Liverpool and asthma inhalers: Is there any substance to the innuendo?
ARTICLES /
CONDITIONING/
LIVERPOOL
WRITTEN BY SIMON AUSTIN — MAY 26, 2022
WHEN monitoring our website analytics over the last few months, one article has regularly featured among the best-read and we struggled to work out why.
It’s
this one, from December 2017, and is about the prevalence of exercise-induced asthma among elite footballers. Which, at first glance, doesn't seem hugely topical.
However, further investigation has revealed the reason why it's being read so often: because social media is currently full of conspiracy theories about the use of asthma inhalers by Liverpool's players and people obviously wanted to find out more.
The genesis of the rumours is a September 2020 article that quotes a “source close to the club” (always a red flag) who “reveals” that 22 member’s of Liverpool’s 35-man first-team squad are asthmatic. The treatment for the condition is then described as being “substances to enhance and support performance.”
So we decided to provide some evidence-based analysis and spoke to the country’s leading expert on asthma in elite athletes,
Professor John Dickinson, the Head of the Exercise Respiratory Clinic at the University of Kent, about the issue.
Dickinson has worked with Premier League clubs, the England national team and Olympic athletes in both diagnosing and treating asthma, as well as publishing numerous research papers on the topic. Our Q&A with him is below:
Q. Any basis to this figure of 22 of 35 Liverpool players being asthmatic?
Professor John Dickinson: The rumour I saw was 63%, as you say. There is no official data out there on this. A club is not going to pin the number of players that are using various medications on a board somewhere. I think that’s what this is - a rumour. Where it came from, who knows?
Back in 2010/11 I did screen the club’s first-team squad and we published a paper on it. That was back in the days when Dr Peter Brukner was Head of Sports Medicine and Science at Liverpool and Zafar Iqbal was first-team doctor.
About 25% of the players had exercise-induced asthma. A lot of clubs wouldn’t have let us publish that data, but they saw it as, ‘We’re doing best practice here and we want to tell everyone about it.’
Q. If the incidence of asthma was so high, would that raise concerns?
It's a higher figure than we’ve published from elite football in the past. In our
previous study that you wrote about (in 2017), we found that 27.8% of footballers within our sample had exercise-induced asthma, so almost one in three. The prevalence within the general population is somewhere between 9 and 12%, so roughly 1 in 10.
This figure of 63% wouldn’t necessarily be unreasonable though. If it was true - and I have no way of knowing whether it is or not - my response would be that the club are being proactive in identifying those athletes who do have asthma.
The reason for the higher prevalence of asthma in elite footballers is two-fold: firstly the high ventilation rates, because they're training and playing at high intensity; and the fact that they are often exposing their airways to cold dry air. These two factors predispose them to increased risk of the condition.
In other elite sports the incidence is actually much higher. In swimming, for example, we’ve reported it to be about 70%. This is largely because the chlorine in the water produces a gas called trichloramine that can trigger an inflammatory response in athletes’ airways.
Q. What treatment is prescribed for asthmatic players?
There is no known cure for asthma, so you are never going to fully get rid of it. Most footballers have it on a mild to moderate basis which in the general population would only require use of an inhaler two to three times a year.
However, elite footballers are exerting themselves to much high ventilation rates, which can trigger an inflammatory process in the airway. This, in turn, triggers a muscle contrition around the airway, which is what we know as asthma.
The blue inhaler is salbutamol and it relieves the muscle constriction, but it doesn’t really touch the inflammation. If an athlete solely relied on that, the inflammation would still be there and their bodies would get used to the salbutamol, so they would have to take more of it as time went on.
So the idea around therapy is that you prevent it occurring rather than dealing with it once you get the airway constriction. The medication athletes should be using most regularly is an inhaled corticosteroid, the brown inhaler, which might be used in combination with a Beta2-agonist, which is the purple inhaler.
They will need to take the brown or purple inhaler every morning and evening regardless of how they are feeling and this will dampen down the inflammatory process in their airways and reduce the chance of experiencing asthma.
If you’re playing a match and are going to exert yourself and might get symptomatic then you could still take your salbutamol inhaler about 20 minutes before going out and that should do you for four hours, so you should be fully protected for the game.
Saying that I’ve not seen any players taking a puff before running out on the pitch or running over to the side to have a puff either. If they were doing that I’d be a little bit worried because it would mean they weren’t controlling their asthma properly.
Q. The big question: Are asthma inhalers performance enhancing?
Within therapeutic doses, no. From an anti-doping point of view an athlete isn’t allowed to use more than six puffs of the blue salbutamol inhaler during a 12-hour period.
However, there have been some studies with endurance athletes in which they've taken 80 puffs of a blue inhaler in a day and have then done time trials to exhaustion. The findings were that there was was no change in performance and no change in oxygen kinetics, which is how fast you can take oxygen in.
The only thing they really saw was an elevated heart rate, which is actually detrimental to performance, because for a given workload you’re having to work harder. There's also a fair chance you would get the shakes and perhaps heart palpitations too.
