Exercise-induced Asthma: Definition, Causes, Symptoms, Diagnosis, and Treatments

Exercise-induced Asthma: Definition, Causes, Symptoms, Diagnosis, and Treatments - welzo

Exercise-induced Asthma Overview

Exercise-induced asthma (EIA) is when the airways constrict during exercise and strenuous physical activities. It causes asthma symptoms like breadth shortness, wheezing, coughing, and chest tightness during or immediately after the exercise. The symptoms mostly normalise during rest. It is known as exercise-induced bronchoconstriction (EIB) in the medical terminology. It causes a significant disturbance of the athletic performance. The untreated cases result in poor athletic performance. 

The exact cause is unknown, and different factors are involved. The cold air was blamed for a long time. However, cold and dry air are known to cause it, as both cause the dehydration of the air passages. The irritation of air passages due to toxic fumes, chemicals, and chlorinated gases are among other major causes. The other risk factors identified by Marie and Bruner (Firelands Regional Health Centre) are having asthma and other respiratory infections like viral bronchitis, engaging in high-intensity athletic activities, air pollution, exposure to chlorine in drinking and swimming pool water, exposure to fumes of paint, dust from the carpet or new equipment, and engaging in activities that need deep breathing for a long time like soccer, swimming and long-distance running.

The symptoms last for a few hours and for longer in untreated cases. The symptoms include breath shortness, wheezing, coughing, chest pain and tightness, fatigue and poor athletic performance. The children tend to avoid the physical activities that trigger signs. For diagnosis, the healthcare professionals ask about the history and presentation of clinical signs. The physical examination of respiratory organs is done. Sometimes, the pulmonologists ask the patients to perform the triggering activity briefly to see the reaction. The spirometry test is used to monitor the lung functions. During spirometry, the patient is asked to exhale forcefully and as fast as possible into a tube attached to the spirometer. The spirometer measures the working efficiency of the lungs after exercise. The other diagnostic tests are peak flow measurement, bronchoprovocation test and fractional exhaled nitric oxide (NO) test. 

The medications alone or in combination are used for the treatment. The commonly used medications are beta-agonists (short-acting and long-acting), corticosteroid inhalers, leukotriene modifiers, and mast cell stabilisers. The prevention tips are allowing a proper warm-up before exercises, monitoring the air quality for pollens and other allergens, covering the nose and mouth when exposure is suspected, keeping a watch on the symptoms, informing the coach or trainers, and seeking immediate medical help. 

What is Exercise-induced Asthma?

Exercise-induced asthma or bronchoconstriction is a reversible and transient contraction of the smooth muscles in the bronchi after physical exertion. People experience different asthma symptoms to a variable degree, like cough, wheezing, chest tightness, and dyspnea. The people experiencing the signs are predominantly (40-90%) asthmatic. However, up to 20% of people developing signs are non-asthmatic. It results from changes in the lungs' physiology due to evaporative water loss, exposure to irritants, poor ventilation, and environmental thermal changes. 

Due to dehydration, the cells undergo shrinkage, causing the signs of illness. As the signs worsen, nasal breathing becomes insufficient, and mouth breathing starts. Mouth breathing causes more exposure to pollutants and dry or cold air, causing further complications. 

What is the other term for Exercise-induced Asthma?

The medical term for EIA is exercise-induced bronchoconstriction (EIB), which describes the narrowing of air passages during exercise. The other terms used interchangeably are exercise-induced bronchospasm, sports-induced asthma, exercise-induced cough, wheezing during exercise, exercise-induced breathlessness and exercise intolerance. 

Sometimes, the healthcare providers generalise the condition by just calling it exercise-induced respiratory distress, athletic asthma or sports asthma. 

How does Exercise-induced Asthma differ from other Types of Asthma?

Exercise-induced asthma is a subtype of asthma that occurs as a response to exercise and has some clear-cut differences from the other types of asthma. In short, the symptoms are similar to the other types of asthma. The difference lies in the nature of triggers, the timing of the onset of signs, diagnostic procedures and response to different treatments. It is triggered by physical exertion, while the other types of asthma are experienced due to factors like workplace exposure to allergens and other triggers like dust, smoke, and chemical allergens. 

The timing of symptoms is different. In EIA, the symptoms develop immediately after or during exercise, persist for a variable time, and begin to improve during rest. In the other types, the symptoms are unrelated to the exercise and last as long as the exposure to the allergens and triggers persists. The diagnosis of EIA needs a short time challenge to the exercise in a controlled environment, while the diagnosis of other types needs identification of other triggers, and an exercise test is not helpful. The EIA responds quickly to short-acting bronchodilators, while other types need a comprehensive program that involves using long-term bronchodilators and avoiding specific triggers.

Is Exercise-induced Asthma normal?

No, despite being a common condition and considered expected and normal in people with airway sensitivity and asthma, it is still not a normal condition and must be managed properly for a successful exercise plan. There are reports of respiratory failure and death in severe cases. The cooling and dryness of airways when exposed to dry or cold air is normal for many people. Not all people develop signs, and mostly, the people having previous sensitivity develop the signs. 

With proper treatment and management, involving bronchodilators, developing an excellent strategy for asthma management, and close cooperation with healthcare professionals, it becomes easily manageable and a normal part of the exercise routine. Proper management allows individuals to engage in physical activities and exercises unhindered and lead a normal life.

What causes Exercise-induced Asthma?  

The major trigger is rigorous training and physical activities in cold and dry air. The mouth breathing allows further dry and cold air to enter, causing more severe signs. 

Major triggers: The other major triggers besides the cold and dry air are high pollen counts in the air, poor air quality and pollution, having other respiratory illnesses and recovering from cold, and breathing in air polluted with smoke and fumes from paints and chemicals. 

Triggering sports: The sports more likely to cause EIA are the endurance exercises performed in a cold environment. The sports that need a constant high level of physical exertion, e.g., basketball, soccer, and long-distance running, and those that are performed in cold environments, like snowboarding, ice skating, ice hockey, and skiing, are especially risky.

The other causes are; 

Hypersensitivity of bronchi: People with hypersensitive bronchi are at higher risk of EIA. The sensitive bronchi react quickly to various triggers like exercise and are very sensitive to inflammatory mediators. These mediators cause a quick reaction resulting in excessive narrowing of air passages during extensive physical exertion. 

Inflammation in the body: Inflammation is the hallmark of asthma. It causes the release of inflammatory mediators like histamine that cause the constriction of airways. The risk of EIA is high in individuals with already occurring inflammation in the body. 

Exposure to environmental risk factors: People living in a polluted environment and having high exposure to allergens experience more severe signs during exercise. 

Underlying asthma: Some people have sensitive airways due to subclinical asthma. Such people have a higher risk of exercise-induced asthma as exercise serves as a trigger in such people. 

Genetics: Some people are genetically exposed to asthma due to the inheritance of certain genes. The asthma genes are GPR154, HLA-G, PHF11, DPP10 and VDR. Due to the inheritance of genetic factors, some people are more sensitive to the inflammation mediators and develop asthma symptoms easily.

Not all people experiencing the symptoms of asthma during exercise have EIA. The symptoms develop in various other conditions like cardiac diseases, vocal cord dysfunctions, panic attacks, anxiety and chronic obstructive pulmonary disease (COPD). Therefore, the signs must be discussed with the healthcare provider for guidance. 

What are the risk factors of Exercise-induced Asthma?

Different risk factors not only cause the disease themselves, but their presence increases the risk of severe signs. The important risk factors are;

Respiratory infections: The current or past exposure to different respiratory infections, like viral bronchitis and the common cold, increases the risk of exercise-induced asthma. The infections cause sensitivity and inflammation of the airways that persist even after the infection. The infections cause more severe and rapid reactions to the triggers like exercise.
Allergic rhinitis and asthma: The risk of EIA is higher in individuals with allergic rhinitis or asthma in the past. Both conditions cause an increased sensitivity of the airways, causing severe signs. The physicians at the Bambino Gesù Children's Hospital, Rome, Italy, found that 40% of the patients of EIB had allergic rhinitis and 30% had asthma. 
Family history: Asthma and EIA have a genetic component. The risk of EIA is high in people with one or more close relatives with the condition. The genetic tendency to develop severe allergic reactions in response to common allergens like exercise atopy is a major risk factor for EIA. According to Simon F. Thomsen (Bispebjerg Hospital, Copenhagen), the risk of developing asthma in people with one affected parent is 25%, increasing to 50% if both parents are affected. 
Environmental factors: Different environmental factors, e.g., cold and dry air, irritants, pollutants, and allergens, cause EIA and increase the severity of the signs. 
Duration and intensity of exercises: Performing strenuous and intense physical activities increases the risk of EIA. Activities that need deep and rapid breathing, e.g., swimming and running, have more risk of causing EIA than low-intensity exercises. 
Weather and climatic factors: The EIA is experienced more commonly in the cold and dry season when humidity is very low. The cool and dry air causes rapid constriction of airways. According to Condair Humidifier, the relative humidity in the exercise room must be 40-60%.
Exercising without warm-up: Proper warm-up allows the body to adapt to the challenge slowly. It causes a rapid mobilisation of the respiratory and energy reserves. It prepares the airways for the coming respiratory challenge. Working without proper warm-up causes an increased risk of developing EIA. Research in South Africa in 2015 found that exercising without war increases the risk of developing EIA by 14.83%. 
Poor conditioning before exercises: People who were leading a sedentary lifestyle for a long time before starting exercise and are not properly conditioned experience more severe signs. Regular physical activities gradually improve lung function and lower the risk of EIA. 
Use of certain medications: Certain medications like non-selective beta-blockers and NSAIDs (e.g., naproxen and ibuprofen) increase the risk of EIA. Such drugs interfere with the bronchodilation. The EIA patients must look at the use of medications and read their potential side effects. 
Psychological issues: Anxiety and emotional stress exacerbate the symptoms of EIA and even cause it in susceptible people. Stress influences breathing patterns and causes constriction of airways during exercise. 
Gastroesophageal reflux disease (GERD): The risk of EIA is high in individuals having GERD. It is a situation in which the stomach acids flow back into the oesophagus. It results in irritation and coughing that exacerbates the signs of EIA. 
Obesity: Obesity is a major risk factor for EIA. It puts mechanical pressure on the respiratory muscles and diaphragm and restricts their movements. Obesity causes a low-level inflammation in the body that sensitises the airways. A study in 2020 found that up to 19% of patients with EIB were obese, and an additional 22% were overweight.

    The presence of one or more risk factors doesn't mean that a person surely develops the condition. The presence merely indicates that the risk is higher in the exposed people. 

    What are the common Symptoms of Exercise-induced Asthma?

    The EIA manifests itself by causing various respiratory and other physical signs. The common symptoms of exercise-induced asthma are;

    1. Wheezing: Wheezing is a musical or whistling high-pitched sound that accompanies breathing, particularly during the exhalation. It results due to the partial blockage and the narrowing down of the respiratory passages, which results in the turbulent flow of the air through the constricted airways. The doctors use a stethoscope to hear the wheezes. 
    2. Shortness of breath: Shortness of breath of dyspnea is a condition in which a person cannot breathe comfortably and get proper air. It results in air hunger and more effort is needed for breathing. The intensity varies depending on the cause. 
    3. Chest tightness: It is a sensation of discomfort, constriction, and pressure in the chest region. It causes a feeling of gripping or squeezing in the chest. The intensity depends upon the causative agents. 
    4. Coughing: It is an involuntary reflex action by the body and is an attempt to remove foreign substances, mucus, and irritants from the trachea, throat, and lungs. It is a protective and natural mechanism that helps protect the respiratory passages by cleaning them and clearing off dust and potential allergens. It is either dry or non-productive or productive. 
    5. Fatigue while exercising: Fatigue or exercise-induced fatigue is a feeling of mental or physical tiredness that develops during and after strenuous and prolonged physical activities. It is natural to experience some degree of fatigue after physical activities. It develops as the body tries to meet the increased physiological demands during exercise. Excessive fatigue negatively influences performance.
    6. Difficulty breathing after exercise: Breathing difficulty or exercise-induced dyspnea is experiencing signs like chest tightness, rapid breathing and breadth shortness during or immediately after exercise. Several contributing factors are the increased oxygen demand, heart rate elevation, dehydration, overexertion, presence of allergies or asthma, poor conditioning and underlying conditions like COPD. 
    7. Decreased performance or endurance during exercise: It is the general decline in the ability to achieve the desired level of performance or sustain physical activities for a long duration. It develops due to fatigue, dehydration, poor conditioning, poor nutrition and training, different medical conditions like heart diseases and respiratory diseases, environmental factors like high altitude and humidity and psychological factors like poor motivation, stress and anxiety.
    8. Rapid breathing: Rapid breathing or Tachypnea is characterised by abnormally shallow and fast breathing during and after exercise. The normal respiration rate in adults is 12-20 per minute. In the case of Tachypnea, it becomes several times higher. Clinical Tachypnea is having a breathing rate higher than 20 per minute. Several contributing factors are high levels of physical activity, stress and anxiety, illness and fever, medical conditions like COPD and working at higher altitudes where oxygen levels in lower. 
    9. The feeling of tightness in the throat: Throat constriction or throat tightness is the sensation of discomfort or pressure in the area around the throat and neck. Its intensity varies and is the response to different factors like allergies, stress and anxiety, Respiratory infections, gastroesophageal reflux disease (GERD), smoking, muscle tension, swelling in the neck and exposure to environmental allergens are the major causes. 
    10. Difficulty speaking or catching one's breath: A severe type of breathlessness negatively influences speech. It happens in several issues e.g., respiratory infections like COPD, allergic reactions like anaphylaxis, respiratory infections like flu and pneumonia, cardiovascular diseases, anxiety and stress, panic attacks, neurological conditions, side effects of certain medications, vocal cord dysfunction and laryngitis. 

    1. Wheezing

    Wheezing is a high-pitched squeaking or whistling sound heard during breathing. The wheezes occur due to the narrowing down and constriction of respiratory passages and are a sign of severe respiratory diseases like general asthma, exercise-induced asthma, allergies, bronchitis, chronic obstructive pulmonary disease (COPD), postnasal drip, forced exhalations by otherwise normal people, congestive heart failure, anaphylaxis, vocal cord dysfunction, compression of airways due to goitre and cancer and inhalation of foreign bodies. 

    The abnormal sound is heard during inhalation and exhalation but is more pronounced in the exhalation phase. The causative triggers cause inflammation, the build-up of mucus in the respiratory passages and the tightening of the muscles around the respiratory passages. It is associated with other respiratory signs like chest tightness, coughing and shortness of breath. It is very common, and more than 50% of the patients experience it during asthma attacks. 

    Exercise is a major trigger of wheezing. During exercise, the athlete breathes more deeply and rapidly, which causes a rapid drying and cooling of the airways. It triggers the inflammation and constriction of the air passages. The air moving rapidly through narrowed passages produces a whistling sound. The severity, nature and duration depend upon the nature and intensity of exercise. The other accompanying symptoms worsen. The symptoms appearing during or immediately after the exercise, particularly 5-10 minutes after the exercise, in the absence of any other triggers, are attributed to exercise. Healthcare professionals use stethoscopes to listen to the sounds and use an exercise challenge test to know whether the cause is exercise.

    2. Shortness of breath

    Shortness of breath or dyspnea is a situation in which a person struggles to breathe and doesn't get enough air. It ultimately results in suffocation and breathlessness. It is experienced in conditions like COPD, asthma, bronchitis, allergic reactions, heart diseases, anxiety and excessive physical exertion. The other accompanying signs are wheezing, chest tightness, rapid heartbeat and rapid breathing. 

    Several exercise-related factors cause a person to run out of air. The increased physical activity causes an increase in the oxygen demand. The body has to rapidly push more air into the body and remove foul gases. The mouth breathing starts as airflow through the nose alone is insufficient. It causes rapid drying and cooling of the airways. The airways have a natural mechanism to keep them moist. When it becomes insufficient, signs of respiratory distress develop. The shortness of breath develops both during and after the exercise, and there are other accompanying signs like chest tightness, wheezing and coughing. 

    The symptoms develop during the exercise and peak 5-10 minutes afterwards. The diagnosis is based on the exercise challenge test in which the controlled exposure to the exercise causes the synonyms. Using bronchodilators before the exercise, practising proper warm-up and avoiding working in dry and cold environments are helpful. Besides EIA, it develops in various conditions like heart diseases, tuberculosis, excessive fatigue and use of certain medications, e.g., beta-blockers, NSAIDs, ACE inhibitors, chemotherapy drugs, digoxin, antihypertensive drugs, calcium channel blockers, anticonvulsants and statins. The patients must consult the healthcare providers for guidance. 

    3. Chest tightness 

    Chest tightness is a sensation of discomfort, constriction, and pressure felt in the chest area during or after the exercise. It is felt as if something is gripping or squeezing the chest, and the patients describe it as a feeling of heaviness and tightness. It varies in intensity and is accompanied by other signs of respiratory stress like pain, coughing and breath shortness. It results from various triggers and causative factors like acute coronary syndrome, GERD, pneumonia/ pleuritis, muscle tension, anxiety, heart diseases like heart attack and angina, lung diseases like COPD, asthma and even digestive diseases. According to Johson and Ghassemdadeh (Riverside Community Hospital), it is the primary cause of 5% of hospital emergency visits

    Exercise is a trigger for sensitive people. During exercise, the increased demand for ventilation increases the exposure to dry and cold air, which causes airway constriction in sensitive people. The constriction of airways results in poor airflow. The body responds to the situation by increasing the force of contraction of respiratory muscles, which results in feelings of tension and tightness in the chest. It doesn't occur alone and is accompanied by other signs of EIA like wheezing, coughing and breadth shortness. 

    The symptoms developing during or immediately after the exercise are attributed to EIA. The GP or pulmonologist observes the response to the challenge exercises to diagnose it. Using bronchodilators before the exercise, working in an environment with proper humidity and temperature control and practising proper warm-up before exercise are important management techniques.

    4. Coughing

    Coughing is a reflex action by the body that involves rapid and forceful expulsion of air from the respiratory passages through the lungs. It is an attempt by the body to clear the respiratory passages of foreign particles, mucus, irritants and allergens. It is a protective response, and duration and intensity depend upon the nature and severity of the triggers. Chronic cough is experienced in a wide range of conditions like respiratory infections like viral bronchitis, common flu, influenza and tuberculosis, allergic reactions to pollens and dust and exposure to smoke and chemical fumes. More than 40% of chronic and acute cough cases are referred to the pulmonologist.  

    The other causes are chronic respiratory illnesses like COPD and asthma. Two common types of coughs are non-productive or dry coughs experienced in flu, cold, asthma, COVID-19, GERD and rhinosinusitis and productive coughs accompanied by phlegm or mucus, which is experienced in lung infections. In exercise-induced asthma, people breathe more deeply and rapidly. It irritates airways due to the rapid drying and cooling. The body produces more mucus. 

    The body's protective mechanisms are activated, producing cough to remove mucus and irritants from the respiratory passages. The signs typically develop during or sometime after the exercise and persist for up to 3 weeks in acute cough and up to 8 weeks in chronic cough. During severe and high-intensity exercises, the breathing from the mouth starts to provide sufficient air. The air from the mouth is not filtered and moistened and causes more exposure to the irritants and more severe signs. The use of bronchodilators before the exercise helps control the cough. 

    5. Fatigue while exercising  

    It is a state of mental or physical exhaustion and tiredness that develops after a strenuous physical activity. It results in a lower capacity to continue the workout, muscle weakness, and general weariness. Experiencing fatigue after exercise is common, particularly for beginners, and the severity depends upon the health status, fitness level duration and type of physical activities. The main causes are depletion of energy reserves in the body, particularly the liver glucagon, the accumulation of waste products of glucose metabolism, particularly lactic acid, damage to the muscles during exercise and dehydration. As the duration and intensity of exercise exceed a certain limit, the oxygen delivery from the respiratory system cannot meet the energy demand.

    Recovery needs proper rest, hydration, and eating balanced and healthy foods. With time, the body makes adjustments to cope with the challenge. Sometimes, excessive fatigue after a workout is a sign of EIA. During EIA, the narrowing and constriction of airways, increased demand for ventilation and the body's responses to meet the demand by increasing respiratory efforts result in fatigue. The symptoms develop shortly after the exercise and persist for hours as the body recovers from the fatigue. Proper warm-up before exercise and using bronchodilators help manage the signs. Over time, the physiological adaptations in the body result in a lower intensity of fatigue.

    6. Difficulty breathing after exercise 

    Difficulty breathing or exercise-induced dyspnea is when a person experiences breathing discomfort or shortness of breath after exercise and physical activities. It is a normal response to physical activities and is experienced mostly in the recovery phase. Pushing the limits too far consistently results in severe signs. Exercise-induced asthma causes various respiratory signs like breath shortness, chest tightness, wheezing and coughing, which peak within 5-10 minutes after a physical activity. It occurs due to the inhalation of large amounts of air, particularly through the mouth, which causes a rapid cooling or drying of the airways. 

    The air entering through the mouth is unconditioned, and causes increased exposure to allergens and irritants. The resultant bronchoconstriction causes narrowing of airways, and signs of respiratory difficulty appear. Physical examination, exercise challenge tests and lung function tests help the doctors to establish the cause. Medications like bronchodilators and muscle relaxants, following proper routines for warm-up and cool-down and avoiding workouts in extreme weather conditions are useful. Beginners particularly experience breathing difficulty. The body adapts to the challenge with time, and the signs must disappear. If they persist, they must be consulted with a doctor. 

    7. Decreased performance or endurance after exercise

    Decreased performance or endurance after exercise is when a person experiences a significant reduction in the ability to perform or sustain the normal duration and intensity of physical activities and exercises. It manifests as an inability to carry out the previous workout levels, weakness and fatigue. It is not always a sign of disease and is reported by the beginners. A sudden onset in previously normal people is a warning sign. Sometimes, it is just a sign of too much burden on the body, and just taking rest and reducing the intensity of the workout is enough.

    The decrease in performance is the culmination of different complications associated with EIA, like coughing, chest tightness, increased mucus accumulation in the airways, which reduces the oxygen supply to the body, wheezing and breath shortness, which causes poor oxygenation of tissues and poor metabolism. Such symptoms significantly impair the ability to engage in physical activities. The bronchoconstriction reduces the airflow into the lungs; anaerobic respiration is activated, which causes increased production of lactic acid that makes the muscles painful and taught.

    8. Rapid breathing 

    Rapid breathing or tachypnea is abnormally shallow and fast breathing. It is a sign of respiratory infections and allergies, including EIA. The breathing rate is faster than normal, but breaths are shallow and carry less air than normal breaths. The normal breathing rate in adults is 12-20 breaths per minute, and a rate higher than 20 is considered tachypnea. Various causes are respiratory diseases like COPD and asthma, fever, anxiety, excessive physical exertion, metabolic disorders and anaemia. It is a response by the body to fulfil the increased demand for oxygen. 

    The other symptoms of respiratory illnesses that accompany are breathlessness, chest discomfort, light-headedness and dizziness. A sudden and severe onset of rapid breathing is a hospital emergency, as it is a sign of heart attack, pulmonary embolism and other life-threatening conditions. Some lifestyle factors that cause rapid breathing are exposure to traffic smoke, environmental pollutants, and cigarette smoking. 

    In exercise-induced asthma, the tachypnea develops due to various factors. During EIA, there is an increased risk of inhalation of irritants and allergens from the air through the mouth into deep airways and lungs. The resultant reaction lowers the air capacities of the lungs, resulting in rapid breathing. The inflammatory mediators released are released that cause constriction of the airways, which obstructs airflow, and the air passes rapidly through the constricted airways. The body increased the breathing rate to compensate for the reduced oxygen supply with each breath. 

    9. The feeling of tightness in the throat

    Throat constriction or tightness (Globus pharyngeus) is a sensation of discomfort or constriction experienced in the throat region. It results from various psychological and physical triggers, e.g., exercise-induced asthma, acid reflux, infections, allergies and anxiety. It creates a feeling as if the throat is closing up. The other accompanying signs are difficulty speaking or breathing, feeling a lump in the throat and difficulty swallowing. 

    It is one of the signs of exercise-induced asthma and develops for the following reasons. 

    Cooling of airways: Rapid and deep breathing during exercise causes dryness and cooling of the airways. In people who are sensitive to asthma, it causes a constriction of airways in the throat, resulting in throat tightness. 

    Exacerbation of inflammation: Heavy exercises exacerbate the underlying inflammation of the airways. It causes the release of inflammatory mediators like histamine that cause constriction of blood vessels in the sensitive area, resulting in breathing difficulties. 

    Increased sensitivity of the airways: The increased ventilation demand in the exercise sometimes increases the sensitivity of the airways. The mouth breathing starts. It results in the entry of non-conditioned cold or dry air containing pollutants and irritants into the airways. Besides EIA, it is a sign of various other health conditions like GERD, allergies, throat infections, postnasal drip, thyroid diseases, oesophagal spasms, vocal cord dysfunction and tension in the neck muscles, and the patients must consult healthcare professionals for diagnosis and treatment.

    10. Difficulty speaking or catching one's breath

    Difficulty speaking or catching one's breath is a condition in which a person experiences severe breathlessness and challenges in speaking during or after exercise. It results from factors like emotional distress, physical exertion and medical conditions like heart disease, chronic obstructive pulmonary disease, asthma and allergies. The primary symptoms noted are gasping for air, rapid breathing, wheezing, breath shortness and a severe inability to speak due to breathlessness. The symptoms vary from person to person, depending upon the cause. 

    Various conditions associated with EIA cause breathlessness and speaking difficulty, e.g., 

    Airway sensitivity: People with EIA have very sensitive airways. During exercise, large amounts of dry, cold and unconditioned air enter through the mouth. It causes the drying and cooling of airways, resulting in rapid constriction. 

    Bronchoconstriction: The combination of airway sensitivity and increased air exchange in the lungs results in bronchoconstriction. The airways become narrow, constricting the airflow into and out of the lungs, causing breathlessness. The symptoms start after the start of exercise and peak some minutes after the end of the activity. 

    The combination of symptoms, e.g., chest tightness, wheezing, breathe shortness and coughing, makes speaking difficult. Experiencing some breathlessness during exercise is normal; only excessive breathlessness is something to worry about. Breathlessness develops in various health conditions and the patients must consult the doctor or pulmonologist for treatment and prevention.

    How is Exercise-induced Asthma Diagnosed?

    The diagnosis of EIA needs a thorough evaluation of the history and clinical signs. The healthcare providers conduct a comprehensive physical examination to find any abnormalities in the respiratory system. Finally, clinical laboratory tests are conducted to evaluate the lung functions and rule out the other suspected conditions. 

    During a physical examination, the physicians look for the signs of anxiety and depression, check if the patient is having respiratory difficulty and using additional muscles in the chest and neck for breathing. The healthcare providers check the presence of cyanosis (bluishness of lips and skin due to poor oxygen supply). The healthcare providers monitor the respiratory rate, hear the lung sounds, and examine the chest for abnormalities. The nasal passages are examined to see if there is nasal congestion. The use of different medications in the past is reviewed. 

    Several methods are available for the diagnosis of EIA. A large variation exists in the sensitivity, specificity, quality and cost of different methods. The diagnostic methods for EIA are of two types: direct and indirect. The direct methods use a pharmacological agent to induce the contractions in the airway smooth muscles. The indirect methods mimic the events in the actual sports field to cause the same. 

    What tests are used to diagnose Exercise-induced Asthma?

    Various diagnostic tests are available for EIA. The tests are needed because many patients don't develop visible signs, and the physical examination alone cannot confirm the diagnosis. The most important diagnostic tests are; 

    Methacholine challenge test: Methacholine directly stimulates the receptors on smooth muscles and causes bronchoconstriction. A measured amount of agent is inhaled, and a spirometer is used to monitor the lung functions. It mimics the events happening in EIA and has a variable yet reasonable sensitivity of 58.6-91.1% for the diagnosis of EIA. It is not recommended in certain situations like in case of myocardial infarction in the past months, uncontrolled hypertension and if the patient had undergone eye surgery in the recent past. 
    Exercise challenge test: It involves challenging the patient with aerobic exercises in dry and cold air. It causes the symptoms of EIA in sensitive people. The intensity of exercises is adjusted as needed to trigger the symptoms. Exercises like climbing stairs are enough. A spirometry test before and after the test helps measure the degree of EIA. The alternatives to exercise challenge are breathing in highly dry air and airway provocation using dry powdered mannitol or hyperosmolar saline (4.5%), which induces EIA by dehydrating the respiratory epithelium. 

      Anti-asthma medications are stopped in the challenge tests, and different parameters like heart rate and time at maximum capacity are monitored. The spirometry is conducted 5, 10, 15 and 30 minutes after the challenge. A more than 10% decrease in the forced expiratory volume (FEV1) confirms EIA. A 10-25% decrease means mild EIA, between 25-50% means moderate EIA and more than 50% means server EIA.

      Lung function tests: Spirometry helps healthcare providers see how well the lungs work. The spirometer monitors how much air a person inhales or exhales and how quickly it is done. Sometimes, the pulmonologist repeats the test after taking bronchodilators, and the difference in the values is compared to see the degree of EIA. It helps rule out chronic asthma as the cause of symptoms. 

        The lung volume test measures the air volume in the lungs (lung capacities) and how much air stays at the end of the breathing cycle (respiratory reserves). The spirometry measures the forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). Another useful test is arterial blood gas (ABG) analysis, which determines the concentration of different gases in the arterial blood.

        Fractional excretion of Nitric oxide test (FENO test): It is a novel testing approach to diagnose and determine the severity of EIA. It measures airway hyperresponsiveness and inflammation by measuring nitric oxide (NO) levels in the exhaled air, which is an important marker of inflammation. It is useful to diagnose EIA from other causes of symptoms differentially. 

          Can Blood Tests be used to diagnose Exercise-induced Asthma?

          No, the blood tests alone are not enough to diagnose the EIA. Blood tests like complete blood count, allergy testing and testing for inflammatory markers like C-reactive protein help rule out other causes of signs like infections, anaemia, inflammations and allergic reactions, but they are not specific to EIA. Healthcare professionals use oxygen saturation testing to monitor how well the lungs function. It is not, however, used for the diagnosis of exercise-induced asthma. 

          An oxygen saturation of less than 95% means respiratory dysfunction. It occurs in various respiratory health conditions like pneumonia and is not a specific test for EIA. Therefore, a person experiencing the signs of EIA must consult healthcare professionals for diagnosis and treatment. 

          How long does a diagnostic test for Exercise-induced Asthma typically take?

          The duration of diagnostic tests varies and depends upon many factors, including the nature of the test, the diagnostic technique used and the skill of the person performing it. The estimated duration of different tests is as follows;

          Challenge tests: The exercise challenge tests take 1-2 hours, and only 4-8 minutes are used in triggering activity. It involves engaging in physical activities like running on a treadmill and cycling to induce the signs. The healthcare provider then monitors and evaluates the signs before, during and after the workout. The methacholine challenge test lasts almost half and varies between 30-60 minutes. It involves inhaling the progressively increasing amounts of methacholine and monitoring the signs of airway sensitivity. The time used for exercise activities is saved. 

          Spirometry: The duration of spirometry is even shorter, and it just needs 15 minutes to complete. It just needs taking a deep breath and exhaling into the spirometer to access the respiratory functions like forced vital capacity (FVC) and expiratory volume (FEV1). A skilled practitioner is able to achieve results in just a few minutes. 

          Lung function tests: Lung function tests include spirometry and occur in the same amount of time. It often takes up to an hour, depending on the precise test and the number of repeat measurements. According to the Medical College of Wisconsin, a complete pulmonary function test takes 45-90 minutes. The FENO test is quick, and according to Rhiannon Hoggins (paediatrician, University Hospitals Dorset NHS Foundation Trust), it takes just 10 minutes

          The durations provided are for guidelines only, and the exact time taken depends upon several factors, like actual conditions in which a test takes place, the necessary preparations needed before a test and the skill of the person performing the test.

          Can Exercise-induced Asthma be diagnosed by symptoms alone?

          No, the diagnosis based solely on clinical signs is challenging and not definite. The signs experienced, like breath shortness, bronchospasm, wheezing and coughing, are highly generalised and are experienced in most respiratory diseases. Only the appearance of signs during or immediately after the exercise provides useful clues. A comprehensive diagnostic plan involving a physical examination, history of the disease, lung function tests, exercise challenge test, methacholine challenge test and bronchial provocation tests are used to diagnose it. Relying only on the clinical signs is risky and often lead to misleading diagnosis and treatment. 

          How long does Exercise-induced Asthma last?

          It is a persistent condition, and a sensitive person continues to experience signs for a long time with gaps between exposures, the signs within one episode resolve within 30-90 minutes. After the resolution of symptoms, a refractory period of 1-3 hours follows in which no exercising does not cause EIA. The intermittent symptoms come and go for a long time and are not always present. Persistent symptoms like dry cough, exercise intolerance, fatigue and increased mucus production are of longer duration and last for days or weeks. Sometimes, it becomes a lifelong condition, particularly if the patient has chronic asthma. 

          The severity, duration and intensity of the signs depend upon treatment. A proper treatment plan using medications, strictly following the asthma treatment and management plan, and avoiding triggers help reduce the severity of the signs and frequency of episodes. The condition has a link to the age. If symptoms like wheezing are experienced in childhood, the children mostly outgrow the signs, which disappear with age. The older adults have poor immunity, and signs, once established, continue for life. 


          What are the Treatments for Exercise-induced Asthma?

          Various treatment options are available for EIA, and the choice depends upon the nature of signs, the drug availability, patient safety and the recommendations of the healthcare professionals. The most common treatment options are;

          Inhaled corticosteroids: The inhaled corticosteroids, e.g., fluticasone, budesonide, mometasone, beclomethasone and ciclesonide, are used if the patient is not responding well to the short-acting beta-agonists (SABA). They work by suppressing the inflammation in the airways. The response is dose-dependent, and ICSs take 2-4 weeks of regular use for proper effect. They are more effective for people who have underlying asthma as the cause. These are not effective as prevention measures before the exercise.
          Mast cell stabilisers: Mast cell stabilisers (MCSs) like nedocromil sodium and cromolyn sodium are used to treat asthma and allergic reactions. They work by preventing the degranulation of mast cells and the release of histamine that causes bronchoconstriction. The MCSs are not widely available and are more effective if combined with switch SABA. 
          Leukotriene modifiers: Leukotriene modifiers, leukotriene blockers, or receptor antagonists are used to treat and manage inflammatory conditions like allergic rhinitis and asthma. These drugs target the leukotrienes, the important mediators of inflammation. These include zileuton, zafirlukast and montelukast, and take 2-4 weeks of regular use to give full benefits. The choice is patient-specific.
          Long-acting bronchodilators: Long-acting bronchodilators are the medications that are used to treat and manage respiratory conditions like COPD and asthma. These drugs cause bronchodilation, widening and relaxing the airways and making breathing easier. Two major long-acting bronchodilators are long-acting beta-agonists (LABA) and long-acting muscarinic antagonists (LAMAs). They are mostly used as maintenance therapy on a long-term basis and provide relief from the symptoms on an ongoing basis. 
          Short-acting bronchodilators: These so-called 'relief bronchodilators' provide quick relief from symptoms like acute bronchoconstriction, as experienced in the EIA. Short-acting beta agonists (SABA) and short-acting muscarinic receptors (SAMAs) are two major types. Such drugs are normally administered through devices like nebulisers or metered dose inhalers (MDIs). These drugs don't treat the underlying cause and provide temporary relief from the symptoms.

            1. Inhaled Corticosteroids 

            Inhaled corticosteroids (ICTs) are the treatment of choice for persistent asthma and to prevent worsening asthma signs. The ICTs are inhaled through the respiratory route to reach the action site directly. Direct inhalation into the respiratory system reduces the dose requirement as a lot of oral drug is destroyed in the stomach. These are administered as dry powdered inhalers or devices like metered dose inhalers (MDIs) and nebulisers. The examples and brand names are fluticasone (Nasofan®, Avamys®, and Flixonase®), budesonide (Budelin® and Pulmicort®), mometasone (Nasonex® and Clarinaze®), beclomethasone (Luforbec® and Fostair®) and ciclesonide (Alvesco®). 

            The ICTs are very potent glucocorticoids and reduce the inflammation of the airways. The production of pro-inflammatory chemicals responsible for bronchoconstriction, like leukotrienes and cytokines, is reduced. The onset of action is slower, and several days or weeks of consistent use are needed to get maximum benefits. The ICTs are highly effective at preventing the symptoms of acute asthma in most of the patients. They significantly reduce the severity and frequency of asthma attacks, and regular use allows people to engage in physical activities without harm. 

            The local adverse effects of ICTs are bronchospasm, coughing, oral thrush and dysphonia (voice disorder). The use of metered dose inhalers reduces the risk of side effects. Consistent and regular use of inhaled corticosteroids caused poor growth in children with chronic asthma. The systemic side effects are clinically insignificant and rare and include impaired glucose metabolism, hypothalamus pituitary adrenal axis dysfunction resulting in hormonal imbalances, stress-related disorders, sleep disturbances, immunosuppression, sexual dysfunction and cognitive impairment, glaucoma and cataracts. 

            Some studies have linked the long-term use of ICTs with osteoporosis and increased risk of bone fractures. Therefore, it is advised that adults using ICTs on a long-term basis must be screened regularly for bone density. Research at the Nottingham University Hospitals in 2014 noted that 30-50% long long-term users of inhaled corticosteroids experienced bone fractures and osteoporosis. 

            2. Mast Cell Stabilisers 

            Mast cell stabilisers or mast cell receptor antagonists are the medications that are used to block the release of pro-inflammatory chemicals like histamine from the mast cells in the airways that cause bronchoconstriction. A common example is sodium cromoglycate (Optrex®, Opticrom®, Hayfever Relief® and Catacrom®), which is available for ocular use. It has been used as an inhalation powder for the treatment of asthma for decades and has a good margin of safety. 

            An important step in the pathology of asthma is the release of histamine from the inflammatory cells, particularly the mast cells. It occurs through a process known as mast cell degranulation. The mast cell stabilisers block calcium channels that are essential for degranulation activity. Blocking of degranulation means no histamine and no constriction of airways. The mast cell stabilisers are used for the preventive treatment of exercise-induced asthma. Their efficacy is less than the inhaled corticosteroids, but still, they cause a sufficient decrease in the severity and frequency of asthma attacks if used persistently. They are combined with or as substitutes for inhaled corticosteroids in people who want to avoid them for any reason and have more than 90% efficacy. 

            They are generally safe and well tolerated by the body. Some long-term users experience issues like Throat irritation: Some users report mild cough and throat irritation. It is associated with overdosing and is avoided by using a spacer device and inhaler. 

            Allergic reactions: The allergies to MCSs are rare. Some people experience allergies leading to signs like swelling, itching, rashes and respiratory difficulty in severe cases. 

            Eye irritation: The MCSs are available as eye drops to treat ocular allergies. Some users report a mild burning and stinging sensation in the eyes.

            In contrast to other medications used for asthma, mast cell stabilisers are associated with no systemic side effects because they are used locally and are safe for long-term use. 

            3. Leukotriene Modifiers

            Leukotriene modifiers, leukotriene inhibitors, or leukotriene receptor antagonists are the drugs used to treat asthma and other allergic reactions. They target leukotrienes, the inflammatory chemicals responsible for inflammation and constriction of airways. Common examples are zafirlukast (Accolate®), montelukast (Singulair®) and zileuton (Zyflo CR®), which are used for the long-term treatment and prevention of asthma, relieving the symptoms associated with allergic rhinitis and preventing exercise-induced bronchospasm. 

            Leukotrienes are the products of arachidonic acid metabolism in the inflammatory cells and cause bronchoconstriction and inflammation of the airways in asthma and EIA. The leukotriene modifiers block the actions of leukotrienes. It prevents the narrowing of airways and inflammation and mucus production in the airways. Both montelukast and zafirlukast are taken orally.

            Montelukast is taken as a single dose 2 hours before physical activities to prevent EIA. Meals do not influence it. Zafirlukast is taken 1 hour before or 2 hours after the meal as food causes a 40% decrease in bioavailability. They are quite effective in managing EIA and are used alone or in combination with other medications. They reduce the severity and frequency of asthma attacks during physical exercises and improve exercise tolerance. 

            Both montelukast and zafirlukast are well tolerated, and side effects are minimal. Montelukast causes some side effects in adults, like dyspepsia, cough, abdominal pain, influenza and headaches. In children, the side effects are an increased risk of viral infections, otitis, laryngitis, nausea, diarrhoea, pharyngitis and sinusitis. Some people experience neurological signs like nightmares, anxiety, insomnia, aggression, depression and suicidal thoughts. The common side effects of zafirlukast are malaise, diarrhoea, abdominal pain, dyspepsia, vomiting, nausea, infections in the upper respiratory tract and headaches. Rarely, some people experience hyperbilirubinemia, elevation of liver enzymes and acute hepatitis.

            4. Long-Acting Bronchodilators 

            Long-acting bronchodilators (LABAs) are the type of bronchodilators that help to relax and open the airways in the lungs. They provide extended relief from the symptoms of EIA and are included in the long-term asthma control program. The LABAs work by stimulating beta 2 adrenergic receptors in the airway muscles. The activation of these receptors causes the relaxation of muscles around the airways, resulting in the opening of airways. The bronchodilation makes it easier to breathe during the exercise. They effectively relieve the symptoms associated with the EIA, and regular use provides better resilience. 

            Examples are salmeterol (Serevent®), formoterol (Perforomist®), aclidinium bromide (Tudorza®), tiotropium bromide (Spiriva) and umeclidinium bromide (Incruse®). They are used alone, and for better efficacy, they are combined with other asthma drugs like inhaled corticosteroids. The choice depends upon the doctor’s recommendations.

            The side effects of the long-acting bronchodilators are due to the activation of the sympathetic nervous system. The most common and frequent side effects are muscle cramps, heart palpitation, nervousness and trembling. Some more severe yet rare side effects are the risk of myocardial infarction, hypokalemia (low levels of potassium in the blood), paradoxical bronchospasm and sudden and severe constriction in the bronchial airways. The patients must consult the doctor in case of any comorbidities. The LABAs are not prescribed to people allergic to them and those with hypokalemia, cardiac arrhythmias, and ischemic heart failure. People with renal failure, older adults and women undergoing labour must consult a physician before using them.

            5. Short-Acting Bronchodilators

            Short-acting bronchodilators (SABAs) or rescue inhalers are the medications that are used to treat the acute symptoms of asthma, including exercise-induced asthma. They provide quick relief from the narrowing of airways experienced in EIA. The SABAs are used 30 minutes before a workout. The onset of action is very quick, within 5 minutes, and the therapeutic efficacy lasts 3-6 hours (Eric and Bajaj, Ross University School of Medicine). They include albuterol (Ventolin HFA®, Proventil HFA®, Proair HFA® and AccuNeb®), levalbuterol (Xopenex® and Xopenex HFA®), pirbuterol (Maxair®), terbutaline (Terbulin® and Bronclyn®) and metaproterenol (available as a solution used in nebulisers).

            The SABAs work by dilating the smooth muscles in the airways. The two major types are anticholinergics and beta-2 adrenergic agonists. The anticholinergics (e.g., ipratropium) block the actions of acetylcholine, a neurotransmitter that causes bronchoconstriction. The beta 2 adrenergic receptor agonists (e.g., Salbutamol and Salmeterol, work by stimulating the beta 2 adrenergic receptors in the airways, which results in their relaxation. Both are used 5-15 minutes before the exercise.

            They cause inhibition of degranulation of the mast cells. They are very effective and provide quick relief from the symptoms of EIA, like chest tightness, breath shortness and wheezing and allow people to engage in physical activities without respiratory distress. They do not, however, provide a long-term solution and are used just as a short-term first-line treatment. 

            They are safe, and side effects are minimal. Some people experience side effects like increased heart rate (tachycardia), mild tremors, palpitations, jittering, nervousness, anxiety, dry mouth (in anticholinergic bronchodilators) and headache. For better safety, the patients must use SABAs as the doctor recommends and not rely on them as long-term options. If the symptoms persist for a long time, they must be discussed with the healthcare professionals for better treatment options.

            Can immunotherapy help treat Exercise-induced Asthma?

            The current research suggests that some help is likely, but immunotherapy is not the main therapy used for EIA. Immunotherapy or allergy shots are designed to decrease the allergic response to different allergens, e.g., pet dander, dust mites and pollens. In immunotherapy, the injections containing small and measured amounts of specific allergens are given to desensitise the immune system. It helps lower the severity of allergic symptoms. Conversely, the EIA occurs in response to different exercise-related factors and is not triggered by specific allergens. So, immunotherapy is not typically used to treat EIA. 

            Immunotherapy promises some benefits in some people whose signs are exacerbated by allergies. For example, a study by the EfficAPSI showed that sublingual immunotherapy helps desensitise people and lowers the risk of onset of asthma symptoms in people with allergic rhinitis. Likewise, according to experts like Martin Munoz (Hospital Universitario Infantil La Paz, Madrid, Spain), immunotherapy is helpful for allergic asthma and prolonged treatment for 3-5 years is required to achieve the best therapeutic efficacy. So, if a person develops EIA due to underlying allergies, immunotherapy offers some help. 

            Does Breathing Exercise help treat Exercise-induced Asthma?

            Yes, breathing exercises help manage exercise-induced asthma. Increasing evidence is available that supplementing the breathing exercises with the treatment options adds value to the therapy and gives better results. The breathing exercises increase the resilience of the respiratory system and induce better resistance to the signs of exercise-induced asthma. Some proven exercises to are;

            Diaphragmatic breathing: It strengthens the diaphragm, a doom-shaped sheet of muscles under the lungs, and helps breathing. Diaphragmatic breathing slows the breathing rate and lowers the body's oxygen demand. It is performed while sitting straight up in the chair or lying on the back with the knees bent and a pillow under the knees. One hand is placed on the abdomen and the other on the chest. Slow breaths are taken while the hand on the chest is still, and the other on the abdomen is moving. Now, the air is breathed out slowly through the pursed lips. A review by Hidetaka Hamasaki (Hamasaki Clinic, 2-21-4 Nishida, Kagoshima, Kagoshima, Japan) in 2020 found that practising diaphragmatic breathing for 4 months increased the maximum voluntary ventilation by 10.96% and lowered the breathing frequency by 11.47%.
            Yoga breathing: Yoga combines deep breathing with exercises. It is known that practising controlled deep breathing, as in different yoga techniques, helps improve lung functions and develop resistance to asthma symptoms. According to Demeke Mekonnen, MD, regularly practising yoga reduced the frequency of attacks and decreased the usage of drugs. 
            Breathing with pursed lips: It is an effective technique to relieve the shortness of breath. In pursed-lip breathing, the trainee is asked to inhale the air through nostrils with a closed mouth. Then, the lips are pursed together as if a person is going to blow a whistle. Then, the air is breathed out through the pursed lips. The process is repeated many times. According to John Nguyen (Florida Atlantic University), pursed-lip breathing opens the airways in patients with asthma and COPD. 
            Nasal breathing: Mouth breathing exacerbates the situation as the air entering through the mouth is unconditioned and carries more allergens and dust. People with EIA symptoms are advised to breathe from the nose as the nasal passage has the mechanisms to make the air warm and damp and filter the dust and allergens, making asthma symptoms worse. The researchers at the Sahlgrenska University Hospital, Sweden, observed that nasal breathing reduced the frequency of asthma attacks.
            Integrated relaxation and breathing training (Papworth method): It is an old method and combines relaxation exercises with deep belly breathing. It trains a person to breathe slowly and steadily from the nose and diaphragm instead of mouth and rib cage muscles. It teaches stress management as stress is an important trigger of EIA. Researchers like Elizabeth Holloway from University College London have suggested that it improves the quality of life of asthma patients by easing the breathing symptoms. 
            Breathing exercises for COPD: Practicing breathing exercises for COPD like segmental breathing, paced breathing, coughing and huffing and yoga breathing reduces breath shortness, increases the resistance to exercises and improves the overall quality of life. The sensitive people must consult the trainers for guidance.  
            Buteyko breathing: It was developed in the 1950s by a Ukrainian doctor named Konstantin Buteyko. It is based on the idea that people are faster and deeper than needed in the exercise. It causes unnecessary hyperventilation and breathing shortness, particularly in people with asthma. The Buteyko breathing causes a person to breathe slower, reducing the respiratory rate and tidal volume. The results of studies are mixed, and some studies have found it useful to improve asthma symptoms and lower the need for medical treatment.

              How to prevent Exercise-induced Asthma?

              Managing exercise-induced asthma is challenging, particularly for people with strenuous physical exercises like professional athletes. Some strategies described below allow sensitive people to prevent EIA while benefiting from the exercises and physical activities. 

              Proper understanding of the condition: Prevention needs a proper understanding of the EIA, its causes, risk factors and implications. It results from any exercise-related factor that causes the narrowing of the airways, making breathing difficult. Identification of the major triggering agents like dry and cold air, high-intensity workouts, dehydration, underlying medical conditions like asthma, environmental pollutants and allergens is very important. Understanding the warning signs of EIA is necessary to take active steps at the initial stages. There are a lot of individual-level triggers, and the patient must identify the triggers unique to them. 
              Consultation with the healthcare professionals: The healthcare professionals, particularly the allergists and pulmonologists, are experienced in providing personalised guidance to patients. Sometimes, consultation with the gym trainer is helpful for the right choice of workouts. The professionals assess the general health, conduct the health tests and design a comprehensive and personalised asthma control program. The plan addresses the core issues like identification of signs and symptoms, proper use of medications and identification of warning signs that need emergency medical assistance. 
              Medical management: In case of an asthma attack, the patients need to use medications like short-acting bronchodilators (e.g., Albuterol) to relax the airways and make breathing easier. Sensitive people must use preventive medications before a workout and always carry a rescue inhaler. The controlled and rescue medications, like inhaled corticosteroids, are used only on prescription. The inhaled corticosteroids reduce the sensitivity of the airways and reduce inflammation. The usage, timing and dosage of medications must be consulted with the healthcare professionals.
              Follow a proper warm-up and cool-down routine: A proper warm-up before a workout allows the body to adjust to the challenge gradually and prevent the severe symptoms of EIA. The light-intensity exercises like squats, lunges, fast-paced walks, arm swings and jogging at the start of the workout gradually increase the breathing rate and heart rate to adjust to the challenge. They prepare the respiratory and circulatory systems for a more intense workout. Likewise, disengagement from the workout needs a cool-down routine to slow heart and breathing rates. Some good cool-down exercises are high knee skips, quick jumps and side-to-side shuffles. It avoids rapid cooling or drying of airways. 
              Use different breathing techniques: Different breathing techniques, like diaphragmatic breathing, pursed lip breathing, Lion's breath, resonance breathing and the Buteyko method, help prevent bronchoconstriction. Practising such techniques allows a person to breathe from the deep diaphragm rather than shallow breaths from the chest. 
              Management of environmental factors: Different environmental factors predispose a person to the EIA and must be addressed. For example, indoor exercise is useful in extremely cold and dry weather. The International Fitness Association recommends that pilates, weight training, cardio and aerobics be performed at 65-680F and yoga between 70-800F. The recommended humidity level for all exercises is 40-60%. If a person is allergic to pollens or dust, the workout must be performed when the allergen levels are low. Placing a scarf or mask on the nose and face is useful as it helps filter out dust and allergens. Choose locations with cleaner or fresh air, like indoor gyms or parks. 
              Monitoring of symptoms: The patients must track symptoms' development, intensity and frequency. Inform the healthcare provider or trainer in case of any signs. It helps the general practitioner know if the plan works or needs any adjustments. Consistently following the instructions and guidelines of health professionals is important. 
              Identify the limits of workouts: The symptoms often appear in response to extreme workouts, and the boundary between safe and unsafe workouts is very blur. It is important to identify individual specific limits and stick to them. The sensitive person must avoid high-intensity exercises and choose low-intensity exercises like walking and jogging. 
              Lifestyle modifications: Many lifestyle modifications help cope with the EIA. A healthy diet containing vegetables, fruits, proteins and healthy fats is helpful to reduce the inflammation in the body. Stress exacerbates the asthma symptoms. Stress reduction techniques like deep breathing, meditation and yoga are useful. Exposure to cigarette smoke must be avoided.
              Alternative treatments: Many alternatives to medications are advised. The evidence in their favour is anecdotal, and limited scientific evidence is available. Some health professionals recommend using vitamin C supplements and fish oil to manage the symptoms of EIA as they help lower the inflammation in the airways and improve pulmonary functions (ClinicalTrials.gov). 

                Should I stop exercising if I have Exercise-induced Asthma?

                No, a person with exercise-induced asthma doesn't need to stop exercising. Regular exercises are beneficial as they improve healthy lung functions and build resistance against signs of exercise-induced asthma. Some important considerations are consulting a general practitioner or a pulmonologist to diagnose the condition and devise a treatment plan, using pre-exercise medications like bronchodilators in consultation with the doctor to help manage the signs, following a proper warm-up routine before a workout, avoiding working in a cold and dry environment or at least wearing a mask during a workout, installing humidifiers in the exercise room and practising within safe limits as symptoms develop and worsen after exceeding the safe limits. Maintaining proper hydration is important as water is an important ingredient of mucus that covers the respiratory epithelium and prevents dryness. Proper management and professional guidance allow a person to enjoy exercise and physical activities without worrying about signs of asthma.

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