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SARS-CoV-2 is the causative virus responsible for the COVID-19 pandemic. This pandemic has necessitated that all professional and elite sport is either suspended, postponed or cancelled altogether to minimise the risk of viral spread. As infection rates drop and quarantine restrictions are lifted, the question how athletes can safely resume competitive sport is being asked. Given the rapidly evolving knowledge base about the virus and changing governmental and public health recommendations, a precise answer to this question is fraught with complexity and nuance. Without robust data to inform policy, return-to-play (RTP) decisions are especially difficult for elite athletes on the suspicion that the COVID-19 virus could result in significant cardiorespiratory compromise in a minority of afflicted athletes. There are now consistent reports of athletes reporting persistent and residual symptoms many weeks to months after initial COVID-19 infection. These symptoms include cough, tachycardia and extreme fatigue. To support safe RTP, we provide sport and exercise medicine physicians with practical recommendations on how to exclude cardiorespiratory complications of COVID-19 in elite athletes who place high demand on their cardiorespiratory system. As new evidence emerges, guidance for a safe RTP should be updated.

Exercise-induced bronchoconstriction (EIB) describes acute airway narrowing that occurs as a result of exercise. EIB occurs in a substantial proportion of patients with asthma, but may also occur in individuals without known asthma. To provide clinicians with practical guidance, a multidisciplinary panel of stakeholders was convened to review the pathogenesis of EIB and to develop evidence-based guidelines for the diagnosis and treatment of EIB. The evidence was appraised and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Recommendations for the treatment of EIB were developed. The quality of evidence supporting the recommendations was variable, ranging from low to high. A strong recommendation was made for using a short-acting β(2)-agonist before exercise in all patients with EIB. For patients who continue to have symptoms of EIB despite the administration of a short-acting β(2)-agonist before exercise, strong recommendations were made for a daily inhaled corticosteroid, a daily leukotriene receptor antagonist, or a mast cell stabilizing agent before exercise. The recommendations in this Guideline reflect the currently available evidence. New clinical research data will necessitate a revision and update in the future.

The larynx is one of the most highly innervated organs in humans and serves a number of vitally important, complex, and highly evolved biological functions. On a day-to-day basis, the larynx functions autonomously, addressing several roles including airway protection, swallowing, and phonation. In some situations the larynx appears to adopt a functional state that could be considered maladaptive or \"dysfunctional.\" This laryngeal dysfunction can underpin and account for a number of respiratory symptoms that otherwise appear incongruous with a clinical disease state and/or contribute to the development of symptoms that appear \"refractory\" to treatment. These include conditions associated with a heightened tendency for inappropriate laryngeal closure (e.g., inducible laryngeal obstruction), voice disturbance, and chronic cough. Recognition of laryngeal dysfunction is important to deliver targeted treatment and failure to recognize the condition can lead to repeated use of inappropriate treatment. Diagnosis is not straightforward, however, and many patients appear to present with symptoms attributable to laryngeal dysfunction, but in whom the diagnosis has been overlooked in clinical work-up for some time. This review provides an overview of the current state of knowledge in the field of laryngeal dysfunction, with a focus on pragmatic clinical assessment and management.

Currently there is no consistent and widely accepted approach to the diagnosis of vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO). Harmonised diagnostic methods are vital to enable optimal diagnosis, advance management and enable research. We aim to obtain consensus on how expert clinicians recognise and diagnose VCD/ILO. Two-round modified Delphi, with workshop validation. Institutional Board Review was obtained from the Monash Health Human Research Ethics Committee. The dissemination plan is for presentation and publication. Registered at Australia and New Zealand Clinical Trials Registry ACTRN12621001520820p.

A welcome addition to the published body of work is the paper by Moulson and colleagues,5 providing novel insight regarding the recovery of athletes with persistent symptoms. More precisely, the study addressed a vexing question for many clinicians of how to determine the cause of persistent cardiopulmonary symptoms following COVID-19 in athletic individuals. In this prospectively designed study, with a real-world ‘feel’ in terms of an assessment protocol, the authors evaluated 21 adult young athletes with cardiopulmonary symptoms that persisted longer than 28 days. This is a relevant timepoint; in a general population study of COVID-19, Sudre et al6 found that approximately 1 in 10 individuals had symptoms lasting this duration, and a similar prevalence was reported in a cohort of Olympic and Paralympic level athletes.2 Most SEM clinicians would agree that cardiopulmonary symptoms lasting over a month represent a significant problem for a competitive athlete.

The coronavirus disease-19 (COVID-19) pandemic led to the prohibition of group-based exercise and the cancellation of sporting events. Evaluation of respiratory aerosol emissions is necessary to quantify exercise-related transmission risk and inform mitigation strategies. Aerosol mass emission rates are calculated from concurrent aerosol and ventilation data, enabling absolute comparison. An aerodynamic particle sizer (0.54-20 μm diameter) samples exhalate from within a cardiopulmonary exercise testing mask, at rest, while speaking and during cycle ergometer-based exercise. Exercise challenge testing is performed to replicate typical gym-based exercise and very vigorous exercise, as determined by a preceding maximally exhaustive exercise test. We present data from 25 healthy participants (13 males, 12 females; 36.4 years). The size of aerosol particles generated at rest and during exercise is similar (unimodal ~0.57-0.71 µm), whereas vocalization also generated aerosol particles of larger size (i.e. was bimodal ~0.69 and ~1.74 µm). The aerosol mass emission rate during speaking (0.092 ng s ; minute ventilation (VE) 15.1 L min ) and vigorous exercise (0.207 ng s ,  = 0.726; VE 62.6 L min ) is similar, but lower than during very vigorous exercise (0.682 ng s ,  < 0.001; VE 113.6 L min ). Vocalisation drives greater aerosol mass emission rates, compared to breathing at rest. Aerosol mass emission rates in exercise rise with intensity. Aerosol mass emission rates during vigorous exercise are no different from speaking at a conversational level. Mitigation strategies for airborne pathogens for non-exercise-based social interactions incorporating vocalisation, may be suitable for the majority of exercise settings. However, the use of facemasks when exercising may be less effective, given the smaller size of particles produced.

ObjectivesTo report COVID-19 illness pattern, symptom duration and time loss in UK elite athletes.MethodsObservational, clinical and database review of athletes with symptomatic COVID-19 illness managed within the UK Sports Institutes. Athletes were classified as confirmed (positive SARS-CoV-2 PCR or antibody tests) or probable (consistent clinical features) COVID-19. Clinical presentation was characterised by the predominant symptom focus (eg, upper or lower respiratory illness). Time loss was defined as days unavailable for full sport participation and comparison was made with a 2016–2019 respiratory illness dataset from the same surveillance system.ResultsBetween 24 February 2020 and 18 January 2021, 147 athletes (25 Paralympic (17%)) with mean (SD) age 24.7 (5.2) years, 37% female, were diagnosed with COVID-19 (76 probable, 71 confirmed). Fatigue was the most prevalent symptom (57%), followed by dry cough (50%) and headache (46%). The median (IQR) symptom duration was 10 (6–17) days but 14% reported symptoms >28 days. Median time loss was 18 (12–30) days, with 27% not fully available >28 days from initial date of infection. This was greater than our historical non-COVID respiratory illness comparator; 6 days, 0–7 days (p<0.001) and 4% unavailable at 28 days. A lower respiratory phenotype (ie, including dyspnoea±chest pain±cough±fever) was present in 18% and associated with a higher relative risk of prolonged symptoms risk ratio 3.0 (95% CI: 1.4 to 6.5) and time loss 2.1 (95% CI: 1.2 to 3.5).ConclusionsIn this cohort, COVID-19 largely resulted in a mild, self-limiting illness. The presence of lower respiratory tract features was associated with prolonged illness and a delayed return to sport.

Background In athletic individuals, a secure diagnosis of exercise-induced bronchoconstriction (EIB) is dependent on objective testing. Indirect bronchoprovocation testing is often used in this context and eucapnic voluntary hyperpnea (EVH) testing is recommended for this purpose, yet the short-term reproducibility of EVH is yet to be appropriately established. Objective The aim of this study was to evaluate the reproducibility of EVH in a cohort of recreational athletes. Methods A cohort of recreational athletes (n = 32) attended the laboratory on two occasions to complete an EVH challenge, separated by a period of 14 or 21 days. Spirometry and impulse oscillometry was performed before and after EVH. Training load was maintained between visits. Results Prechallenge lung function was similar at both visits (P> .05). No significant difference was observed in maximum change in FEV1(δFEV1max) after EVH between visits (P> .05), and test-retest δFEV1max was correlated (intraclass correlation coefficient = 0.81; r2 = 0.66;P = .001). Poor diagnostic reliability was observed between tests; 11 athletes were diagnosed with EIB (on the basis of δFEV1max >=10%) at visit 1 and at visit 2. However, only 7 athletes were positive at both visits. Although there was a small mean difference in δFEV1max between tests (-0.6%), there were wide limits of agreement (-10.7% to 9.5%). Likewise, similar results were observed for impulse oscillometry between visits. Conclusions In a cohort of recreational athletes, EVH demonstrated poor clinical reproducibility for the diagnosis of EIB. These findings highlight a need for caution when confirming or refuting EIB on the basis of a single indirect bronchoprovocation challenge. When encountering patients with mild or borderline EIB, we recommend that more than one EVH test is performed to exclude or confirm a diagnosis.

[...]there are many new sections (eg, patient consent, sniff nasal inspiratory pressure tests, paediatric testing and several sections have benefited from extended details, especially quality control, reference values, lung volume testing by all methods, blood gases and muscle function testing). Both these changes are evidence based; the former may help primary care spirometry practitioners, whereas most lung function staff will usually achieve the 100 mL target in >90% of tests.10 The use of Z-scores and LLN will help clinical utilisation and interpretation of the bronchodilator response which has always been problematic in defining what’s a meaningful change.10 The document has evolved over 4 years and has had to accommodate the new global guidance that has been published in that time7 8 but even so, there was no anticipating the COVID-19 pandemic and particularly the changed perceptions and emerging evidence around infection control and personal protective equipment for lung function staff. Some would argue that ATS/ERS technical standards cover this area well, but they are written for a larger audience and have to satisfy the North American markets (carbon monoxide diffusing capacity vs carbon monoxide transfer factor), and their standards are largely aimed at the equipment manufacturer’s so are more relevant to a global respiratory equipment market including the UK.