Are Asthma And COPD The Same Disease

I have read this in a few research articles. There are actually several theories attempting to explain asthma and COPD. One is that asthma and COPD are the same disease with different presentations. So, is it possible this theory is true?

I don't know. No one knows. And I bet the theory is not without many critics. However, if true it would certainly make sense. Consider the following: 

• Both diseases are caused by abnormal immune responses to substances in the air. With asthma its harmless substances like allergens. With COPD it's harmful substances such as chemicals released from burning biomass (tobacco smoke, wood smoke). 
• Exposure to certain substances causes oxidative stress. This stress causes cells to release substances like Reactive Oxygen Species. This triggers an immune response.
• In response, immune cells release pro-inflammatory markers. These are your prostaglandins, cytokines, and chemokines and the like. These cause your airway inflammation. 
• If you're always exposed to these substances, the inflammation becomes chronic over time. And here you get your eosinophilic inflammation in asthma and neutrophilic inflammation in COPD.
• Although there is some overlap. There are some asthmatics with neutrophilic inflammation and some COPDers with eosinophilic inflammation. 
• Eosinophilic inflammation responds best to beta adrenergics and corticosteroids. But, neutrophilic inflammation responds poorly to these treatments. It responds best to muscarinics. Other than that, there is not effective treatment for neutrophilic inflammation. 
• So, because it's treatable, those with eosinophilic inflammation can obtain good control of their disease (mostly asthma, but sometimes COPD). Since it is less treatable, those with neutrophilic inflammation often experience some degree of shortness of breath every day (mostly COPD, but sometimes asthma). 
• Some people with severe asthma have presentations similar to COPD. They may even have something now sometimes called Asthma/ COPD Overlap Syndrome (ACOS). However, some cases of severe asthma are not ACOS yet still present similar to COPD.
• There are 100 plus known asthma genes. Each asthmatic has a random assortment of these genes. This causes each asthmatic to present somewhat differently. There is only one known COPD gene. Still, less than 50% of people who smoke develop COPD. So, is it possible that all COPD is genetic just like asthma? And, is it possible that asthma genes are also those genes that cause COPD (it just has a unique presentation)? 
• Asthma genes are all immune genes that have mutations on them. These mutations cause a change in the recipe how that gene makes a specific protein. So, it seems it would make sense that the same genes might also cause COPD, another disease caused by abnormal or overactive immune response. 
• Some asthma genes are active when we are born. But, most are only activated when exposed to certain environmental factors (allergens, cigarette smoke, increases or decreases in female and male hormones, etc.). COPD is known to be caused by an immune response to harmful substances that are inhaled. So, is it possible that different "keys" unlock different asthma/ COPD genes? And this causes the uniqueness of the presentation. 

So, this is an interesting subject. I'm just giving you my extemporaneous thoughts on the subject. It's education guided by common sense. In the future I'm going to investigate this further and report my findings. 

COPD Resolutions You Should Keep

The following was written by me and published at healthcentral.com/copd on January 4, 2016

COPD Resolutions You Should Keep

A New Year's Resolution can be a powerful aide to helping you live well with COPD. Here are some we think would be perfect for you to choose from.

 

1.  Learn about your disease.  Both COPD and Asthma are complex diseases that researchers are learning more and more about every day. It's a good idea purchase a book so you can become a pseudo expert on your disease. Or, at the very least, continue to hang out at sites like this, as we do our best to keep you updated with the latest wisdom. This is also important because there are a lot of new respiratory medicines in the pipeline, and you'll want to be aware of them when they come out. Who knows, the next discovery might lead to a cure for our disease.

 

2.  Walk more frequently.  I recently wrote a post about titled, "9 Ways Exercise Improves Asthma Control."  You should go ahead and read that article (and then come back here), because the same is true for COPD. The more you exercise, the stronger your heart and lungs become, and the more efficient they become at pumping oxygen and nutrients through your body. This leads to better breathing.  As a bonus, it also improves your mood and your overall sense of wellbeing. Look, there are even victims of COPD who walk marathons.

 

3.  Join a pulmonary rehabilitation program.  This kind of goes along with walking more frequently. Pulmonary rehabilitation programs can help you get the exercise you need while educating you about your disease, and helping you meet others just like you to give you the support you need.  Actually, Pulmonary Rehabilitation is now a top-line recommendation for anyone with a COPD diagnosis, especially if you get winded doing normal routines (like going to the bathroom or brushing your teeth). Again, exercise makes your cardiovascular system work better, making you more tolerent to exercise.

 

4.   Eating healthier.  Look, many of us have difficulty maintaining a healthy weight. But if you have a breathing disorder, it's almost essential that you eat healthier.  Most experts recommend eating five or six smaller meals, rather than three large ones. The reason is that a full stomach pushes up on your diaphragm, making less room for your lungs to expand. You could try to do this on your own, or, better yet, you could have your doctor refer you to a dietician who can give you tips to healthier eating.

 

5. Eliminate carbonated beverages from your diet.  A good idea for any person with a lung disease is to lay off the pop and beer. For one thing, they can cause gas and bloating, and this causes your stomach to push up on your diaphragm making less room for your lungs to move.  They may also increase the carbon dioxide in your blood, which is chronically elevated in some COPD patients anyway. A good idea is to avoid them altogether, or at least limit your intake to one or two a day.

 

6.  Go on vacations.  Even if you need supplemental oxygen 24/7, the equipment is now so modernized you should be able to go anywhere. You can travel across the state to visit relatives you haven't seen in a while, or simply go on a vacation for fun (like to Disney World).  The idea here is that you can still keep living, you can still have fun, even with a chronic lung disease like COPD.

 

7.  Participate in a COPD community like ours.  The best place to learn about your disease is to hang out at communities like ours.  Here you will get the expert advice from doctors, nurses, and respiratory therapists like me.  We will educate you about your disease, provide tips to help you live better with it, and sometimeseven share our own stories. Along with experts like me, you will also meet other people living with it just like you. So feel free to hang out with us, sign up for our newsletters if you want, and have a Happy Easy Breathing New Year!

 

You May Also Enjoy Reading:

• 10 Tips to Living An Active Life With COPD
• Have COPD? Here's 6 Things To Keep Handy
• Maining Control Of Your COPD

Christmas-time COPD triggers

The following was written by me and published at healthcentral.com/copd on December 18, 2015.

8 Christmas COPD Triggers

In order to get the most out of the Christmas season, those of us with lung disorders have to be wary of Christmas asthma triggers. Here are those seven triggers along with some tips to help you get around them.   

1. Real Christmas Trees.  Christmas trees are a common decoration in homes during the Christmas season.  But they may also be filled with unseen substances that can get into the air, such as dust mites, pollen and mold spores.  When you carry them into your home, and shake them, these allergens end up in the air of your home for you to inhale, possibly causing flare-ups. While some experts recommend avoiding them altogether, others suggest that rinsing them off with water, and letting them air dry, prior to bringing them into your home should remove most of these allergens. It may be best, however, to delegate this job to someone else.

2. Artificial Christmas Trees. So, if real trees are full of COPD triggers, fake trees should be better, right? Well, experience shows this not to be the case.  Artificial trees may be fine the first time you set them up.  But after storing them in boxes in closets and basements, they become breeding grounds for dust mites.  When you open the box and put the branches on the tree, you’re inadvertently  freeing these microscopic critters into the air and inhaling them. The best solutionhere, other than avoiding them, is to rinse the tree off with water and letting it dry before setting it up. But this job should be delegated to someone other than you.  Another solution is to store your tree in an airtight container.  

3. Decorations. Dust mites are the culprits here too.  Decorations are stored in boxes in closets, attics, and basements.  Like fake trees, they become infested with dust mites.  One way to avoid this is to store decorations in plastic storage bins to keep dust mites out.  Another solution is to let someone else set up the decorations.

4. Visitors. Okay, so the greatest joy of the holiday season is spending time with friends and family. Still, visitors carry germs that can get you sick, and even a common virus (common cold) can cause a flare-up.  The greatest culprits here are little children, who love to share their germs through their sniffles and sneezes, but also their hugs and kisses.  We certainly recommend spending time with those you love, just make sure they know that their germs might take your breath away. As best you can, try to stay away from sick people. And, no matter who you’re spending time with, just note that the single best method of avoiding the spread of germs is by frequent hand washing with antimicrobial soap or hand sanitizer.

5. House Cleaning.  Of course part of the holiday season is getting your home ready for guests. While this may seem like no big deal, chemicals inside some cleaning supplies can act as rather potent COPD triggers.  Just make sure you are careful not to use cleaning supplies that may cause problems for you. One solution here is to simply stick with the cleaning solutions you’ve already been using. Or, better yet, let someone else do the cleaning.  

6. Scented Candles. Candles and incense can make your home smell good for the holiday season.  But it’s also good to remember that strong smells may also act as COPD triggers.  Likewise, smoke from candles and incense may also act as triggers.  It’s probably best just to avoid them altogether.

7. Wood Fires.  A fire in the fireplace can make a home feel very cozy for the holiday season.  The problem is that wood smoke in and of itself may trigger flare ups. Also posing a problem is the stack of wood next to the fireplace, which may contain mold spores and pollen. So it’s best to just avoid lighting the fire and keep the logs outside.  However, newer fireplaces can be lit by electricity or gas, and these should be fine.

8. Stress. So you’re known for shopping long hours searching for that perfect gift.  You’re known for spending hours decorating your home just right, and preparing the perfect meal.  These are things that can cause ongoing pressure during the holiday season, causing a rise in hormones that may weaken your immune system and cause flare-ups.  The best solution here may be to delegate some of the responsibilities that come with the holiday season to others.  And, chances are, they will be more than willing to help you.

Enjoy the holiday season!  So long as you are aware of them, these eight potential COPD triggers should not stop you from having a joyous holiday season. Here’s our opportunity to wish you and your family a Merry Christmas and a Happy New Year!

Further Reading

• MNT: Wood Smoke Exposure Multiplies Damage From Smoking, Increases Risk of COPD
• 7 COPD Winter Triggers
• 10 Tips To Living An Active Life With COPD
• Living With COPD: 10 Tips To Enjoy The Holidays 

6 Things COPDers Should Keep Handy

The following post was written by me and published at healthcentral.com/copd on November 4, 2015

Have COPD? Here's 6 Things To Keep Handy

Having a chronic disease like COPD means being prepared for that inevitable flare-up. This requires having easy access to all the tools needed to help you breathe better. Here are six things to keep handy at all times.

1.  Controller Medicines.  These are all the medications meant to keep you breathing well.  They usually include a combination of inhalers and nebulizer medications. They should be kept in a location that is easy for you to access, such as your medicine cabinet, or even your bedside or kitchen table. You must make sure you take these every day exactly as prescribed.  Not only are these meant to prevent flare-ups, they may also make inevitable flare-ups less severe and easier to control.  

2.  Oxygen equipment.  If you have oxygen at home, and you wear it all the time, you probably don’t have to worry here.  However, many who have home oxygen only wear it at night, or in times of trouble. This equipment needs to be in a very convenient location so you can get to it even when you feel like you can’t catch your breath.  Depending on the cause of your flare-up, many times oxygen alone can help you feel better.

3  Rescue medications.  These are the medicines -- like Albuterol and Xopenex -- meant to help you catch your breath. Inhalers can easily fit in your purse or pocket, but they are also easy to lose. Make sure you have a spare nearby.  If you take breathing treatments, you’ll need easy access to both the nebulizer, the air compressor, and the medicine to go with it.

4  Emergency phone numbers. These include the numbers to anyone who can help you decide what to do, or who can drive you to your doctor or to the hospital.  Numbers to include are your doctor, hospital, and caregiver.  This list will also tell emergency professionals who to call in the case of an emergency.  

5.  Directions.  So your doctor wants to see you at the office. When you can’t breathe, sometimes it’s hard to remember how to get places. Don’t just assume your caregivers know where to go.  Have addresses, and directions, easily available. Directions to the nearest hospital should also be included.

6  COPD action plan.  This is a plan to help you decide what action to take in the event a flare-up does occur.  Should you use your oxygen? Should you use your rescue medicine? Should you call your caregiver, your doctor, or 911?  It should also include emergency phone numbers and directions. An ideal place for this plan is on your refrigerator or on top of a table nearby where you spend most of your time.  You should also keep a copy in your wallet or purse.  This way anyone who cares for you has easy access to it.

Be prepared.  It’s normal to have trouble moving around, or to have trouble deciding what to do, when you’re having trouble breathing. This is why it’s so important to plan ahead and have readily available all the tools you or anyone else needs to help you breathe better.

Related Links:

• 10 Tips to Living An Active Live With COPD
• What Controller Medicine Works Best For You?
• What Is A COPD Action Plan?
• Do You Need Oxygen Therapy?
• What Is A Nebulizer?
• RT Cave Facebook Page
• RT Cave on Twitter

Learning Basic Lungsounds

The following was written by me and published at healthcentral.com/copd on January 25, 2016

Lungs 101: Learning Basic Lung Sounds

I have been listening to lung sounds for 20 years now, and every so often someone wants to know what I heard and what it means. That said, here is a pithy lesson on the five basic lung sounds and what they mean. 

First, however, a few definitions. 

Auscultation: The process of listening to lung sounds.  It can be done ear to chest, although most health professionals prefer to use a stethoscope. 

Stethoscope: It's a medical device used to auscultate (hear) lung and heart sounds.

Listening to lung sounds is an important part of assessing a patient. Based on what is heard can help a caregiver both diagnose and treat patients, and determine the progression of lung diseases over time. 

There are basically only five lung sounds.  You'd think that would make listening to them easy, but that's not always the case considering every patient is different. Regardless, here are the basic five and what they might mean.

1.  Clear.

This is a normal lung sound. It means the airways are open and air is easily moving through airways.

2.  Diminished.

This means that air movement is difficult to hear. It's quite common for COPD patients to develop diminished lung sounds, perticularly in the bases, or in the lower lobes. This is most commonly found when emphysema is present, as there is less lung tissue to move air. Of course it may also be due to a COPD flare-up where airways are obstructed by bronchospasm and increased secretions. This may indicate a need for a bronchodilator (like albuterol).

3.  Rhonchi. 

This is the sound of air moving through secretions.  It is a low-pitched, continuous sound that is best heard on expiration. Some describe it as coarse lung sounds, as it sounds coarse. Some say it sounds like snoring. It's usually lower than a wheeze because it's occurring in the larger airways.  It is also sometimes audible, and sometimes occurs with gurgling. Quite often rhonchi clears up with a good cough. Since this is common among COPD patients, we often teach methods to make a cough more effective.

4.  Wheeze. 

This is a high-pitched continuous sound heard on inspiration, expiration, or both. It's most commonly heard on expiration, though.  It is the sound of air moving past an obstruction in the airway. This can occur in the large airways or smaller airways.  An obstruction in the larger airways may produce an audible wheeze.  However, obstructions in the smaller airways, as what occurs with asthma and COPD, will cause a wheeze that can only be heard by auscultation.  Wheezing is a symptoms of bronchospasm, and may clear up after using a bronchodilator.

5.  Crackles. 

This is often described as a discontinuous sound, like the sound of velcro being torn apart. It usually needs a further qualification.

• Fine Inspiratory Crackles.  This is when the crackle is heard on inspiration. A cause might be the popping open of an air sac (alveoli) that had been collapsed. This is a common sound in the lung bases of people with COPD, and it can become a normal sound for them.  When crackles are heard in one lobe, this can be a sign of lobar pneumonia.
• Coarse Crackles (Rhales):  This is when crackles are heard on inspiration and expiration, and is the sound of air moving through fluid.  The fluid can be excessive secretions the patient is unable to cough up, or it could be pulmonary edema caused by heart failure. It means that the lungs are wet (the patient has wet lungs). Usually, but not always, this lung sound is heard on both sides of the lungs equally, as fluid is not prejudiced to one side of the lung. 

People with asthma should have clear lungmsounds when their asthma is controlled, and between asthma attacks. You can have clear lungs ounds with COPD too.  After using a bronchodilator, diminished lung sounds may become clear.

Or, sometimes, as airways open up, wheezing may occur. This we consider good, as it means air is moving better, and so wheezing can now be heard. So, you see, wheezing can be good, too. So auscultating before and after rescue medicine usage is one tool we have to determine if it's working (a peak flow meter is another such tool). Of course another tool is you, because you can just tell us that you feel better.

Pneumonia is a common complication of chronic bronchitis.  Fine inspiratory crackles can often be heard before pneumonia shows up on an x-ray, allowing your physician to start treating you early. As the pneumonia improves the crackles may go away. So, in this way, you can see how auscultating lung sounds can show how your illness is progressing over time.

Keep in mind that lung sounds are subjective, so every person may describe them somewhat different. Still, the basic principles are the same. It takes some practice to be able to hear and describe the different lung sounds. Nonetheless, I hope this post gives you a little better idea of what lung sounds are and what they mean. 

To hear the lung sounds described above you can check out practicalclinicalskills.com, "Auscultation Lesson." You can also check out UCLA's "Auscultation Assistant."

See More Helpful Articles

• Best Coughing Techniques For COPD
• What Is A Nebulizer?
• What Is Rescue Medicine
• What is a Peak Flow Meter?
• How Does Chronic Bronchitis Affect the Lungs?

The Benefits of Pulmonary Rehabilitation

The following was written by me and published at healthcentral.com/copd on January 11, 2016

Would Pulmonary Rehabilitation Benefit You 

Pulmonary rehabilitation is a top-line recommendation for patients with chronic obstructive pulmonary disease (COPD), and this seems to be true whether you have mild, moderate, or severe COPD. So what is pulmonary rehabilitation, and how might it help you?

It generally involves three elements:

1.  Exercise training.  Health experts show you what exercises are best for people with COPD, and the safest ways of doing them. Most programs meet once or twice a week for about 8 weeks. You may also be able to make arrangements to continue participating even after programs end. 

2.  Education. You will learn about your disease and the medicines used to treat it. You will learn how to properly use inhalers and nebulizers.  You will learn coughing techniques to help you remove secretions. You will learn how to conserve energy and reduce fatigue to help you make it through a day.  You will learn how to reduce anxiety and depression.  You may also learn how to quit smoking, if you still smoke.

3.  Psychological support.  Along with the experts, you will also meet others just like you who can help to support you on your journey, motivate you to stay on track in your efforts to easy breathing and living a quality life. Dieticians and psychologists are also often available if needed.

Why should you participate?  Studies (such as Lacasse et al) show that these programs help reduce dyspnea (shortness of breath, the feeling of air hunger) that results from physical exertion, and this in turn improves the quality of life.  This makes sense, considering other studies confirm that regular exercise, even if it's simply walking, makes your heart and lungs stronger, increases your energy, and reduces fatigue. Plus, the more you exercise the more tolerant to exertion you become over time. 

I recently wrote a post for asthmatics explaining the benefits of exercising called,9 Ways Exercise Improves Asthma Control—you should read that post, as all the benefits described also apply to anyone with COPD.

Who should participate?  Traditionally, pulmonary rehabilitation was only recommended if you were diagnosed with moderate or severe COPD.  However, the latest research suggests that it helps anyone with COPD live better with it, including those with the mild form.

The April, 2014, issue of RT Magazine has a nice article on this subject by Cristina Ja'come and Alda Marques, Pulmonary Rehabilitation for Mild COPD: A Systematic Review. They said that even those with mild COPD (or FEV1 of 80 percent or less) already show evidence of decreased activity level, which results in muscle loss that makes it increasingly difficult to stay physically active.

They discuss a review of studies performed on the subject, and concluded that "most of the pulmonary rehabilitation programs implemented in the included studies had significant positive effects on the exercise capacity and health related quality of life of patients with mild COPD.

However, and as usual, they say that further evidence will be needed to verify this finding. Still, it clearly seems that pulmonary rehabilitation benefits anyone with a COPD diagnosis.

Begin a pulmonary rehab program today.  The evidence clearly shows the benefits of pulmonary rehabilitation programs for anyone with COPD. They also benefit individuals diagnosed with other lung diseases, such as those with cystic fibrosis or severe asthma. So, if you haven't done so already, talk to your doctor about pulmonary rehabilitation. Chances are pretty good there is one available in your area.

You may also enjoy reading

• 8 Ways to Improve Quality of Life With COPD
• The Latest in COPD Treatments: Doctor Q&A
• 10 Tips for Exercising With COPD

Living Longer with End Stage COPD

The following was written by me and published at healthcentral.com on October 6, 2015.

9 Ways to Live Longer with End Stage COPD

End Stage COPD, also known as Severe COPD or Stage IV COPD, severely limits your airflow, making it hard to perform any basic activities. At this stage you may have also developed Cor Pulmonale or Congestive Heart Failure. While your quality of life may be limited, this is not a death sentence—there are still ways to live in the "end stage." You may, however, have to alter your life to adjust, starting with...

Quit Smoking. Studies show that quitting smoking, even in the late stages of the disease, is the most effective way of prolonging life. This is why your doctor will encourage smoking cessation even in the later stages of disease -- if you haven’t quit already.  

COPD Action Plans. These are agreements you create with your doctor to help you decide what actions to take when you feel symptoms.  Read my post “What Is A COPD Action Plan?”  The key to these plans is that it is essential that you take action sooner rather than later.  The earlier you seek help for flare-ups, the easier it will be to fix you and to get you back home.

Drug Therapy. As the disease progresses, most people with COPD benefit from a combination of medicines.  Bronchodilators and anticholinergics open airways and keep them open long term. Corticosteroids reduce inflammation to keep airways open to prevent and treat flare ups. Anxiolytics are useful for treating and preventing anxiety, and to assure adequate sleep at night. Opiates are useful for relieving the feeling of air hunger (dyspnea). While poor lung function in COPD cannot be reversed, studies suggest a combination of these medicines can help you take a deeper breath and reduce the feeling of dyspnea.

Oxygen Therapy. If resting oxygen levels are low, supplemental oxygen should be worn to maintain safe oxygen levels.  

Oxygen is the only drug proven to prolong life.

Noninvasive Positive Pressure Ventilation (such as CPAP and BiPAP). This is a pressure supplied to your airway by a mask.  It’s usually only worn while you are sleeping, because that’s when your breathing is most relaxed. CPAP supplies a pressure on inspiration and expiration to keep your airways patent and to assure adequate oxygenation.  BiPAP supplies CPAP plus a pressure on inspiration to assure you take deep enough breaths to blow off carbon dioxide.

Pulmonary Rehabilitation. Other than quitting smoking and wearing your oxygen as prescribed, this might be the most important part of any treatment program.  Such programs keep you in touch with experts who specialize in training you how to obtain proper exercise, conditioning, nutrition, and coping skills. It also keeps you in touch with others like you who will motivate you to stay fit and active so you can keep up your strength.

Nutrition. You may need to see a dietician to learn how to eat properly with COPD.  Most experts recommend that you eat smaller meals with increased frequency, as opposed to three larger meals. There may also be other tips a dietician can give you to help you keep up your strength and live better with it.

Education.  Educators, which may include your doctor, nurse, respiratory therapist, physical therapist, or rehabilitation specialist, will teach you about your disease and the importance of sticking with your agreed to treatment regime.  They will assure you that the best way to live long and well is to be the gallant COPD patient who stays positive and does everything right.

Follow-up.  The end stages of this disease are when most hospital admissions occur.  Recent efforts by hospitals have focused on following-up with COPD patients after they are discharged to assure they are being compliant with their treatment programs, as compliance is the key to staying well.  Early studies suggest these programs are effective in preventing recurring flare-ups and readmissions.

Bottom Line.  The fact that people are living longer with End Stage COPD is just the beginning—the quest to find better options to help the nearly 13 million people living with it breathe better is ongoing.

See More on This Topic:

• Recommendations for End-of-life Care for Patients with COPD
• 10 Ways COPD Affects The Heart
• Common COPD Co-Morbidities
• When to Seek Help for COPD
• RT Cave Facebook Page
• RT Cave on Twitter

Learning about end stage COPD

The following post was written by me and published at healthcentral.com/copd on September 29, 2015.

What is End Stage COPD?

So you, or a loved one, have been diagnosed with End Stage COPD.  What is this, and what does it mean for you or your loved one?

First off, it must be understood that there is no generally accepted clinical definition to End Stage COPD. What it means for one physician may not mean the same thing for another.  In fact, The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines "severe COPD," but it does not even mention the phrase “End Stage COPD.”

That said, here is what End Stage COPD might entail, if this term is used by your doctor.

Stage IV COPD or Severe COPD. What is it?

• Severe airflow limitation, meaning it’s very hard to blow out a candle
• FEV1 during pulmonary function testing (PFT) will be 30 percent or less. Unlike asthma, this does not improve with medicine. However, medicine can help you take a deeper breath and reduce the feeling of dyspnea (air hunger).
• You get winded (short of breath, dyspnea) with minimal exertion, meaning you may get winded going to the bathroom, or even brushing your teeth.
• You have trouble engaging in activities, meaning you might have to skip out on that birthday party or wedding.
• You have frequent flare-ups, that sometimes require hospitalizations.
• You take a variety of medicines to keep your airways open.
• You require supplemental oxygen, probably around the clock.
• You may require CPAP to keep your airways open while you are sleeping.
• You may require BiPAP to assure you take deep enough breaths, and to assure you are adequately oxygenating while you are sleeping..
• You may have other ailments with it, such as frequent pneumonia, heart failure, osteoporosis, depression, anxiety, and hypertension.

 Others will diagnose it when you develop Cor Pulmonale and Congestive Heart Failure.

Cor Pulmonale. This is when the right side of your heart becomes enlarged after years of working hard to pump blood through diseased lungs. This makes it a weaker pump.

Congestive Heart Failure (CHF). With COPD, this usually begins with cor pulmonale. When the left side of the heart becomes too weak to pump blood through the lungs, this leads to left heart failure or CHF. This is when the heart is too weak to pump blood through the body, so blood pools in the ankles causing pedal edema. This can also lead to pulmonary edema, or fluid backed up in the lungs, making it hard to breathe. To learn more, read my post on How COPD Affects the Heart.

CHF may cause COPD flare-ups, or exacerbate them. Thankfully, modern medicine can both prevent and treat flare-ups caused by heart failure.  Still, once a diagnosis of heart failure is made, this is often considered the end stages of COPD.

Some, however, suggest that providers and caregivers avoid using phrases such as "End Stage COPD" and "Advanced Stages of COPD" altogether.

Okay, so what does this mean for you or your loved one? As Jane Martin once wrote for us, “Being told you have ‘end-stage COPD’ is not a death sentence. There is a lot you can do, and you can live a long time.”

She is right: it is not a death sentence. However, it’s your doctor’s job to tell you when he thinks your disease has progressed to this point.  It’s a way of saying: “Hey, this is it. If you want to continue living, and if you want to have some quality in your life, you are really going to have to work at it." 

I will describe some things you can do to live longer with End Stage COPD in my next post.

See more articles like this one:

• GOLD: Pocket Guide to COPD Diagnosis
• ERJ: Series on comprehensive management of COPD
• NCBI: Exacerbation rate, health status and mortality in COPD -- a review of potential interviews
• 10 Ways COPD Affects The Heart
• End Stage COPD: What is it? What does it mean?
• Common COPD Co-Morbidities
• Breaking Down a PFT
• RT Cave Facebook Page
• RT Cave on Twitter

What is Emphysema?

The following was originally published by me at healthcentral.com/copd on on September 2, 2015

What is Bullous Emphysema?

Essentially, emphysema starts in the lung parenchyma, which consists of the small bronchi, alveoli, and capillaries. For a quick review of pulmonary anatomy, see take my journey down the respiratory tract.

Alveoli. These are small balloon-like structures that inflate like balloons when you inhale. After full inhalation, elastic recoil allows them to resume their natural shape, allowing exhalation to occur. They join with capillaries, so it’s here gas exchange occurs.

Emphysema. Certain conditions -- like smoking -- cause alveolar walls to become inflamed and breakdown.  They lose their elasticity, or their ability to regain their normal shape after a full inhalation. They eventually rupture, creating small air spaces. This also destroys surrounding capillaries, creating alveoli that no longer participate in gas exchange.  So emphysema is the gradual, progressive loss of lung tissue.  

Barrel Chest.  Lacking elastic tissue, alveoli lose the ability to contract during exhalation.  When the elastic tissue of enough alveoli are destroyed, these portions of the lungs expand all the way to the ribcage.  This gives the appearance of having a chest full of air even after fully exhaling.

Airflow Limitation.  When lungs are fully expanded this way, pressure is put on small bronchi causing them to become narrow.  This causes increased resistance to air flowing through airways during both inspiration and expiration, slowing the flow of air. This is airway obstruction that does not respond to rescue medicine.

Prolonged Expiration.  During exhalation, pressure inside the chest increases, thereby squeezing the airways, causing even more resistance to airflow.  This causes a prolonged exhalation.  Expiratory airflow may be so limited that you cannot blow out a candle.

Air Trapping.  The inability to exhale completely causes air to become trapped inside your lungs.  In other words, air can more easily get in than out. This may also add to the appearance of a barrel chest.

Bulla (Bullae).  As more lung tissue is destroyed over time, this creates one large air space rather than many smaller ones. These air spaces are called air pockets, blebs, or bullae, and range in size from 1-20 cm across. When representing greater than 30 percent of a hemithorax (half of the chest) they are considered giant bullae. They are diagnosed either by chest X-ray or CT.

Bullous Emphysema.  Bullae were first reported in 1937 by Burke in a 35-year-old man who had progressively worsening shortness of breath. He referred to it as Vanishing Lung Disease because the lungs appeared to be disappearing on X-ray. While bullae may occur spontaneously in young men, they may also be associated with emphysema.

Symptoms. Even giant bullae may present with no symptoms. However, as bullae expand they may take up too much space and compress surrounding lung tissue, inhibiting otherwise functional airways from distributing air. This may result in progressively worsening shortness of breath, chest pain, and low oxygen levels.

Complications.  Bullae may become infected and cause an abscess to form that may leak out into the pleural cavity causing empyema, a painful infection that may cause worsening shortness of breath. Bullae may rupture or pop, allowing inhaled air to escape into the pleural cavity that surrounds the lungs. This causes respiratory distress, sharp chest pain, and anxiety.  

Treatment. Generally, this is no different than for typical emphysema, and includes:

• Quitting smoking (slows progression of the disease)
• Controlling COPD triggers (prevents flare-ups)
• COPD Medicines  (prevents and controls flare-ups)
• Pulmonary rehabilitation. (to maintain quality of life)
• Chest tube (necessary if pneumothorax occurs)
• Antibiotics (necessary if lung infections occur)
• Bullectomy (if symptoms become severe)

Bullectomy. This is when the bullae is surgically removed, allowing surrounding alveoli to re-expand, once again become functioning gas exchange units. Surgery will not cure the emphysema, but has been shown to greatly reduce symptoms and improve quality of life, if you qualify.

What to do. American Thoracic Society COPD Guidelines suggest that most people with COPD have enough good alveoli that they do not need surgery, or have too many smaller bullae to benefit from surgery. So the most logical choice for most patients with bullous emphysema is to continue working with your doctor to maintain good control of your COPD.

Further reading and References:

• Respiratory Care: Principles and Practice, 2016, page 815
• AAPI Journal: A Rare Case of Vanishing Lung Syndrome
• Chest: Surgical Treatment of Bullous Emphysema
• Thoracic Surgery: Blebs, Bullae, and Spontaneous Pneumothorax
• Boston Medical Center: Bullectomy
• ATS: COPD Guidelines
• RT Cave Facebook Page
• RT Cave on Twitter

My Best Asthma/ COPD Posts for 2015

The following was written by me and published at healthcentral.com/asthma on December 21, 2015

Looking to improve your repiratory health in the new year? As one of HealthCentral's health guides,  I was asked to write an article with a list of my best articles going forward into 2016, with an explanation of why I chose each one and why it’s important to respiratory health readers.

Here are my picks for the best respiratory health articles from 2015: 

1.  The Natural Progression of COPD. This is probably the most important article I’ve ever written, and I refer to it every time I’m encouraging my patients to quit smoking. I discuss the Fletcher-Peto Curve.  It’s a telling visual for anyone with COPD because it shows that smoking speeds up the progression of the disease, and that quitting smoking at any age slows the progression of the disease, thus prolonging life.  

2.  Smart Inhaler the Future of Asthma Control. This article is neat because it shows how far technology has come to helping people live better lives. Smart inhalers have special sensors that track when you use your inhaler and the quality of the air around you. Doctors can track this data on their computers and send you messages on your smartphone with tips to help you breathe better. The system can even send reminders to use your inhaler.  This is a very impressive system.

3.  What Are Asthma Subtypes And Groups?  Researchers learning so much about our disease (which is actually now called a syndrome) it’s simply amazing. Now they understand that asthma is a heterogenous disease, which means that all asthmatics are different, and should be treated different. By breaking asthma into different subtypes, researchers should be able to create guidelines specifically tailored to you to help you breathe easier.  This is compared with the old system where one set of guidelines were created that treated all asthmatics the same.  

4.  What is Severe Asthma? This is just one subtype, but an important one. Researchers observed that about 10 percent of asthmatics do not respond to conventional asthma medicines. Now they understand that this is because these asthmatics develop certain airway changes similar to patients with COPD. Now that this subtype is recognized, researchers are working overtime to learn more about it and to find treatment options to help these patients breathe easier and live better lives.  

5.  Do You Need Oxygen Therapy? and Understanding Oxygen and Oxygen Levels With COPD. Did you know that oxygen is the only drug proven to prolong life? It’s true. If your body is not getting the oxygen it needs, it causes your heart to work harder to pump blood through your body, and you become increasingly winded.  Inhaling a small amount of oxygen is sometimes all that’s needed to ease the work your heart has to do, thus making your breathing easier and prolonging your life.  

6.  Should You Join An Asthma Study?  Researchers are working overtime to learn more about asthma so they can come up with solutions to help us live better with it.  In order to make this work they need to study those of us who have it.  If you have time, it’s important for you to volunteer some of your time (and maybe some of your sputum) for the good of the cause. Future asthmatics are counting on you.

7.  Links Between Asthma and Genetics. I love writing articles explaining what researchers are learning about our disease, even if that means sifting through complex “law-like” material and spending hours and hours doing research.  Of course then I have to simplify it so it’s easy to read and understand. I do this because I’m passionate about understand my disease, and I love to share what I learn.  It’s fun, and as long as I can still breathe I’m going to continue writing posts like this.  

What not to say to end stage COPDers

Sort of a touchy subject for physicians is dealing with end of life issues. We respiratory therapists see this quite often, particularly when it comes to end stage COPD.  We have patients who are at the extremes of the limits of what medicine can offer them.  While we have to somehow manage to help them keep up their spirits and live somewhat normal lives, we also have to be honest with them. 

This subject was recently brought up at the COPD.net facebook page when a patient wrote: 

"I'm a 66 yo just had my Dr tell me there is nothing else I can do or take to improve or even stay where I am. Working that through before my next lung evaluation in 2 weeks."

A similar comment I once heard was:

"You have two weeks to live." 

Another similar comment was:

"If you go home you're gonna die."  

Now, how does a physician know when a patient is going to die?  Surely you don't want patients thinking they are going to miraculously get better. Still, you don't want to deflate all  hope either.

In fact, the last time I heard a physician tell a patient with end stage COPD that he only had a few weeks to live, that patient went on to live two a few more years. Surely he lived within the limits of COPD, but he was still able to do things.

The patient who was told by one doctor he was going to die if he went home became very confused and depressed.  This only added to his problems.  I assured him that if he is a gallant COPD patient, takes all his medicine exactly as prescribed, wears his oxygen 24-hours-seven-days a week, and wears his BiPAP at night, that he has a very good chance of gaining a few more quality years.

This seemed to cheer up this patient.  The next day I worked he was breathing so much better that he was euphoric.  He was back to enjoying Westerns and telling jokes that made us all laugh.  He was breathing a whole lot better and feeling alive again.

The patient who was told there was nothing else he could do was advised by us COPD.net moderators to seek a second opinion, preferably that of a pulmonologist.  He has since informed us that this is exactly what he expects to do at his next appointment.

As healthcare providers, we must be aware that we are caring for people, not just objects on assembly lines. We must be honest with our patients, but not in a way that deflates their will to live.

Most Aerosolized medicine is wasted

According to the American Association of Respiratory Care's "Guide to Aerosolized Medications," not much of the medicine inhaled by inhalers and nebulizers makes it into airways.

By device, here's how much medicine reaches the lungs?

• Metered Dose Inhalers:  9%
• Metered Dose Inhalers with spacer:  15%
• Small Volume Nebulizer:  12%
• Dry Powdered Inhaler:  13%

So that means that most of the inhaled medicine, or a whopping 85-91% depending on the device used, "is lost in the oropharynx, the device, the exhaled breath, and the environment," according to the guidelines.

When a patient is intubated the percentage of medicine getting to airways is 2.9%, according to one study. 

It appears that the best distribution into the airway is obtained by inhaler and spacer.  Of course, this would only be possible if good technique is used.  Considering studies show that up to 93% of asthmatics do not correctly use their inhalers (93% to be exact), this kind of knocks inhalers and inhalers with spacers down to a level playing ground with nebulizers.  

While some might panic at these percentages, one should not worry. Pharmaceutical companies are well aware these when the formulate their dosing criteria.  So chances are that, regardless of the route used, most patients get plenty of medicine for maximum effect. 

Plus, it must be considered that 2.5 mg of albuterol solution mixed with 3cc of normal saline contains about twice as much ventolin as in the 200 mcg of albuterol inhaled via an inhaler.  So, again, patients are getting plenty of albuterol, and probably more than enough when an SVN is used. 

So who wins the battle of inhalers vs. nebulizers?  Well, as far as distributing medicine to airways, they all work equally well.

This post was originally published on March 11, 2010.  It has been edited for accuracy by Rick Frea.  

Further reading:

• When do you end a breathing treatment?
• Aerosolized delivery in intubated, mechanically ventilated patients, Critical Care Medicine, Feb., 1985, MacIntyre, et al
• AARC: Guide to Aerosolized Medications
• Respiratory Care Principles and Practice, 2nd edition, 2012, page 316, edited by Hess, et al
• Aerosols in Critical Care, by James Fink, April, 2009, slideshow
• Most people don't correctly use their inhalers
• RT Magazine: Nebulizers VS Inhalers: And The Winner Is?

Here's how NIV benefits CO2-retaining COPD patients

I often tell my patients that nothing I do cures any ailment.  To the contrary, I tell them that the procedures I perform treat acute symptoms, while the doctor and nurse do other things that will provide the cure.

A perfect example of this is with noninvasive ventilation (NIV) for treatment of acute respiratory distress due to chronic obstructive pulmonary disease (COPD). Savi et al, 2014, notes the following:

Noninvasive ventilation benefits patients with COPD, and it seems reasonable to expect that NIV would increase tidal volume and improve CO2 elimination, and thus reduce respiratory drive.

The note the studies have proven that NIV results in the following when used on COPD patient's presenting to the emergency room with flare-ups:

• Reduction of treatment failure
• Lower mortality
• Fewer complications
• Lower Intubation rates

However, the studies also conclude that:  "In these patients CO2 elimination is increased but overall ventilation-perfusion mismatch is not changed during NIV. 

What does improve ventilation, the authors note, are the following:

• Treating precipitating factors (eg, infection with antibiotics)
• Increase expiratory flow (eg, with beta agonists)
• Reduce pulmonary inflammation (eg, with corticosteroids)
• Manage gas exchange (eg, improve oxygenation)

Without NIV, studies have shown, patient's who have COPD with CO2 retainers should receive an FiO2 just enough to maintain an SpO2 of 88-92%, as higher FiO2s (either due to the loss of hypoxic drive, or V/Q mismatching) have been shown to cause a rise in PaCO2.  

However, this effect is negated with NIV.  Savi et al concludes:

During NIV with an FiO2 sufficient to maintain a normal PaO2, a further increase in FiO2 does not result in an increase in PaCO2 in CO2-rataining COPD patients, since no changes occur in (minute ventilation).

Crossley et al had similar results, concluding, that "CO2-retaining COPD patients following a period of mechanical ventilation with PaO2 in the normal range can safely receive supplemental oxygen without retaining CO2 or a depression of respiratory drive.  A new ventilation-perfusion relationship is established during ventilation to normoxia, and it is not altered by further increasing FiO2," Savi et all reports.

Since NIV helps COPD patients take deeper breaths, thus improving their ventilation (allowing them to blow off CO2), high levels of oxygen do not cause rising PaCO2 levels while a patient is receiving NIV therapy.  However, we often find that, while using NIV, many patients require less oxygen compared to prior to the NIV start.

Bottom line:  NIV is beneficial to CO2-retaining COPD patients because it increases their tidal volume, increases CO2 elimination, and reduces their drive to breathe.  By treating these symptoms, caregivers are provided an opportunity to do whatever is necessary to treat the cause of the exacerbation (even if that means utilizing higher oxygen levels).

References:

1. Savi, Augusto, Jucara Gasparetto Maccari, Tulio Frederico Tonietto, Ana Carolina Pecanha Antonio, Roselaine Pinheiro de Oliveira, Marcelo de Mello Rieder, Evelyn Cristina Zignani, Emerson Boschi da Silva, and Cassiano Teixeira, "Influence of FiO2 on PaCO2 During Noninvasive Ventilation in Patients With COPD," Respiratory Care, March, 2014, volume 59, number 3, pages 383-387

Oxygenating with home BiPAP and CPAP machines

When using a ventilator, either for mechanical ventilation or noninvasive ventilation, a fixed FiO2 is set during ventilatory support. This is the best way of supplying supplemental oxygen to patients, especially because it may be adjusted to maintain a desired saturation.

However, when using a patient's home noninvasive ventilation equipment, either set up for BiPAP or CPAP, oxygen is typically placed directly into the circuit using a constant flow.  When this occurs, the amount of oxygen actually inhaled depends on a variety of factors:

• Oxygen flow
• Leakage
• Circuit
• Interface (face mask, nasal mask, etc.)
• Location of where oxygen is bleed into the system

Studies are still inconclusive as to where the best place to insert the oxygen into the system.  Some therapists place it near the machine, while others place it near the patient interface.  Ideally, the oxygen flow should be adjusted to maintain a desired Spo2.  This may be important for patients who are using their home units in the hospital setting.  

For patients who present in acute respiratory failure, when adequate oxygenation is not obtained with a patient's home unit, a ventilator (which may include a noninvasive ventilation device such as a Vision or V60) should be used in order to deliver a fixed FiO2 that can be easily adjusted to maintain an adequate SpO2.

References:

1. Storre, Jan H, Sophie E. Huttmann, Emelie Ekkernkamp, Stephan Wlterspacher, Claudia Schmoor, Michael Dreher, and Wolfram Windisch, "Oxygen Supplementation in Noninvnasive Home Mechanical Ventilation: The Crucial Roles of CO2 Exhalation Systems and Leakages," Respiratory Care, January, 2014, volume 59, number 1, pages 113-119

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