Expert: Marc Rubin, RPh Asthma Educator - 7/17/2008

Question
Hello.
I was diagnosed with sports induced asthma when I was 16, and given
Albuterol. But it continued to get worse and I was on 3 inhalers by the time I
was 18. I am now 26, I take Advair (250/50 one inhalation a day) and
Albuterol (as needed, I take it maybe two or three times a week at most). My
main trigger is smoke, but I am also sensitive to pine and cats if I'm around
them too long.
My question is; I have walked three half marathons, but would like to run in
my next one. I walk because of a bad knee, but through some new training
and more strengthening exercises, my knee can take some running,
unfortunately my lungs seem to be protesting. My doctor says I can do this,
just take it slow. And while I have been taking it slow, I haven't gotten any
further. I still run about a quarter of the time because of my recovery time of
walking in between running. My goal is to take that time up to half! Are there
breathing exercises or something I could be doing to help me breath better
while running?
Thank you for any help or suggestions you can give.

Answer
Hi Kerry,

My first concern is the medical status of your knee. Is there miniscus damage, tendon/ligament issues, or bone-on-bone problems? Was the doctor who cleared you on this an orthopedic surgeon specializing in sports medicine? The reason I ask is that if there is a knee replacement surgery in your future, you are very young to have to have one of these done. If the answer is yes, then we'll address the training issue.

If you have read any of my previous posts, you've learned that control is a balance of prevention and medication.

We'll begin with prevention:
1) Peak flow meter. If you don't have one, you need to get one. Your allergist may have some free ones (GSK, which makes Advair, distributes them to doctors and some pharmacies for free), otherwise, they cost ~ $25. You need to determine YOUR personal best. The meters come with a chart..which is a good starting point, but to be truly of value, you need to determine your own 100% point. For proper instructions go to:
http://www.aaaai.org/patients/publicedmat/tips/whatispeakflowmeter.stm
 You should not start or continue exercise if your values are below the green zone. During your training, if you fall into the yellow zone, stop  and take a rescue treatment. Your doctor may have instructed you to pre-treat before exercise, and there are a number of approaches to this that we'll discuss later.
2) Hydration: begin drinking fluids ~ 1 hour prior to starting your exercise, and continue to drink fluids during your workout. Stores that are dedicated to runners carry waist belts which have water bottle attachments. Dehydration will trigger an attack, so this is very important.
3)Warmup and cool down: at the beginning and end of exercise, take about 5-10 minutes to warm up your muscles, and establish a smooth breathing rate. At the end, walk for another 5 minutes or so to cool down.
4)Breath through your nose. Your nose acts as a filter for the air you inhale, and it helps make it warmer prior to entering the lungs. Cold, dry air is a trigger for asthma (I know, it's summer, but most athletes workout year-round). When it is cold outside, exercise indoors. If you don't have that option, wear a warming face mask, scarf or neck gator (usually fleece: basically the neck part of a turtle-neck sweater). And in cool/cold weather, hydration is even more critical.
5)Check air quality. In addition to:

http://www.aaaai.org/nab/index.cfm for pollen, also check:

http://www.weather.com or http://www.wunderground.com to get ozone information.

If air quality is poor, take a pass.

Please note: pollen is usually the highest from 5am to 10am, and air quality becomes poorer between 10am and 3pm (particulates and ozone)
Also, if there is a storm front with severe weather heading into your area, on the leading edge comes a wave of ozone that was released by the lightning. You notice it in that fresh, cool breeze that hits about 15 minutes before the rain. As you know, ozone irritates the lungs, so prepare yourself.


Now for treatment.
You say that you only take Advair once a day. It is a medication that needs twice a day (every 12 hours) use. The fact that you may need your rescue more than twice a week during the day is an indication that you are in need of improvement in control. Was this dosing at the direction of an allergist or general physician? Is the MD aware of your exercise goals and present status?

Three approaches to treatment:
1) the standard: ~ 15 minutes pre-exercise, take an albuterol treatment. May still use this as rescue later if needed. This approach may increase your heart rate, and if uncomfortable, there are two other options, although they are not in the NHLBI guidelines.
2)Singulair, a table taken ~ 2 hours before exercise. Some studies are showing benefit to this approach. Of course, if you are already on Singulair (which is normally taken in the evening), go on to #3.
3) Intal (cromolyn sodium). This is an inhaler containing a medication that stabilizes the lung membranes, so when allergens and irritants are inhaled, the tissue doesn't release the chemicals that cause inflammation and constriction. It is not 100%, and the effect only lasts ~ 4 hours.

Main point here: if you are not in the green zone, you first have to get your lung function under better control before moving forward. You have to also have patience. It will take longer for an asthmatic to achieve their goals, but it is certainly doable. As I've stated in the past, ~ 15% of Olympic athletes have asthma, and they got there through excellent asthma control and persistence. As a final read, one of the organizations I belong to  (AAAAI) this month has an article on  fighting exercise induced asthma. Knowledge is the greatest strength you can develop. http://www.aaaai.org/patients/topicofthemonth/0708/

Good Luck!! :)

Marc