Asthma and Winter Exercise: Q and A with Dr. Mark Titi

If you’re asthmatic you may think that you can’t handle much activity outside in winter…that you can’t exercise…that it may do you more harm than good.  But the truth is that you probably can, if you take some precautions.

The first one and the most important, is to get a thorough medical evaluation from your allergist… whether you want to exercise in any kind of weather.  You may need to take some medications that will make it easier for you.

Dr. Mark Titi of our Allergy & Asthma Center is an allergist, sportsman, skier and all-around outdoorsman. He offers some special advice, precautions and hope for asthmatics in winter.

Q: Dr. Titi, why is winter hard on asthmatics?

Dr. Titi: Winter air tends to be very cold and dry and we feel that this type of air dehydrates the lung tissue and that leads to swelling and spasm of the airways causing asthma symptoms.

Q:What are those symptoms if you have exercise-induced asthma?

Dr. Titi : Generally, you would have more than the usual shortness of breath, chest tightness, wheezing or persistent coughing either during or after exercise. Usually it’s a dry cough.

Another way to know if it’s exercise induced asthma is if it responds rapidly to a bronchodilator, or a medication that relaxes bronchial muscles, opening up the bronchial air passages. You can also test your breathing rate with a peak flow meter before exercise, during exercise and after exercise to see if there is a decrease in the air flow either during or after the exercise.

Q: Can an asthmatic safely take part in any kind of outdoor exercise in the winter?

Dr. Titi: Most asthmatics that are properly treated can do much or all of the activities they want to. I would say a very high percentage. There are occasional cases where it is still difficult but that is much less common with the new treatments available.

Q: In selecting an exercise to do outside, how do you pick one that will be good for you, or at least one you can tolerate?

Dr. Titi: Exercise at a moderate pace can be helpful. The main challenge is just the air itself and the level of activity. The higher the aerobic level the more you are likely to encounter some problems. Exercise like cross-country skiing or downhill skiing are quite aerobic and certainly could bring on bronchospasm, a constriction of the air passages of the lungs. Prolonged running outdoors is also a big cause of exercise-induced asthma.

Q: What are the key elements you have to consider?

Dr. Titi: The exercise itself, the intensity and the duration. Usually it takes at least five to ten minutes of sustained exercise to bring on exercise-induced asthma. For example, it is unusual to get it after a single sprint.

Q: How about some forms of usually acceptable exercise? I am not talking about skiing here, but something maybe a little less strenuous outdoor exercise.

Dr. Titi: A form of exercise easily accomplished might include walking outdoors at a brisk pace. I think if you have exercise-induced asthma probably the most important thing is to pre-treat with the medication your doctor has recommended. The other thing, which is helpful, is if patients can breathe at least partially through their nose because that helps warm and humidify the air. If the nose is blocked and the patient breathes directly through their mouth they will tend to have more trouble because the air reaching their lungs is going to be colder and drier.

This brings up scarves. Certainly using something like a scarf or a muffler to cover the nose and mouth, which will warm and humidify the air, can be very helpful. Many of my patients have determined that on their own even before they have come in to see me. 

Q: I was trying to think of some of the things someone might do outside in the winter if he or she had asthma and I don’t know if I am right… so I am going to ask you. Playing in the snow?

Dr. Titi: Usually okay.

Q: Sledding?

Dr. Titi: Usually okay although climbing the hill might bring on symptoms.

Q: Short ski runs?

Dr. Titi: Should be fine.

Q: How do you define short when you talk about a short ski run?

Dr. Titi: Probably a couple of minutes should be fine. In this area most of the runs would probably be okay. If you go to Vermont or out west it would probably be more problematic.

Q: How about ice-skating?

Dr. Titi: Ice skating is moderate to highly aerobic and depending upon how much you push it determines whether you are going to have trouble or not.

Q: You mentioned breathing through the nose, not the mouth …as much as you can… about pre-treatment with proper medications, dressing warmly and covering your nose and mouth with a neck warmer. Do you also need to do some kind of conditioning exercises before or after, as you do with other kinds of exercise? Warm up or cool down?

Dr. Titi: It is interesting you should mention that. If a patient warms up to the point they bring on some mild exercise induced asthma then after they have reached that point… for some period of time after that… perhaps one-half hour to a number of hours, they are less likely to have a second bronchospasm. It is what we call a refractory period during which the person doesn’t react.

Sometimes, we do need to induce this sort of refractory period by bringing on some mild exercise- induced asthma. Therefore, for some of our patients it is important they start with a vigorous warm-up, which is enough to bring on some mild symptoms, and then they tend to improve after that. It is almost like they are running through their asthma, so to speak.

Q: What would be included in that warm-up?

Dr. Titi: About eight to ten minutes of fairly aerobic activity getting up to one’s target heart rate would probably bring on this type of phenomenon.

Q: Do you have to cool down when you are through also?

Dr. Titi: Cooling down is always a good idea, mainly in terms of your vascular system to prevent light-headedness and such. But in terms of exercise- induced asthma I don’t think it’s that important. 

Q: How about some general advice for parents of asthmatics as they face winter activities outside?

Dr. Titi: Probably the main thing is they make sure their child is on the right kind of medication to prevent the episodes. For many children this would be one medication. For some children it may be as many as two or three medications to optimally prevent this from occurring. That, overall, is the most important thing.

The main point I would like to make about this is that most patients can do the sports they want to do if they are properly treated. The cases where they can’t do the sport and have to sit out tend to be fairly infrequent with proper treatment.

Q: How do you define proper treatment?

Dr. Titi: There are some patients who even with pre-treatment may need to repeat their inhaler treatment once during a game or other winter activity. If that only happens occasionally I feel the treatment is still at a pretty good level. If that is happening frequently then we need to step back and see if there is another therapy we need to consider.

It’s also a good idea for the asthmatic patients to have their bronchodilator available during the winter, particularly if they are planning to engage in any aerobic activity. An occasional patient has found it is important to keep the inhaler close to the body so it stays warm and functions properly. Most of these inhalers will operate fairly well over a pretty broad range of temperatures but in extremes, it may be important the inhaler medication is kept warm close to the body.

Q: What are some typical regimens for asthmatics in terms of medication?

Dr. Titi: A typical regimen would usually start out with an inhaled bronchodilator, usually one to two puffs, anywhere from five to twenty minutes before exercise. There are some cell stabilizing medications which can help prevent bronchospasm. Sometimes inhaled steroids are used… sometimes long-acting bronchodilators.

In addition, there are now some medications in pill form called anti-leukotrienes which can be helpful in asthma.

Q: Anything else you want to say to parents?

Dr. Titi: Yes. It may be necessary for nasal allergies to be treated so the child is able to breathe through the nose properly . Sometimes that can be a significant problem.

Also, you’ll want to check on allergies which may lead to swelling or inflammation in the lungs that can pre-dispose a person to have more problems with asthma.

Testing…evaluating…treating. That’s what we do to make it possible for many, many asthmatics to lead more normal lives more fully.

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