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Introduction

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You have to think of asthma the same way you think of diabetes. You wouldn’t just take your insulin once in a while.

Susan Auch, speed skater, Olympic medal winner. Quoted by Dakshana Bascaramurty in Globe and Mail, 3 December 2009

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The normal functioning of the respiratory system is critical to athletic performance. The integrity of this system results in the delivery of oxygen to the blood (and subsequently to exercising muscles) and the elimination of waste products such as carbon dioxide. Any dysfunction of these processes results in impaired performance. A number of medical conditions (such as asthma and respiratory infections) may affect performance.

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Common respiratory symptoms

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There are a number of symptoms with which a sportsperson may present that indicate the presence of respiratory disease. These include:

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  • shortness of breath (dyspnea)

  • wheeze

  • cough

  • chest pain or tightness.

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Shortness of breath and wheeze

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Some degree of breathlessness (dyspnea) is a normal physiological response to exercise. Often occurring during intense exercise, it may represent the reaching of maximal exercise and ventilatory capacity. However, an individual complaining of excessive shortness of breath, chest tightness, and/or wheezing, particularly during rest or low-intensity exercise, may be suffering from a respiratory or cardiac condition.

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Breathlessness is a subjective symptom that can be defined as “an increased difficulty in breathing.” Despite the frequency of this complaint, the exact physiological mechanism is unknown. The most important cause from an athletic point of view is asthma (exercise-induced bronchospasm). In the older sportsperson, especially with a history of smoking, chronic obstructive pulmonary disease (COPD) and cardiac ischemia should be considered. Dyspnea may be classified clinically as acute, chronic, or intermittent (see box).

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Causes of dyspnea in sportspeople Acute

  • Asthma

  • Cardiac causes

  • Infections

  • Spontaneous pneumothorax

  • Pulmonary embolism (rare)

  • Aspiration of foreign body (can occur in sportspeople with dental prosthesis or those who chew gum)

Chronic
  • Asthma

  • Chronic obstructive pulmonary disease (COPD)

  • Cardiac dysfunction—cardiac failure, ischemia, valvular

  • Anemia

  • Metabolic disorders (e.g. diabetes mellitus)

  • Pulmonary dysfunction

  • Obesity

Intermittent
  • Asthma (most likely)

  • Left ventricular dysfunction

  • Mitral stenosis

  • Psychological

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Examination of the patient together with the history of the dyspnea may indicate the likely cause of the dyspnea. It is important to remember that examination of both the patient with exercise-induced bronchospasm and the patient with cardiac ischemia may be normal at rest.

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A musculoskeletal examination should be performed to assess for the presence of thoracic stiffness and/or costochondritis.

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Investigations
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Respiratory function tests (e.g. spirometry) are required to further assess dyspnea. Spirometry pre- and post-bronchodilator should be performed, and if required a bronchial provocation challenge test.

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If a cardiac cause is suspected, an exercise ECG/EKG and echocardiogram are required, often combined in a stress echocardiogram. A chest X-ray is essential to assess ...

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