Norwegian Nebulizer Use at World Junior Championships Stuns North Americans

Norwegian team doctors prescribed asthma medication to young cross-country skiers without any diagnosis of the disease the country’s state broadcaster NRK reported. The incident occurred at 2016 Junior and U23 World Championships in Rasnov, Romania.

Petter Olberg, who was a physician on the team staff in Rasnov, said that the treatment was due to air-quality issues which irritated the airways of some athletes.

American and Canadian competitors and team staff at the event, however, did not recall any air quality problems. They expressed surprise that competitors who were still teenagers would be offered such drugs without a medical diagnosis of asthma.

“I am shocked to hear about this story and I do not recall there being poor air quality in Rasnov other than the coal burning pollution,” Julia Kern, an American who had two top-20 finishes in Rasnov, wrote in an email to FasterSkier. “My hope is that the doping regulations are set up to only help fix a medical disease instead of giving people an advantage.”

The medication allegedly prescribed, budesonide, is a glucocorticosteroid which is not prohibited for inhalation by the World Anti-Doping Agency (WADA). It was delivered by a nebulizer, rather than through inhalers; Olberg said he had also recommended that some athletes take a salt-water inhalation treatment through the nebulizer to improve their symptoms.

The case has caused a stir partly because a more senior Norwegian skier, Martin Johnsrud Sundby, was slapped with a suspension after taking asthma medication from a nebulizer. However, that was a different drug – salbutamol, which is a beta-2 agonist rather than a glucocorticosteroid – which is prohibited by WADA when used in high doses.

Air Quality Plagues FIS Site Selection, and Racers’ Lungs

Air quality has been a major issue at past Junior and U23 World Championships.

“When the World Junior & U23 Championships were held in Erzurum, Turkey in 2012 and Almaty, Kazakhstan in 2015, the air was possible the worst I have ever seen at a race venue,” Logan Hanneman of Alaska Pacific University (APU) wrote in an email.

Of the four Junior/U23 World Championships Hanneman has competed in, Erzurum and Almaty stood out for one reason: smog.

“In both locations, it seemed that the pollution was caused by poorly-regulated and designed coal power plants,” he explained. “With the large surrounding mountains in both locations, the inversion that would form during the night would suppress the pollution down to the valley floor and into the town where the teams were staying. The race venue in Almaty was above the pollution, but only in the early morning before it began to rise up the mountains.”

That was a nightmare for many athletes, including those who do suffer from asthma. Kern, now a U.S. Ski Team member based at Stratton Mountain School and Dartmouth College, remembers Almaty and its health challenges well.

“I had the experience of having my worst asthma attack ever in Almaty and I attribute that to the poor air quality,” she wrote. “I know some of my teammates who have never had any issues breathing even mentioned having some issues in Almaty.”

In fact, the International Olympic Committee released a consensus statement about asthma and elite athletes in 2008. In it, they addressed the influence of air pollution on the prevalence of airway problems during training and competition.

“Airway function can be affected by exposure to seasonal and perennial allergens in sensitized individuals, dry/cold air, and poor quality air containing pollutants such as chlorine derivatives in swimming pools, ozone and oxides of nitrogen, and fine and ultrafine PM derived from combustion,” the group wrote. “The effects may be greater in subjects with asthma than without asthma.”

Other air characteristics are sometimes considered in assessing safety. The International Ski Federation (FIS) has a cutoff of -20° Celsius (-4°F), below which it is not permissible to hold competitions; one reason is frostbite, but another is airway damage. FIS is considering raising that lower limit, perhaps to -12° Celsius, specifically to protect athletes’ lung function from long-term damage.

But the pollution aspect of air quality does not appear to be a concern. Air quality is not discussed anywhere in the International Competition Rules (ICR), meaning that technical delegates and race juries do not have clear guidelines for deciding whether to adjust race schedules due to smog.

And by selecting sites like Erzurum and Almaty that are clearly plagued by such problems, FIS does not appear to make the issue a priority when awarding event bids.

They are not alone. The International Olympic Committee (IOC) awarded the 2008 Summer Olympics to Beijing, China, which has some of the worst smog in the world. That caused some long-distance runners to choose not to prioritize the marathon, for fear that prolonged exposure to the air while racing would cause asthma attacks.

Such an attitude by governing bodies must be changed, a growing number of athletes assert.

“My personal belief is that if we are racing in an area with high pollution, I think it is okay for people to use legal asthma medications at a legal dose in order to protect their lungs from damage,” Kern wrote. “But more importantly, I do not think races should be allowed to be held in places of pollution because it not only hurts the health of athletes in the short term, but in the long term as well.”

Comparatively Clean Air in Rasnov

Romania is not known for its clean air. The industrial sector burns coal, while coal and wood are used for home heating. Pollution from traffic emissions is also a concern. As a result, by several metrics Bucharest has the dirtiest air of any European capital.

At Rasnov, where the ski competitions were held, traffic exhaust was less of an issue.

“The only thing that was polluting the air was the exhaust from coal burning, which is easy to recognize because it has a strong odor,” Kern wrote.

Of all airborne pollutants this type of exhaust can be particularly inflammatory to airways, according to Dr. Michael Kennedy at the University of Alberta, who studies respiratory health of endurance sports athletes.

“The ultrafine particles (UFP) are the most troublesome,” he explained in an email. “In any active person (most of the literature is from active transport — like bike commuting)… deposition of UFP in systemic circulation as well as lung function can be significant. Diesel is the worst of the polluters and fits with Romania and Kazakhstan, where High Emission Pollutants likely influenced lung health in all competitors. For those with [Exercise Induced Bronchoconstriction] it was likely worst.”

So it’s not crazy to suggest that athletes could have struggled to race in particulate-laden air, as Olberg suggested was true for the Norwegians.

But that’s not the way other teams remember Rasnov. Because of the way the venue was situated, American competitors did not notice the coal-produced UFP’s while they were skiing.

North American Perceptions of Air Quality in Rasnov

“I did not notice the ‘poor air quality’ in Rasnov as my biggest concern was the lack of snow. I think this is an excuse and if the air was bad in Romania I hate to think of what they were taking for Junior Worlds in Kazakhstan where the smog and air pollution was extremely prevalent.”

–Ian Torchia, USA (Northern Michigan University): 15^th in the junior 10 k skate 

“In Bucharest, the city air was definitely thicker, but the venue (Cheile Gradistei) was quite remote, at least 20 or 30km from any major cities (or industrial sites, that I know of), out in the countryside, surrounded by rural farmland and fields. Water quality seemed to be a much greater concern in Romania.”

– Jenn Jackson, Canada (NDC Thunder Bay): 29^th in the U23 sprint

“The air quality appeared okay to me, however there was heating with wood in the area. That can irritate some but no significant quality issues like we saw in Kazakhstan and Turkey. Romania was very warm and early warm conditions can bring on pollen, however I didn’t notice that either.”

– Bryan Fish, U.S. Ski Team coach/trip leader 

“While I’m by no means an air-quality expert, I wouldn’t say the air quality was bad in Rasnov, at least at the race site. The race site was up high on a hill in a very agricultural area, on the edge of some mountains… I never had a moment where I thought to myself ‘wow – this air quality is bad’ and as a coaching staff we never had a discussion that indicated that air quality was an issue with the site. We were mainly focused on having snow to ski on… That being said, in my opinion, it also wasn’t great. There was a big smokestack from what I’m assuming was some sort of boiler that burned wood. It was also pretty dusty from the overall construction.”

– Kieran Jones, Nakkertok Nordic coach/Canadian team staff member

Like Kern, Hanneman has been diagnosed with asthma. In his case, he believes that it is a result of growing up in Fairbanks, Alaska, and “racing and training in the very cold and dry air.” He said that he was prescribed a small inhaler to treat his symptoms after a major flare-up in Erzurum, but he didn’t experience a similar problem in Romania.

“I seem to remember that my asthma related problems were not very present in Rasnov,” Hanneman explained. “I took my inhaler like I normally do for races, but the air did not seem to bother me as much as the previous locations. It helped that it was also 55 degrees.”

Why Offer Athletes a Nebulizer?

So, then, was giving new medications to some junior athletes necessary?

“When I first heard the news I was extremely fired up,” wrote Torchia, who initially assumed that the juniors were prescribed the same drug which Sundby had used, rather than a non-prohibited one. “My initial anger eventually turned to being demoralized that doping had come down to the junior level. You hear about the scandals on the World Cup but when it comes to the people you race, it felt like a punch in the gut. The most frustrating thing I have heard was the Norwegian doctor offering asthma medication to healthy athletes. This shows a clear indication from the upper levels of the system to cheat their way to victory. If you can’t compete clean, don’t compete at all.”

As it turns out, it was not salbutamol but budesonide which the athletes were using. Budesonide is not prohibited for inhalation, although like other glucocorticosteroids, it cannot be injected or ingested orally in or out of competition.

Olberg told NRK that from his viewpoint, saying that the athletes without an asthma diagnosis were “healthy” was incorrect. The athletes, he said, were sick because of the air quality.

“I believe that we don’t medicate healthy people,” he explained to NRK. “If we medicate it is because they have gone ill. They have a symptom, a distress of some kind and then they reach out to me. We treat the symptoms…. I believe that to say that they are healthy is completely wrong, because if they’re healthy they wouldn’t have had the symptoms, and if that was the case they would not receive treatment.”

The North American athletes seemed to struggle internally about whether this was appropriate – especially since it’s relatively unclear whether non-asthmatics even receive benefits of such drugs. That’s even true in the case of salbutamol, the beta-2 agonist which is prohibited at high doses.

But the athletes felt that the intent of their competitors mattered, whether their performance was enhanced or not.

“After talking with [Northern Michigan University coach] Sten [Fjeldheim] and my exercise physiology professors and doing some personal research, it seems unclear on the performance enhancing benefits of taking salbutamol, especially in healthy athletes as the oxygen uptake is already at maximum potential,” Torchia wrote. “However… whether it is performance enhancing or not, if you are a healthy athlete and are taking synthetic drugs with the intention of helping your performance, you are cheating, and there should be repercussions.”

Hanneman and Kern, who take inhalers to treat their diagnosed asthma, had a hard time parsing whether it was wrong to use such medications without such a formal diagnosis.

“My hope is that the WADA has set the limitations and bans on certain drugs in ensure that the drugs permitted at legal doses would not have a positive impact on performance, but would only help treat the illness of asthma for those with the ‘disease’ (not sure what technical term to use),” Kern wrote.

“Having exercise induced asthma myself, and seeing the health benefit that the medicine provides, I support the use of prescribed medications, but in limited quantities,” Hanneman agreed. “People who have not been treated previously should not be allowed to use such a medicine I feel.”

Many drew a distinction between whether such drugs were used as part of a long-time treatment plan, or prescribed more casually by doctors who are not intimately familiar with an athlete’s medical history.

“I am very much opposed to widespread usage of any medication,” U.S. Ski Team development coach Bryan Fish wrote. “That being said, there are athletes that have unique respiratory issues & these athletes should go through testing by qualified medical staff. The qualified medical staff should then create a unique and specific plan for that particular athlete.”

And as more and more such “gray area” incidents accumulate, it’s hard for athletes to interpret whether their competitors are seeking an unfair advantage or not – much less whether they are actually getting one.

“I don’t understand how people can be so invested in maximizing their performance that they’re willing to leave the white area and step into the grey,” Jackson wrote. “Unfortunately, medicating and supplementing just seems to be the norm these days, in sport and everyday society. People will do what they’ll do, so long as they feel it’s ‘normal’ or ‘okay’ – whether that be Norwegian juniors using asthma medication at the World Championships, Russians using xenon for Sochi, [Poland’s Justyna] Kowalczyk taking injections for her foot in 2014, or [Norwegian Therese] Johaug’s doctor providing her that super skin cream. I suppose it’s inevitable, as you approach the limits of human potential, that you toe the line between white and grey, but I don’t feel like I’m close enough to that point to really understand why someone would.”