Reducing EIPH During Exercise | Therapeutic Considerations after EIPH Diagnosis | Partner with Your Vet

Managing EIPH in horses requires a balanced strategy to reduce both the immediate impact of bleeding and long-term lung health consequences. While there is no cure, certain treatments and management techniques can lessen bleeding frequency and severity, protecting your horse’s overall health. It is important to stay informed and continually educate yourself regarding advancing treatment research, and which ones are supported by science. Since EIPH is a complex and multifactorial problem, multimodal treatments considering all of the contributing causes are key and will provide the greatest success. Managing EIPH is quintessential since the lungs are the limiting factor in performance.

Recognize that all EIPH treatments have efficacy limitations. None are curative. Management of EIPH focuses on reducing severity rather than complete prevention. There no currently known means to “stop” EIPH. Because EIPH is multifactorial it is reasonable that a multimodal approach tailored to your horse’s needs and competition demands, is typically most effective. Use treatments proven by research to avoid interfering with overall therapy. When needed, many of the antibiotics, corticosteroids, and bronchodilators can be administered via inhalation. Investing in a proven nebulizer will allow safe nebulization of medications and prevent unwanted side effects due to systemic exposure. It is also important to know which medications and treatments negatively interact.

When considering treatment, regulatory rules must be considered. Some medications may be restricted in races or shows. Always check competition regulations to avoid disqualification or penalties.

The following is an overview of treatment options to discuss with your veterinarian. It should be noted that some are for reducing the severity of EIPH during exercise, some for treating the acute impact of EIPH, some for healing, and some are beneficial for overall lung heath care. Proper management and a healthy respiratory system are key to reducing EIPH. 

REDUCING EIPH DURING EXERCISE

Only two options have been repeatedly shown to reduce EIPH in clinical studies. Both are used during exercise or administered within a period of time around when exercise will occur. 

1. FLAIR® EQUINE NASAL STRIPS

• Non-Pharmacological Option: FLAIR Equine Nasal strips are the only non-drug solution proven to reduce EIPH severity. The Strips work by reducing inspiratory airway resistance commensurate with the exponential increase in resistance normally seen as the exercise intensity increases, and this effect parallels the decrease in pressure across the fragile pulmonary capillary membrane, lessening EIPH severity. In essence FLAIR Strip have a proportionately greater impact on EIPH reduction as exercise intensity increases. Studies show the Strips are equally or even more effective than Lasix during maximum exercise efforts, making them a suitable choice in competitions as an alternative to or in addition to Lasix.
  
  • Performance Optimization: Decreased airway resistance reduces the effort to breathe and therefore the oxygenated blood required for the muscles of inspiration, thus sparing and diverting blood flow to the muscles of locomotion which increases exercise tolerance.
  • Approved for Competition: FLAIR Nasal Strips strip are approved for use in flat- and harness-racing within North America. FLAIR Strips have been approved for use by all key non-racing regulatory bodies, including the Federation Equestrian International, the American Horse Shows Association, the National Reining Association, the United State Equestrian Team, the United States Polo Association, the National Barrel Horse Association, and the American Quarter Horse Association. In the international market, FLAIR Strips have been approved for racing in : Mexico, Brazil, Canada, South Africa, New Zealand, Australia, Trinidad, Barbados, Jamaica, the Netherlands, United Arab Emirates, Qatar, Bahrain, Saudi Arabia, India, , Korea, Singapore and other countries FLAIR Strips are also approved by most international sport horse regulatory bodies.

2. LASIX (FUROSEMIDE)

• Reducing Lung Blood Pressure: Lasix, a diuretic, is the only medication proven to reduce EIPH severity by reducing blood volume through diuretic effects, thus lowering lung blood pressure. NSAIDs dampen or block the Lasix-induced reduction in lung blood pressure, and this is important since many performance horses are taking but for musculoskeletal problems.
• Secondary benefits: These include redistribution of exercising blood flow within the lung to protect against EIPH and may have bronchodilatory effects. Lasix has performance enhancing effects including alkalinizing effect on the blood to counter lactic acid build up and weight loss which culminate in improved race times and ward off fatigue.
• Side Effects: Lasix has side effects, such as dehydration (potential colic issues) and electrolyte imbalance, and effectiveness diminishes over time with long-term repeated use.
  • Consider Electrolyte Replenishment: Use specially formulated electrolytes for horses on Lasix.

Some events may restrict Lasix use, so consult with your vet on its pros, cons, and alternatives. 

3. SUPPORTIVE SUPPLEMENTS

• Vitamin C and Bioflavonoids: These support capillary stability and immune health, potentially strengthening lung tissues.
• Herbal Formulations: Some claim to offer anti-inflammatory or bronchodilator effects but should be used under veterinary supervision.
• Caution with Other Mediations: Current evidence supporting Aminocaproic Acid & Conjugated Estrogens for reduction of lung bleeding is not strong, with possible negative performance effects occurring with aminocaproic acid. Erectile dysfunction medications with the secondary effect of reducing pulmonary hypertension have not been proven beneficial thus far in reducing EIPH. While some EIPH supplements on the market claim that Vitamin K provides benefit for horses with EIPH, there is no evidence or study that supports this claim. Vitamin K is beneficial to help blood coagulation but blood coagulation has not been shown to be a factor for horses experiencing EIPH.

THERAPEUTIC CONSIDERATIONS AFTER EIPH DIAGNOSIS

Effectively managing EIPH involves a combination of rest, environment control, diet, training adjustments, and collaboration with your vet and barn team.

HERE'S A STRAIGHTFORWARD GUIDE:  

1. INFECTION CONTROL WITH ANTIBIOTICS

• Preventing Secondary Infections: Blood in the lungs can lead to infections, so antibiotics are sometimes used as a precautionary measure.

2. REGENERATIVE THERAPIES

• Healing and Reducing Scarring: Platelet-rich plasma (PRP), amnion-based treatments, concentrated equine serum, and possibly other regenerative biologicals, modulate excessive inflammation to support quicker transition to the reparative phase of tissue repair with less scarring.
  • Avoid Adult Stem Cells: Risk of tumor or calcification formation.
  • Compatible Treatments: Hyperbaric oxygen therapy can enhance regenerative treatments, but corticosteroids may interfere and negatively impact healing.

3. BRONCHODILATORS & CORTICOSTEROIDS

• Improving Lung Function: Medications like clenbuterol and albuterol help dilate airways, making it easier for blood removal after an episode and for corticosteroids to reach inflamed areas and slow scar tissue formation when infection is no longer a concern.
  • Administer with Corticosteroids: Bronchodilators should be used with corticosteroids to avoid receptor downregulation.
  • Inhalation Benefits: Inhaled medications minimize systemic side effects, focusing on local effects in the lungs.
  • Non Steroidal Anti-inflammatory drugs (NSAIDs): Not typically effective for lung inflammation.

4. STALL REST & CONTROLLED EXERCISE 

• Rest Period: Following an EIPH episode, a three-week period of stall rest aids lung healing, followed by a gradual reintroduction to exercise over the next eight weeks. A hemorrhage is considered substantial if hemosiderophages—scavenger cells clearing blood—exceed 25%, which typically returns to baseline within four weeks. A follow-up BAL to confirm recovery may help reduce the risk of severe EIPH upon returning to work.
• Extended Rest if Needed: If EIPH recurs, increase stall rest to four weeks, followed by pasture turnout, with a possible six-month layup.
• Why It Works: Limiting activity reduces further lung damage and allows inflammation to subside.

5-8 below are recommended here to improve recovery after EIPH, however, it should be noted that these recommendations should be part of any equine management program to enhance general respiratory health and reduce the likelihood and severity of lower airway inflammation that contributes to EIPH.

5. ENVIRONMENTAL CONTROL

• Reduce Irritants: Dust, mold, and ammonia irritate the respiratory tract and worsen EIPH. Opt for dust-free bedding, such as wood pellets, course shavings, cardboard, or paper versus sawdust or straw.
• Barn Tips:
  • Avoid storing hay over stalls and keep barn sweeping and the use of fans and leaf blowers to a minimum.
  • Move horses outside before arena work starts.
• Ventilation: Maximize pasture turnout and ensure the stable has optimal ventilation.
• Travel: Before travel, ensure your horse’s vaccinations are up-to-date and practice good biosecurity at shows to avoid exposure to respiratory viruses that lead to increased inflammation in the lungs.

6. HEALTHY DIET

• Omega-3s for Inflammation: Adequate doses of omega-3 fatty acids (DHA and EPA) can reduce lung inflammation and improve red blood cell flexibility, aiding their passage through the lungs' small blood vessels. A three-month loading period is required for optimal effect. Avoid flaxseed, as horses cannot convert it effectively.
• Dust-Free Forage: Steam hay to reduce dust and bacteria while preserving nutrients. If soaking hay, limit it to 30 minutes to prevent nutrient loss and bacterial growth, or consider feeding a complete pelleted diet instead.
• Avoid Round Bales: Round bales tend to produce dust and mold, which can worsen respiratory conditions.

7. TRAINING ADJUSTMENTS

• Build Gradually & Strategize: Training represents about 90% of a horse’s career, making it a critical factor in managing EIPH-related lung damage. While the damage from training is generally milder than that from competition, it accounts for the majority of cumulative lung damage and is directly proportional to the duration of training. By focusing on gradual and strategic training, you can build a solid fitness foundation while lowering the risk of EIPH.
  • Emphasize Endurance and Stamina: Begin with low-speed stamina work (walk, trot, canter) and gradually increase the workload. This helps build foundational fitness and reduces lung strain. High-intensity exercises like galloping or sprinting should be introduced only after the horse achieves this base fitness, and the frequency should align with the specific athletic discipline.
  • Monitor Heart Rate: Use heart rate monitors to ensure the horse stays below 150 bpm, which indicates the aerobic training zone. Staying within this range keeps airway and lung blood pressure manageable, reducing the risk of EIPH.
  • Tools To Increase Workload: To increase workload without speed, consider using water resistance (10–30 cm depth), hill work, underwater treadmills, swimming, extra weight, extended walk/trot sessions, cavaletti exercises, and small circles. Note that some of these can intensify bleeding if used at high intensities.
  • Avoid Rapid Acceleration Events: Activities like sprint racing and barrel racing can quickly spike lung blood pressure in the lungs, increasing the risk of severe bleeding. Limit these events and follow with adequate rest and recovery.
  • Plan for Recovery and Tapering: Avoid intense workouts on consecutive days. Alternating work and rest days across the week is ideal. Include rest days between hard sessions to allow lung tissue to recover. Additionally, taper the workload 3–7 days before competitions to support tissue repair and minimize bleeding risk.
  • Return to Work Gradually After Layoffs: After an EIPH episode or a break in training, ease the horse back into work. For breaks under a month, a 7–10-day gradual return is sufficient; for longer layoffs, reintroduce work progressively over a period equal to the duration of time off.
  • Structure Weekly Training: Aim for 3–4 days of cardiovascular (aerobic) training weekly to build fitness and maintain with 1–2 days per week. Limit session durations to 45–60 minutes. For strength and speed work, plan 2–3 days per week for gains, backing off to 1 day weekly for maintenance, using interval training as a safer option.
  • Incorporate Inspiratory Muscle Training: Consider using a mask with valve-controlled resistance to strengthen respiratory muscles. This can improve lung function while reducing strain.

By combining knowledge with smart exercise strategies, you can get your horse fit and competition-ready while minimizing the risk of bleeding associated with EIPH.

• • Minimize Risk Factors: Avoid hard ground, excessive frequency or duration of intense workouts, and situations that add strain, such as training obese horses, using heavy riders, and moderate- to high-impact activities (e.g., steeplechase, hurdling, and high-level jumping). Cold-air exercise (below 20°C) can also worsen EIPH. Consider tack adjustments, like bits and headgear, to reduce upper airway obstructions, and avoid training in extreme heat, which exacerbates airway inflammation.
  • Strategic Use of Treatments During Training: Apply treatment strategies not only during competition but also in training to prevent persistent inflammation and cumulative lung damage, extending the horse’s athletic career. Racehorses are three times more likely to bleed without Lasix. Plan training sessions so that a single dose of Lasix, paired with controlled water intake, may cover two sessions, as its effects can last beyond 24 hours. Since Lasix is particularly effective in reducing EIPH during fast acceleration or sprint-type exercises, reserve its use for these sessions to minimize side effects and reduced efficacy with repeated long-term use. Utilize FLAIR Strips for both sprint and endurance workouts, as they effectively reduce bleeding with both types of exercise and without side effects. Maintain continuous use of immunomodulating interventions to help control inflammation.

8. ADJUST COMPETITIVE SCHEDULE

• Extend Intervals: Prioritize lung health by allowing more time between competitions or races, focusing on gradual fitness gains rather than immediate performance boosts. Whenever possible, avoid high-dust environments like indoor arenas and avoid overloading the competition schedule. Travel thoughtfully by taking regular breaks to let the horse drink and lower its head to clear dust and debris from the lungs, helping to prevent inflammation. Although competition makes up only about 10% of a horse’s career, it’s often where the most severe lung damage occurs.
• Long-Term Benefits: A more spaced-out schedule reduces the recurrence of EIPH, supports lung recovery, and helps sustain performance over the long term.

PARTNER WITH YOUR VET

Each of these therapeutic modalities supports a multimodal approach to improve lung health, reduce EIPH severity, and extend your horse’s competitive career. Regular veterinary checkups can help you monitor EIPH progression, manage inflammation, and adjust treatments as your horse’s needs evolve.

1. WORK WITH YOUR VET FOR REGULAR MONITORING

• Routine Check-Ups: EIPH can worsen over time, so regular vet visits help track any progression and adjust treatment as needed.
• Catch Changes Early: Ongoing monitoring lets you adapt management strategies to meet your horse’s changing needs. Keep a training and competition journal for accurate documentation.

2. EMBRACE A TEAM APPROACH

• Coordination Matters: Working closely with your vet, trainers, and barn staff ensures that everyone is aligned on the best practices for supporting your horse’s health and performance.

While EIPH cannot be prevented, these management steps, combined with professional support, can help protect your horse’s lung health, manage symptoms, and extend their athletic career.