Article Text

Download PDFPDF
Prevalence of lower airway dysfunction in athletes: a systematic review and meta-analysis by a subgroup of the IOC consensus group on ‘acute respiratory illness in the athlete’
  1. Oliver J Price1,2,
  2. Nicola Sewry3,4,
  3. Martin Schwellnus3,4,
  4. Vibeke Backer5,
  5. Tonje Reier-Nilsen6,
  6. Valerie Bougault7,
  7. Lars Pedersen8,
  8. Bruno Chenuel9,10,
  9. Kjell Larsson11,
  10. James H Hull12,13
  1. 1 School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
  2. 2 Leeds Institute of Medical Research at St. James’s, University of Leeds, Leeds, UK
  3. 3 Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
  4. 4 IOC Research Centre, Pretoria, South Africa
  5. 5 Centre for Physical Activity Research, Rigshopitalet, Copenhagen University, Denmark, Copenhagen, Denmark
  6. 6 The Norwegian Olympic Sports Centre, Oslo, Norway
  7. 7 Laboratoire Motricité Humaine Expertise Sport Santé, Université Côte d’Azur, Nice, France
  8. 8 Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
  9. 9 Centre Hospitalier Régional Universitaire de Nancy, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, Service des Explorations de la Fonction Respiratoire, Université de Lorraine, Nancy, France
  10. 10 Medical Physiology, Université de Lorraine, Nancy, France
  11. 11 Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
  12. 12 Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  13. 13 Division of Surgery and Interventional Science, Institute of Sport, Exercise and Health (ISEH), University College London, London, UK
  1. Correspondence to Dr James H Hull, Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6HP, UK; j.hull{at}


Objective To report the prevalence of lower airway dysfunction in athletes and highlight risk factors and susceptible groups.

Design Systematic review and meta-analysis.

Data sources PubMed, EBSCOhost and Web of Science (1 January 1990 to 31 July 2020).

Eligibility criteria Original full-text studies, including male or female athletes/physically active individuals/military personnel (aged 15–65 years) who had a prior asthma diagnosis and/or underwent screening for lower airway dysfunction via self-report (ie, patient recall or questionnaires) or objective testing (ie, direct or indirect bronchial provocation challenge).

Results In total, 1284 studies were identified. Of these, 64 studies (n=37 643 athletes) from over 21 countries (81.3% European and North America) were included. The prevalence of lower airway dysfunction was 21.8% (95% CI 18.8% to 25.0%) and has remained stable over the past 30 years. The highest prevalence was observed in elite endurance athletes at 25.1% (95% CI 20.0% to 30.5%) (Q=293, I2=91%), those participating in aquatic (39.9%) (95% CI 23.4% to 57.1%) and winter-based sports (29.5%) (95% CI 22.5% to 36.8%). In studies that employed objective testing, the highest prevalence was observed in studies using direct bronchial provocation (32.8%) (95% CI 19.3% to 47.2%). A high degree of heterogeneity was observed between studies (I2=98%).

Conclusion Lower airway dysfunction affects approximately one in five athletes, with the highest prevalence observed in those participating in elite endurance, aquatic and winter-based sporting disciplines. Further longitudinal, multicentre studies addressing causality (ie, training status/dose–response relationship) and evaluating preventative strategies to mitigate against the development of lower airway dysfunction remain an important priority for future research.

  • asthma
  • athletes
  • epidemiology
  • risk factor

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @oliverjprice, @VBougault, @Breathe_to_win

  • Correction notice This article has been corrected since it published Online First. The title has been corrected.

  • Contributors Conception and design: OJP, NS, MS, VBa, TR-N, VBo, LP, BC, KL, JJH. Analysis and interpretation: OJP, NS, MS, JHH. Drafting the manuscript for important intellectual content: OJP, NS, MS, VBa, TR-N, VBo, LP, BC, KL, JHH. OJP and JHH confirm full responsibility for the content of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.