SHORTNESS OF BREATH, TIGHTNESS IN THE CHEST, wheezing, persistent coughing, and thick mucus: if you have chronic lung disease, these symptoms may be all too familiar. When your lungs aren’t working well, you may have trouble getting enough oxygen to your organs, and you may not be able to get rid of unhealthy waste air containing carbon dioxide. There are many types of lung disease; the most common are asthma, chronic bronchitis, and emphysema. In each of these diseases there is something getting in the way (an obstruction) of the airflow in and out of the lungs. Chronic bronchitis and emphysema are often referred to as chronic obstructive pulmonary disease (COPD). Although asthma, chronic bronchitis, and emphysema can be described separately, many people have a mixture of these diseases. Self-management and treatment of these conditions are similar and often overlap.
Special thanks to Cheryl Owen, RN, Karen Freimark, and Roberto Benzo, MD, for help with this chapter.
Understanding Asthma
Asthma is caused in two ways: by a tightening of the muscles in the walls of the airways known as bronchospasm and by inflammation and swelling of the airways (see Figure 15.1). The airways (bronchioles) are very sensitive, and when exposed to irritants such as smoke, pollens, dust, or cold air, the muscle contracts, and the airway narrows (see Figure 15.2). As the airway narrows, the flow of air is obstructed or blocked. This causes an “asthma attack” or flare-up characterized by shortness of breath, coughing, chest tightness, and wheezing (a high-pitched whistling sound as air pushes through narrowed airways). Treatment is aimed at relaxing the temporarily tightened airway muscles.
The irritants (sometimes called triggers) also cause inflammation of the airways. When this happens, the airways swell and produce mucus. To make things worse, chemicals are released from the lining of the airways that make them even more sensitive to irritants. This sets up a vicious cycle leading to more bronchospasm and more inflammation.
An acute flare-up of asthma can be treated with medications that relax the muscles in the airways (bronchodilators), but that may not be enough. Effective treatment also includes avoiding irritants and the use of anti-inflammatory medications such as corticosteroids or cromolyn. These medications reduce the swelling, inflammation; and excessive sensitivity of the airways. To prevent attacks, you should avoid irritants, not smoke, and avoid secondhand smoke. If cold brings on symptoms, you should cover your nose with a scarf in cold weather and not exercise outside. In addition, you may need to take anti-inflammatory medications even when you have no symptoms.
Figure 15.1 Normal Lungs
Figure 15.2 The Bronchiole or Small Airway
Asthma varies greatly from person to person. Symptoms may consist of mild wheezing or shortness of breath at night (asthma symptoms tend to be worse during sleep). The attacks may be mild and infrequent or severe and life-threatening. Asthma can usually be managed, but you must be an active partner. Learn your triggers and avoid them. Take action to prevent symptoms and acute attacks. Your health care provider may also teach you to monitor your lung function. Develop a plan with your doctor to recognize and treat symptoms. Learn how to breathe effectively and exercise properly. Although these measures cannot completely cure or reverse the disease, they can help you reduce symptoms and live a full, active life. By taking an active self-management role, you should be able to participate fully in work and leisure activities, sleep through the night without coughing or wheezing, and avoid urgent visits to the doctor or emergency department.
Understanding Chronic Bronchitis
In chronic bronchitis, the walls inside your airways become swollen and thick. This inflammation narrows the airways and interferes with breathing. The inflammation also causes the glands that line the airways to produce large amounts of thick mucus. The results are often a chronic cough that produces mucus (sputum) and shortness of breath.
Chronic bronchitis is primarily caused by smoking or inhaling secondhand smoke. Air pollutants, dust, and toxic fumes can also be causes. These keep the airways inflamed and swollen. The key to management is to stop smoking, stay away from smokers, and avoid other irritants. If this is done, especially early in the disease, you can often prevent it from becoming worse. If you have chronic bronchitis, you should get an influenza (flu) vaccine shot once a year and a onetime pneumococcal pneumonia vaccine as well. If you have a respiratory condition or are above age 65, you may need a second pneumonia vaccination. You should also avoid exposure to anyone with a cold or flu; these infections can make bronchitis much worse. Your doctor may also recommend the use of medications to thin and liquefy mucus as well as occasional treatment with antibiotics if symptoms get worse (increased cough with yellow-brown sputum, increased shortness of breath, fever).
Understanding Emphysema
In emphysema, the tiny air sacs (alveoli) at the very ends of the airways are damaged (see Figure 15.1). The air sacs lose their natural elasticity, become overstretched, and often break. If the air sacs are damaged, it is harder for your blood to get oxygen and to get rid of carbon dioxide. The tiniest airways also narrow, lose their elasticity, and tend to collapse when you breathe out. This traps the stale air in the air sacs and prevents fresh air from coming in.
A large amount of lung tissue can be destroyed before there are any symptoms. This is because most of us have more lung capacity than we need. However, eventually the lung capacity is lessened to the point where you begin to notice shortness of breath with activity or exercise. As the disease progresses, the shortness of breath becomes worse with less activity. It may be present even at rest. You may also have a cough that produces mucus.
Smoking and secondhand smoke are the major causes of emphysema. Cigarette smoking is the most common and most dangerous cause, but cigar and pipe smoking are also damaging. Even if you do not smoke, daily exposure to secondhand smoke is almost as bad. It is important that your home, car, and workplace be smoke-free. There is also a rare hereditary type of emphysema caused by not having enough of an enzyme that protects the elastic tissue in the lungs.
Emphysema tends to get worse over time, especially if smoking continues. The key to prevention and treatment is avoiding all smoking. Although quitting smoking sooner rather than later is better, quitting at any stage of the disease can help preserve remaining lung function. People with emphysema can learn a variety of self-management skills, from proper breathing to exercise. These will help them lead an active life. Medications and oxygen can sometimes be helpful in emphysema. We describe these later in this chapter.
Asthma, chronic bronchitis, and emphysema most often overlap, so you may have one or more of them. You may have pulmonary function tests (PFTs or spirometry tests) to evaluate your lung problem and the types of treatment that might help you. Although the treatment varies somewhat depending on the specific symptoms and disease, some of the principles and strategies of management are similar. Let’s take a look at some self-management tools that are specific for chronic lung disease.
Avoiding Irritants and Triggers
The best way to manage chronic lung disease is to avoid the things that make it worse. Several irritants can trigger the symptoms of asthma and worsen the symptoms of other chronic lung disease. Fortunately, you can get rid of or avoid most of these.
Smoking
Smoking is the main cause of chronic bronchitis and emphysema and a major trigger of asthma. Whether you smoke yourself or are around people who smoke, smoking irritates and damages the lungs. The hot smoke dries, inflames, and narrows the airways. The poisonous gases paralyze the cilia, the tiny hairlike “sweepers” in your airways that help clean out dirt and mucus. The carbon monoxide in cigarette smoke robs your blood of oxygen and makes you feel tired and short of breath. The irritation from smoking makes infections more likely. This same irritation can irreversibly damage the air sacs in your lungs. Unfortunately, once air sacs are destroyed, they cannot be repaired. The good news is that most of these harmful effects can be eliminated by quitting smoking and by avoiding secondhand smoke.
If you have tried to quit and failed, do not give up. This is a common experience. Get help. Ask your health care professional or insurance plan about what can be done to help you quit smoking. This is not something you have to do on your own.
Air Pollution
Car exhaust, industrial wastes, household products, aerosol sprays, and wood smoke can irritate sensitive airways. On particularly smoggy days, check your radio and TV for air pollution alerts, and stay indoors as much as possible.
Cold Weather or Steam
For some people, very cold air can irritate the airways. If you can’t avoid the cold air, try breathing through a cold-weather mask (available at most drugstores) or a scarf. For some people, steam, as from the shower, can also be a trigger.
Allergens
An allergen is anything that triggers an allergic reaction. If you have asthma, an attack may be triggered by almost anything, indoors and out. Avoiding your allergens completely can become a full-time job. Still, a few sensible measures significantly reduce exposure.
To avoid outdoor allergens, close the windows and use an air conditioner when pollen and mold spore counts are high. For some people the major allergic triggers are found indoors, in the form of house dust mites, animal dander, and molds. Often pets (dogs, cats, and birds) must be banished from the house or at least from bedrooms. Bathe dogs and cats weekly to reduce allergens. House dust mites tend to live in mattresses, pillows, carpets, upholstered furniture, and clothing. If this is a problem, vacuum your mattress and pillows and then cover them with an airtight cover. Wash bedding, including blankets and bedspread, weekly in hot water; avoid sleeping or lying on upholstered furniture; remove carpets from the bedroom; and if possible, avoid dusting and vacuuming and use a damp mop instead. Change heating and air-conditioning filters each month. Avoid air cleaners that produce ozone; these can make asthma worse. All of this takes time, but in the long run the effort will pay off.
Asthma symptoms can be triggered by perfumes, room deodorizers, fresh paint, and some cleaning products. Sometimes indoor air cleaners can be helpful in reducing allergens in the air.
Foods can be triggers for some people. The worst offenders are peanuts, beans, nuts, eggs, shellfish, and milk products. Food additives (such as sulfites in wine and dried apricots) can also sometimes trigger asthma symptoms.
If you cannot identify your triggers, allergy testing may be helpful. Immunotherapy (“allergy shots”) may also help desensitize some people to certain allergens.
In addition to breathing problems, some people with respiratory conditions also have gastric reflux. This happens when acid from the stomach backs up and irritates the esophagus and airways. This may or may not cause heartburn symptoms. The irritation of the airways may cause coughing or trouble breathing. Treatment of reflux includes keeping your head and chest elevated when sleeping; avoiding smoking, caffeine, and foods that irritate the stomach; and when necessary, taking antacids and acid-blocking medications.
Medications
Some medications, including anti-inflammatory medications such as aspirin, ibuprofen (Advil), and naproxen (Naprosyn, Aleve) and beta-blockers such as propranolol (Inderol), can cause wheezing, shortness of breath, and coughing. ACE-inhibitor medications (lisinopril, benazepril) often used to treat hypertension and congestive heart failure and protect the kidneys in diabetes can also cause a dry, tickling chronic cough. If you suspect that you have symptoms related to a medication, do not stop your medication, but do talk to your health professional about it soon.
Infections
For individuals with lung problems, colds, flu, sinus infections, and infections of the airways and lungs can make breathing more difficult. Though you can’t prevent all infections, you can reduce your risks. Be sure to get your flu and pneumonia shots. Try to avoid people with colds, wash your hands frequently, and don’t rub your nose and eyes. Talk with your doctor about how to adjust your medications if you get an infection. Early treatment can often prevent serious illness and hospitalization.
Exercise
Exercise can be a problem or a benefit for people with chronic lung disease. On one hand, physical activity can improve strength and enhance the capacity of the heart and lungs. On the other hand, vigorous physical exercise can trigger asthma symptoms and cause uncomfortable shortness of breath in people with chronic lung disease. There are ways to choose exercise routines (see pages 254–256) and to adjust your medications before exercising to prevent exercise-induced asthma. If being able to exercise comfortably is a problem, discuss this with your physician.
Emotional Stress
Stress does not cause chronic lung disease. However, it can make the symptoms worse by causing the airways to tighten and breathing to become rapid and shallow. Many of the breathing and relaxation exercises in this book can help prevent the worsening of symptoms. Also, learning how to manage your disease helps you feel more in control and less stressed.
Note that triggers can add up. For example, your cat may not trigger an attack, but if you add a cold, cleaning chemicals, or stress, an attack may occur.
Monitoring Lung Disease
Lung disease changes over time. Sometimes it will be under better control than at other times. By monitoring your symptoms, you can often predict when a flare-up is coming and do something to keep from getting worse.
There are two ways to monitor lung disease. It is important to use at least one of them. For best results, use both symptom monitoring (for asthma, COPD, bronchitis, and emphysema) and peak flow monitoring (for asthma).
Symptom Monitoring (for Asthma, COPD, Bronchitis, Emphysema)
This monitoring requires that you pay attention to your symptoms and how they change. Here’s how you can tell that a flare-up is coming:
Symptoms (coughing, wheezing, shortness of breath, chest tightness, fatigue, increased or thickened sputum, or new fever) are worse, occur more often, or are greater in number than usual.
More puffs than usual are needed of quick-relief medicine (such as an albuterol inhaler), or the medicine is required more often than twice a week (other than for physical activity).
Symptoms cause you to wake up more frequently or are interfering with work, school, or home activities.
If you are having any of these changes in symptoms, discuss them with your doctor or other health professional.
Peak Flow Monitoring (for Asthma)
This uses a tool called a peak flow meter to measure if the breathing tubes are open enough for normal breathing. Peak flow measurements can let you know when a flare-up is starting (even before symptoms increase) and can help you figure out how bad the flare-up will be.
If you have moderate or severe asthma, the peak flow meter can become a best friend. It can alert you to problems before they become severe. It can help you and your doctor know when medications need to be increased and when they can be safely tapered. It can help you distinguish between worsening asthma and breathlessness caused by anxiety or hyperventilation. Most of all, it can help you manage your asthma better.
When the peak flow reading is closer to your personal best benchmark (to be described shortly), the breathing tubes are more open, and the asthma is under better control. When the peak flow reading is farther from your personal best, the breathing tubes are more closed. Even if you feel OK, a lower peak flow reading can warn you that a flare-up is starting and you need to take action and adjust your medications (see the Asthma Self-Management Plan on pages 242–243).
Asthma Self-Management Plan
Work out a plan with your doctor about what specific actions you should take and when. The following guide may be a place to start.
Managing Your Asthma: A Day-to-Day Self-Management Plan
GREEN ZONE: GO AHEAD
Your asthma is in good control.
No Symptoms
You can sleep without waking.
You have no cough, wheezing, chest tightness, or shortness of breath.
“Quick-relief” medicines are needed no more than 2 days per week (except for exercise).
You are able to participate in most activities without asthma symptoms.
Work or school is not missed.
You rarely, if ever, need emergency care.
Your peak flow is 80%–100% of your personal best.
GO AHEAD
Take your medicine daily as prescribed, and avoid triggers.
YELLOW ZONE: BE AWARE
You are having a mild asthma attack.
Possible Symptoms
You are experiencing some coughing.
Wheezing is mild.
You have slight chest congestion or tightness.
Breathing when resting may be slightly faster than normal.
You need to use quick-relief medications more than 2 days per week (except before exercise).
Your peak flow is 50%–80% of your personal best.
BE AWARE
1. Take quick-relief medicine every 4 hours as needed to relieve symptoms.
2. Increase the dose of your inhaled “controller” or “preventer” medicine until you no longer need quick-relief medicine and are back in the Green Zone. Do not take extra Advair, Serevent, or Foradil.
3. If symptoms continue more than 2 days or if quick-relief medicine is needed more than every 4 hours, see Red Zone. Call for advice if needed.
RED ZONE: STOP AND TAKE ACTION
You are having a severe asthma attack.
Possible Symptoms
You are experiencing persistent coughing or wheezing.
You have difficulty breathing when at rest.
Coughing, wheezing, or shortness of breath wakes you up.
Your breathing is faster than usual.
Your symptoms are not getting better after 2 days in the Yellow Zone.
Your peak flow is less than 50% of your personal best.
TAKE ACTION
If you need quick-relief medicine every 2 to 4 hours and you still have Red Zone symptoms, take the following steps:
1. Take quick-relief medications immediately. If symptoms do not improve after 20 minutes, take the medications again. If symptoms do not improve after another 20 minutes, take the medications for a third time and contact your doctor.
2. Start “burst” medicine, if prescribed. Keep in mind that it may take 4 to 6 hours for burst medicine to work.
3. If you have taken steps 1 and 2 and there is no relief, you are having a severe asthma attack. Go to the nearest emergency department or call 911 now, and continue to take quick-relief medicine as needed.
If you do not have a peak flow meter or are not sure how to use it, ask your health professional. You will need to measure your personal best peak flow when you are feeling well and in good control so that you can then take quick action when your peak flow begins to drop. Because different meters can give different readings, use the same meter all the time.
You can keep track of your symptoms and peak flow measurements by writing them in an asthma diary. (Your medical professional can give you one, or you can make your own.) Keeping an asthma diary can help you figure out what triggers the asthma, whether the medicines are working, and when flare-ups are about to begin.
You’ll need to work out an individual plan of action with your doctor (see the asthma self-management plan above). If you wait until your symptoms get worse, they will be more difficult to treat. Early action and adjustment of your medications can make a critical difference.
Medications
Medications cannot cure chronic lung diseases, but they can help you breathe easier. Effective management often involves more than one medication. Do not worry if you are prescribed several medications. A wide range of current medications are described in Table 15.1.*
Bronchodilators relax the muscles surrounding the airways, open the airways, and relieve wheezing and shortness of breath. Most inhaled bronchodilators can be used frequently and work within minutes. The exception is Serevent (salmeterol), which should be used no more often than every 12 hours.
Table 15.1 Medications Useful for Managing Chronic Lung Disease
Anti-inflammatory medications may also be prescribed to reduce the inflammation, swelling, and reactivity of the airways. Medications to loosen mucus (mucolytics and expectorants) as well as antibiotics may be helpful if you have chronic bronchitis or emphysema.
Some of the medications may be used to relieve symptoms such as wheezing, while others may be used to prevent symptoms. Some medications may be used to both treat and prevent. When the medications are being used to prevent symptoms, they must be taken regularly, even when symptoms are not present. Too often people stop their medications because they feel better. Discuss with your doctor which medications to continue and which may be stopped as symptoms improve.
Some people worry that they will become addicted to the medications or that they may become “immune” and no longer respond to the medication. None of the medications used to treat lung disease are addictive. Nor do patients become “immune” to the medications. If your medications are not working well to control your symptoms, discuss this with your doctor so that adjustments can be made.
Metered-Dose Inhalers
Some lung medications, including bronchodilators, corticosteroids, and cromolyn, can be taken by inhalation. They come in a special canister called a metered-dose inhaler (MDI). When used properly, inhalers are a highly effective way of quickly delivering medication to your lungs. By breathing medicine directly into the lungs instead of swallowing it in pill form, you take less medication into the bloodstream, causing fewer side effects. Inhaling medication also allows more to reach the lungs. The key to using a metered-dose inhaler is to first exhale gently to empty your lungs and then inhale slowly through your mouth at the same time as you press down on the MDI canister to release the medication. Hold your breath for 10 seconds and then wait a minute before taking any additional puffs to let the previous puff work.
Learning to use an inhaler properly is more difficult than swallowing a pill. It takes proper instruction and some practice. One study revealed that whereas 98% of patients said they knew how to use their inhalers properly, fully 94% made errors in using them. So even if you think you are an expert, it is a good idea to have a health professional check out your technique every so often. Pharmacists can often help you learn the most effective and safe technique. If you have never been taught how to use an inhaler, ask your health professional for instructions. Improper use of inhalers is one of the most important reasons for difficulty in controlling symptoms. So if you are prescribed an inhaler, be sure to get help in using it properly. You can also watch videos on using an inhaler at http://www.kp.org/asthma or search for videos on the Internet.
Common Errors to Avoid When Using an Inhaler
Forgetting to shake the canister
Holding the inhaler upside down (mouthpiece should be on the bottom)
Forgetting to exhale before inhaling with the inhaler
Breathing through your nose
Inhaling too fast
Not holding your breath for 10 seconds
Using an empty inhaler (see page 248)
Using the medications
Use the quick-acting symptom-relieving (bronchodilator) medication first. Wait several minutes for it to open up the breathing tubes so that the preventive controller (inhaled anti-inflammatory) medication can get into your lungs better.
Spacers or holding chambers
To make using an inhaler easier, safer, and more effective, many doctors strongly recommend using a spacer device or holding chamber. This is a chamber (usually a specially designed tube or bag) into which you spray the medication from the inhaler. You then inhale the medication from the spacer. The spacer makes it more likely that you can inhale the smaller, lighter droplets of medication farther into your airways. The spacer also collects on its walls some of the larger, heavier droplets of medication that would otherwise settle in your mouth or throat. This can reduce side effects such as yeast infections in the case of inhaled steroids. Some spacer devices have a whistle that sounds if you are inhaling too rapidly. This also reminds you not to take a fast breath. A fast breath deposits more of the medication in your mouth and less in your lungs.
Inhalers with spacers are easier to use than metered-dose inhalers without spacers. You don’t have to worry about pointing the spray in the right direction, and your inhalation doesn’t have to be as carefully timed and coordinated with the spray. Because more of the medication reaches your lungs and less is left in your mouth with a spacer, the medication tends to be safer and more effective. This is especially important if you are using a steroid inhaler.
If you are using a corticosteroid inhaler, rinse your mouth out with water after use. Do not swallow the water. Swallowing the water will increase the chance that the medication will get into your bloodstream. This may increase the side effects of the medication. Some powder may build up on the inhaler, but it is not necessary to clean the inhaler every day. Occasionally rinse the spacer or mouthpiece, cap, and case.
How to determine how many puffs are left in the metered-dose inhaler
An inhaler may still seem to release puffs of medicine even when there is no medicine left. The best way to tell how many puffs of medicine are left is to keep track of how many puffs have been used already. There are two ways you can do this:
Read the label on a new canister to find out how many puffs it contains. Write down one number for each puff on a sheet of paper. For example, if your canister has 100 puffs in it, you would write each number from 1 to 100 on a sheet of paper. Each time you take a puff of the medicine, cross off a number. When all the numbers are crossed off, the canister doesn’t have any more medicine in it.
Divide the number of puffs of medicine in the inhaler by the number of puffs you use each day. This gives you the number of days the medicine will last and lets you know when you will need to start using a new canister. For example, if the inhaler has 100 puffs and you take 2 puffs a day, the inhaler will last 50 days (100 puffs divided by 2 puffs a day = 50 days). Count off the days on a calendar, and mark the day when the inhaler will be empty. Ask your medical professional for a refill before you run out of medicine.
Note: If you cannot find the number of puffs on the label of the inhaler, ask your medical professional or your pharmacist.
Caution: In the past some people tried to float their MDI canister in water to figure out how many puffs were left. This method does not work. We recommend that you use one of the two methods we’ve just described.
Dry Powder Inhalers
Dry powder inhalers (DPIs) deliver the medicine as a powder. They are used without a spacer. When using a dry powder inhaler, you need to exhale first and then inhale rapidly and deeply. Note that unlike the slow inhalation described for metered-dose inhalers, with dry powder inhalers the inhalation needs to be rapid.
Nebulizers
Nebulizers are machines that deliver quick-relief medicine as a fine mist. They are often used in the clinic or the emergency room to give a 5-to 10-minute “breathing treatment” or at home for people who cannot use an inhaler with a spacer. Nebulizers are bulky and are less convenient than inhalers. Taking four to six puffs of quick-relief medicine from an inhaler with a spacer, when done correctly, works just as well as a breathing treatment with a nebulizer.
Oxygen Therapy
Some people with chronic lung disease cannot get enough oxygen from ordinary air because the lungs are damaged. If you are tired and short of breath because there is too little oxygen in your blood, your doctor may order oxygen. Oxygen is a medicine. It is not addictive. Yet some people try not to use it for fear of becoming dependent on it. Other people do not like to be seen with oxygen equipment. Supplemental oxygen can provide the extra boost your body needs to remain comfortable and enable you do the things you want and need to do without extreme shortness of breath. Most important, it may slow down your disease and make your brain function better. Some people may require continuous use of oxygen, while others may need oxygen only to help them with certain activities such as exercise or sleep.
Oxygen comes in large tanks of compressed gas or small portable tanks of oxygen either as a gas or a liquid. If you are using oxygen, be sure to know the proper dose (flow rates and when to use it and for how long), how to use the equipment, and how to know when to order more. Do not worry. Your oxygen tank will not explode or burn. However, oxygen can help other things burn, so keep the tank at least 10 feet away from any open flame, including cigarettes.
How to Breathe Better
In addition to medications, there are other things you can do to improve your breathing.
Breathing Exercise
We breathe in and out nearly 18,000 times a day. It is not surprising that breathing is a central concern of people with lung disease. Yet many people find it surprising that proper breathing is a skill that has to be learned. This is especially important for people with lung disease. You can learn some ways to breathe that will enhance the functioning of your respiratory system.
Diaphragmatic or abdominal breathing helps strengthen respiratory muscles (especially the diaphragm) and helps rid the lungs of stale, trapped air. One of the primary reasons why people with lung disease feel short of breath and can’t seem to get enough air in is that they don’t get the old air out. These breathing exercises can help you empty your lungs more completely and take advantage of your full lung capacity. (See pages 44–45 for instructions on how to do the breathing exercises.)
Posture
If you are slouched over, it may be very difficult to breathe in and out. Certain body postures make it easier to fill and empty your lungs. For example, if you are sitting, try leaning forward from the hips with a straight back. You can then rest your forearms on your thighs or rest your head, shoulders, and arms on a pillow placed on a table. Or use several pillows at night to make breathing easier. See page 47.
Clearing Your Lungs
Sometimes excess mucus blocks the airways, making it difficult to breathe. Your doctor or respiratory therapist may recommend certain positions for “postural drainage.” For example, by lying on your left side on a slant with your feet higher than your head, you may be able to help the mucus from certain areas of the lung drain more effectively. Ask your doctor, nurse, or respiratory therapist which, if any, postures would be helpful for you. Also remember that drinking at least six glasses of water a day (unless you have ankle swelling or are told to limit fluid intake by your doctor) may help liquefy and loosen the mucus. See page 44.
Controlled Coughing
A deep cough, one that produces a strong jet of air, is a good way of clearing mucus from the airways. By contrast, a weak, hacking, tickle-in-the-throat type of cough can be exhausting, irritating, and frustrating. You can learn to cough from deep in your lungs and put air power into a cough to clear the mucus. Start by sitting in a chair or on the edge of the bed with your feet planted on the floor. Grasp a pillow firmly against your abdomen with your forearms. Take in several slow, deep belly breaths through your nose, and as you exhale fully with pursed lips, bend forward slightly and press the pillow into your stomach. On the fourth or fifth breath, slowly bend forward while producing two or three strong coughs without taking any quick breaths between coughs. Repeat the whole sequence several times to clear the mucus. See page 46.
Exercising with Chronic Lung Conditions
Exercise is among the simplest and best ways to improve your ability to live a full life with chronic lung disease. Physical activity strengthens the muscles, improves mood, increases energy level, and enhances the efficiency of the heart and lungs. Although exercise does not reverse the damage to the lungs, it can improve your ability to function within whatever limits you have due to your lung disease.
One of the most important things to remember when you start to exercise is to begin at a low intensity (for example, a slow rather than a brisk walk) and for short periods of time. You can gradually increase what you do as you find that you can do more with less shortness of breath. Good communication with your health care providers to manage your symptoms and adjust medications will let you get the most benefit and enjoyment from an exercise program.
Here are a few tips for exercising with a chronic lung condition:
Use your medicine, particularly your inhaler, before you exercise. It will help you exercise longer and with less shortness of breath.
Exercising with Asthma
Some people with asthma may cough or wheeze when they exercise. If you do, you may wish to discuss with your doctor using two puffs of albuterol (Ventolin, Proventil) or cromolyn (Intal) 15 to 30 minutes before starting exercise. Wearing a scarf or a mask over your face in cold weather may help prevent the cold air from triggering asthma. Swimming usually does not trigger asthma.
If you become severely short of breath with only a little effort, your doctor may want to change your medicines or even have you use supplemental oxygen before you begin your conditioning activities. Mild shortness of breath is normal during exercise, but it may take you some time to find the right combination of exertion and time to stay in your comfort zone.
Take plenty of time to warm up and cool down during conditioning activities. This should include exercises such as pursed-lip breathing and diaphragmatic or abdominal breathing (see page 45).
Everyone experiences a normal “anticipatory” increase in heart rate and breathing rate even before exercise begins. This can be worrisome if you are afraid of getting too short of breath. Pursed-lip and diaphragmatic breathing will help you relax and stay calm.
Pay attention to your breathing to make sure you breathe in deeply and slowly and use pursed-lip breathing when you breathe out (see pages 44–45). Learn to take two or three times longer breathing out as you do breathing in. For example, if you are walking briskly and notice that you can take two steps while you’re breathing in, you should breathe out through pursed lips over four to six steps. Breathing out slowly will help you exchange air in your lungs better and will probably increase your endurance.
Remember that arm exercises may cause shortness of breath and a faster heart rate sooner than leg exercises.
Cold and dry air can make breathing and exercise more difficult. This is why swimming is an especially good activity for people with chronic lung disease.
Strengthening exercises such as calisthenics, light weightlifting, and rowing may be helpful, particularly for people who have become weakened or deconditioned it is helpful whether due to medications or other causes
Exercising with Severe Lung Disease
If you can get out of bed, you can exercise 10 minutes a day. Here is how you do it. Every hour, get up and walk slowly across the room or around your chair for 1 minute. Doing this 10 times a day gives you 10 minutes of exercise. Then you can increase gradually to a daily exercise routine that will help you feel stronger and more comfortable moving. Here are some things to remember as you start to get more active:
Sleep Apnea
If you snore and you tend to feel sleepy during the day, you may have a special type of breathing problem called sleep apnea. If you have sleep apnea, your throat becomes blocked during sleep. Then for short periods of time (10 seconds or more), you may stop breathing (this is called apnea). If you have sleep apnea, you probably don’t know it until someone says something to you about your snoring. This condition is one of the most common undiagnosed serious health problems today.
Sleep apnea may cause you to wake up feeling tired or with a headache or to feel sleepy or have trouble with concentration throughout the day. Sleep apnea can also lead to more serious problems such as high blood pressure, heart disease, and stroke. It can even mimic the memory problems seen in dementia and Alzheimer’s disease. Sleep apnea is diagnosed by doing a sleep study in a laboratory or wearing a small monitor at home.
You can treat sleep apnea at home by making lifestyle changes. These include losing weight, if appropriate; sleeping on your side; avoiding alcohol; not smoking; and using medication to relieve nasal congestion and allergies. You also can use a breathing device that uses gentle air pressure to keep tissues in the throat from blocking your airway. This is known as continuous positive air pressure (CPAP). Or your doctor may recommend using a dental device (oral breathing device) to help keep your airway open.
Don’t hurry. Many people with lung disease hurry up to get there before their breath runs out. It is much better to slow down. Move slowly, breathing as you go. At first, this will take a real effort. With practice, you will find that you can go farther more comfortably. If you are afraid to try this alone, have someone walk with you, carrying a chair (a folding “cane chair” might be useful), or use a walker with a seat so that you can sit down if necessary.
As you begin to feel stronger and more confident, walk 2 minutes every hour. You have just doubled your exercise and are now up to 20 minutes a day. When this feels comfortable, change your pattern to walking 3 to 4 minutes every other hour. Wait another week or two, and then try 5 minutes three or four times a day. Next, try 6 to 7 minutes two or three times a day. You now have the basic idea. Most people with severe lung disease can build up to walking 10 to 20 minutes, once or twice a day, within a couple of months.
If being up on your feet is a problem, try using a restorator (portable bicycle crank and pedals). This is especially helpful if you have a low level of endurance, do not have standby help, or are afraid of exertion. The restorator lets you sit where you are and use your legs to pedal. It’s a good device to build confidence and get accustomed to exertion in a secure atmosphere.
Asthma, chronic bronchitis, and emphysema are not curable. But you can, in partnership with your health care team, work to reduce the symptoms and improve your ability to live a rich, rewarding life. The goal is to control your symptoms so that you can do daily activities, exercise, sleep comfortably, and prevent having to go to the hospital or emergency department.
Suggested Further Reading
Haas, François, and Sheila Spencer Haas. The Chronic Bronchitis and Emphysema Handbook. New York: Wiley, 2000.
Marcus, Bess, Jeffrey S. Hampl, and Edwin B. Fisher. How to Quit Smoking Without Gaining Weight. New York: Pocket Books, 2004.
Plaut, Thomas F., and Teresa B. Jones. Asthma Guide for People of All Ages. Amherst, Mass.: Pedipress, 1999.
Shimberg, Elaine Fantle. Coping with COPD: Understanding, Treating, and Living with Chronic Obstructive Pulmonary Disease. New York: St. Martin’s Griffin, 2003.
Snowdrift Pulmonary Foundation. Frontline Advice for COPD Patients. Denver: Snowdrift Pulmonary Foundation, 2002; free download at http://www.copd-alert.com/Frontlin.pdf
Other Resources
American Lung Association, (800) 586-4872: http://www.lung.org
Asthma and Allergy Foundation of America, (800) 7-ASTHMA or (202) 466-7643, http://www.aafa.org
COPD Foundation, (866) 316-COPD: http://www.copdfoundation.org
Kaiser Permanente: http://www.kp.org/asthma
National Asthma Education and Prevention Program: (301) 951-3260: http://www.nhlbi.nih.gov/about/naepp/
National Heart, Lung, and Blood Institute, (301) 592-8573: http://www.nhlbi.nih.gov
National Jewish Health: (800) 222-5864 (Lungline): http://www.nationaljewish.org
Pulmonary Paper: (800) 950-3698: http://www.pulmonarypaper.org