CEXP 538 Module 10 PDF

In 1-3 words how would you describe your experience with the breathing exercise? Click Present with Slido or install our Chrome extension to ⓘ activate this poll while presenting.  CEXP 538 RESPIRATORY DISEASE Fall 2024 Module 10 OUTLINE RESPIRATORY DISEASE...

In 1-3 words how would you describe your experience with the breathing exercise? Click Present with Slido or install our Chrome extension to ⓘ activate this poll while presenting.  CEXP 538 RESPIRATORY DISEASE Fall 2024 Module 10 OUTLINE RESPIRATORY DISEASE INTRODUCTION ETIOLOGY RISK FACTORS TREATMENT PHYSICAL ACTIVITY RESPIRATORY DISEASE: INTRODUCTION  RESPIRATORY DISEASE Introduction Primary role of respiratory system is to facilitate an exchange of oxygen and carbon dioxide between external environmental air and the body’s interior. At rest, a healthy adult consumes approximately 300 mL·min−1 of oxygen while exhaling 250 mL·min−1 of carbon dioxide.  RESPIRATORY DISEASE Introduction Respiration Inspiration–Breathing in Exhalation–Breathing out The NOSE is the preferred entrance for outside air into the respiratory system. Air also enters through the MOUTH, especially for those who have a mouth-breathing habit, whose nasal passages may be temporarily blocked by a cold, or during heavy exercise. The THROAT collects incoming air from your nose and mouth then passes it down to the windpipe (TRACHEA). SINUSES are hollow spaces in the bones of your head above and below your eyes that are connected to your nose by small openings. Sinuses help regulate the temperature and humidity of inhaled air.  RESPIRATORY DISEASE Introduction Your right lung is divided into three LOBES, or sections. Your left lung is divided into two LOBES. The PLEURA are the two membranes, actually, one continuous one folded on itself, that surround each lobe of the lungs and separate your lungs from your chest wall. The TRACHEA is the passage leading from your throat to your lungs. The windpipe divides into the two main BRONCHIAL TUBES, one for each lung, which divides again into each lobe of your lungs. These, in turn, split further into BRONCHIOLES. Your bronchial tubes are lined with CILIA (like very small hairs) that move like waves. This motion carries MUCUS (sticky phlegm or liquid) upward and out into your throat, where it is either coughed up or swallowed. Mucus catches and holds much of the dust, germs, and other unwanted matter that has invaded your lungs. You get rid of this matter when you cough, sneeze, clear your throat or swallow. ALVEOLI are the very small air sacs where the exchange of oxygen and carbon dioxide takes place.  RESPIRATORY DISEASE Introduction (Bozic et al., 2009) Respiratory System Musculoskeletal system The diaphragm This dome-shaped muscle below your lungs separates the chest cavity from the abdominal cavity. The diaphragm is the main muscle used for breathing. The muscles between your ribs Called intercostal muscles, these muscles play a role in breathing during physical activity. Abdominal muscles Used during physical activity. The muscles of the face, mouth, and pharynx These control the lips, tongue, soft palate, and other structures to help with breathing. The pharynx is the part of the throat right behind the mouth. Problems with any of these muscles can narrow the airway, make it more difficult to breathe, and contribute to sleep apnea. Muscles in the neck and collarbone area Used during inspiration  RESPIRATORY DISEASE Introduction https://www.youtube.com/watch?v=NM3PK5qy9uA Nervous System Parasympathetic nervous system slows your breathing rate. It causes your bronchial tubes to narrow and the pulmonary blood vessels to widen. Sympathetic nervous system increases your breathing rate. It makes your bronchial tubes widen and the pulmonary blood vessels narrow.  RESPIRATORY DISEASE Introduction Diagnosis Pulmonary Function Tests Spirometry–Measures the amount of air you can breathe out or exhale and how fast you can empty air from the lungs https://www.youtube.com/watch?v=Zs8Fs5HaJHs Lung volume test–Measures the volume of air in the lungs your lungs can hold. It also measures the amount of air that remains at the end after you exhale https://www.youtube.com/watch?v=3eIw7JhB7rQ Lung diffusion capacity test–Measures how easily oxygen enters the bloodstream Pulse oximetry–estimates oxygen levels in your blood Imaging tests–chest x-ray, computed tomography Pulmonary exercise test–Evaluates how well your lungs work when active 6-minute walk test Incremental shuttle walk test  RESPIRATORY DISEASE Introduction Total lung capacity (TLC) Maximum amount of air healthy adult lungs can hold is about 6 liters Inspiratory reserve volume (IRV) The volume of air that can be inspired maximally at the end of a normal inspiration Tidal volume (TV) The volume of air in a normal breath Expiratory reserve volume (ERV) The volume of air that can be expired maximally after a normal expiration Residual volume (RV) The volume of air remaining in the lungs after a maximal expiration Forced vital capacity The maximum amount of air you can forcibly exhale from your lungs after fully inhaling. It is about 80 percent of total capacity, or 4.8 liters, because some air remains in your lungs after you exhale. Forced vital capacity can decrease by about 0.2 liters per decade, even for healthy people who have never smoked. Forced expiratory volume (FEV1) The amount of air you can exhale with force in 1 second. FEV1 declines 1 to 2 percent per year after about the age of 25, which may not sound like much but adds up over the course of a lifetime. RESPIRATORY DISEASE: ETIOLOGY  RESPIRATORY DISEASE Etiology Group of common disorders with lesions primarily occurring in the trachea, bronchi, alveoli, and chest cavity The central pathology of respiratory disease is an exaggerated inflammatory response due to chronic exposure to noxious gases and particulate Beginning around 25 years of age, the respiratory reserve capacity as measured by forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) decreases by approximately 30 mL per year in men and 23 mL per year in women. This decline continues until about age 65 years, at which point it tends to accelerate for both sexes Depending on the interplay between different inflammatory and repair mechanisms, chronic bronchitis, emphysematous, mixed, or asthma–COPD overlap phenotype of the disease can emerge.  RESPIRATORY DISEASE Etiology Symptoms Shortness of breath doing everyday activities. Frequent coughing or wheezing. Trouble taking deep breaths due to chest tightness or heaviness. Excess phlegm or mucus. Fatigue or extreme tiredness. Types Restrictive Obstructive Restrictive Lung Conditions Limit the ability of a person’s lungs to expand during inhalation Pneumonia Tuberculosis Sarcoidosis Fibrosis Rheumatoid Arthritis Obesity Obstructive Lung Conditions Limit the ability to exhale air from the lungs due to an airway obstruction Asthma COPD Cystic fibrosis  RESPIRATORY DISEASE Introduction COPD is primarily a disease of the large and small airways and the lung parenchyma that is characterized by inflammation, airway narrowing, and poorly reversible airflow obstruction COPD manifests as: Dyspnea skeletal muscle weakness exercise intolerance Causes Tobacco smoke Air Pollution  RESPIRATORY DISEASE Chronic Obstructive Pulmonary Disease COPD refers to two main conditions: Emphysema develops when there is damage to the walls between many of the air sacs in the lungs. Normally, these sacs are elastic or stretchy. When you breathe in, each air sac fills up with air, like a small balloon. When you breathe out, the air sacs deflate, and the air goes out. In emphysema, it is harder for your lungs to move air out of your body. Chronic (long-term) bronchitis is caused by repeated or constant irritation and inflammation in the lining of the airways. A lot of thick mucus forms in the airways, making it hard to breathe. Normal, healthy bronchial tube Chronic bronchitis Normal vs. Impaired alveolar elastic recoil Radiographs of the normal lung (left) and the lung of a patient with chronic obstructive pulmonary disease  RESPIRATORY DISEASE Etiology Consequences People with COPD are more likely to have difficulty:1 Working or doing usual activities. Walking or climbing stairs. Concentrating, remembering, or making decisions. They are also more likely to have: Other chronic diseases like asthma, heart disease, and diabetes. Depression or mental health condition. Reported poor health. Lung infections, like the flu or pneumonia Lung cancer Heart problems Weak muscles and brittle bones  RESPIRATORY DISEASE Risk Factors COPD A history of childhood respiratory infections Smoke exposure from coal or wood burning stove Exposure to secondhand smoke People with a history of asthma People who have underdeveloped lungs Those who are age 40 and older as lung function declines as you age  RESPIRATORY DISEASE Asthma Heterogeneous chronic inflammatory disorder of the airways that is characterized by: History of episodic bronchial hyperresponsiveness Variable airflow limitation Recurring wheeze, dyspnea, chest tightness, and coughing that occur particularly at night or early morning Symptoms are variable and often reversible Can be provoked or worsened by exercise May contribute to reduced participation in sports and PA and ultimately to deconditioning and lower cardiorespiratory fitness With deconditioning, the downward cycle or “spiral” continues with asthma symptoms being triggered by less intense PA and subsequent worsening of exercise tolerance. Pathology of Asthma  RESPIRATORY DISEASE Asthma Causes Unknown, different in people Triggers Second-hand smoke Dust mites Air pollution Pests Pets Mold Infections linked to flu, colds, and RSV Sinus infections, allergies, or pollen Breathing in some chemicals or fragrances Acid reflux Bad weather, such as thunderstorms or high humidity and cold, dry air Some foods and medicines for people allergic to them Physical exercise or strong emotions that lead to very fast breathing  DIABETES MELLITUS Risk Factors Asthma Family history If you have a parent with asthma, you are three to six times more likely to develop asthma than someone who does not have a parent with asthma. Allergies Some people are more likely to develop allergies than others, especially if one of their parents has allergies. Certain allergic conditions, such as atopic dermatitis (eczema) or allergic rhinitis (hay fever), are linked to people who get asthma. Viral respiratory infections Respiratory problems during infancy and childhood can cause wheezing. Some children who experience viral respiratory infections go on to develop chronic asthma. Occupational exposures If you have asthma, exposures to certain elements in the workplace can cause asthma symptoms. And, for some people, exposure to certain dusts (industrial or wood dusts), chemical fumes and vapors, and molds can cause asthma to develop for the very first time. Smoking Cigarette smoke irritates the airways. Smokers have a high risk of asthma. Those whose mothers smoked during pregnancy or who were exposed to secondhand smoke are also more likely to have asthma. Air Pollution Exposure to the main component of smog (ozone) raises the risk for asthma. Those who grew up or live in urban areas have a higher risk for asthma. Obesity Children and adults who are overweight or obese are at a greater risk of asthma. Although the reasons are unclear, some experts point to low-grade inflammation in the body that occurs with extra weight. Obese patients often use more medications, suffer worse symptoms and are less able to control their asthma than patients in a healthy weight range.  RESPIRATORY DISEASE Prevalence CDC In 2022, 4.6% of adults, reported a diagnosis of COPD (chronic obstructive pulmonary disease, chronic bronchitis, or emphysema. Rates were greater among: ○ Non-Hispanic white individuals compared to other racial and ethnic groups ○ Women compared to men ○ Those ages 65 and older compared to younger age groups 4.2% of physician-based office visits indicated COPD on the medical record in 2019 Affected an estimated 262 million people in 2019 (WHO) 7.7% of Americans have asthma Black individuals and Indigenous Peoples have the highest current asthma rates compared to other races and ethnicities. In 2022, Black individuals (10.3%) were 44% more likely than white individuals (8.4%) to still have asthma. Latino individuals (6.7%) and Asian individuals (4.4%) had lower current asthma prevalence rates than other racial and ethnic groups.  RESPIRATORY DISEASE Prevalence Mortality Chronic lower respiratory diseases (including asthma) deaths in US Number of deaths: 147,382 Deaths per 100,000 population: 44.2 Cause of death rank: 6 455,000 deaths were reported worldwide in 2019 (WHO) More than 3,500 people die of asthma each year, nearly a third of whom are age 65 or older ALA More women than men die from COPD (72,727 versus 66,098), but men are more likely than women to die from the disease (36.8 versus 31.5 per 100,000). Most (85%) COPD deaths occur among those age 65 years or older. The rate of deaths from COPD are much greater among older age groups. Fortunately, death rates have been decreasing among those in this age group. COPD death rates are highest among white individuals, lowest among Asian or Pacific Islander individuals, and higher among men than women for every racial and ethnic group.  RESPIRATORY DISEASE Financial trends The estimated economic cost of asthma is $50 billion annually A 2024 study in CHEST Journal concluded that the total direct costs for COPD in the United States in 2019 were $31.3 billion and projected to grow to $60.5 billion in 2029 The medical cost of COPD is $24.0 billion each year among adults 45 years of age and older, including $11.9 billion in prescription drug costs, $6.3 billion in inpatient costs, $2.4 billion in office-based costs, $1.6 billion in home health costs, $900 million in emergency room costs, and $800 million in outpatient costs. COPD medical costs are $4,322 per patient each year on average. Average COPD medical costs per year increased 72% from 2000 to 2018, including an increase in prescription drug costs of eight times.  RESPIRATORY DISEASE Financial trends  DIABETES MELLITUS Treatment Goal Better control symptoms Slow the progression of the disease Reduce the risk of exacerbations or flare ups Improve your ability to stay active Action Plan Smoking cessation Pharmacological Pulmonary rehab–diet, exercise, education Supplemental oxygen Non-invasive ventilation Endobrachial valve therapy Surgery Clinical trials Complementary therapies like acupuncture, yoga, and massage RESPIRATORY DISEASE  RESPIRATORY DISEASE Effects of physical activity During exercise, oxygen consumption and carbon dioxide production rates can increase 10- to 20-fold depending on the exercise intensity and the individual’s level of fitness  RESPIRATORY DISEASE Effects of physical activity Tips to maintain an active lifestyle when air quality is poor: Exercise earlier in the day. Both particulate pollution and ground level ozone tend to accumulate throughout the day. The vast majority of air pollution comes from tailpipes – cars and trucks on the road – so avoid outdoor activity during commuting time (7:30 a.m. – 9:00 a.m., and 4:00 p.m. – 7:00 p.m.), and when possible avoid exercise next to heavily trafficked roadways. Consider indoor activity opportunities like going to the gym, walking laps at the mall or working out along with an exercise video (local libraries often lend these for free). It is important to note that a scarf or paper mask does not protect you from the poor air quality.  RESPIRATORY DISEASE Effects of physical activity-COPD Dyspnea or SOB with exertion is a cardinal symptom of COPD resulting in PA limitations and deconditioning. Disuse muscle atrophy is common in individuals with COPD because of the adverse downward spiral of increasing ventilatory limitations, SOB, and further decreases in PA The beneficial effects of exercise occur mainly through adaptations in the musculoskeletal and cardiovascular systems that in turn reduce stress on the pulmonary system during exercise  RESPIRATORY DISEASE Effects of physical activity-COPD ACSM exercise testing recommendations: Exercise testing (e.g., treadmill, cycle ergometer, 6-MWT) has multiple purposes in the assessment of individuals with chronic lung disease. These purposes include quantifying exercise capacity prior to PR entry, establishing a baseline for outcome documentation, evaluating drug treatment efficacy, assisting in the development of the Ex Rx , evaluating unexplained dyspnea and exercise intolerance, and prognostic evaluation for individual risk stratification. Ideally, all individuals who enter a PR program should have some form of exercise assessment evaluation prior to PR entry (e.g., cardiopulmonary exercise test, 6-MWT, or shuttle walk test). Evidence-based guidelines confirm the utility of cardiopulmonary exercise testing (CPET) in adults with COPD as well as other chronic lung diseases (i.e., interstitial lung disease, primary pulmonary hypertension, and CF) in providing an objective measure of exercise capacity, mechanisms of exercise intolerance, prognosis, disease progression, and treatment response. Incremental exercise tests (e.g., GXT on a treadmill or electronically braked cycle ergometer) may be used to assess cardiopulmonary function and CRF. Modifications of traditional protocols (e.g., smaller work rate increments) may be warranted depending on functional limitations and the onset of dyspnea. A test duration of 8–12 min is optimal in those with mild-to-moderate COPD (131), whereas a test duration of 5–9 min is recommended for individuals with severe and very severe disease (123). Individuals with moderate-to-severe COPD may exhibit oxyhemoglobin desaturation with exercise. Therefore, a measure of blood oxygenation, either the partial pressure of arterial oxygen (PaO2) or percent saturation of arterial oxygen (SaO2), should be made periodically during the initial GXT and during any follow-up GXTs to help determine degree of improvement or decline in peripheral blood oxygenation (82). Submaximal exercise testing may be used depending on the reason for the test and the clinical status of the individual. However, individuals with pulmonary disease may have ventilatory limitations to exercise; thus, prediction of V̇ O2peak based on age- predicted HRmax may not be appropriate as criteria for terminating the submaximal GXT.  RESPIRATORY DISEASE Effects of physical activity-COPD ACSM exercise testing recommendations: A constant work rate (CWR) test using 80%–90% of peak work rate achieved from the GXT is appealing, as it assesses the type of work-related activity levels likely to be encountered in everyday life particularly when performed on a treadmill. The measurement of flow volume loops during the GXT using commercially available instruments may help identify individuals with dynamic hyperinflation and increased dyspnea because of expiratory airflow limitations. Use of bronchodilator therapy may be beneficial for such individuals. The 6-MWT is a widely used exercise assessment tool for cardiorespiratory function in PR. The test is safe, easy to administer, involves the use of minimal technical resources, is well tolerated, and accurately reflects walking abilities. To obtain valid and reliable results, it is essential to standardize the test procedure (i.e., staff, exercise track or hallway distance/configuration, individual instructions, verbal reinforcement used during testing, type and flow rate of supplemental oxygen, walking aides, and number of trials). The minimal clinically important difference in 6-MWT distance has been reported to be a mean of 30 m (98.42 ft). Incremental (ISWT) and endurance (ESWT) shuttle walk tests are also used to assess cardiopulmonary function in individuals with chronic lung disease. The ISWT is an incremental, symptom-limited walk test that simulates a symptom-limited CPET. This test measures a symptom-limited walking distance over a marked walking course of 10 m (33 ft). This distance correlates well with V̇O2peak in individuals with chronic lung disease and has been shown to be a reliable, valid, and responsive measure of estimated functional capacity in interstitial lung disease and asthma. The ISWT utilizes an audible pacing timer to incrementally increase the pacing frequency. The individual walks according to the pacing timer frequency until they are too breathless to continue or cannot keep pace with the external pacing signal. Like the 6-MWT, the primary test result of the ISWT is the total distance walked. The ESWT is a derivative of the ISWT, where the individual walks as long as possible at a predetermined percentage of maximum walking performance assessed by the ISWT on a subsequent day of testing (141). For this test, the outcome measure is total time walked (minute).  RESPIRATORY DISEASE Effects of physical activity-COPD ACSM exercise testing recommendations: Exertional dyspnea is a common symptom in people with many types of pulmonary diseases. The modified Borg Category- Ratio 0–10 (CR10) scale has been used extensively to measure dyspnea before, during, and after exercise. Individuals should be given specific, standardized instructions on how to relate the wording on the scale to their level of breathlessness. Because dyspnea scales are subjective, some caution is advised in their interpretation as exercise intolerance may be accompanied by exaggerated dyspnea scores without corresponding physiological confirmation.  RESPIRATORY DISEASE Effects of physical activity-COPD ACSM exercise testing recommendations: The exercise testing mode is typically either walking or stationary cycling. Walking protocols may be more suitable for individuals with severe disease who lack the muscle strength to overcome the increasing resistance of cycle leg ergometers. Although arm ergometry is a good adjunct to aerobic weight-bearing exercises, it should be used with caution in individuals with COPD because it can result in increased dyspnea that may limit the intensity and duration of the activity. In addition to standard termination criteria exercise testing may be terminated because of severe arterial oxyhemoglobin desaturation (i.e., SaO2 ≤80%).  RESPIRATORY DISEASE Effects of physical activity–COPD ACSM exercise training considerations: Higher intensities yield greater physiologic benefits (e.g., reduced V̇E and HR at a given workload) and should be encouraged when appropriate. For individuals with mild COPD, intensity guidelines for healthy older adults are appropriate. For those with moderate-to-severe COPD, intensities representing >60% peak work rate have been recommended. Light intensity aerobic exercise is appropriate for those with severe COPD or very deconditioned individuals. Intensity may be increased as tolerated within the target time window. Interval training may be an alternative to standard continuous endurance training for those who have difficulty in achieving their target exercise intensity due to dyspnea, fatigue, or other symptoms. Several randomized, controlled trials and systematic reviews have found no clinically important differences between interval and continuous training protocols in exercise capacity, health-related quality of life, and skeletal muscle adaptations following training. Thus, individual characteristics will warrant the use of either interval or continuous exercise training protocols. Supervision at the outset of training allows guidance in correct execution of the exercise program, enhanced safety, and optimizing benefit.  RESPIRATORY DISEASE Effects of physical activity–COPD ACSM exercise training considerations: Ventilatory limitation at peak exercise in individuals with severe COPD coincides with significant metabolic reserves during whole body exercise. This may allow these individuals to tolerate relatively high work rates that approach peak levels (80) and achieve significant training effects. As an alternative to using peak work rate or V̇O2peak to determine exercise intensity, dyspnea ratings of between 3 and 6 on the Borg CR10 scale may be used. A dyspnea rating between 3 and 6 on the Borg CR10 scale has been shown to correspond with 53% and 80% of V̇ O2peak, respectively. Most individuals with COPD can accurately and reliably produce a dyspnea rating obtained from an incremental exercise test as a target to regulate/monitor exercise intensity. Intensity targets based on percentage of estimated HRmax or HRR may be inappropriate. Particularly in individuals with severe COPD, resting heart rate (HRrest) is often elevated, and ventilatory limitations as well as the effects of some medications prohibit attainment of the predicted HRmax and thus its use in exercise intensity calculations. The use of oximetry is recommended for the initial exercise training sessions to evaluate possible exercise-induced oxyhemoglobin desaturation and to identify the workload at which desaturation occurred. Flexibility exercises may help overcome the effects of postural impairments that limit thoracic mobility and therefore lung function. Regardless of the prescribed exercise intensity, the exercise professional should closely monitor initial exercise sessions and adjust exercise intensity and duration according to individual responses and tolerance. In many cases, the presence of symptoms, particularly dyspnea/breathlessness, supersedes objective methods of Ex Rx.  RESPIRATORY DISEASE Effects of physical activity–COPD ACSM exercise training considerations: Peripheral muscle dysfunction contributes to exercise intolerance and is significantly and independently related to increased use of health care resources, poorer prognosis, and mortality, which emphasizes the importance of strength training in these individuals. Maximizing pulmonary function using bronchodilators before exercise training in those with airflow limitation can reduce dyspnea and improve exercise tolerance. Because individuals with COPD may experience greater dyspnea while performing ADL involving the upper extremities, include resistance exercises for the muscles of the upper body. Inspiratory muscle weakness is a contributor to exercise intolerance and dyspnea in those with COPD. In individuals receiving optimal medical therapy who still present with inspiratory muscle weakness and breathlessness, IMT may prove useful in those unable to participate in exercise training or can be used as an adjunct for those who participate in an exercise program. IMT improves inspiratory muscle strength and endurance, functional capacity, dyspnea, and quality of life, which may lead to improvements in exercise tolerance in those with COPD and with asthma. There are no clear evidenced-based guidelines for IMT for specific chronic lung disease populations, although a training load intensity of ≥30% of maximal inspiratory pressure has been recommended. Supplemental oxygen is indicated for individuals with a PaO2 ≤55 mm Hg or an SaO2 ≤88% while breathing room air. This recommendation applies when considering supplemental oxygen during exercise. In individuals using ambulatory supplemental oxygen, flow rates will likely need to be increased during exercise to maintain SaO2 levels >88%. Individuals suffering from acute exacerbations of their pulmonary disease should limit exercise until symptoms have subsided.  RESPIRATORY DISEASE Effects of physical activity  RESPIRATORY DISEASE Effects of physical activity-Asthma Exercise-induced bronchoconstriction (EIB), defined as airway narrowing that occurs as a result of exercise, is experienced in a substantial proportion of people with asthma, but people without a diagnosis of asthma may also experience EIB. For athletes, environmental triggers such as cold or dry air and air pollution including particulate matter, allergens, and trichloramines in swimming pool areas may stimulate a bout of EIB. EIB can be successfully managed with pharmacotherapy. Strong recommendations have also been made for 10–15 min of vigorous intensity or variable intensity (combination of light and vigorous intensity) warm- up exercise to induce a “refractory period” in which EIB occurrence is attenuated  RESPIRATORY DISEASE Effects of physical activity–Asthma ACSM exercise testing recommendations: Assessment of physiologic function should include evaluations of cardiopulmonary capacity, pulmonary function (before and after exercise), and oxyhemoglobin saturation via noninvasive methods. Administration of an inhaled bronchodilator (i.e., β2-agonists) (see Appendix A) prior to testing may be indicated to prevent EIB, thus providing optimal assessment of cardiopulmonary capacity. Exercise testing is typically performed on a motor-driven treadmill or an electronically braked cycle ergometer. Targets for high ventilation and HRs are better achieved using the treadmill. For athletes, a sports-specific mode may be more relevant. The degree of EIB should be assessed using vigorous intensity exercise achieved within 2–4 min and lasting 4–6 min with the individual breathing relatively dry air. The testing should be accompanied by a spirometric evaluation of the change in forced expiratory volume in one second (FEV1.0) from baseline and the value measured at 5, 10, 15, and 30 min following the exercise test. The criterion for a diagnosis of EIB varies, but many laboratories use a decrease in FEV1.0 from baseline of ≥15% because of its greater specificity.  RESPIRATORY DISEASE Effects of physical activity-Asthma ACSM exercise testing recommendations: Appropriately trained staff should supervise exercise tests for EIB, and physician supervision may be warranted when testing higher risk individuals because severe bronchoconstriction is a potential hazard following testing. Immediate administration of nebulized bronchodilators with oxygen is usually successful for relief of bronchoconstriction. Evidence of oxyhemoglobin desaturation ≤80% should be used as test termination criteria in addition to standard criteria. The 6-MWT may be used in individuals with moderate-to-severe persistent asthma when other testing equipment is not available  RESPIRATORY DISEASE Effects of physical activity-Asthma ACSM exercise training considerations: Caution is suggested in using target HR based on prediction of maximal heart rate (HRmax) because of the wide variability in its association with ventilation and the potential HR effects of asthma control medications. Individuals experiencing exacerbations of their asthma should not exercise until symptoms and airway function have improved. Use of short-acting bronchodilators may be necessary before or after exercise to prevent or treat EIB (see Appendix A). Individuals on prolonged treatment with oral corticosteroids may experience peripheral muscle wasting and may therefore benefit from resistance training. Exercise in cold environments or in the presence of airborne allergens or pollutants should be limited to avoid triggering bronchoconstriction in susceptible individuals. EIB can also be triggered by prolonged exercise durations or high intensity exercise sessions. There is insufficient evidence supporting a clinical benefit from inspiratory muscle training (IMT) in individuals with asthma. Use of a nonchlorinated pool is preferable because this will be less likely to trigger an asthma event. Be aware of the possibility of asthma exacerbation shortly after exercise, particularly in a high-allergen environment.  RESPIRATORY DISEASE Effects of physical activity-Asthma  ALA Breathing Videos https://www.lung.org/lung-health-diseases/we llness/breathing-exercises