Most exercise scientists would agree that the physiological determinants of peak endurance performance include the capacity to transport oxygen to the working muscle, diffusion from the muscle to the mitochondria, energy production and force generation, all influenced by signals from the central nervous system. In general, the capacity of the pulmonary system far exceeds the demands required for ventilation and gas exchange during exercise. Endurance training induces large and significant adaptations within the cardiovascular, musculoskeletal and haematological systems. However, the structural and functional properties of the lung and airways do not change in response to repetitive physical activity and, in elite athletes, the pulmonary system may become a limiting factor to exercise at sea level and altitude. As a consequence to this respiratory paradox, highly trained athletes may develop intrathoracic and extrathoracic obstruction, expiratory flow limitation, respiratory muscle fatigue and exercise-induced hypoxaemia. All of these maladaptations may influence performance.