International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - Vol 05 Issue 20, October, 2013

Pages: 89-93

Date of Publication: 02-Nov-2013

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Author: Rajani Bala Jasrotia, Arvind Kanchan

Category: Healthcare

Abstract:The relationship between asthma and physical activity is very interesting and complex. The terms like exercise, asthma, airway dynamics, bronchospasm, bronchoconstriction, hyper-responsiveness, hyper-reactive, bronchial lability are being very frequently used in medical literature. These terms are very confusing sometimes due to their interchanging use. This review article was attempted to define and describe the phrases which contains these terms, with special attention towards their pathophysiology for better understanding. It was found that although sounds very similar, the terms like ?Exercise induced asthma?, ?Exercise induced bronchospasm?, ?Airway hyper-responsiveness? and ??Exercise induced bronchial lability? are very different in their pathophysiology, and should be used very appropriately.

Keywords: exercise, asthma, hyper-responsiveness, lability

Full Text:


Since many years, physical exercise has been used to understand the airway dynamics in asthma patients, thus developed as an important tool to diagnose the asthma and, whereas at another side it is as being used as a patient management tool for preventive, therapeutic as well as prognostic purpose. This composite relation between exercise and asthma lead to the frequent use of various terms which contain the exercise and airway dynamics in its core. Following is the detailed description of each phenomenon:

Exercise induced asthma

There are many asthmatic patients, who do not have daily symptoms, but they suffer only after exercise; this is called exercise induced asthma (EIA). EIA is characterized by symptoms of coughing, wheezing, shortness of breath, and chest tightness during / after exercise, and associated with demonstrable airway obstruction as a drop in pulmonary function parameters1. Its definitive diagnosis requires symptoms associated with objective demonstration of a drop in flow rates, typically ≥15% for forced expiratory volume in one second (FEV1) and ≥15–20% for peak expiratory flow rate (PEFR) after a physical exercise2.

EIA can be seen in subjects at any level of exercise ranges from school children running or playing to elite Olympic-level athletes. This large range is due to differing physical activity protocols and depends on the type of activity, its intensity, duration, environmental conditions, severity of the disease and variations in preventative therapy regimens3. Certain sports activities such as long distance running, jumping, or cycling are considered more problematic in contrast, swimming is considered the relatively safe. The most challenging activity for asthmatics is relatively short and intense spell that may cause a significant rise of heart rate and/or maximal oxygen uptake5. High intensity exercise is mostly related to the induction of asthma attacks6.

Exercise–induced bronchospasm (EIB) is almost a very similar phenomenon, but it may also be seen in normal healthy individuals, without known to be an asthmatic7. The diagnosis after objective exercise challenge methods in conjunction with similar clinical history is must. Objective testing should begin with spirometry at rest, in true EIB the results should be within normal limits. Abnormal resting value is seen in asthma and other chronic lung conditions. There is no reason why asthma and exercise-induced bronchoconstriction should not co-exist, but the distinction is important because without successful treatment of underlying asthma, treatment of an exercise component will likely be unsuccessful.

The pathologic mechanisms that explain EIA or EIB are based on at least two contrasting theories: the airway rewarming theory described by McFadden et al8 and the hyper-osmolarity theory described by Anderson et al9. The cooling of airway was demonstrated by recording temperature in the esophagus, and later by direct recording within the airways.  It was found that at identical levels of respiratory heat loss (RHL) all exercise produces equal bronchospasm and there was a significant linear relationship between the quantum of RHL and alterations in lung mechanics. Mc Fadden et al10 and Gilbert et al11 explained that the airways cool during exercise or hyperventilation and rewarm once the exercise or hyperventilation stops. The rewarming of these cooled airways causes reactive hyperemia which directly affects bronchial caliber and obstructs the airflow. However, some researchers found that responses to exercise at various levels are not significantly different despite the large RHL differences12. This led to proposal of a hypothesis that respiratory water loss and not only heat loss is also the triggering event13,14. It was proposed that hyperventilation induced hyperosmolarity of the airway membrane (due to water loss) as another operating mechanism. Bar-Yishay15 studied that children who made to swim while breathing dry air, developed more bronchoconstriction than swimming breathing humid air from pool surface, still they developed significantly less airway obstruction than after running with breathing dry air.  Studies also showed that asthma closely resembling EIA could be provoked by inhaling hypotonic or hypertonic salt solutions16.

The possibility that chemical mediators are involved in the intermediary pathway seems more likely, although much of the evidence in favor is highly circumstantial. Neutrophil chemotactic factor and mast cell-derived mediator which rise in blood during exercise in patients developing EIA and that rise could be prevented by pretreatment with Sodium Chromoglycate.17 One of the characteristic features of EIA is being refractory to a subsequent challenge for some time after the initial attack. Therefore it was thought the depletion of the presumed stores of mediators which were liberated by the trigger and cause bronchospasm and sufficient time is required to resynthesize these stores18. Stearns et al suggested that refractoriness was due to the secretion of endogenous catecholamines19. Recently, Tahan et al hypothesized that the development of exercise-induced bronchoconstriction in asthmatic children may be in relation to a reduced endogenous lipoxin activity. Lipoxin mimetic and related compounds could provide novel therapeutic approaches to the treatment of exercise-induced bronchoconstriction in asthma20.

Airway hyper-responsive or hyper-reactivity:

Airway hyper-reactivity or hyper-responsiveness (AHR) is used to describe the exaggerated response to any trivial stimuli, commonly seen in patients with asthma. This reactivity may be seen with cold air, pollen, mold, animal exposure, upper respiratory infections and laboratory testing (e.g. histamine or methacholine). In patients with asthma, airway inflammation is the primary underlying disease process, even when patients are asymptomatic and this inflammation is associated with AHR.

Both genetic predispositions (associated with atopy) and environmental factors could be involved in its pathogenesis21,21. AHR is a composite physiological disorder, determined by a heterogeneous mechanism in asthma23 as well as in other chronic obstructive pulmonary diseases (COPD)24 e.g. chronic bronchitis and peripheral airway diseases. It is associated with inflammatory disorders in the airways in all these disease entities. In asthma, the mucosal inflammation comprises epithelial desquamation, thickening of the sub-epithelial reticular layer, micro-vascular congestion, plasma exudates and edema and sub-mucosal infiltration with mast cells, activated lymphocytes and eosinophils25, 26. In COPDs the inflammatory disorders differ between the various subtypes of the disease26, 27. Activated T-lymphocytes and macrophages seem to be the predominant infiltrating cells, without concomitant basement membrane thickening28, 29. Several of the above mentioned inflammatory abnormalities were correlated with the results of inhalation challenge tests. Therefore, the degree of AHR indirectly reflects the severity of the disease process in the airways in asthma and COPDs. Exercise is one of the trigger stimuli like others, which interact with hyper-responsive airway to precipitate the asthmatic attack. 

Exercise induced bronchial Lability

Bronchial lability is an important feature of asthmatic patient which demonstrate in response to various apparently unrelated factors, such as allergy, infection, emotion, exercise and drugs30. This is a different entity than just airway or bronchial responsiveness. There are many bronchial challenges devised or understood which could test the bronchial lability. Exercise has been used as a stimulus to test bronchial lability because it can be produced in a controlled and reasonably repeatable reaction which mimics clinical asthma in a number of aspects31. The response of the airway or bronchi to a short bout of exercise is biphasic: initial airway dilation followed by a constriction. The cause of the initial bronchodilation during exercise may be related to an increase in sympathetic activity33.

The bronchial lability is expressed in terms of rise in peak flow rate during exercise and fall in peak flow rate after exercise, each given as a proportion of the pre-exercise, resting peak flow rate and also in term of the total bronchial lability or exercise lability index (ELI) which is the sum of the percent rise and fall. The ELI is thus, the measure of total change in airway caliber i.e. bronchodilation and bronchoconstriction32.

(ELI = Highest PEFR during exercise – Lowest PEFR after exercise / Initial PEFR x 100); ELI > 22 is being considered abnormal34.

Exercise testing is also being used for another two important reasons – awareness that resting cardiopulmonary measurements do not provide a dependable estimation of functional capacity and impact of physical exertion in the clinical decision making process. Several modalities of exercise testing are being used in clinical practice. The following are the most popular clinical exercise tests, in order of increasing complexity35: Six Minute Walk Test (6MWT), Shuttle Walk Test, Exercise Induced Bronchial Lability (EIB), Cardiac Stress Test and Cardio-pulmonary Exercise Test (CPET).

Silverman and Anderson32 showed that 70% of asthmatic children had a significant fall in peak expiratory flow rate after treadmill running. They suggested that this increased lability was a feature of asthmatics and that it was not closely related to the clinical condition in individual patients. Konig et al36 demonstrated that there was a significant increase in bronchial lability among the wheezy bronchitis group compared with the controls. In the mildly asthmatics children who had wheezy bronchitis as infants, majority had an abnormal post exercise fall of FEV1 and abnormal total bronchial lability35. Balfour et al37 found that exercise induced bronchial lability was a sensitive indicator of clinical asthma, which disappeared when the patient was symptom free. Thus bronchial lability is an intrinsic characteristic of an individuals’ broncho-pulmonary system.



Exercise-induced asthma, occurs when the airways narrow as a result of exercise. The exercise does not cause asthma, but is an asthma trigger. So, the preferred term for this condition is exercise-induced bronchoconstriction or bronchospasm. Bronchospasm can occur in healthy individual with normal airway, however, asthma and exercise-induced bronchoconstriction frequently co-exist. Airway hyper-reactivity or hyper-responsiveness is a state characterized by easily triggered bronchospasm. The hyper-responsiveness is an important feature of asthma but also occurs frequently in people suffering from COPD. Bronchial lability is an inherited characteristic of airway, which must combine with a triggering mechanism to result in clinical asthma. Thus the terms like EIA, EIB, AHR and EIBL are very different in their pathophysiology and should be used with caution during writing of research paper, academic teaching-learning activities, clinical practice  and finally in management.


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Dr. Pramod Kumar Manjhi joined Editor-in-Chief since July 2021 onwards

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Awards, Research and Publication incentive Schemes by IJCRR

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to for more details.

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‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to for more details.

Best Article Award

A Study by Amr Y. Zakaria et al. entitled "Single Nucleotide Polymorphisms of ATP-Binding Cassette Gene(ABCC3 rs4793665) affect High Dose Methotrexate-Induced Nephrotoxicity in Children with Osteosarcoma" is awarded Best Article for Vol 13 issue 19
A Study by Kholis Ernawati et al. entitled "The Utilization of Mobile-Based Information Technology in the Management of Dengue Fever in the Community Year 2019-2020: Systematic Review" is awarded Best Article for Vol 13 issue 18
A Study by Bhat Asifa et al. entitled "Efficacy of Modified Carbapenem Inactivation Method for Carbapenemase Detection and Comparative Evaluation with Polymerase Chain Reaction for the Identification of Carbapenemase Producing Klebsiella pneumonia Isolates" is awarded Best Article for Vol 13 issue 17
A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
A Study by Chandran Anand et al. entitled "A Prospective Study on Assessment of Quality of Life of Patients Receiving Sorafenib for Hepatocellular Carcinoma" is awarded Best article for Vol 13 issue 15
A Study by Rosa PS et al. entitled "Emotional State Due to the Covid – 19 Pandemic in People Residing in a Vulnerable Area in North Lima" is awarded Best Article for Vol 13 issue 14
A Study by Suvarna Sunder J et al. entitled "Endodontic Revascularization of Necrotic Permanent Anterior Tooth with Platelet Rich Fibrin, Platelet Rich Plasma, and Blood Clot - A Comparative Study" is awarded Best Article for Vol 13 issue 13
A Study by Mona Isam Eldin Osman et al. entitled "Psychological Impact and Risk Factors of Sexual Abuse on Sudanese Children in Khartoum State" is awarded Best Article for Vol 13 issue 12
A Study by Khaw Ming Sheng & Sathiapriya Ramiah entitled "Web Based Suicide Prevention Application for Patients Suffering from Depression" is awarded Best Article for Vol 13 issue 11
A Study by Purushottam S. G. et al. entitled "Development of Fenofibrate Solid Dispersions for the Plausible Aqueous Solubility Augmentation of this BCS Class-II Drug" is awarded Best article for Vol 13 issue 10
A Study by Kumar S. et al. entitled "A Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India" is awarded Best Article for Vol 13 issue 09
A Study by Mardhiah Kamaruddin et al. entitled "The Pattern of Creatinine Clearance in Gestational and Chronic Hypertension Women from the Third Trimester to 12 Weeks Postpartum" is awarded Best Article for Vol 13 issue 08
A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Leow Jun Xian and Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh et al. entitled "Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
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List of Awardees

A Study by Ese Anibor et al. entitled "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award

A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award

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