The results from this survey indicate that it is common for family practitioners to encounter individuals with exercise-related respiratory symptoms; with over a third reporting at least one case per month. When faced with such a scenario nearly three quarters of respondents (71%) indicated they would select objective testing to diagnose EIB. However the most commonly selected tests, namely exercise PEFR (44%) and spirometry with bronchodilator (35%), have been found to have poor diagnostic accuracy for EIB [11
]. In addition, a quarter of family practitioners (23%) indicated they would treat empirically based upon clinical features alone. Overall this raises concern that diagnosis of EIB may be inaccurate or indeed missed [6
] and as such, these findings have implications for the welfare of athletes with this problem. They also have ramifications for competitive athletes given the mandatory requirement for objective evidence in application for inhaled β2
-agonists TUE from Jan 2009; perhaps in particular for those athletes who may apply to renew their TUE on the back of an unsound initial diagnosis.
The International Olympic Committee-Medical Commission (IOC-MC) has recently renewed its consensus guidelines for the diagnosis of EIB in athletes with respiratory symptoms [13
]. It is recommended that athletes with abnormal baseline spirometry (FEV1
< 80%, FEV1
/FVC < 0.7) should be investigated initially with a bronchodilator challenge and otherwise with a bronchoprovocation challenge; the latter being defined as a test with the purpose of evaluating change in airway calibre in response to an airway challenge (e.g. exercise, EVH, methacholine, or mannitol provocation).
This guidance is based on the fact that bronchodilator testing in athletes is unlikely to detect airway reversibility in those with normal resting spirometry [1
] and that bronchoprovocation testing has the highest sensitivity and specificity for diagnosis [14
]. The IOC-MC guidelines also underline use of FEV1
as a marker of airway narrowing [8
] given that use of PEFR may lead to misclassification [11
] and as such is no longer recommended in guidelines or accepted by WADA. Please see relevant section in http://www.100percentme.co.uk
for approach and algorithm recommended for UK athletes.
The choice of objective tests made by family practitioners when faced with this problem appears at odds with these recommendations. Bronchoprovocation was not selected by any respondent as a test of preference and PEFR was the most commonly used measure of airway narrowing. A key reason for this appears to be the limited access to bronchoprovocation challenges in primary care. In our cohort, 85% of family practitioners have no access to any sort of bronchoprovocation testing; 11% have access to laboratory-based exercise tests while only 4% reported access to EVH, methacholine or mannitol provocation testing. Our findings are supported by the UK TUE applications completed by family practitioners, which indicated PEFR in 28% of cases, spirometry in 3% and bronchoprovocation in 0.05% (personal communication, UK Sport). In contrast sports medicine specialists completing the TUE application provided supporting evidence of diagnosis with bronchoprovocation in 14% of cases. This may relate to differences in patient populations; however, does highlight the fact that the physicians most likely to initially encounter individuals with this condition have least access to the most accurate diagnostic tests. Furthermore, as of January 2009, the lack of access to these tests has important implications for the preparation of a medical file to fulfil the criteria for TUE and as such potentially limits the ability of family practitioners to manage competitive athletes with this problem.
The approach to an athlete with suspected EIB by family practitioners in England appears to contrast with that of family practitioners in the US [9
]. On presentation of a similar case scenario, 81% of family practitioners in the US opted for empirical treatment and 18% for investigation vs. 23% and 72% respectively, in our study cohort. The practise of family practitioners in England appears more in line with US pulmonologists who were four-fold more likely than the family practitioners to employ testing initially. However, it should be noted that the US survey format only offered bronchoprovocation testing as means of investigation and in no instance was this method selected by responders in this study
When initiating treatment the vast majority of family practitioners in England (90%) indicated they would initiate treatment with a SABA alone. This is in line with guideline recommendations [12
] and with reports of similar therapy preference in US family practitioners [9
] and Finnish doctors [15
]. In the treatment of EIB in athletes it is increasingly recognised that treatment with β2
-agonists alone may not be adequate and has problems including tachyphylaxis and unfavourable side effects [16
]. Furthermore, given the fact that there is recognised inflammatory component [17
] and that athletes require medication regularly it has been recommended that early initiation of ICS is preferable [12
]. In this study, 6% of family practitioners indicated they would initially treat with ICS, although this rose to 75% when faced with a re-consult at two months. Perhaps alarmingly, given the recommendations not to prescribe LABA without ICS, 3% of family practitioners chose this treatment strategy. Interestingly, despite an 'other' option being available in the answer section, no respondents indicated alternative recognized treatment options such as a warm-up [18
], avoidance of triggers [2
] or dietary modification [19
]. Further work is needed to determine whether this may reflect a definitive choice on the part of family practitioners or be the result of a lack of dissemination or awareness of current evidence or teaching of sport and exercise medicine in England [21
The approach chosen by many respondents to initiate treatment empirically is confounded by the poor correlation between subjective symptoms and objective evidence of airway narrowing [7
]. It also presents a number of diagnostic difficulties if an individual represents with ongoing symptoms. The PRACTALL guidelines recommended that if EIB treatment is not successful then other diagnoses should be re-considered including vocal cord dysfunction, arterial hypoxemia and general poor physical fitness [10
]. However, other possibilities include: insufficient treatment; poor therapy compliance; or ineffective inhaler technique. To explore this further we represented the athlete at two months after initiation of empirical treatment. Interestingly, almost half of respondents opted to arrange investigation at this point, whilst only one third opted to change treatment.
In treating competitive athletes, the majority of respondents (66%) indicated they were unsure which medication(s) a competitive athlete (in this scenario a cyclist) was permitted to use without notifying their governing body (Table ). These findings are in keeping with previous surveys of family practitioners in the UK and France suggesting a limited knowledge of the implications of prescribing medication to this specialist population [22
]. Although the onus remains on the athlete to inform a governing body of prohibited medication use, physicians should be aware of the process especially given the changes in the requirements for a medical file for TUE from January 2009.
Our study has a number of limitations. Firstly, similar to the report by Parsons and colleagues [9
] the methods employed to distribute the survey meant that we were unable to accurately assess response rate. An electronically distributed method was selected in order to allow realistic feedback however as such did not allow us to determine delivery confirmation. To our knowledge, this study is the first to use this approach to survey family practitioners nationwide using the electronic e-mail database. We have no reason to believe bias in one direction within responses and furthermore our findings are supported by family practitioner completed TUE applications. Secondly, the wording of case scenario was selected to be suggestive of EIB, however it is acknowledged that the differential diagnosis is broad and potentially includes other respiratory and cardiac pathologies. We therefore provided an 'other' option and correspondingly a small proportion of family practitioners selected investigations, such as chest radiographs and electrocardiographs. Finally, the methods employed only permitted a single distribution of the survey. As such the findings would be supported and further validated by repeating assessment on an additional occasion.