Please note that we do not sell directly to individual consumers
Businesses, please Log In to a registered account or Apply for a new business account.

Apply for New Account

To ensure fair access, some purchases of whole herbs, powdered herbs, and extracts are temporarily limited to 5 units per item. For larger orders, please contact customer service. No limits apply to pills or tablets. Free ground shipping with most orders of $199.
Internal Medicine, Pediatrics

Understanding Exercise Induced Asthma from a CM Perspective

Skye Sturgeon, DAOM |

Exercise induced asthma is a type of bronchoconstriction that occurs in individuals who have underlying asthma. When this condition appears in people who do not have asthma, it is termed ‘exercise-induced bronchoconstriction’ (EIB), which is the current preferred term for all types. EIB describes the narrowing of the airway that occurs with exercise. Ten to twenty percent of the general population and forty to ninety percent of persons previously diagnosed with asthma may experience exercise-induced bronchoconstriction. When underlying asthma is present, exercise can be seen as a trigger for an asthma attack, rather than a cause of asthma.

girls playing soccer

Higher rates are found among females and those participating in winter sports. High-risk sports typically involve prolonged periods of continuous exercise lasting more than 5 to 8 minutes, often in environments with cold, dry air or exposure to irritants like pollution, smoke, or the chlorine used in swimming pools. These sports include long-distance running, long-distance cycling, cross-country or downhill skiing, ice hockey, ice skating, hiking or climbing at high-altitudes, swimming, water polo, and triathlons. Medium-risk sports, such as soccer, rugby, football, basketball, volleyball, baseball, cricket, and field hockey, generally involve shorter bursts of activity, with athletes rarely exercising continuously for more than 5 to 8 minutes. Low-risk sports, such as sprinting, tennis, fencing, gymnastics, boxing, golf, weightlifting, bodybuilding, and martial arts, are less likely to trigger EIB due to the intermittent or short duration of exertion.

Although there are clear health benefits of regular physical activity, especially for people with asthma, individuals with EIB may choose to avoid exercise due to concern about shortness of breath, coughing, chest tightness, and wheezing that may accompany such activity. This avoidance, particularly among adolescents, can lead to social isolation, obesity, and overall poor health. Because of this, the wiser course is to choose sports that involve exertion durations that are short or require intermittent bursts of activity.

EIB has been increasingly recognized as a significant concern for pediatric athletes. Studies show the prevalence of EIB in children with atopic predispositions, revealing a potential link between allergic sensitivities and exercise-induced respiratory symptoms, along with an inflammatory reaction caused by genetic factors or triggers that may involve environmental or physical contact with antigens. An IgE blood test can reveal if a person has high levels of immunoglobulin E antibodies, which the immune system creates when exposed to certain allergens.

Diagnosis of EIB requires objective testing, since respiratory symptoms alone have poor predictive value. Recommended tests include exercise challenge tests and eucapnic voluntary hyperpnea (EVH). EVH is an objective measurement of airflow before and after exercise. It is used as an alternative to traditional spirometry tests, which only measure volume of air while breathing and respiratory rate. Other diagnostic evaluations may include pulmonary function testing (such as spirometry), exercise challenge testing, and allergy tests (including IgE).

Treatment of EIB involves the application of short-term (rapid acting or rescue) medications such as Short-acting Beta Agonists (SABAs), like albuterol, which is used 15-30 minutes before exercise. Patients with frequent symptoms of bronchoconstriction or asthma may require longer term drugs such as inhaled corticosteroids (ICS), which are taken daily to reduce inflammation in a patient’s airways. Another approach involves leukotriene-receptor antagonists (LTRAs), which prevent leukotrienes from binding to their receptors, e.g., Montelukast, Zafirlukast, and Zileuton. Other recommendations include pre-exercise warm-up, nasal breathing, and face masks in cold environments which may help reduce symptom incidence. Some individuals may respond to antihistamines.

Traditional Chinese Medicine

In Traditional Chinese Medicine (TCM), EIB would fall under the category of Xiào chuǎn / 哮喘, literally, ‘heavy breathing’ (or wheezing or asthma). There are numerous syndromes that may cause asthma in TCM including external pathogens, Spleen deficiency, Phlegm (Damp or Heat), Liver Qi stagnation, Lung deficiency (Qi or Yin), and Kidney deficiency. In the case of EIB, the focus will be on the relationship between Liver and Lung, but not to the exclusion of other etiologies that should be considered.

five element assessment

Here are two cases from my own practice which are illustrative of this pattern.

Case One

Zara was a 14--year-old female who was an outstanding soccer player and played on the varsity team at her high school, even though she was a freshman. Although the soccer season was in the spring, practice began in late February when the weather could still be quite cool in Western North Carolina. At the end of practice, the soccer coach had a habit of requiring the players to jog around the field for four laps, followed by a series of wind sprints, where the athletes were to run the length of the pitch and back as fast as they were able. Slower players were punished, and they had to run an extra sprint. Zara confessed that she hated this part of practice, and she did not see what it had to do with soccer.

One afternoon during this portion of practice, Zara suddenly stopped running at the end of the pitch. She bent over and grabbed her knees and began hyperventilating. She found herself unable to get her breath and started wheezing. The coach and several of the players came over to her and helped her to the ground. After a few minutes she was able to breathe normally. Unfortunately, the next day she was unable to complete regular practice because while running on the pitch during practice, this phenomenon occurred again. The next day her mother took her to their family doctor where she was diagnosed with ‘exercise induced asthma’ and prescribed an albuterol inhaler, which she was instructed to use before beginning practice. Her mother was a patient of mine and was unhappy with the doctor’s diagnosis. “Zara does not have asthma.” She also disliked the idea that her daughter needed to take an inhaler medication before she was able to play soccer.

When I met Zara in my clinic, I noticed she had a muscular and well-developed lower body and legs, but her upper body was more petite and under-developed.  Her medical history revealed that her menarche was just after her thirteenth birthday and that as a child she had experienced numerous upper respiratory diseases nearly every fall and winter, which usually devolved into a dry lingering cough. Zara was the oldest in a family of three and her father had died about a year prior of a ruptured brain aneurysm at the age of 41. When I asked her about it, she began crying and told me that she was quite close to her father and that she missed him terribly. Although her father was a successful businessman, he had left his family in difficult circumstances and Zara was having trouble reconciling the change in her family’s life. She remarked how it was not fair, and not right. As she was sitting in my treatment room, I also noticed that she was breathing very shallowly and this persisted throughout my interview. When I looked at her tongue, it appeared dry with a slightly red tip, and her pulse was slightly rapid, thin and weak on the right side and thin and slightly wiry on the left. My diagnosis was Lung Yin and Qi deficiency with Liver insulting Lung. Her treatment plan included acupuncture, Chinese herbs, and Qigong, which I taught her the first day and then I had her come to my weekly Qigong lessons for a few weeks.

The Qigong was focused on using the diaphragm to breathe, making the outbreath longer than the inbreath. Acupuncture points included Lu 9, Lu 7, Lu 1, LI 4, LV 3, St 36, Ren 4, Ren 17, PC 6 and HT  7, along with UB 13, !5, 17, 18, 23, and 43. The raw herb formula that I prescribed was a decoction, which was a modified combination of Shu Shen Mai Dong Yin, Sheng Mai San, and Xiao Yao San, with one bag lasting two days.

After three acupuncture appointments and three weeks of taking the Chinese herbs, she felt she was able to return to soccer practice. She continued to use the albuterol inhaler for about a week but then she decided she didn't need it and she stopped. She was very enthusiastic about the Qigong exercises and even wound up teaching some of her teammates how to breathe more deeply. I also recommended to her mother to consider grief counseling for the entire family, but she did not think that was possible for them in their current financial situation. Fortunately, Zara did not exhibit symptoms of EIB after this intervention and went on to receive a soccer scholarship to the University of North Carolina.

Case Two

Rusty was a seventeen-year-old senior in high school who was an All-Star second baseman for his school’s baseball team. After some encouragement from his friends, he decided to join the school’s cross-country team. The CC season ran from September through mid-December, so this did not interfere with baseball. One day in mid-November, Rusty was slightly late for practice, and he decided to sprint to catch up with his teammates who had already started jogging. It was a cold, dry day and within about ten minutes, Rusty was panting and breathing through his mouth while running at top speed. He remembered that he was already frustrated because he was late, for which he blamed his mother, and that he was unable to catch his buddies, when he felt a sudden tightness in his chest. He began to panic and because he felt like he was choking and unable to get his breath; he wondered if he was having a heart attack. He recalled while breathing rapidly through his mouth, that his mouth and throat had become completely dry. The coach saw him fall to the ground, called 911, and he was transported to the hospital. When he arrived at the ER he was breathing normally, and his vital signs were within normal limits. A chest x-ray was normal as were his laboratory tests.  The ER doctor diagnosed him with exercise induced asthma, primarily based on his description of the incident and his history of asthma when he was younger. His mom, who was a friend of my family, relayed that they thought he had ‘grown out’ of his asthma since he hadn’t any symptoms in years and that it was ironic that the reason that he took up sports in the first place was at the suggestion of his pediatrician because, generally, exercise improves asthma in children. Their primary care physician prescribed albuterol as a rescue inhaler and suggested that if symptoms persisted, a daily inhaled corticosteroid may be indicated. Rusty had already been down that route when he was younger, and his mother believed that the corticosteroid-use was responsible for his small stature and noticeable mood swings. Looking for alternatives, she brought him to my clinic.

At 5’5”, Rusty was short for his age, with a wiry and athletic body. His tongue was reddish with a thin white coat. His pulse was 68 bpm, strong and wiry on both sides except in the cun position on the right side, which was noticeably weaker. While he was sitting in my treatment room, I noticed that his breath was generally rapid and shallow with occasional, intermittent deep inhales, which he would hold for a moment before releasing with a loud sigh through his nose. His mother relayed to me that Rusty had been ‘acting out’ with bursts of anger for the last two years since she and his father divorced. Subsequently, his dad had moved to Michigan to take a teaching position at a college, and his mom had been seeing a new boyfriend who was nine years younger than her. His older sister was finishing college at Duke, and Rusty disclosed he was upset about the changes in his home life and blamed his mother for destroying his family.

My diagnosis for Rusty was Liver Qi Stagnation insulting the Lungs causing the Lung Qi to fail to descend. His treatment plan included acupuncture, Chinese herbs, and Qi gong, which I taught and practiced with Rusty every time he came in for a treatment. The Qigong was focused on using the diaphragm to breathe and to make the outbreath longer than the inbreath. I had him concentrate when breathing out that he was ‘letting go’ and that each inbreath was ‘now new’ and an opportunity to change his interpretation of his circumstances.  Acupuncture points included Yin Tang, Lu 5, LI  4, LV 3, LV 5, LV 14, Ren 17, and PC 6, along with UB 13, !5, 18, 23, and 43. I prescribed Xiao Yao San in a raw herb decoction, but he refused to take raw herbs so he was given   Xiao Yao Wan in teapill form at a dosage of 12 pills, 3x/day.

Rusty received five acupuncture treatments and took the herbs for nearly a month. Following the incident on the cross-country course, he did not experience a recurrence of any shortness of breath or asthma symptoms, although he disclosed that he was reluctant to return to running and spring training for baseball season was only a couple of months away. Rusty received a sports scholarship to Rice University in Houston, TX and played in the Minor Leagues for three years.

These cases show that when a patient is assessed according to mind, body, and spirit, a clear understanding of the syndromes involved can be determined. This viewpoint involves a little-taught pathway of Five Element Theory that can be easily understood. Children and young adults are generally not considered as being Yin deficient (since depletion usually involves aging), but rather pure Yang, since they are growing and maturing. However, the Yin (that is, the tissues and organs) of their bodies may develop at different rates during their maturation, creating relative Yin deficiency at certain times. Likewise, the manifestation of their pure Yang may create periods of stagnation, including emotional and psychological surges and challenges. Yes, as they mature, they may indeed grow out of these imbalances, but growing up can be difficult and traditional Chinese medicine can offer substantial and meaningful support.

References

About the Author

Skye Sturgeon, DAOM is the Quality Assurance Manager and Special Consultant for Mayway, USA. Skye was the former Chair of Acupuncture & East Asian Medicine and core faculty member at Bastyr University, core faculty member and Faculty Council Chair at the American College of Traditional Chinese Medicine, and President and Senior Professor of the Acupuncture & Integrative Medicine College, Berkeley. Before making Chinese medicine his career choice, Skye held various positions in the Natural Foods Industry for 12 years and prior to that was a clinical biochemist and toxicologist.

Back to top