Aborting or Preventing an Attack of Asthma by Relaxation Exercises

The conventional treatment of asthma with drugs has extensively been changed during the last 20 years. Modern therapy of asthma is fully reliable to prevent or to abort an attack of asthma but we should not ignore the ancillary advice of yoga experts. It is eminent to mention here that customized breathing exercises propagated by yoga experts are also a reliable method to abort or to prevent an attack of asthma. It is more important to learn that how to relax respiratory muscles and thereby make it easier for lungs to overcome an attack of asthma. In fact, general relaxation of all voluntary muscles of the body, practised daily, also helps.

The essential abnormality in asthma is the narrowing down of the bronchi (the breathing tubes of the lungs). The patient feels uncomfortable when passage of air through these narrowed bronchi becomes difficult. The patient should not panic at this time of distress rather try to relax. Our respiratory process has two components: 1) Inspiration and 2) Expiration. Inspiration is an active process, the chest muscles expand the chest and the air is sucked in. The expiration is achieved by allowing the chest muscles to relax like gently deflating an air filled balloon. In normal health we do not have to force the air out during expiration.

In the case of asthma, the inspiration (breathing in) needs palpable and visible effort due to narrowing of bronchi but greater difficulty arises in expiration (breathing out). An asthmatic, therefore tries to force the air out and in this process the bronchi get even more narrowed. The asthmatic has thus to put in even more vigorous effort to empty out the lungs. This explains why in case of asthma the lungs stay inflated. The struggle involved in breathing in during an attack of asthma, brings into action all the respiratory muscles that stay relaxed during the normal breathing. The tension spreads to the upper abdominal muscles (muscles of the tummy) causing abdominal distension during an attack of asthma. The muscles of the bronchi are involuntary muscles that do not obey orders like voluntary muscles of our limbs, chest wall and elsewhere. The drugs used to treat asthma have a powerful action on the involuntary muscles that have constricted the lumen of bronchi (the breathing tubes). So, the secret of treating an attack of asthma is to open up the narrowed breathing tubes by relaxing their muscles.

Relaxation Exercises:

1. One should avoid tension by thinking away from asthma and thus try to relax the mind. Intended relaxation of mind by sitting calm with closed eyes for 10 minutes twice daily would be beneficial. After relaxation exercise one should gradually and peacefully shift to routine assignments.
2. One should not try to breathe rapidly but try to slow down the process and take deeper breaths. Your deliberate effort to regulate the process of breathing would bring you relief from unpleasant symptoms of over-breathing.
3. One should allow the lungs to relax before taking the next breath in and should not try to force emptying of the lungs during an attack of asthma.
4. One should learn to breathe with the chest muscles and also use the upper part of abdomen. If you distend your tummy along with your chest during inspiration and pull in tummy during expiration, that would exercise your diaphragm muscles and make you feel more comfortable. As one tries to take a long breath, one should try to keep the upper chest muscles relaxed and gently distend the abdomen (tummy). If an asthmatic practises this technique during asymptomatic periods, it would minimize the severity of an attack.
5. Relaxation techniques should be learnt and practised when one is symptom free.
6. Yoga offers excellent 'asanas' (sitting postures) to achieve relaxation of muscles.
7. If the attack of asthma is eminent in spite of your best efforts to prevent or abort it, immediately take a dose of drug prescribed by your treating physician.

Childhood Asthma

A wheezing child has over 80% chances of having asthma. Though wheezing has been considered as a hallmark feature of asthma but it may be associated with other disorders. Recurrent wheezing in infants and children should be considered a diagnostic feature of asthma, but all asthma does not wheeze. Pulmonary function tests (PFT) should be performed to confirm a diagnosis of asthma. Non-wheezing asthma is called 'occult asthma'. Spasmodic, persistent or recurrent cough may also be a feature of asthma. In the absence of wheezing a diagnosis of asthma may be missed in children. All cases of suspected asthma should be subjected to PFT. The response to asthma therapy can also be assessed with PFT. General pulmonary fitness in-between attacks should be monitored at home or at doctor's clinic by Peak Expiratory Flow Rate (PEFR) meter. Various precipitating and aggravating factors may differ with age in children and the trend may continue during adult life.

Because of various misconceptions, asthma is highly undertreated disorder in children. Symptoms of asthma may vary with age and asthmatic children always have different clinical patterns. Type and duration of pharmacotherapy appropriate for one pattern may be inappropriate for the other, so it is important both for the physician and the parents of children to understand these patterns.

Childhood Asthma: Pattern-I

Allergic, viral or exercise induced asthma are included in pattern-I. Here the chest congestion with wheezing and breathlessness (bronchospasm) occurs in minutes or hours and rarely lasts for more than a few days. Around 50% percent of all cases of childhood asthma have pattern-I asthma. There may be 1 to 5 episodes per year. The lung functions are near normal and these cases respond well to bronchodilators along with anti-allergic treatment and rarely need steroids.

Childhood Asthma: Pattern-II

Aetiology and features of this type also resemble pattern-I but number of attacks may be 5 to 6 per year. Longer duration of treatment with bronchodilators and sometimes steroids may be required.

Childhood Asthma: Pattern-III

Undertreated children may develop this pattern where overt symptoms of asthma may be variable with impairment of PFT. These children require steroids along with bronchodilators and the course of treatment may be longer.

Childhood Asthma: Pattern-IV

Children with this pattern experience breathlessness without considerable wheezing. Variable but persistent airway obstruction and impaired PFT have been documented in children affected by pattern-IV asthma. These patients need long term treatment with bronchodilators and steroids.

Childhood Asthma: Pattern-V

Children having no symptoms of asthma during the day but having asthmatic attack at midnight or early in the morning should be labeled as the cases of pattern-V asthma. These patients may need aerosol therapy with steroids or beta agonists at night to control the cough and wheezing. Concurrent exposure to various aggravating factors may induce severe effects. Aggravation of symptoms by exercise or a specific allergen should be recognized and reported to the treating physician.

Management of Asthma

The asthma means bronchospasm and for its effective management we need bronchospasm relaxants. There are a variety of preparations containing sympathomimetics in the form of aerosols, inhalations, tablets and syrups capable of producing bronchodilations by stimulating b₂-adrenergic receptors in the bronchial smooth muscle. The choice and mode of treatment depends on the age of patient and severity of asthmatic conditions. Inhalations and aerosols may not be convenient mode of treatment in infants and children. Salbutamol and terbutaline are relatively selective drugs for b₂-adrenergic receptors. These produce optimal bronchodilations at lower concentration than those required to stimulate b₁-adrenergic cardiostimulatory receptors. Respiratory stimulants like doxapram and nikethamide are of no value and may be harmful in cases of asthma. As per the experience of a close friend of mine, sympathomimetics like salbutamol and terbutaline produce immediate relief in reversible bronchospasm associated with asthma and allergic bronchitis. Excessive and long term use of these drugs may cause cardiac arrhythmias.

Xanthine derivative drugs such as aminophylline, theophylline and etophylline are known to produce smooth muscle relaxation and bronchodilation by inhibiting the enzyme phosphodiesterase which leads to an increase in the intracellular levels of cAMP. Xanthine derivatives also produce diuresis (increase in the urinary output) and cardiopulmonary stimulation. Corticosteroids as aerosol inhalation help to reduce the mucosal edema, hypersecretion of mucous and bronchial hypersensitivity. Corticosteroids act by preventing the release of phospholipids from cell membranes in the lungs and their anti-inflammatory action helps to underplay the mediators of inflammation. Oral corticosteroid therapy should be reserved for acute exacerbations and chronic cases but after the radiological evaluation of lungs and investigations of sputum for Mycobacterium tuberculosis (tubercle bacilli or TB) and other bacterial or fungal infections. Asthmatic patients should avoid total dependence on aerosols or inhalations and should ask their physicians to prescribe them oral drugs also for emergency use. A combination of salbutamol and aminophylline or theophylline as tablets or syrup is a reliable form of treatment for asthma advisable under the guidance of a medical practitioner only.

Chemistry of Asthma and Allergy

The allergy and asthma are very serious immunologic disorders. Everyone of us has been blessed with immune system to fight infections and respond to vaccines for acquiring active immunity. Allergens too are immunogenic but elicit hypersensitive response which could cause a local or systemic reaction like asthma. It has been learnt through animal experiments that the animals sensitized (immunized) with egg albumin react very dramatically on subsequent challenge with egg albumin. In my experience the animals have shown the symptoms of generalized anaphylaxis, respiratory distress and 50% of them died probably due to asphyxia as an intense constriction of bronchioles and bronchi was observed due to the contraction of smooth muscles. Similar reactions also occur in human subjects due a variety of conditions/causes. An injection of penicillin or an insect bite may trigger anaphylaxis in sensitive individuals. Only a timely intravenous injection of adrenaline may help in countering the smooth muscle contraction.

Mediators of Anaphylaxis or Allergic Reaction:

It was resolved by Sir Henry Dale that histamine mimics the systemic changes of anaphylaxis. Experimental studies in guinea-pigs had demonstrated that serum from sensitized animals could passively sensitize normal animals of the same species. Sir Henry Dale had demonstrated that the uterus of sensitized guinea-pig released histamine and contracted on exposure to antigen. The cells that release the mediators of anaphylaxis are the mast cells (in tissues) and basophils (in blood). The mast cells in sensitive subjects are coated by hemocytotropic antibodies of IgE class (reagins) and on interaction with the specific allergen or antigen stimulate the mast cell degranulation and release of mediators of anaphylaxis. In addition to histamine, 5-hydroxytryptamine (serotonin) is also released in some species. The contraction of smooth muscles is associated with the explosive degranulation of mast cells. Other mediators released are: slow reacting substance of anaphylaxis (SRS-A; capable of inducing prolonged contraction of certain smooth muscles), platelet activating factor (PAF), heparin and chemotactic factor for both the neutrophils and eosinophils (types of white blood cells).

Anti-anaphylaxis substances produced by Eosinophils:

The mediators of anaphylaxis released by mast cells are countered by certain substances produced by eosinophils like: histamine produced by mast cells is neutralized by histaminase, eosinophil chemotactic factor (ECF-A) is countered by aryl sulfatase and SRS-A is neutralized by phospholipase produced by eosinophils in an effort of the body to control the reaction. Systemic allergic reaction as well as percutaneous anaphylaxis leads to changes in cyclic nucleotide levels. A fall in cyclic AMP (c-AMP) and a rise in cyclic GMP (c-GMP) level, favors degranulation of mast cells, whereas high concentration of c-AMP stabilize the mast cell granules. All the anti-allergic drugs either neutralize histamine or activate c-AMP to stabilize mast cells or bind to b-2 receptors on smooth muscles to counter the smooth muscle contraction.

Asthma during Pregnancy

Pregnancy does not have a uniform effect on the symptoms of asthma. There could be pregnancy associated asthma or an asthmatic lady may represent aggravation of asthma symptoms during pregnancy. Asthma is probably the most common chronic illness that severely affects around 8% of pregnant women. Pregnancy alters the respiratory and cardiovascular physiology and these alterations may lead to severity of asthma. Proper control of asthma in pregnant women could significantly reduce the complications of perinatal period. The underlying mechanisms responsible for the altered state of asthma due to pregnancy are unknown. Poorly controlled asthma during pregnancy may lead to perinatal mortality and complicate labour. Prevalence of low birth weight of babies and preterm births in asthmatic women as compared to non-asthmatic women have also been documented.

Worsening of asthma during pregnancy may be due to large number of contributing factor. There could be exposure to allergens, infections of the upper respiratory tract, gastroesophageal reflux, non compliance or poor compliance of medication or unwanted use of drugs. Patients with severe asthma prior to conception and patients whose asthma has worsened during previous pregnancies could be labeled as high risk patients. Acute asthma episodes during pregnancy may significantly decrease fetal oxygenation and need medical intervention. However, the management and treatment of asthma are the same in pregnant women as in non-pregnant women and men. Following guideline need special considerations during pregnancy to prevent asthma exacerbations during pregnancy:

1. Avoid intentional exposure to known allergens like pollens, dust, animal furs, feathers and certain food stuffs.


2. Strict medical consultations are needed throughout the pregnancy for optimal control of
   asthma.


3. Delay in the diagnosis and treatment of should be avoided.


4. Smoking cessation is a must.


5. Other health problems like rhinitis, gastric reflux and any infection of upper respiratory tract should be treated effectively.


6. Pulmonary function (assessment or expiratory air flow with Spirometer) should be assessed at least once in a month.


7. Periodic antenatal fetal surveillance should be got done by a specialist.