Breathless on the Peaks: Asthma in the Backcountry

2012, March/April Adirondac Adirondoc

Trek up Algonquin from Lake Colden with a pack and you are likely to find yourself breathing rapidly and deeply. Although it will probably slow you down, this pattern of breathing is actually a good thing: the extraordinary effort demands extra oxygen, so the body knows to take in breaths which are deeper and more rapid. Stop for some water, a snack, and a rest (not on the vegetation, please), and breathing quickly normalizes.

For some, however, difficult breathing is not the normal response to exercise but rather a sign of disease. Asthma is one such disease. For reasons which are not completely clear, the incidence of asthma in the U.S. has been increasing, and with it deaths from acute attacks have become more common. Three to four thousand people die in the U.S. annually because of asthma. Asthma deaths are particularly sad since they are largely preventable. We now have a host of excellent medications for controlling this disease. Most of these target one of two problems in asthma: constriction of the small airways in the lungs, and inflammation around these airways. Combinations of such drugs are generally able to keep asthma symptoms under control and stop acute attacks.

Should people with asthma attempt backcountry treks? Of course they should. Aerobic exercise is an important component of overall health. Indeed, many world-class athletes compete successfully with controlled asthma. The operative word here, of course, is “controlled.”

“Control” of asthma begins with an understanding of the factors which trigger an acute attack. These are different for everyone, and include infections (simple colds), environmental factors (smoke), inhaled allergens (pollen), cold temperatures, and exercise. Knowing one’s personal triggers can then permit strategies such as avoiding the backcountry during seasons where pollen triggers are present, or pretreating before exercise. It makes very good sense to begin one’s wilderness experiences with day hikes of increasing intensity to gauge the impact of backcountry travel on asthma. This is particularly important in terms of determining the role of exercise as a trigger, since not all types of exercise lead to symptoms.

Central to the treatment of asthma in the twenty-first century is the development of a personal “asthma action plan” (AAP). This is a document developed between the patient and physician which provides individualized medication advice for specific circumstances. There are a number of versions of the AAP, but a typical example is available online at (new link: If you have asthma in 2012, you simply must have an AAP, and carry it with you along with each of the medications included on it. For longer treks, I usually recommend carrying a spare rescue inhaler in a location separate from the primary inhaler.

How can one help an individual having an acute asthma attack in the backcountry? Providing calming reassurance and helping the individual locate his or her medications is a good first step. There is some evidence that encouraging the patient to exhale forcibly against resistance (as if blowing out a candle) is helpful. If the symptoms are not improving, or if there seem to be changes in mental status, sending for immediate help is mandatory.

Returning to the strenuous hike which started this column: how can one tell if difficult breathing is the body’s response to hard work, anxiety, or an asthma attack? I confronted this problem a while ago with an asthmatic client hiking to Panther Gorge. When breathing regularly, we usually take the same amount of time to inhale as we do to exhale. When exercise or anxiety makes our breathing more rapid, this 1:1 ratio is maintained. During an acute asthma attack, however, individuals spend more time on the exhalation phase, often using twice or more as much time to breathe out as in. Making this determination does not require any particular skill or equipment; just try breathing along with the person and it will become very obvious. The rapidly breathing hiker who has a 1: 1 ratio of exhalation to inhalation just needs some rest. The hiker who is spending more time on exhalation needs to activate his or her AAP!

~Tom Welch, MD

Tom Welch is professor and chair of pediatrics at Upstate Medical University and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: Dr. Ran Anbar, director of Upstate’s pulmonary and asthma program, reviewed this column and provided helpful assistance.

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Topics: General First Aid