Special Considerations for Asthma and Interstitial Lung Disease
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This chapter presents the background and special considerations for assessing and developing exercise prescriptions for individuals with asthma and interstitial lung disease (ILD). The following will provide awareness about the vastly different disease profiles, symptoms, treatments, and nuances for establishing exercise programs in this important population. The case study presents a patient with persistent asthma symptoms and provides an overview of the assessment and pulmonary rehabilitation (PR) experience.
Case Study 17-1 |
Ms. Case Study-Asthma
Ms. Case Study-Asthma is a 46-year-old nonsmoking woman with a history of adult-onset asthma and allergic rhinitis 10 years ago. She is 87 kg (191 lb) in body weight and 167 cm (65.7 in) in height for a body mass index (BMI) of 31.2 kg ∙ m−2 (moderate obesity). Most recently, she experienced an “asthma attack” and called 911. She was admitted via the emergency department and hospitalized for 5 days; no intubation or mechanical ventilation was required. Prior to the hospitalization, she visited the emergency department on two other occasions for exacerbations. Since her hospital discharge 4 months ago, she complains she has not yet recovered and has been unable to return to her normal activities. She reports having gained 10 lb since her hospitalization. She has a notable history of anxiety and long-standing clinical depression. She is treated with medication and sees her psychiatrist monthly. Ms. Case Study-Asthma reports significant anxiety since the hospitalization and fears having another asthma attack. She has been relatively sedentary since the hospitalization.
Ms. Case Study-Asthma estimates her exercise tolerance to be less than a half a block and rates dyspnea as category rating of 3–4 with walking on the level. She frequently stops to catch her breath when walking up one flight of stairs to get to her apartment. She is no longer able to take her dog for daily walks. She is able to openly express being afraid to walk around the block for fear she will not make it back home. She reports to having two to three exacerbations on the average per year, all of which have required oral corticosteroids for prolonged periods. She is currently taking 20 mg of prednisone daily. She is prescribed inhaled corticosteroids (ICS) in combination with a long-acting β2-agonist (LABA) as well as a short-acting β2-agonist (SABA) to be used as needed. Her gastroesophageal reflux disease (GERD) is being well managed. There are no orthopedic concerns or use of any assistive devices. She has an individualized asthma action plan (AAP) and several peak expiratory flow (PEF) meters which she received from her physician at hospital discharge. She is not using either at present. She does share that her primary care physician has discussed the importance of monitoring her symptoms to detect changes and to notify him earlier to avoid trips to the emergency department. She says she feels overwhelmed and asks for help to return to walking her dog every day. Additionally, she feels she could benefit by having a review of her medications and use of her PEF.
The patient was instructed and performed two 6-minute walk tests (6MWT) following recommended standards with 20-minute rest between tests. The patient was observed incorrectly administering two actuations during one breath of the SABA, albuterol. Poor coordination between breath and actuation was noted with administration midway into the inspiratory effort. She did not administer her controller or maintenance dose of ICS and β-agonist (as prescribed) on the morning of testing as she perceives use to yield little-to-no benefit. No supplemental oxygen has been prescribed. She walked 315 m (1,033.5 ft) and rested a total of 44 seconds. Oxygen saturation was 96% pre- and 98% post-6MWT. Resting heart rate (HR) was 88 bpm and increased to 110 bpm. She rated dyspnea as (C-R) 4, leg muscle fatigue as (C-R) 3, and very slight low back pain. There was no use of pursed lips breathing, shoulders were slightly elevated, and no accessory muscle use was observed. Balance was adequate, and gait was even. No safety concerns were assessed. Mild-to-moderate audible wheezing was assessed upon test completion and resolved within 5 minutes posttesting. See Table 17.1 for pulmonary function test results.
Pulmonary Function Test Results: Ms. Case Study-Asthma |
| Prebronchodilator | Postbronchodilator |
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| Predicted | Measured | Predicted | Measured | % Change |
FVC (L) | 3.77 | 2.94 | 78 | 2.89 | −2 |
FEV1.0 (L) | 3.14 | 2.02 | 64 | 2.25 | 12% |
FEV1.0/FVC (%) | 83 | 68 |
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FVC, forced vital capacity.
The patient was enrolled in an 8-week PR program that included supervised exercise, individualized education, and weekly peer psychosocial support sessions with a psychologist. The PR team provided individualized education on inhaled medication and techniques and peak flow meter and nebulizer use. Teach-back methods were used for medication delivery and PEF devices to assure comprehension and verify skill. The patient was asked to perform home daily PEF testing and bring logs for review and discussion to sessions. In addition, exacerbation prevention was discussed, and an individualized AAP was developed.
After 2 weeks of supervised exercise training, the patient was provided with a home exercise program and instructions to track her activity. Her home exercise program included the use of free weights for strength training twice weekly and taking her dog for daily walks, as this was an important patient goal established at the initial evaluation.
Supervised exercise consisted of both resistance and aerobic exercise twice weekly for 8 weeks. Resistance training consisted of three upper extremity exercises and two lower from a seated position and one standing. An overview of exercise training can be seen in Tables 17.2 and 17.3. The following exercises were used for strength training: shoulder press, bicep curls, side lateral raises, leg extension, hip flexor raises, and hamstring curls. She also trained using an upper body cycle ergometer and walked on the treadmill. Her training target was set to a symptom limit using a category scale (C-R) of 3–6 for dyspnea and muscle fatigue.
Weekly Average Aerobic Endurance Training for Ms. Case Study-Asthma |
Week | BP (mm Hg) | Sat/HR | TM (mph) | Time (min) | Sat/HR | Dyspnea | MF | Comments |
1 | 108/67 | 94/86 | 1.5 2.0 1.5 | 5 15 3 | 95/86 | 3 | 1 | SABA used 15 min before session 1:1 Coaching on pursed-lip breathing (PLB) and shoulder relaxation Constant encouragement provided PEF trending at 250–300 L ∙ s−1 |
2 | 109/66 | 95/88 | 1.5 2.2 1.5 | 5 20 5 | 94/87 | 3 | 5 | Patient reports slight quad muscle soreness. SABA 30 min prior, 100% cuing required with PLB No PEF monitoring by patient |
3 | 115/79 | 95/88 | 1.5 2.2 | 5 7 | 95/90 | Unable to obtain | — | Stopped session: patient crying; met 1:1 to discuss feelings of depression, no suicidal thoughts Appointment with psychiatrist later today |
4 | 106/73 | 94/95 | 2.3 | 30 | 94/100 | 3 | 2 | SABA used 30 min prior; 50% cuing required with PLB/PEF 430 this AM |
5 | 110/71 | 94/86 | 2.2 dropped to 1.8 | 26 | 93/88 | 4 | 0.5 | Complained of increased breathlessness before session SABA used 15 min prior with some relief PEF 400 this AM Patient encouraged to track PEF and follow AAP |
6 | 108/70 | 96/72 | 2.3 | 30 | 95/123 | 3 | 3 | PEF 300 with audible wheezing SABA administered with subjective improvement before exercise |
7 | 110/71 | 93/87 | 2.4 | 30 | 95/115 | 3 | 2 | Patient administered nebulizer with SABA 1 h prior to session |
8 | 114/73 | 97/88 | 2.5 | 35 | 95/115 | 3 | 2 | SABA prior to session; PEF 350 |
9 | 110/69 | 96/88 | 2.5 | 30 | 93/129 | 4 | 4 | SABA prior to session; PEF 325 |
10 | 105/70 | 98/85 | 2.7 | 30 | 93/125 | 4 | 3 | SABA prior to session; PEF 400 |
11 | 114/79 | 95/83 | 2.5–2.7 | 30 | 96/114 | 3 | 4 | Woke up short of breath at 4:00 AM. Administered SABA via nebulizer; improved wheezing SABA taken 15 min prior to walking |
12 | 110/68 | 96/92 | 2.7 | 35 | 94/117 | 3 | 3 | Feeling good today; SABA 20 min prior to session |
All training was done on room air. No reported pain throughout training. Dyspnea and muscle fatigue were rated using a symptom category scale.
BP, blood pressure; Sat, oxygen saturation; TM, treadmill; MF, muscle fatigue, 0–4 scale; AM, morning.
Progressive Resistance Training for Ms. Case Study-Asthma |
Week | UBE Min. 60 RPM at 400 kg ∙ m−1 ∙ min−1 | Dyspnea | Fatigue | U/L Weights | Reps/Sets |
1 | 5 | 4 | 4 | 2/2 | 8/1 |
2 | 7 | 0 | 4 | 2/2 | 12/1 |
3 | Not donea | — | — | 2/2 | 12/2 |
4 | 10 | 4 | 4 | 3/2 | 12/2 |
5–7 | 15 | 3 | 4 | 3/2 | 12/2 |
6–8 | 16 | 3–4 | 4 | 3/3 | 12/2 |
10–12 | 20 | 4 | 5 | 3/3 | 12/2 |
Min., minutes; RPM, rev/min.
Clinic equipment and space limitations allowed a program of seated exercise using an upper body ergometer (UBE), hand (upper or U) and ankle (lower or L) weights. Training progression was targeted to a symptom limit of symptom category rating (CR) of 4–6.
aNo reported pain. Exercise deferred; patient visibly upset and crying, expressed feeling of sadness. No thoughts of self-harm. Has appointment with psychiatrist later today.
Ms. Case Study-Asthma was encouraged to use her albuterol puffer 10–15 minutes before exercise and to gradually warm up for 5 minutes at a lower level of intensity. She was also encouraged to extend her cool-down period to include walking an additional 5 minutes at a lower intensity. Throughout training, her oxygenation remained above 90% breathing room air. Her back pain remained slight and did not impede progress.
Ms. Case Study-Asthma began using her albuterol puffer 10–15 minutes before exercise with symptom improvement. She decided to purchase a treadmill for home use during her 8-week PR training to support walking for longer durations on a level surface and in a climate-controlled environment. Under physician supervision, oral systemic corticosteroid doses were tapered and eventually withdrawn midway into training.
In summary, postprogram assessments showed an improvement of 70 m (229.7 ft) in her 6MWT. Walking durations improved significantly as well as intensity levels of 1.5–2.8 mph for up to 35 minutes. Additionally, resistance levels and durations improved with cycle ergometer use from 5 minutes at baseline to 15. She found the group support sessions to be valuable in helping her to better cope and manage recent health changes. She opted to join the postprogram maintenance exercise group weekly for added support and to maintain contact with rehab team members. Of note, measures of self-efficacy and standardized shortness of breath scores improved significantly postprogram. Depression scores showed some improvement but remained elevated postprogram.
Case Study 17-1 Quiz: |
Ms. Case Study-Asthma 1. How is the diagnosis of asthma made? 2. Why is assessing and observing inhaled medication use important in people with asthma? 3. Is there a disparity between the patient’s perceptions of her baseline exercise tolerance in comparison to the C-R rating with the 6MWT? |
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Asthma is a heterogeneous disease usually characterized by chronic airway inflammation (13). The Global Initiative for Asthma (GINA) Guidelines supports confirming a diagnosis by a positive history of respiratory symptoms of wheezing, shortness of breath, chest tightness, and cough that varies over time and in intensity and presents with variable expiratory airflow limitation (13). Variations in symptoms and airflow obstruction are often triggered by factors such as exercise, allergen or irritant exposure, changes in weather, or viral respiratory infections (13). Asthma continues to be a major public health concern (13,35). The World Health Organization (WHO) estimates that 334 million people are affected by asthma with a majority living in low- and middle-income countries worldwide (8,35).
 | Preparticipation Health Screening, Medical History, and Physical Examination |
The diagnosis of asthma is made through a medical history, physical examination, and objective assessment of lung function (7,13). An assessment of symptom patterns and evidence of airflow limitation are essential in confirming asthma (7,13).
Airway hyperresponsiveness and chronic airway inflammation may persist despite the absence of symptoms or when lung function is within normal limits (13). Episodes of wheezing, chest tightness, shortness of breath, and coughing are common and typically resolve spontaneously or with appropriate treatment (7,13,26). According to GINA, some patients with asthma will have normal physical assessments (13). Dougherty and Fahy (7), cites the presence of wheezing with auscultation as being the most common abnormal physical finding. There are several risk factors for poor asthma outcomes, among them are uncontrolled asthma symptoms, high SABA use, inadequate use of ICS, incorrect metered dose inhaler use, comorbid conditions such as obesity and GERD, and major psychological or socioeconomic concerns (13). Some data suggest that even patients with mild disease may limit or avoid activities that may be perceived as triggering asthma symptoms (13). It is not uncommon for exercise and strenuous activity to diminish when symptoms worsen either acutely or in progressive chronic asthma (21).
Asthma diagnosis, treatment, and symptom control are crucial prior to initiating a program of exercise and physical activity. Patients should avoid known triggers and adhere to prescribed medications. Asthma treatment goals target controlling symptoms, supporting normal physical activity, and preventing exacerbations (8,13).
Patients with asthma are prescribed controller or maintenance medications for regular use to reduce airway inflammation, control symptoms, and reduce future risks for exacerbations and threats to declining lung function (3,13,27). GINA guidelines recommend the use of ICS and leukotriene receptor antagonists (LTRA) to reduce airway inflammation (13). Inhaled SABA, LABA, and anticholinergic bronchodilators (i.e., anti-muscarinic antagonists, or long-acting muscarinic antagonists [LAMA]) are added to relieve airflow limitation (3,9,13,27). Expert consensus supports the use of reliever or rescue medications (SABA) for all patients for relief when needed and with those experiencing exercise-induced bronchospasm (EIB) (13,19). Add-on therapies are used with severe asthma when symptoms persist or exacerbations occur despite optimized treatment (Box 17.1) (13,19).
Box 17.1 | Exercise Benefits for Adult Patients with Asthma |
The following are exercise benefits for adult patients with asthma: | |
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The use of AAPs has been identified by GINA as a key component to exacerbation prevention and is recommended for all patients with asthma (3,8,13,26). There are currently no studies or recommendations to guide physical activity based on symptom control with the use of AAP staging. AAPs are written sets of instructions developed by patient and provider to recognize worsening asthma symptoms. Action plan instructions help patients to urgently modify treatment and seek appropriate medical attention when warranted (26). Patients and their providers collaborate to develop plans that include recommendations to adjust or add medications when symptoms increase. Involving patients to share in making treatment decisions has been shown to improve adherence and asthma outcomes (13).
AAPs may include color categories to symbolize stages of symptom control (Fig. 17.1). Asthma symptoms are generally well controlled within the green zone. The yellow zone signifies caution as symptoms are less controlled with regard to increased cough, and/or wheezing, with possibly reduced activity tolerance. Changes to medications are advised to provide relief and control symptoms (3,13). The red zone is serious and represents the most severe breathing impairment. When patients are assessed within this zone, it often means symptoms have failed to respond to prior treatment adjustments, management is elusive, and acute care intervention is necessary. Exercise should be deferred during this period until symptom control can be restored.
FIGURE 17.1. Asthma action plan. (Reprinted with permission from the Asthma and Allergy Foundation of America.)
There are currently no studies or recommendations to guide exercise intensity based on symptom assessment with the use of action plans or PEF monitoring. PEF monitoring has been recommended once asthma has been diagnosed to assess pharmacological treatment response for up to 3 months (13). Monitoring PEF may also be helpful in earlier detection of exacerbations mainly in patients with “poor perception of airflow limitation” (13). Lung function, as defined by forced expiratory volume in one second (FEV1.0), has not been shown to correlate well with asthma symptoms in adults and children (13). For this reason, GINA recommends long-term PEF monitoring for some patients with severe asthma and for those with impaired perception of airflow limitation (13).
It can take up to several days or longer to recover from airway inflammation and clearance of excess secretions as a result of an exacerbation of asthma (32). This is an important factor for patients and health care providers to keep in mind. Returning to baseline function and gaining symptom control may be slower in some and quicker in other patients. Coaching patients to return to baseline physical activity levels should include a review of current medications (i.e., oral corticosteroids) and the use of rescue or fast-acting bronchodilators. Patients who are weaning onto lower systemic corticosteroid doses and eventual withdrawal may note increasing symptoms of breathlessness. Patients need to return to regular exercise when they are able for overall general health. It is important to note that Garcia-Aymerich and colleagues (10) demonstrated reductions in exacerbations in patients who participated in regular exercise. Clinicians who support exercise in patients with asthma should be familiar with action plans and engage patients in conversations about their plans. Reviewing symptom status and plans with patients may also help to gain insight into the patient’s understanding of asthma control and variability with medication use.
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The ACSM’s Guidelines for Exercise Testing and Prescription, 10th edition (GETP10) reviews the most common methods for assessing exercise in asthma and related airflow limitations of EIB (2). “Exercise-induced bronchospasm is a phenomenon of the airways that occurs during or after exercise or physical exertion” (25). The mechanism of EIB is poorly understood. Molis and Molis (25) provide a succinct description of EIB as airway cooling and dryness during periods of hyperventilation (with exercise) leading to airway dehydration and the release of cellular inflammatory mediators (26). EIB in elite athletes is well documented as well as in patients with asthma and can be managed with pharmacotherapy (2,25,29). The use of SABA is the recommended treatment of choice for EIB (2,25,29). Spirometry testing is recommended before and after exercise along with cardiopulmonary capacity and noninvasive monitoring of oxygenation (2). American College of Sports Medicine (ACSM) guidelines recommends some level of vigorous activity for 10–15 minutes while breathing dry air (13,25). An FEV1.0 decrease of ≥15% from baseline is often considered as a positive result for EIB (2,25,29). 6MWTs may be used in those with moderate-to-severe persistent asthma when other testing is unavailable. Additional testing methods are reviewed in the GETP10 (2).
