Hello, my name is Dr. John Dickinson and I'm from the School of Sport and Exercise Sciences and I'm going to talk to you today about breathing success and the issues that athletes have around respiratory problems that they report during competition and training. My background is that I'm an exercise physiologist sports scientist. I've been working with elite athletes for 15 years. Initially working at the Olympic Medical Institute and then going on to work with the English Institute of Sport in the build-up to the Athens and the Beijing Olympic Games. Since then I've come into academia and I've balanced doing research projects alongside applied practical work with athletes since that time. From a consultancy side of things a lot of the work we do is preparing athletes to get ready for the Olympic Games to prepare for professional competitions such as the Premier League and the Aviva Premiership, the ATP Tour, WTA Tour and things and major competitions like the World Cup. So a lot of the work we do is applied but we also try and collect research along the way to try and explain why we're helping athletes in the way we are and why it's effective as well. Exercise respiratory symptoms are very common with elite athletes. If we look at the most commonly reported issue at major competitions its respiratory symptoms. Somewhere between one to three one in two athletes report with respiratory symptoms at major competitions. The symptoms they report are tight chest, wheezing, coughing, difficulty in breathing and these symptoms can be debilitating. They can stop an athlete performing to hard training. They can get in the way of them performing at their best at major competitions and an individual that has good lung function without disease, respiratory issues shouldn't really be the limiting factor to their performance. So a lot of the work we do is to try and uncover what is the cause of these symptoms and we can't use the symptoms alone to diagnose because we know these symptoms are nonspecific to one particular disease. A common issue linked to these symptoms is asthma but we know we if use these symptoms alone to diagnose asthma it's like flipping a coin some of the work done back in the early 2000s demonstrates that if you use symptoms alone you're going to get it 50% right and 50% wrong. So what could cause these issues. We've got cardiovascular disease which we can screen for, it could be the individuals not fit enough but with an elite athlete population that's usually not usually the case. A large proportion of the time these symptoms are put down to asthma or another condition that's very similar to asthma called exercise-induced bronchoconstriction. Or it could be that it is more of a dysfunctional breathing issue and  that dysfunctional breathing issue can be broken down to it could be a laryngeal obstruction, it could be a breathing pattern disorder or it could be they've got some sort of anxiety hyperventilation syndrome that's causing this causing the issues. What we do know though is that athletes are significantly more likely to develop an asthmatic condition than non athletes so in the general population 9% of the general population has an asthma condition in the UK. In an elite athlete population the work we did with the British Olympic team in the build-up to the Athens Olympic Games demonstrate the 21% of that Olympic team demonstrated evidence that they had an asthma related condition, so a significantly higher number of athletes are more likely to report and develop an asthmatic condition. Why is that? Elite athletes spend a longer period of time breathing in larger volumes of air to complete their training and their competition. But they’re not just breathing larger volumes of air they are breathing it through their mouths and sometimes these larger volumes of air are also dry or they contain pollutants. Or they've got allergens in them and these provocative stimuli can cause and develop an inflammatory process in the lower airways and that inflammatory process in the lower airways can cause a muscle constriction which limits airflow. This is what we see in our bronchioles in the lower airways and this is effectively what asthma is. So we look on your left hand side you'll see a bronchial that's nice and open. Where there's very little inflammation in the airway lining and the smooth muscle that keeps the airway open is nice and relaxed, so air can flow nicely in and out of this bronchial. Now if an individual inhales this dry air that might have a provocative stimulant in it as well. It can drive it's susceptible individuals to produce an inflammatory response in that lower airway and that inflammatory response can make the airway lining swell. It can also cause the smooth muscle around the airway to constrict and so therefore when an individual tries to breathe out now, it's much harder for them to breathe out. It takes a longer period of time for them to totally empty their airways and so if we detect an athlete with an asthmatic condition like this we can offer inhalers we can offer an inhaled corticosteroid which is the brown inhalers and these inhale corticosteroids dampen down the inflammatory response and we can also offer what is called an inhaled beta-2 agonist which usually the blue inhalers you'll see using quarter salbutamol and they relax the smooth muscle around the airway. Using the combination of these two inhalers allows an athlete’s airways to open up and they can effectively compete as they would if they didn't have asthma. So puts someone on that level playing field. It doesn't give them super lungs and make their lung function perform better than their non-asthmatic counterparts. With elite athletes the best way to actually find out in the individual has asthma or not is to objectively test for it. The test you can see behind me is an assessment called a eucapnic voluntary hyperpnoea challenge and effectively what this is it mimics breathing rates that an athlete gets to during high-intensity exercise and what we do is we measure their lung function before they start we ask them to breathe really hard and fast for six minutes breathing in this dry air so we know they're getting a big dose of dry air into their airways and then we measure their lung function after the test. In an individual that hasn’t got asthma their lung function is maintained so we don't see any significant drop-off in their lung function after this test. Whereas an individual with an asthma related condition their lung function deteriorates and we can objectify this and if it has deteriorated we can offer them an inhaler so the blue inhaler. That will relax a smooth muscle around the airway and if we see an improvement in lung function after they're taking that inhaler we can demonstrate and in the individual is susceptible to an asthma condition but also they respond to the inhaler and that confirms our diagnosis of the asthma related condition with that particular athlete. Now what we see is that not every sport has the same prevalence of asthma. We see some sports have a lower prevalences and some sports have higher prevalences than the 21% we talked about as a whole from the teams from the British Olympic team. So some of the work we did in the build up to the 2016 Olympic Games in Rio is we screened the British boxing team and we screened the British swimming team. The British boxing team prevalence we found was 8% which is in line with the general population of the UK. Where as in the British swimming team we found this significantly higher prevalence of 68 percent of the British swimming team gave us a positive test for an asthma related condition. Now the reason for the difference in the prevalence between sports is usually because of the ventilation requirements linked to the sport and also the environment the sport takes place in. So the swimmers significantly hold a higher ventilation for a longer period of time when compared to the boxers. So the swimmers train five hours a day, six days a week and probably most significantly is in their environment. In an indoor pool environment there are potentially a lot of try chloramines which are a byproduct of the chlorine that cleans the pool and if we breathe these try chloramines in over a significant period of time i.e. the five hours a day, six days a week that can cause significant inflammatory processes in the lower airway and the airway can become more hypersensitive to those inflammatory responses and the athlete develops an asthmatic condition over time. It's not going to be a problem for a recreational swimmer. It's more of a consideration for an individual who is training and competing as an elite swimmer would. So if you swim three days a week for half an hour this isn't really an issue for you,this is more the elite athlete end of swimming. But we know that if sports take place in environments that are provocative, dry air, cold, have allergens in them or pollutants or substances like try chloramine and are accompanied by high minute ventilation rates then the athletes are more susceptible to developing asthma in those sports than the sports that have a lower ventilation rates or take place in environments that don't have asthma genic triggers. What we also see is athletes struggle to recognize symptoms of asthma. So some athletes may o always trained having a bit of a tight chest after training or a bit of a post exercise cough and just put that down to the fact that they've been training really hard. If you flog your body every day of the week you're used to pain you're used to not feeling 100% after you’ve those training sessions and it can be sometimes hard to differentiate between what is the symptoms of just training hard and what are symptoms of asthma related conditions related to exercise. We started to notice this in our early work and so what we did in the build-up to the Beijing Games and around that time is we went into the various groups of elite athletes and screened those who had never had an objective test for asthma done before and what we found was we found that 34% of our 228 athletes gave us a positive test for asthma related condition. What is more significant was that a large number, so 73% of that group that were positive, had no previous history and weren't using aspirin inhalers at the time of the testing. So we could see a large number of athletes that actually couldn't recognize symptoms but potentially could benefit from using aspirin inhalers that would allow their lung function to perform as if they didn't have asthma, protecting their airway health and also allowing them to make sure that their performance isn't being affected and they're not giving themselves a disadvantage before they even step on the starting line. On the flip side we also see a lot of athletes who are very symptomatic who are given an asthma inhaler without objective testing who can't give us a positive test. Some of the work we did with Premier League football in championship level football footballers demonstrated that of the players that were using inhalers that hadn't had an objective test when we actually gave them an objective test 50% of them couldn't give us a positive test. So we're seeing a large number of athletes who are symptomatic but these symptoms aren't related to asthma so again it just drives home that point don't just use symptoms alone to diagnose an asthmatic condition. We need to consider other issues which we'll talk about in a little bit and so what is the impact if we actually detect an individual with an asthmatic condition what is the impact of that on their airway health what is the impact of it on their exercise performance and what we did very recently is we've screened just short 100 Premier League and championship level football players and we found that 29% of them gave us a positive test so demonstrated they had some sort of asthma related condition and they had no previous history of it and so therefore we gave them the appropriate inhaler therapy at therapeutic doses and asked them to use it for six weeks and what we saw on our follow-up test was their airway health improved so the asthma severity dropped to demonstrate the inhalers were providing a protective effect but interestingly we also saw that their fitness improved by about 7%. So we saw that their aerobic fitness overtime improved by about 7% and actually improved them to the point where they became as fit as their non-asthmatic counterparts. So even though it was a small improvement it was potentially significant enough that it's not going to put them at a small disadvantage against the non-asthmatic counterpart basically highlighting that if we can screen individuals in elite sport for asthma related conditions we may be able to one protect their airway health for the long term but also we're not they're able to perform at their highest level possible. But a lot of individuals say well this John this is just doping this is just handing out inhalers to people who are positive on your test and you're giving them an advantage. However some of the research that we've done has demonstrated that if you give an inhaler to an asthmatic individual at therapeutic doses it allows their lung function to perform as it would if they weren't asthmatic. It doesn't give them super lungs. We don't see them with a significantly greater ability to use oxygen aerobically or significant improvements in their time trial performance. We also know that if we give non-asthmatic individuals asthma medication at therapeutic doses their performance doesn't improve either so just giving inhalers out and telling that individuals to use inhalers will not improve their performance it won't improve their lung performance either at therapeutic doses. However there are still some concerns around using asthma inhalers and athletes need to be well educated to make sure they don't have doping violations linked to using the inhalers. So one issue that can occur if an individual takes a large dose of an asthma inhaler it is possible that they could potentially have a doping violation so as long as they stay within the world anti-doping agency limits there's a reduced chance but there's still a chance that they could go above the decision criteria to give them adoping violation link to using too much of the subutimal medication. We also know that if an athlete takes a significantly large dose of beta-2 agonist which is part of the subutimul inhaler group they can potentially benefit from having an increased muscle mass, improvements in strength and power which will also obviously improve their performance and we know that if we take oral doses of medication which is usually reserved for individuals in hospitals we know that can potentially improve their endurance performance and their perceptions of fatigue. So there are some anti-doping considerations that the powers-that-be, the anti-doping authorities need to consider to tighten down that one athletes with asthma are able to protect themselves and put themselves at no disadvantage in their competition in training but also to make sure athletes don't abuse the rules and don't take too much of an inhaler that's not necessarily treating their asthmatic condition and maybe trying to see an advantage that is ergogenic from taking super therapeutic doses. There are rules in place currently that allow athletes to do this but potentially there are ways of manipulating the rules at the moment which mean athletes may benefit from some of those ergogenic effects if they're being unscrupulous should we say. But we've talked a lot about these respiratory symptoms not necessarily always been down to asthma. It could be that an individual has a cardiovascular problem but we can screen for that. It is unlikely they're not going to be fit enough so the other issue that we talked about was dysfunctional breathing and there's some subtleties in the difference in how the symptoms present as to whether it's dysfunctional breathing that's causing the athletes respiratory problems or whether it's asthma. So we look at when the symptoms occur usually if it's dysfunctional breathing it occurs during high-intensity exercise and as soon as they finish the high intensity exercise the symptom starts to die away quite quickly. In asthma the symptoms start to build during exercise and then they linger and they can last for up to an hour after the exercise has finished. If we look at wheeze, an asthmatic wheeze is usually expiration, when an individual breathes out. If it's  dysfunctional breathing and there's a wheeze it's usually when they're breathing in and if there's any cough usually in dysfunctional breathing it's a dry irritable cough and in exercise induced asthma the cough is usually accompanied by coughing up mucus. So there's subtleties in the symptoms that maybe we can tease out to start giving us ideas as to whether the individuals got asthma which is the issue or dysfunctional breathing. But it is possible that they can coexist together. So I'm going to show you a video of a few different forms of breathing dysfunction. The first one is it is a laryngeal obstruction 
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So you can hear the noise that the individual is making when they're breathing in. That is their larynx closing in as they're breathing in. So that wheeze that noise is only the loudness closing in and that's causing distress up here, it's causing limitation to airflow going in so the athletes starting to report they can't get satisfying breath they feeling potentially chest tightness and shortness of breath with that. This next athlete has a dysfunctional breathing pattern so you can see if you watch her abdomen and chest they're not moving in synchrony together. This form of breathing pattern is going to mean the individual reports maybe a tight chest, can't get a satisfying breath it can be quite painful to breathe this way and ultimately in both scenarios whether it's laryngeal obstruction or dysfunctional breathing pattern the athlete is not going to be able to perform high intensity training sessions and they're going to end up stopping their high intensity training sessions because of their respiratory symptoms not because their arms and legs are tired. Regardless of whether it's a laryngeal obstruction or breathing pattern we can start to try therapy that doesn't involve inhalers. We can use various techniques that evolve around good breathing technique. We can look at posture the athletes holding and we can also use inspiratory muscle training. Using one or a combination of these therapies we've got evidence that it can impact significantly on these symptoms so an individual doesn't experience them at all or to a significant lesser extent during training allows them to train and compete at high levels and so their symptoms don't limit their performance and it's really important to detect whether it's asthma or whether it's dysfunctional breathing that's causing the limitations of performance because if we get it right an athlete has the best opportunity to succeed. So in summary we know that elite athletes are more susceptible to asthma related conditions than the general population. We know that if we appropriately treat individuals with asthma their performance isn't affected, their airway health is maintained and they can effectively compete as if they didn't have an asthmatic condition. We know that if we give therapeutic doses of asthma medication to non asthmatic it doesn't improve their performance but if they take super therapeutic doses there are anti-doping considerations that needs to be looked at to make sure athletes aren't having a gain in performance advancements from using too much of the drug and also consider dysfunctional breathing as a cause of the symptoms especially when an athlete is complaining that their respiratory system is limiting their maximal performance and consider it could be a laryngeal obstruction it could be a breathing pattern disorder and we know that therapy such as breathing technique postural work and inspiratory training can significantly impact on these individuals experiencing dysfunctional breathing. Thank you very much.