“What are your suggestions for working with clients who have exercise-induced asthma?”

Asthma is nothing to ignore or minimize in your clients. Even if asthmatic clients haven't had an episode in a long time, you need to keep asthma at the forefront of your mind throughout your programming and during their sessions.

Here are a few things to remember when working with clients with asthma:

1. Make sure they have an inhaler on them at all times during and after exercise. Scrambling through the locker room while they're in the middle of an asthma attack is not advisable.
2. Begin with aerobic activity, and progress to resistance training. Walking is usually best to start with, as they should already be comfortable walking. If they prefer to walk outside, make sure you monitor the air quality. They can progress to different modalities of aerobic activity, but always start slowly and easily. Work up to longer-duration exercise. Higher-intensity aerobic activities should be avoided. However, if asthmatic clients would like to try more intense aerobic activity in the future, help them progress very gradually.
3. Resistance training should be moderate, 12–15 reps and a total of 15–18 sets per workout, focusing on compound exercises. Remember that exercises involving both upper and lower extremities will have a greater impact on clients' oxygen consumption. These exercises may be more taxing, and clients may need more time to recover.
4. If asthmatic clients are on a long-term corticosteroid, like prednisone, they may have muscle wasting in their lower extremities and a weakening of their bones, especially trabecular bone (e.g., in the neck of the femur). These clients, even though they may look healthy, may have steroid-induced osteoporosis. Therefore, I would eliminate high-impact or plyometric activities until you have spoken with their doctor.
5. If clients are experiencing any asthma symptoms, stop the
   exercise immediately.

In general, high-intensity exercise will bring on an attack much more than low-intensity exercise with longer duration. Give clients plenty of rest between sets, and monitor their breathing patterns to see how hard they are working. Target heart rate may not be the best indicator of their effort; therefore, I prefer using the talk test. If they are exercising too intensely to talk to you, scale down the intensity. When in doubt, do less not more.

     Brian Richey
     Owner, Fit 4 Life DC
     Washington, D.C.

Clients with exercise-induced asthma should have a prolonged (15-minute) warm-up and cool-down before and after exercise to limit exercise-induced bronchospasm. Research suggests a warm-up should attain an exercise intensity equivalent to 60% of the asthmatic's VO2max; be intermittent with a range of intensities; and include dynamic activity involving range of motion, balance, agility and neuromuscular activation.

The following tips can help an asthmatic client reduce symptoms while exercising:

• Use inhaled medication 20 minutes before exercise.
• Perform a prolonged moderate-intensity warm-up and cool-down, preferably of variable intensity and including a burst of high-intensity activity.
• Avoid known irritants during exercise.
• Avoid pollens; exercise indoors during pollen season.
• Avoid exercise in high-pollution environments or at peak pollution times of day.
• In cold weather, exercise inside or wear a mask or scarf outside to limit moisture loss and trap moisture so that the air breathed in is warm.
• Exercise in warm, moist environments (such as on the pool deck at a fitness facility).
• Use a dyspnea (breathing) scale, which works much like the rating-of-perceived-exertion scale.
• Avoid exercise during any viral infection.

Data is mixed concerning appropriate exercise intensities, although prolonged, high-intensity training has been shown to increase bronchiole inflammation and incidence of exercise-induced asthma. In fact, there is now concern that the high flow rates required in exercise at an elite level may be detrimental to an athlete's respiratory health. So moderate-intensity exercise still seems to be an appropriate goal and a recommendation for clients with known exercise-induced asthma.

The exercise environment is extremely important. Warm, moist exercise environments that are protected from pollution and pollen exposure may best serve these clients.
     Greg Anderson, PhD
     Dean, Office of Applied Research & Graduate Studies, Justice Institute

       of British Columbia

     Vancouver, British Columbia

The trick to training clients who have exercise-induced asthma is in the warm-up. Warm-ups that have intense bouts with rest between them are better than steady-state bouts. Part of the reason is that intense bouts cause the release of greater concentrations of catecholamines, and these bronchodilators act as the body's own EpiPen®. Instruct clients to breathe through their nose rather than their mouth, as nose breathing causes less water loss.

Hydration is also imperative, as water is an antihistamine. This is one of the reasons cold weather induces asthma more. Water in the tissues is used to warm the air coming in, which leads to faster dehydrating effects in the mucus membranes of the airways. Taking 1–2 grams per day of vitamin C also can lessen an exercise-induced asthma occurrence.

     Jade Teta, ND
     Founder, Metabolic Effect
     Winston-Salem, North Carolina and Los Angeles

Watch asthmatic clients closely, be attentive to signs like excessive coughing, and remind them to breathe from the nose and not from the mouth.

I also try to avoid exercises in the prone position, as I find it's harder to breathe when pressing against the esophagus. Other tactics I use are teaching breathing and relaxation techniques; avoiding back-to-back exercises; and allowing time for stretching and sipping water between exercises and sets. Also, it is always good practice to encourage clients to verbalize to you how they are feeling.
     Anette Lynch
     Personal Fitness Training Ltd.

     Wilmette, Illinois

In clients with exercise-induced asthma, exercising may bring on an asthma attack. However, exercise is also an important method for relieving asthma as exercise helps to strengthen the accessory respiratory muscles, making breathing an easier process.

It is recommended that asthmatic clients take part in aerobic activity on 3–7 days per week, for 20–30 minutes, at an intensity that is appropriate to the client's level and does not cause an asthma attack. In early stages of exercise, it may be necessary to split the training time across two sessions in the day. It is important to monitor the level of exertion using the Borg Scale for Rating of Perceived Exertion and heart rate, as well as the modified Borg dyspnea (breathlessness) scale. The latter scale works in a similar manner to the RPE scale, with 0 being not out of breath at all and 10 being unable to breathe. The most worrying signal is when a client is at a very low intensity according to RPE and heart rate but experiencing an 8 on the dyspnea scale. At that point, you should stop the exercise session.

In terms of resistance training, implement a full-body resistance program 2–3 times per week, alternating between upper- and lower-body exercises at 70% of one-repetition maximum, over 15 reps, for 1 set.

In addition, design a program of activities of daily living that meets the minimum requirements of aerobic activity. A general full-body flexibility routine should also be implemented.

Take the following precautions when working with clients who have exercise-induced asthma:

• Do not exercise on days when wheezing and allergies are troubling or the weather is very cold.
• Do extended warm-ups.
• Consider interval training.
• Use exertion and breathlessness scales to monitor intensity.
• Avoid too much upper-body cardiovascular exertion.
• After a severe flare-up, start with resistance training, and then gradually introduce
  cardiovascular exercise.
• Consider the use of a bronchodilator prior to exercise.
• Ensure medication is always available.
• Exercise mid to late morning.
• Avoid extreme temperature and high humidity.

     Tom Godwin
     Managing Director, Foresight Fitness
     Manchester, England

I teach optimal breathing sequences one-on-one to help clients with asthma get off medication and be able to exercise. The first thing we do is shift from mouth breathing to nostril breathing. Most people are shallow mouth breathers, which creates too much sympathetic response and too much inflammation. Mouth breathing is a sympathetic (hot) response, and nostril breathing is a parasympathetic (cooling) response and reduces inflammation. The less inflammation there is in the throat and lungs, the deeper we can inhale and exhale. The longer and deeper our nasal inhalations and exhalations, the more the diaphragm and vagus nerve are engaged.

In general, breath control in the exercise warm-up and cool-down periods is critical, but mostly in the warm-up sequences. Preparing the body for higher heart rates with more of a parasympathetic cooling response is crucial for people with breathing issues. Mouth exhalations are typically very fast; exhaling through the nose is slower and more of a fat burner or inflammation reducer. Less inflammation means it is easier to breathe freely.
     Ed Harrold
     Go BE Great Inc.
     Aspen, Colorado