthmatics suffer from EIB.

John discussed how the narrowing of the bronchioles affects the collapsible lower airways. Treatment, including inhaler therapy, can reduce airway inflammation and the severity of bronchoconstriction. This leads to improved airway health and reversal of symptoms and enables the athletes suffering from the condition to compete on a level playing field.

For the objective assessment of EIB, John discussed the use of baseline spirometry and objective testing, including reversibility challenges, direct airway challenges and indirect airway challenges.

John described different types of inhaler therapy that may be prescribed depending on EIB severity. Treatment targets the inflammatory process and is required daily. John noted that therapy should be individualised, and athletes should be aware of anti-doping rules on the use of inhalers.

Asthma/ EIB Prevalence

John discussed the prevalence of asthma or EIB in different sports with large variations compared to the UK population, where the prevalence is 9% – 12%. For example, in boxing, the prevalence is as low as 8%, whereas in swimming prevalence ranges from 44% – 68%.

John considered triggers for EIB which may explain variation in prevalence across different sports. Triggers include increased minute ventilation (activity with higher breathing demand), dry air, ozone, and particulate matter.

From John’s work with GB swimming, the lessons are that a combination of the activity type and swimming pool environment may all contribute to a higher prevalence of asthma. Through checking the inhaler technique, John identified that many athletes inhale too fast. This can be addressed using a pocket chamber and education around the inhaler technique.

Management of Athletes with Breathing Pattern Disorder (BPD)

Professor Dickinson discussed BPD, where athletes may be unable to breathe efficiently and/ or their breathing pattern is inappropriate in response to external stimuli.

Causes include:

• Physical limitation (fitness/ obesity)
• Laryngeal disorders
• Anxiety/ hyperventilation syndrome
• Cardio-pulmonary disorders
• Inappropriate postural control

Characterised by:

• Inappropriate activation of respiratory muscles
• Inappropriate activation of accessory respiratory muscles
• Inadequate movement of the chest wall
• Reduced tidal volume
• Increased breathing frequency
• Increased respiratory flow rate

John described how the prevalence of BPD is unknown but is estimated between 20% – 80% where there are accompanying co-morbidities. BPD can occur in the absence of any identifiable underlying respiratory disease.

The forms of BPD in athletes were considered by Professor Dickinson, including:

1. Excessive accessory respiratory muscle recruitment and shoulder activation or excessive accessory muscle use.
2. Asynchrony between abdominal and chest movement.

John discussed Exercise-Induced Laryngeal Obstruction (EILO), where the following issues might lead to the development of EILO:

• Inappropriate activation of respiratory muscles
• Inappropriate recruitment of accessory respiratory muscles
• Compromised movement of the chest wall
• Increase breathing frequency and inspiratory flow rate to compensate

John described how breathing frequency in athletes with BPD and EILO would increase faster than in a healthy individual. John considered how there is no standardised method to diagnose BPD during exercise, although current methods include:

• Diagnosis by the exclusion of symptoms
• Observation of breathing patterns during exercise
• Emerging technology and methods to assess breathing pattern

John discussed objective ways to measure breathing patterns, including:

• Cardiopulmonary Exercise Testing
• Respiratory Inductive Plethysmography (RIP)
• Structured Light Plethysmography (SLP)
• Optoelectronic Plethysmography

Measures can assess expected movement between the rib cage and abdomen and identify any issues or abnormalities compared to healthy breathing patterns.

Breathing Training Tool Box

Professor Dickinson shared details of how toolbox to support breathing training, which includes:

• Breathing pattern advice
• Functional breathing pattern training
• Postural control – core stability exercises
• Inspiratory muscle training
• Anxiety management
• Imagery training

Further Reading and Information

For more information about breathing problems in athletes, please see John’s book, “Complete Guide to Respiratory Care in Athletes”.

Q&A

John kindly answered questions put forward by the practitioners who attended the session.

Q1. Can inhaled corticosteroids (ICS) be used for exercise-induced bronchoconstriction (EIB)?
A1. Yes, although there are limits on the quantity athletes can take. A therapeutic use exemption (TUE) is not needed.

Q2. Do variations in female hormones affect respiratory function?
A2. This is a good research question, and more work is required in this area. There does seem to be anecdotal evidence in relation to the influence of hormones on asthma. There is no data in relation to BPD.

Q3. If footballers have developed new symptoms, could it be due to a laryngeal obstruction?
A3. The best advice is to take a video and ask an expert to diagnose it. If the symptoms are linked to high-intensity exercise, then it may be more likely to be a laryngeal obstruction.

Q4. Has there been an increase in athletes with breathing problems post covid?
A4. There is currently no strong evidence to suggest this, but potentially more athletes with BPD. An increase in athletes with BPD may be more due to raised awareness and not necessarily linked to covid.

Q5. Is testing young athletes a good way of improving performance?
A5. Screening is recommended for all respiratory problems. Treating EIB can boost performance.

Q6. At what age may breathing problems in sports become apparent?
A6. Breathing problems can be identified from early years but are commonly identified in sports from age 10+.

Q7. How long does treatment take for athletes with BPD?
A7. Treatment can be as little as one week but can take time due to the reprogramming required. Improvements are often seen in 4-8 weeks. In some cases, it may take up to 18 months to complete treatment/ rehabilitation, so it’s important to review on a regular basis with frequent appointments.

Q8. If an athlete has a negative Eucapnic Voluntary Hyperpnoea (EVH) test, is it still possible for them to develop asthma?
A8. Asthma can be developed at any time and is seasonal too. It’s important to undertake different types of tests to assess breathing problems in athletes. Practitioners should consider the full history and symptoms of athletes to choose the right test.

Presentation Recording

The recording of John’s presentation is available to watch here.

Follow John Dickinson

• University of Kent website
• Twitter @ProfJDickinson

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