Eliminate Exercise - Induced Asthma
Taken from the Oxygen Advantage by Patrick McKeown
"The Asthma Care approach made a significant difference to my breathing during sports performance and throughout my daily life. It is simple, makes sense and should be taught to all asthmatics."
- Frankie Sheahan, Munster and Ireland Rugby Union footballer
"I would have no hesitation in recommending the Asthma Care program for exercise induced asthma. I use it myself and the difference to my playing is considerable. This is something which should be taught to all players with asthma. Breathe through your nose and correct your breathing. Things can only get better. "
Damien Burke. Galway County footballer
"The Asthma Care approach has proven to me that with dedication anything is possible! It is unbelievable to think that the key to success is by breathing through your nose! Try it and reap the rewards."
Brian Carroll. Offaly County Hurler
"Where a fraction of a second makes a big difference, correct breathing is an area that we cannot ignore. While I am not asthmatic, I use the Asthma Care program and have found improved performance and health benefits overall. I think in time, all athletes will be considering this approach to retain their competitive edge."
Brian Maher. Kilkenny City Harriers
Both professional and amateur athletes attending the AsthmaCare program have experienced significant improvements to:
- Eliminating chest tightness and exercise induced asthma
- Improving performance
- Reducing and eliminating the need for asthma medication
- Reducing lactic acid
- Quicker recovery
- Increased energy
- Lowering resting pulse
- More stamina
The word asthma derives from Greek and means 'to pant'. While asthma has been around for a very long time, it affects more people today than ever before. Exercise-induced asthma affects an estimated 4-20% of the general population and 11-50% of certain athlete populations.1 Interestingly, one study showed that while 55% of football athletes and 50% of basketball athletes displayed airway narrowing conducive to asthma, no athletes from the sport of water polo showed any asthmatic symptoms.2 Later on in this section we will investigate why this might be.
So, what causes asthma? The most common theories include the hygiene hypothesis, which rests on the premise that too much cleanliness means children are not exposed to enough germs, resulting in diminished immune capabilities later on in life. A second commonly-cited explanation is an increase in pollution, but while this may well be a trigger, it is not necessarily the cause. For instance, the west of Ireland, where I live, has a high asthma rate but very clean air quality.
Might there be another factor which plays a significant role in causing asthma; namely that of habitually breathing too much? If this were true, then surely reducing breathing volume could result in a reversal of the condition. By looking at the causes and symptoms of asthma, and the physiological changes resulting from the condition, we can begin to determine just how important breathing exercises can be in treating asthma.
Since asthma is a condition characterised by difficulty in breathing, a logical approach would be to attempt to find the root cause by first addressing poor breathing habits. Tackling asthma from this angle is not new and was employed by the ancient Greek and Roman physicians Galen and Paracelsus, who recommended breath holding and breathing exercises for the treatment of coughing and narrowed airways.3
Studies have shown that the prevalence of asthma increases relative to wealth. Increased wealth leads to a change in living standards; food becomes more processed, competitive stress increases, houses become airtight, we perform less physical exercise and the majority of our jobs are sedentary. Fifty years ago, our living and working situations were quite different and asthma rates were significantly lower. During that time, we ate more natural foods, had less competitive stress, our houses were draughty and most occupations involved physical labour. Back then, our lifestyle was conducive to a more normal breathing volume and, as a result, asthma was far less common.
Normal breathing volume for a healthy adult is generally agreed to be 6 litres of air per minute4, but individuals with asthma demonstrate a resting breathing volume of 10-15 litres per minute.5,6,7 This is a significant increase, showing that asthmatics breathe two to three times more than required. Imagine the effect on the respiratory system when an individual breathes twice or three times too heavily all day, every day.
Normal breathing during rest involves regular, silent, diaphragmatic breaths drawn in and out through the nose. Asthmatics, on the other hand, display habitual mouth breathing with regular sighing, sniffing, and visible movements from the upper chest. During an exacerbation of asthma, symptoms like wheezing and breathlessness increase along with respiratory rate, relative to the severity of the condition.8 In other words, as asthma becomes more severe, there is also an increase in breathing volume.
While it is well-documented that asthmatics breathe too much, there is a need to determine whether the increase to breathing volume is a cause or effect of the condition. As the airways narrow a feeling of suffocation is generated, and a normal reaction is to take more air into the lungs to try to eliminate this sensation. So, do asthmatics breathe heavily because of their condition, or does heavy breathing cause the airways to narrow? Either way, it is a vicious cycle; narrowed airways lead to heavier breathing which causes an increase in breathing volume, resulting in the narrowing of the airways and on and on, worsening the condition and establishing bad breathing habits as a matter of necessity.
The only way to determine whether breathing too much causes asthma is to investigate what happens when a group of individuals with asthma practise breathing exercises designed to bring their breathing volume towards normal.
A study at the Mater Hospital in Brisbane found that when the breathing volume of asthmatics decreased from 14 litres to 9.6 litres per minute, their symptoms reduced by 70%, the need for rescue medication decreased by 90%, and the need for preventer steroid medication decreased by 50%.7 The study found a direct relationship between the reduction of breathing volume and improvement to asthma. The closer breathing volume reduced towards normal, the greater was the reduction of asthmatic symptoms such as coughing, wheezing, chest tightness and breathlessness. Furthermore, the trial's control group – who were taught the hospital's in-house asthma management programme – made zero progress. The reason for this was solely due to the fact that there was no change to their breathing volume.7 Further studies compounded these findings by showing that asthmatics who practised reducing their breathing volume had far better asthma control with a significantly reduced need for preventer steroid and rescue medication within 3-6 months.9,10
Based on the fact that a number of clinical trials have shown that asthma symptoms and the need for asthma medication significantly reduces following the employment of reduced breathing exercises, there is no doubt that over-breathing is a significant cause of asthma.7,9,10 Of course, it is also normal for asthmatics to increase their breathing volume to compensate for a feeling of suffocation, but this action is simply part of a 'feedback loop'. Elements of modern living increase breathing volume, which can activate asthma in genetically predisposed individuals. As their asthma takes hold, the individual breathes faster and more intensely, worsening the condition. While it is important to recognise this feedback loop, the first step to addressing asthma is to reduce excessive breathing habits.
I can relate to any child or adult with asthma because for over 20 years I struggled with the same symptoms; I was unable to perform even the most basic physical exercise, my nose was constantly stuffed, and I continuously breathed through an open mouth. Year after year my asthma medication increased with no signs of my symptoms abating. My sleep, concentration, mood and quality of life were all adversely affected. It was only by chance, when I learned of the work of Russian doctor Konstantin Buteyko, that I was able to reverse my asthma. Within a few short days my wheezing decreased dramatically, simply from learning to unblock my nose and normalise my breathing volume. I have now been wheeze-free for the past 12 years, and all I did was to learn to breathe normally again.
This had such a tremendous impact on my life, that I changed careers in 2001 and retrained under the auspices of the late Dr Buteyko. In 2002, I founded Asthma Care to help publicise this information to children and adults with asthma. Our clinics are now offered in 15 countries.
A marathon journey...
In his early years, treatments for Julian's asthma included cough mixture, trips to the coast for the benefits of sea air, and inhaling steam from a boiling kettle...
By the late 1980s he had been prescribed various reliever and preventative medications, interspersed with trips to the hospital for nebuliser treatment. Although Julian tried to keep fit by cycling over 60 miles per week, at other times he was unable to breathe, particularly during the small hours of the night.
Fast forward to 2006 and Julian was taking higher doses of medication while his fitness levels gradually reduced; a totally unproductive cycle that was beginning to seriously affect his health and well-being.
During a lunchtime bookshop visit, he happened across my book, Asthma Free Naturally and soon after reading it, made contact with me. Julian attended one of my Dublin courses in early 2007 during which we focused on practical techniques to retrain his breathing habits. Julian took his last dose of reliever medication the day after the course.
Within six months, Julian's asthma had drastically improved, and by Christmas 2007, he had his last dose of preventative medication. His fitness also improved and he was able to swim a mile per day, five times a week. In 2008, Julian's GP agreed to reclassify his medical record as "asthma resolved".
Over the next three years, Julian's exercise plan evolved to include eight hours of high-intensity indoor cycling, circuits and stretching classes per week, as well as the techniques of nasal and reduced volume breathing he learned from my course.
These changes, along with adjustments to his eating habits, allowed Julian to improve his performance and enjoy more energy and endurance at a higher level of activity.
During 2012, Julian ran five half marathons and covered over 750 training miles. He achieved a personal best of 1:46 in his third half-marathon two weeks prior to completing the Berlin full marathon in 3:57. Following the Berlin marathon, he ran the Dublin city marathon in 4 hours. In six months, Julian had knocked over 8 minutes off his first half-marathon time.
In six years, Julian progressed from a chance encounter with one of my books to attending my reduced breathing course, improving his fitness, completely eliminating prescription medicine for his asthma, and running half and full marathons in a very respectable time!
The first step to addressing chronic over-breathing is to make the switch from mouth to nasal breathing. While nasal breathing is important for everyone, for asthmatics it is vital. When breathing volume is greater than normal, there is a tendency to open the mouth in order to allow more air enter the lungs. Asthmatics often feel they are not taking in enough air while breathing through the nose, which causes them to breathe through the mouth.11,12
Mouth breathing influences asthma in a number of ways:
- Air taken in through the mouth is not filtered of airborne particles, including germs and bacteria13;
- The mouth is simply not as effective as the nose in conditioning air to the correct temperature and humidity prior to entering the lungs13;
- Because the mouth provides a larger space to breathe through than the nose, breathing volume will be higher, causing too much carbon dioxide to be expelled from the lungs. Carbon dioxide is a natural 'opener' of the smooth muscles surrounding the airways. The loss of carbon dioxide therefore causes asthmatic airways to narrow even more;
- Unlike nasal breathing, mouth breathing does not benefit from the addition of the gas nitric oxide, which supports the body's defensive capabilities.14, 15, 16
Taking all these factors into consideration, it is not surprising that mouth breathing causes a reduction in lung function in mild asthmatics, and plays a significant role in the exacerbation of asthmatic symptoms.17
Not only is it important to breathe through the nose during rest, it is also beneficial to nasal breathe during physical exercise. In a paper published in the American Review of Respiratory Disease, researchers studied the beneficial effects of nasal breathing on exercise-induced asthma. The study observed that most asthmatic subjects spontaneously breathed with their mouths open when instructed to breathe 'naturally'. The authors found that mouth breathing during exercise caused the airways to narrow even further. In contrast, when subjects were asked to breathe only through their nose during exercise, exercise-induced asthma did not occur at all. The paper concluded that "the nasopharynx and the oropharynx play important roles in the phenomenon of exercise-induced bronchoconstriction."18 In simple terms, the effects of breathing through the nose are integral to reducing or avoiding exercise-induced asthma completely.19
The fact that elite athletes with asthma often favour swimming above other forms of exercise is not a coincidence. During swimming, the face is immersed underwater, reducing the amount of air taken into the lungs and increasing the athlete's tolerance for carbon dioxide. Although the swimmer may draw their breath in through the mouth, the protective effects of reduced breathing are still evident. Another factor which may contribute to an asthmatic's preference for swimming is the way in which the water exerts a gentle pressure on the chest and tummy, further restricting breathing volume and improving athletic performance.
The difference between land-based exercise and swimming in terms of breathing pattern and volume is significant for asthmatics.20 On land, your breathing pattern during exercise is not restricted the way it is in water, meaning that you can very easily over-breathe, resulting in constricted airways, a reduction in the amount of CO2 in your blood, and a lower BOLT/CP score. For an asthmatic, over-breathing during rest leads to over-breathing during exercise, which in turn leads to exercise-induced asthma. However, exercising in water naturally causes you to restrict your breathing and lower your breathing volume towards normal, providing a much safer and more productive environment for asthmatics to exercise.20
At the beginning of this section we looked at statistics which showed that narrowing of the airways affected 55% of football athletes and 50% of basketball athletes, but 0% of water polo athletes.2 With such a glaring disparity, what factors could possibly explain the difference? The answer, as I hope you have guessed by now, is simple. Water polo training involves breath holding and swimming underwater, resulting in a higher tolerance to carbon dioxide and a reduced breathing volume. With a more normal breathing volume, asthmatic tendencies don't appear.
However, if you are asthmatic and do not wish to take up swimming, there is a simpler way! The OxyAthlete approach incorporates all of the beneficial aspects of swimming and more. Although the act of swimming has its merits, it is well-documented that spending time in chlorinated pools is not ideal for asthmatics, as the chlorine can cause damage to lung tissue. 21-24 Furthermore, while swimming reduces breathing volume, it is still important to address poor breathing habits outside of the pool. Many swimmers remain habitual mouth breathers and continue to employ poor breathing habits which reduce their athletic performance and maintain their asthma.
Your success in addressing asthma will be based on your ability to increase your BOLT/CP using the reduced breathing and breath hold exercises described in this book. You will find a programme specific to your needs in chapter 15. The general aim is to increase your BOLT/CP to 40 seconds. The best time to measure BOLT/CP to track your progress is first thing in the morning and if your BOLT/CP measurement remains less than 20 seconds then your asthma symptoms will persist. However, when your early morning BOLT/CP is greater than 20 seconds, symptoms such as wheezing, coughing, breathlessness, and chest tightness will disappear. It's important to note that you may still be susceptible to certain symptoms even when you have achieved a BOLT/CP of 20 seconds when exposed to a trigger; a BOLT/CP of 40 seconds is needed to fully eliminate your asthmatic symptoms.
In addition to employing nasal breathing and achieving a high BOLT/CP, it is also very important to warm up properly in order to avoid exercise-induced asthma. The minimum time spent warming up should be ten minutes. A good warm-up consists of fast walking while practising a medium to strong breath hold every minute or so. After the ten minute warm-up, the pace should be increased to moving as fast as you can while maintaining nasal breathing. If you feel the need to open your mouth, slow down. Following your physical exercise, encourage your breathing to calm towards normal.
The positive results of reduced breathing exercises and nasal breathing on the symptoms of asthma are fast and astounding. With such a simple method, there really is no reason why anyone need suffer from the discomfort of asthma for a single day longer.
Eliminate Exercise - Induced Asthma
- 1) Rundell KW, Im J, Mayers LB, Wilber RL, Szmedra L, Schmitz HR. Self-reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc.2001 Feb;33(2):208-13
- 2) Sidiropoulou MP, Kokaridas DG, Giagazoglou PF, Karadonas MI, Fotiadou EG. Incidence of exercise-induced asthma in adolescent athletes under different training and environmental conditions. J Strength Cond Res.2012 Jun;(26(6)):1644-50
- 3) Zinatulin S.N. HEALTHY BREATHING: Advanced Techniques. 1st ed. Dinamika Publishing House; 2003
- 4) McArdle William, Katch Frank L, Katch Victor L. Pulmonary structure and function. In: (eds.) Exercise Physiology: Nutrition, Energy, and Human Performance . 1st ed. United States: Lippincott Williams & Wilkins; Seventh, North American Edition edition ; (November 13, 2009). p263
- 5) Johnson BD, Scanlon PD, Beck KC, Regulation of ventilatory capacity during exercise in asthmatics ,J Appl Physiol. 1995 Sep; 79(3): 892-901.
- 6) Chalupa DC, Morrow PE, Oberdörster G, Utell MJ, Frampton MW, Ultrafine particle deposition in subjects with asthma Environmental Health Perspectives 2004 Jun; 112(8): p.879-882.
- 7) Bowler SD, Green A, Mitchell CA, Buteyko breathing techniques in asthma: a blinded randomised controlled trial. Med J of Australia 1998; 169: 575-578.
- 8) GINA. GINA Report, Global Strategy for Asthma Management and Prevention. http://www.ginasthma.org/guidelines-gina-report-global-strategy-for-asthma.html (accessed 27 December 2012). Page 74
- 9) McHugh P, Aitcheson F, Duncan B, Houghton F.. Buteyko Breathing Technique for asthma: an effective intervention. The New Zealand Medical Journal.2003 Dec 12;():116(1187):U710
- 10) Cowie RL, Conley DP, Underwood MF, Reader PG.. A randomised controlled trial of the Buteyko technique as an adjunct to conventional management of asthma.. Respiratory Medicine.2008 May;102(5);726-32
- 11) Hallani M, Wheatley JR, Amis TC. Initiating oral breathing in response to nasal loading: asthmatics versus healthy subjects. European Respiratory Journal.2008;(Apr;31(4)):800-6
- 12) A paper published in the medical Journal Chest which noted that "asthmatics may have an increased tendency to switch to oral (mouth) breathing, a factor that may contribute to the pathogenesis of their asthma."
See: Kairaitis K, Garlick SR, Wheatley JR, Amis TC. Route of breathing in patients with asthma. Chest.1999;(Dec;116(6)):1646-52
- 13) Fried R. In: (eds.)Hyperventilation Syndrome: Research and Clinical Treatment (Johns Hopkins Series in Contemporary Medicine and Public Health). 1st ed. : The Johns Hopkins University Press ; December 1, 1986.
- 14) Djupesland PG, Chatkin JM, Qian W, Haight JS. Nitric oxide in the nasal airway: a new dimension in otorhinolaryngology. Am J Otolaryngol.2001 Jan-Feb;(22(1)):19-32
- 15) Scadding G. Nitric oxide in the airways. Curr Opin Otolaryngol Head Neck Surg.2007 Aug;(15(4)):258-63
- 16) Vural C, Güngör A.. [Nitric oxide and the upper airways: recent discoveries]. Tidsskr Nor Laegeforen.2003 Jan;(10(1)):39-44
- 17) Hallani M, Wheatley JR, Amis TC. Enforced mouth breathing decreases lung function in mild asthmatics. 6) Respirology.2008;(Jun;13(4)):553-8
- 18) Shturman-Ellstein R, Zeballos RJ, Buckley JM, Souhrada JF. The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. American Review Respiratory Disease.1978;(Jul;118(1)):65-73
- 19) Researchers studied the effects of nasal breathing and oral breathing on exercise-induced asthma. Fifteen people were recruited for the study and asked to breathe only through their nose. The study found that 'the post-exercise bronchoconstrictive response was markedly reduced as compared with the response obtained by oral (mouth) breathing during exercise, indicating a beneficial effect of nasal breathing'.
See: Mangla PK, Menon MP. Effect of nasal and oral breathing on exercise-induced asthma. Clin Allergy.1981;(Sep;11(5)):433-9
- 20) In the words of respiratory consultant Dr Peter Donnelly, which were published in the medical journal The Lancet, 'In most land based forms of exercise, patterns of breathing are not constrained, ventilation increases proportionately throughout exercise and end tidal CO2 tensions are either normal or low. Therefore, there is no hypercapnic (increased carbon dioxide) stimulus for bronchodilation (airway opening) and asthmatics have no protection'.
See: Donnelly Peter M . Exercise induced asthma: the protective role of Co2 during swimming. The Lancet.1991;(Jan 19;337(8734):):179-80
- 21) Uyan ZS, Carraro S, Piacentini G, Baraldi E. Swimming pool, respiratory health, and childhood asthma: should we change our beliefs? Pediatr Pulmonol.2009 ;(Jan;44(1)):31-7
- 22) Fjellbirkeland L, Gulsvik A, Walløe A . Swimming-induced asthma. Tidsskr Nor Laegeforen. 1995 Jun 30;(115(17)):2051-3
- 23) Bernard A, Carbonnelle S, Michel O, et al . Lung hyperpermeability and asthma prevalence in schoolchildren: unexpected associations with the attendance at indoor chlorinated swimming pools. Occup Environ Med .June 2003;(60 (6)):385–94
- 24) Nickmilder M, Bernard A.. Ecological association between childhood asthma and availability of indoor chlorinated swimming pools in Europe. Occup Environ Med.2007 Jan;(64(1)):37-46
How do we teach it?
The classes are taught to small groups of
no more than 12 people. This enables sharing
of information,experiences, support and
First day: Each person is taught the basics of the asthmacare.ie program
Second day (second week): More in-depth teaching and review of progress
Third day (third week): Completion of training.