Olympic gold medalBy P.K. Daniel 

As athletes compete in the Summer Olympics in Rio de Janeiro, more than a few will be reaching for their inhaler to deal with asthma symptoms.

Asthma is the most common chronic condition among Olympic athletes, according to several studies. A 2012 study of the five Summer and Winter Olympic Games between 2002 and 2010 found approximately 8 percent of Olympians had asthma.

No one knows for sure why some elite-level athletes develop asthma and exercise-induced asthma (EIA – also called EIB, or exercise-induced bronchospasm), but some medical experts say it could be related to long-term intense training in endurance sports and very high airflow rates they generate. Multiple studies show a high percentage of asthma in athletes who complete in sports like long-distance running, cycling and swimming.

Many people with asthma list exercise as their top symptom trigger, and elite-level training can certainly worsen an underlying condition like asthma, says Tod Olin, MD, director of the Pediatric Exercise Tolerance Center at National Jewish Health in Denver.

Asthma symptoms related to exercise and EIA are “largely caused by the airway drying,” Dr. Olin says. “The two main things that dry an airway are dry air and high airflow rates. The sport itself predisposes the athlete to bronchospasm, mostly likely due to the breathing requirements.”

Among aquatic sports, swimmers had the highest prevalence of asthma, according to a 2015 study in The Journal of Allergy and Clinical Immunology. The study cited the level of endurance swimming required and pool environment issues, such as chlorine, as factors.

Two-time Olympic champion and former world-record holder Tom Dolan was diagnosed with allergic and exercise-induced asthma when he was 12 years old. Dolan won golds in the 400-meter individual medley in Atlanta in 1996 and again in Sydney in 2000.

Dolan, who runs a swim school in Sterling, Virginia, says one of the biggest asthma triggers for him, especially with indoor pools, is the chlorine levels. “The first 5 to 7 inches off the surface of the water is where chloramines sit and that’s what you breathe in. For asthmatics, that’s a challenge,” he says.

Getting Up to Speed

Studies show regular exercise actually helps people with asthma improve breathing and reduce stress and anxiety that can trigger flares. Symptom management and treatment are the same for elite athletes as they are for those who play sports for recreation or exercise to stay in shape, Dr. Olin says.

  • See a board-certified allergist or pulmonologist for a complete diagnosis and Asthma Action Plan that can detail steps to take before, during and after exercise and what to do if symptoms worsen.
  • If you have been diagnosed with asthma and exercise is a trigger, your allergist may prescribe an inhaled corticosteroid to take daily; this will help calm inflamed airways and prevent asthma symptoms. Those diagnosed with EIA only may not need a daily controller medication.
  • Use a prescribed bronchodilator inhaler 15-30 minutes before exercise and if symptoms arise during or after exercise.
  • Warm up 15-20 minutes before competition or exercise to reduce the chances of airway constriction during exercise.
  • Stay hydrated.
  • Cool down after exercise by slowly walking and stretching for several minutes.
  • If you exercise outdoors, check local air quality reports online; air pollution may be an asthma trigger for runners, cyclists and other athletes.

Sports that require short bursts of activity such as volleyball, gymnastics, baseball, golf and some track and field events are less likely to trigger asthma and EIA symptoms.

Even though many Olympic swimmers have asthma, swimming also is a good exercise option for recreational athletes with asthma because it’s in a warm, moist environment that won’t dry airways. Those affected by chlorine while swimming in pools should see an allergist for a treatment plan.

The Asthma Advantage?

In the 2008 Beijing Games, 17 percent of cyclists and 19 percent of swimmers had asthma and yet they captured 29 and 33 percent of the medals in those sports, respectively.

It has been referred to as the “asthma advantage” – when athletes with asthma appear to perform better than athletes without asthma.

How is this possible? The asthma advantage is fascinating, but poorly understood.

It is well known that a rigorous warm-up generates a “refractory period” in which the airways are primed to stave off an asthma flare during exercise. Athletes with asthma essentially become protected from- albeit temporarily- asthma symptoms, National Jewish Health’s Tod Olin, MD, says. As a result, these athletes – who have typically been training intensely for long periods of time – are able to compete at their highest level.

What is not known is how these athletes perform at a higher level than their non-asthmatic counterparts.


Are Asthma Meds Prohibited At Olympics?

In order for Olympic athletes to manage their asthma during and out of competition, they first have to make sure their medications are approved. If the medications are prohibited, they are required to get what is known as a “TUE” – a therapeutic-use exemption.

Former U.S. Olympic swimmer Tom Dolan was limited in what asthma medications he could take due to the doping regulations at the time he competed. When new and better asthma drugs came on the market, he wasn’t able to take advantage of them because the respective governing bodies had to test them before they could be approved for Olympic athletes.

Dolan noted the process today is a lot more efficient. “There is a much greater understanding now than when I swam as to what exactly inhalers do,” he says.

Inhaled beta2 agonists

In 2002, all inhaled beta2 agonists – including albuterol, or as it’s known in Europe and other parts of the world, salbutamol – were prohibited by the World Anti-Doping Agency (WADA) because there was concern athletes were misusing them, says Kenneth Fitch, MD, a leading sports medicine expert at The University of Western Australia and a member of the International Olympic Committee (IOC) Medical Commission from 1985 to 2012. Albuterol is a short-acting bronchodilator used for quick-relief treatment of asthma symptoms.

In 2010, WADA reversed course and took albuterol off the prohibited list. Two years later, long-acting bronchodilators formoterol and salmeterol, which are used to prevent asthma symptoms, were taken off the prohibited list. All three are now allowed up to certain maximum doses.

“A number of studies have shown these drugs do not cause enhanced performance in non-asthmatic athletes,” says Denver allergist William Storms, MD, a member of the United States Olympic Committee (USOC) Sports Medicine Advisory Committee. “They just cause some jitters.”

Oral glucocorticoids

Oral glucocorticoids, a class of corticosteroids used to treat severe asthma flares, are prohibited because they are deemed to enhance performance. The asthma medication prednisone, for example, is an oral glucocorticoid and would require a TUE for Olympic competition. Inhaled glucocorticoids such as asthma corticosteroids used to control inflammation, are not prohibited.


Swimming In Unsafe Waters

Dead and rotting fish, trash and raw sewage are among pollutants that have been found in the water sports venues of Rio de Janeiro, Brazil, site of the 2016 Summer Olympics, resulting in viral and bacterial pathogens that could affect athletes with asthma.

Rodrigo de Freitas Lake, where rowing and canoeing events will take place; Guanabara Bay, site of sailing and windsurfing events; and waters off Copacabana Beach, where the 10k open-swimming event and swimming portion of the triathlon take place, are contaminated.

Independent testing of the water, commissioned by the Associated Press a year before the Games, determined it had high levels of active and infectious adenoviruses and enteroviruses, which are known to cause respiratory and digestive illnesses. The viruses can enter the respiratory tract, worsening asthma.

What can athletes do? Not much. Some swimmers hope to build immunity by arriving early to Rio. Some rowers are reportedly planning to wear anti-microbial athletic clothing, although it’s uncertain how much they will help.

“I’m not exactly sure what is in the water,” says Denver allergist William Storms, MD, a member of the United States Olympic Committee (USOC) Sports Medicine Advisory Committee. “But it doesn’t sound good, so I’m sure it could irritate the lungs of asthmatics.”