Diagnosis and management of allergy and respiratory disorders in sport: An EAACI task force position paper

Abstract

Allergy and respiratory disorders are common in young athletic individuals. In the context of elite sport, it is essential to secure an accurate diagnosis in order to optimize health and performance. It is also important, however, to consider the potential impact or consequences of these disorders, in recreationally active individuals engaging in structured exercise and/or physical activity to maintain health and well-being across the lifespan. This EAACI Task Force was therefore established, to develop an up-to-date, research-informed position paper, detailing the optimal approach to the diagnosis and management of common exercise-related allergic and respiratory conditions. The recommendations are informed by a multidisciplinary panel of experts including allergists, pulmonologists, physiologists and sports physicians. The report is structured as a concise, practically focussed document, incorporating diagnostic and treatment algorithms, to provide a source of reference to aid clinical decision-making. Throughout, we signpost relevant learning resources to consolidate knowledge and understanding and conclude by highlighting future research priorities and unmet needs.

Keywords: allergy; exercise; immunology; physiology; sport.

FIGURE 1

Diagnostic algorithm for the assessment of exercise‐related allergic and respiratory conditions. ^#Denotes consider passive warming test to help differentiate cholinergic urticaria; *denotes consider potential co‐morbidity between EIB ± asthma, EILO, BPD; **denotes consider potential co‐morbidity between allergic rhinitis and EIB ± asthma. Asthma (≥12% increase in FEV₁ post bronchodilator); BPD, Breathing pattern disorder; CLE, continuous laryngoscopy during exercise; CPET, cardio‐pulmonary exercise testing; CV, cardiovascular; EIAn, exercise‐induced anaphylaxis; EIB, exercise‐induced bronchoconstriction (≥10% fall in FEV₁ post exercise and EVH or ≥15% fall in FEV₁ from baseline or 10% fall in FEV₁ between two consecutive doses for inhaled mannitol); EILO, exercise‐induced laryngeal obstruction; EIU, exercise‐induced urticaria; EVH, eucapnic voluntary hyperpnoea; FeNO, fractional exhaled nitric oxide; GI, gastrointestinal; IgE, immunoglobulin E; IOS, impulse oscillometry; SPT, skin prick test.

FIGURE 2

Case study example of exercise‐induced urticaria in a recreationally active 24‐year‐old male footballer: (A) upper body; (B) lower back (wheal diameter >5 mm).

FIGURE 3

Continuous laryngoscopy during exercise. The laryngoscope is placed in situ and secured to a headset via a facemask. The screen provides real‐time feedback of the structural and functional behaviour of the larynx in response to incremental exercise.