SYMPTOMS

Asthma is characterized by episodes of transient airflow obstruction that make breathing difficult.
These episodes are commonly referred to as asthma attacks and are a result of the smooth muscle
surrounding the bronchioles contracting (bronchoconstriction), and fluid (oedema) accumulating
within these narrowed airways. The classic symptoms of an asthma attack are therefore: a
shortness of breath (dyspnoea), chest congestion and tightness, wheezing and coughing.

DIAGNOSIS
Asthmatics will exhibit significant postexercise bronchoconstriction whereas non-asthmatics exhibit
slight bronchodilation.
EXERCISE-INDUCED
Exercise-induced asthma (EIA) affects about 4% of people who do not experience asthma
symptoms at rest. In addition to asthmatics exhibiting impaired lung function during an asthma
attack, about 8090% of asthmatics are susceptible to EIA. Breathlessness is a normal response to
sustained exercise of a strenuous intensity. However, it should not develop during or after exercise
of a relatively mild or moderate intensity, but if it does, it may indicate that the person suffers from
EIA. Exercise-induced asthma typically occurs 5 to 20 minutes after exercise and in most cases it
will resolve spontaneously within 45 to 60 minutes. Symptoms of breathlessness during exercise are
generally attributed to poor conditioning and pre-existing obstruction rather than EIA, as respiratory
assessments indicate bronchodilation rather than bronchoconstriction to dominate during exercise.
Assessment of EIA Clinical assessments for the diagnosis of EIA generally involve an exercise bout
of 6 to 8 minutes at an intensity of 6575% of predicted VO2max. Running, during which large
volumes of cold dry air are inhaled, is most likely to induce EIA, whereas swimming far less so,
since the inhaled air is already saturated with water vapour and hence has little evaporative effect on
the fluid within the lungs.

ASTHMA ATTACK PATHOPHYSIOLOGY (NON-EIA)

An asthma attack is caused by exposure to a trigger factor, such as dust, house mites, pollutants,
pollen, chemicals, fumes, animal fur or feathers. Asthmatics are hypersensitive to one or a
combination of these factors, which means that when they encounter them, the mast cells that line
their bronchioles will release chemical mediators that initiate a chain of reactions leading to
bronchoconstriction and inflammation. Whilst the exact aetiology of an asthma attack is not fully
understood, it is evident that soon after exposure histamine, leukotrienes, bradykinin and serotonin
are involved and cause increased vasopermeability of the bronchiole lining, contraction of
bronchiole smooth muscle and increased mucus production. This causes oedema, airway
constriction, wheezing and cough.

BREATHING TECHNIQUE AND AIDS One of the proposed causes of the bronchoconstriction
and inflammation associated with an asthma attack is the inhalation of cold dry air. During
strenuous exercise, pulmonary ventilation will be very high, sometimes exceeding 150 litres per
minute in fit athletes, and this rate far exceeds the ventilation rate that could be achieved through
nasal breathing alone, which is approximately 40 litres per minute. Thus oral breathing is required
during strenuous PA/exercise. To facilitate strenuous exercise in cold dry environments the
asthmatic can try using a facemask that warms and humidifies the inhaled air.

REDUCING THE RISK OF EIA

To reduce the risk of EIA, it may be helpful to exercise at a time of day when the air is warmer,
avoiding air pollution by exercising away from major roads and industrial areas that may have
airborne chemicals. Likewise, exercising indoors on high pollen count days may be advocated if
grasses or pollens are an allergen, and it is sensible to avoid exercising in areas where there may be
cigarette smoke and dust.

PHYSICAL ACTIVITY/EXERCISE
The health benefits gleaned by the asthmatic from PA/exercise participation are primarily the same
as for non-asthmatics. Subjective reports also suggest that exercise can facilitate improvements in
the quality of life of asthmatics, and perceptions of a reduced impact of asthma upon their life. The
physiological adaptations induced by exercise training for asthmatics are the same as those for non-
asthmatics, including a reduction in the relative exercise intensity of a specific workload, such as a
particular walking or jogging speed. One of the consequences of this is reduced pulmonary
ventilation at each speed or workload, which will thereby reduce the likelihood of adverse
evaporation and cooling of the airways, and hence reduce the risk of an EIA attack being triggered.
Adaptations to physical training
Specific improvements following cardiovascular exercise training therefore include increased
capacity to utilize oxygen (VO2max), maximum minute ventilation (VEmax), anaerobic threshold
and oxygen pulse. These are manifested by a reduced perceived exertion, lower heart rate, lower
pulmonary ventilation and lower concentrations of lactate at submaximal exercise intensities.

EXERCISE PRESCRIPTION Given the large spectrum of severity for the asthmatic condition,
exercise prescription will clearly relate to each individuals situation. For example, the goals of an
exercise programme may be orientated towards participation in a particular sport and/or be directed
towards increasing their capacity to perform activities of daily living and health-enhancing physical
activity. Likewise, as for nonasthmatics, exercise adaptations will be in accordance with the type,
intensity and duration of exercise undertaken. Therefore exercise programmes may be targeted
towards improving cardiovascular and/or musculoskeletal fitness.

TYPES OF PHYSICAL ACTIVITY/EXERCISE

For adults whose asthma is classified as mild or moderate, exercise prescription will be similar to
that for non-asthmatics, with due attention being paid to the appropriate use of prophylactic
medication. Thus, physical activity should involve the large muscle groups, be rhythmical in nature,
performed at a moderate intensity for 30 to 40 minutes on most and preferably all days of the week.
Walking, swimming, cycling, aerobics and similar activities are beneficial, as is general incidental
physical activity such as household chores and gardening. For more severe asthmatics, exercise
sessions may be designed as interval sessions with repeated intermittent bursts of activity separated
by periods of lowintensity recovery. The choice of exercise can also be guided by the same
principles as those used for non-asthmatics, with the aim being to facilitate fitness, health and
physical capacity, whilst promoting enjoyment and compliance with the levels of physical activity
advocated for health. However, for those with severe asthma the goals are likely to be more oriented
towards achieving a functional capacity that enables the performance of activities of daily living.
For non-athletes, initial exercise sessions may include walking at a moderate intensity, and for those
for whom further progression is deemed appropriate after a number of weeks, the walking may be
interspersed with periods of jogging. The duration of these may commence at 10 to 30 seconds and
be extended as fitness improves. Water-based Swimming is commonly prescribed for asthmatics, as
it appears to be less likely to induce bronchoconstriction and EIA because the air is more saturated
with water vapour than other environments. Participating in intermittent PA/exercise or team games
is less likely to induce EIA than continuous hard physical activity such as running and for more
severe asthmatics, exercise sessions may be designed as interval sessions with repeated intermittent
bursts of activity separated by periods of low-intensity recovery.

POST-PHYSICAL ACTIVITY/EXERCISE
After PA/exercise, asthmatics should ensure that they do not become cold and should change into
warm clothing, as they may be susceptible to sudden changes in temperature. Respiratory infections
will increase the asthmatics susceptibility to EIA and therefore they should take precautions to
minimize infection, such as avoiding people with colds and other upper respiratory tract infections.
It has been suggested that exercises for breathing control be included at the end of each exercise
session, including diaphragmatic (abdominal) breathing and breathing against a resistance to
increase the strength and endurance of respiratory muscles.

WARMING UP AND COOLING DOWN

An extended warm-up can minimize the impact of EIA. They advocate initially warming up at a
low intensity until a light sweat is induced and then performing close to maximum exertion for 5
minutes, and then resting. Aso report that a high-intensity warm-up at 8090% maximum will
partially, if not entirely, reduce the severity of EIA. Following strenuous physical activity, moderate
to low physical activity should be used as a gradual cooldown, in an environment that is not too
cold. However, it should be remembered that one of the proposed stimuli for EIA is a large
temperature differences between the inspired air during and after exercise, so this should not be too
great. The rationale for using gentle exercise to cool down as a prophylactic for EIA is that by
continuing to maintain a ventilation rate above resting values, the rate of airway rewarming will be
slow and hence the stimuli for EIA reduced.

CONSIDERATIONS WHAT TO DO IN AN ASTHMATIC ATTACK

If a client/patient has an attack either during rest or PA/exercise, remain calm to avoid any
additional anxiety that will make the situation worse; also encourage them to find a comfortable
position and ask them to focus on their breathing and employ a technique known as pursed lip
breathing. Encourage the asthmatic to inhale as normal but to actively exhale the air through
pursed lips. Most asthmatics will be familiar with this technique. The cause of this shortness of
breath is the inability to exhale carbon dioxide (CO2) through the constricted bronchial tubes. The
active blowing out stretches the bronchial tubes, allowing CO2 to be exhaled