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Dr. Cheeley:
Welcome to Clinician’s Roundtable on ReachMD.  I’m your host, Dr. Mary Katherine Cheeley, and here to discuss his study, titled “Results From a National Survey of Asthma Provider Beliefs and Practices Regarding Exercise and Asthma: A Work Group Report of the AAAI Committee on Sports, Exercise, and Fitness,” that was published in the Journal of Allergy and Clinical Immunology: In Practice in 2022—I’m welcoming Dr. Basil Kahwash.  He’s an assistant professor of medicine on the Clinical Educator track in the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University in Nashville, Tennessee. 

Dr. Kahwash, welcome to the program. 

Dr. Kahwash:
Thank you so much. 

Dr. Cheeley:
Let’s start by laying some groundwork on the challenges patients with asthma face regarding exercise.  Can you talk to us a little bit about all these obstacles? 

Dr. Kahwash:
Absolutely.  Obviously, a lot of asthma patients will struggle with exercise because exercise is one of the triggers for asthma.  I mean, when you step back and think about what asthma is, it is narrowing of the lower airways that can happen in certain settings.  It’s reversible.  It’s not like a fixed narrowing of the lower airways that’s an anatomic thing.  It’s your airways get tighter and narrower in response to certain stimuli.  So those can be allergies, those can be like inhaling smoke, things like that, pollutants, but they can also be physical triggers, like exercise, for instance, because when we’re exercising, we’re pulling in air more quickly, we are pulling in sometimes colder air and drier air, and that can provoke some constriction of those airways.  So a lot of asthma patients will feel like, “Oh, when I’m exercising, my asthma symptoms will flare up, so I need to avoid exercise,” or they may take that a step further and say, “It’s not safe for me to exercise because I’m making my asthma actually worse.”  So that creates a challenge because here’s the thing, there’s so many health benefits of exercise.  It’s like every day you pull up a new article that shows that exercise is good for you in a different way that we didn’t realize before; physical health, mental health, obviously, that includes things like cardiovascular health, mechanical health.  Especially, as we’re talking about people getting older, into older age, you want to be able to focus on maintaining some sense of mechanical stability as well in those individuals. 

So people with asthma, we want them to be able to get those benefits of exercising, absolutely.  So the avoidance of exercise, if for no other reason, is wrong in the asthma patients.  It is something we don’t want to encourage for that reason, but there’s another layer to it also, which is actually that moderate exercise over time will lead to better asthma control.  So for that reason, we really want to get a good sense of why are asthma patients avoiding exercise, how can we counsel them, and how can we talk to them and encourage them to exercise in a way that is safe. 

Dr. Cheeley:
So let’s jump into your study.  Can you tell us about the population? 

Dr. Kahwash:
The population in this particular study was not a patient population.  This was an asthma specialist population.  We sent this survey out to hundreds of asthma specialists across the country just basically soliciting what counseling practices they have in speaking to patients about exercise, speaking to their asthma patients about exercise, and also what are their underlying beliefs about exercise and asthma.  And we got 91 responses back from those asthma specialists.  These are people who are either pulmonologists or allergist immunologists who, regardless, have a focus on treating individuals with asthma.  And we got some reassuring responses, namely in the area of is it safe for an asthma patient to exercise, or is it safe for a severe asthmatic to exercise.  The overwhelming majority of our responses said it’s safe for the general average asthma patients who exercise.  More than 80 percent said it’s safe for severe asthmatics to exercise.  But one thing that was a less reassuring finding was that when it comes down to individual as exercise counseling practices in the asthma clinic, not as many of our survey respondents, these physicians, were affirmative of the fact that—or not as many of them, I should say, acknowledge that they themselves currently counsel exercise in their asthma patients, at least not to the sufficient level that it would convince a regular asthma patient to be pursuing exercise.  So that’s a gap that we identified that clearly needs to be addressed.

But the comforting thing here is that we know that these patients should be exercising.  The specialists know.  The asthma patients, not all of them know, so we know that we have room to grow in terms of developing what the best counseling practice is and spreading the message among our asthma specialists that they should be counseling and giving them tools to counsel exercise in that population.

Dr. Cheeley:
Based on your study that you guys have, what other knowledge gaps did you recognize in our healthcare providers?

Dr. Kahwash:
So I think, again, this was a study of asthma specialists, and thankfully, knowledge gaps were not abundant.  I think the knowledge is there.  It’s the matter of putting the knowledge into practice, that we need to figure out ways in which the system will allow us to do that.  So there are so many challenges.  We looked at barriers and facilitators to exercise counseling also.  So the number one barrier cited is time, of course.  I mean, we all know this.  If we’re in a healthcare system where the volume of patients that you see in a day is one of the main focuses of any outpatient clinic, and that really limits how much time you have face-to-face with every patient, and you need to skip over something, you might skip over exercise counseling or lifestyle counseling.  

Dr. Cheeley:
For those of you just tuning in, you’re listening to Clinician’s Roundtable on ReachMD.  I’m Dr. Mary Katherine Cheeley, and I’m speaking with Dr. Basil Kahwash about the national survey regarding exercise and asthma. 

I want to jump back into this because I’m just really intrigued by this study.  I love the fact that it’s provider-focused.  So can you tell me some of the key findings?  We’ve talked about some, but specifically, from the specialists that you were talking with, what was the biggest thing that reassured you?  What was the biggest thing that made you kind of question a little bit more how we can do this better?

Dr. Kahwash:
Yeah, great question.  We left a space for people to write their comments.  So one of the biggest reassuring things was that a lot of people wrote comments like, “Thank you for doing this survey,” “Thank you for bringing attention to this,” “This is something that we want to be doing more of,” especially, some that were very highly motivated.  I will say that there may have been a little bit of selection bias in our survey population because more than half of the respondents said that they’re physicians who exercise 150 minutes a week or more themselves, so these are people that are getting the recommended amount of physical activity per national exercise guidelines, which is not a majority of people, but it was a majority of our respondents, so this is a physically active cohort itself.  But there’s good news in that, which is that, in order to be empathetic with your patients, you also have to be somebody who puts into practice the thing that you’re counseling, so it’s reassuring to know that so many of our physicians are out there exercising themselves and have personal experience to talk about some of what they’re doing with their patient population.   

The more challenging side, the side that reminds me that we still have a lot of work to do, is that even though we get all these responses, a lot of people are also highlighting the fact that despite how motivated they are, despite how motivated we are, it often just doesn’t happen, either because of time, either because of just the tools not being available for us to try and make that communication easier, or because we don’t have enough outside of clinic resources to share with our asthma patients that will really give them more to look for in terms of their own exercise knowledge and building that foundation.

Dr. Cheeley:
So how do we make this happen in practice? 

Dr. Kahwash:
Great question.  I think it probably will require more attention outside of just the clinic time.  There’s a role for counseling during the clinical practice, but as our survey respondents highlighted, they feel qualified to talk about exercise, but of course, they don’t feel qualified to design an exercise plan.  That’s not what I was trained for as a doctor, not what you were trained for.  There are people who are athletic trainers, coaches, personal trainers,  sports kinesiologists, people who really understand what that looks like and can package that in a way for a patient.  That’s something that I think probably not the majority or many, many patients may not have access to.  That’s something that requires some resources and certainly some personal resources.  And certainly, I don’t expect that every single patient is going to have the ability or the time to sit down with a trainer and come up with an exercise plan for them personally. 

There are some amazing tools out there right now.  We’ve worked on one called an exercise Rx, or an exercise prescription, that is basically, just a standardized form.  My committee worked on that a couple of years ago, and it just got published online last year that I can send you the link for that if you want to throw that up with the show notes.  But that’s a form that anybody, any physician can just print out in their office.  It is geared towards asthma patients.  It tells them things like how to use their inhaler before exercise, how to warm up before exercise, exercises that they can do, even just very basic exercises that they can do inside the home to try and get themselves moving around a little bit more and just lays out some concrete targets for how physically active they can be.  It’s a start.  I mean, it’s not like an extremely personalized asthma exercise plan, but it is a start. 

There’s also some cool things now coming out with artificial intelligence, things like ChatGPT, where you can just type in a prompt like, “Help me write an exercise plan for an asthma patient” or “a severe asthma patient who has these specific exercise tools available to them, doesn’t have a gym membership” or “does have a gym membership,” and the output from that, it’s surprising how accurate that can be in terms of giving you an actual plan that a patient can follow through on. 

Dr. Cheeley:
I think you gave some really great tips that I’m going to take back to my clinic with me, so thanks.  But also thinking about it from a health equity standpoint, so you mentioned that pollutants in the air make asthma worse.  We also know that lower-income areas tend to suffer more from asthma, or they have less resources.  So I think that’s huge thinking about the community engagement, getting with your local YMCA or Boys and Girls Club or something along those lines to give education there.  I love those resources, but health equity I feel like is something, especially, in the asthma space, that we need to make sure that we’re thinking how to get around. 

Before we close, any final thoughts that you want to leave our audience with today?

Dr. Kahwash:
I think my final thoughts are just that, as they say, the obstacle in the way can become the way.  So if exercise is an obstacle for somebody, then the way to overcome it is through moderate exercise really at the end of the day.  If an asthma patient sees any physical activity as potential, as having the potential to provoke their asthma symptoms, then the best thing for them to do is to just train their body to learn how to tolerate some physical activity.  That’s going to happen, of course, in a gradual way, has to be done safely, and preferably, should be done under the guidance of an asthma specialist, but it’s not something that they need to shy away from totally.  Otherwise, you’re left with much greater vulnerability than you would otherwise have.  Exercise can strengthen your inspiratory muscles, and we know now that it can help improve some of the inflammation in the lungs that is associated with asthma.  So really, the benefits we’re learning more and more about that.  This is just the beginning of the conversation.  

Dr. Cheeley:
This has been such a great discussion.  I’ve really enjoyed it.  I would like to thank my guest, Dr. Basil Kahwash, for joining me today to share his insights on a recent asthma and exercise study.  It was a pleasure talking to you today. 

Dr. Kahwash:
Likewise, Dr. Cheeley.  Thank you. 

Dr. Cheeley:
For ReachMD, I’m Dr. Mary Katherine Cheeley.  To access this and other episodes in our series, visit Clinician’s Roundtable on Reachmd.com where you can Be Part of the Knowledge.  Thanks for listening.