NOTE: The first of this series is a separate Knoll entitled:
COPD and Emphysema Self-Care (Part 1)
The second in this series is in a separate Knol entitled:
COPD and Emphysema Self-Care (Part 2)
The third of this series is a separate Knoll entitled:
COPD and Emphysema Self-Care (Part 3)
***********************************************************************************************************************************
This web site is mainly devoted to chest physiotherapy and breathing training, and will not be discussing COPD oxygen and medication therapy in detail. These modalities are generally derived from prescriptions written by your physician. Questions about oxygen or your various medications should be referred to your doctor. In the COPD Links module a number of references will be given that discuss these topics in greater detail.
As to medications, it is important that you take them regularly, in the prescribed manner. It is surprising how many patients take their medications irregularly, or confuse one medication for another. And with regard to your inhaled aerosol drugs or Metered Dose Inhalers, previous modules have stressed the importance of exhaling effectively. You must do this in order to correct Dynamic Hyperinflation and lung overinflation problems, in order that you may achieve a larger breath volume, to more effectively carry the medication deep into your lungs. This is particularly important if you are having an acute episode of increased dyspnea.
Oxygen therapy needs to be discussed in greater detail, as adequate oxygen is now known to be critically important to your general health, and in fact how long you will survive. Unfortunately, oxygen deficiency and the need for supplemental oxygen therapy can be subtle, and quite variable, and dependent on various circumstances which you need to understand.
Remember, the lungs have two basic functions. The first is to get waste Carbon Dioxide removed from your body, and much of our discussion of breathing training up to this time has been concerned with this function. The second is to get the vital energy source of Oxygen into your body, and this process has been linked to breathing patterns.
As previously discussed, it has long been known that slower breathing, with a larger Tidal Volume breath volume generally improves oxygen transfer into the body, and biofeedback training with oxygen measuring devices have been used to alter breathing patterns to improve blood Oxygen Saturation. Furthermore, an end-inspiratory breath hold pause should improve oxygenation, by means of improved alveolar collateral ventilation, at least in some patients with a low blood Oxygen Saturation. It has become apparent that breathing patterns play a small but significant role in improving blood oxygenation.
It is critically important that the adequacy of your oxygen level be diagnosed, as clinical diagnosis of a low oxygen level is very difficult and unreliable, except in severe levels of blood Oxygen Desaturation, called Hypoxia. It is very easy to miss a diagnosis of moderately severe, but clinically important hypoxia.
This may present some difficulties. The most accurate way is a direct Arterial Blood Gas analysis. The simple common venous blood sample unfortunately is not adequate for blood Oxygen and CO2 measurement. If the oxygen level is sufficiently deficient while you are resting quietly, the diagnosis of hypoxia (i.e. low oxygen) is easily made. Hypoxia may also be diagnosed indirectly, by sampling through the skin or a fingernail, by a device known as an Oximeter, which measures the so-called Oxygen Saturation (or commonly referred to as the "O2 Sat") of the blood, expressed as a percent saturation. Oximeters are very convenient, though slightly less accurate, and avoids the sometimes uncomfortable direct sampling required when putting a needle into an artery. Fortunately small portable Oximeters suitable for home use, and reasonably priced, have become available.
However, to complicate this situation, an adequate level of oxygenation while you are resting quietly does not completely exclude the diagnosis of significant hypoxia. At the present time, based on some old studies, hypoxia is diagnosed to be qualified for oxygen therapy reimbursement by blood oxygen levels at rest. There is widespread concern in the pulmonary physician community that some patients would benefit by broadening the definition of hypoxia for different circumstances other than simple resting hypoxia. Recommendations of an expert study group for further research in this area were published in July 2006, and hopefully future research will clarify these issues.
Hypoxia may be present under the following common conditions:
* When you are exerting yourself.
* When you are sleeping.
* If you go to a higher altitude (including commercial aircraft flying).
* After hard and prolonged coughing attacks.
* If you become ill with a Bronchitic Exacerbation, or other medical problems.
Exertion Hypoxia is common, and to diagnose this situation requires a controlled exercise stress. Exercise stress may be safely provided by walking (e.g. the Six Minute Walking Test, or similar tests), Stair Climbing, Bicycle Ergometry (i.e. a specially calibrated stationary exercise bicycle), or a stationary exercise walking Treadmill. Your physician and other trained personnel monitor you continuously with safety precautions. And if a Bicycle Ergometer or Treadmill is used, as an extra precaution, a continuous Electrocardiogram (EKG) of your heart is commonly performed, along with continuous Oximetry measurements. Should significant hypoxia develop, supplemental oxygen may be provided, and the exact amount necessary may re determined.
Sleep Hypoxia is also fairly common, and may be due to other problems than COPD which may need to be treated. The various conditions may be diagnosed with a formal "Sleep Study." This requires you to spend the night at a Sleep Laboratory. Multiple sensors may permit a more detailed diagnosis as to why hypoxia is developing, and a more specific therapeutic program, in addition to defining the oxygen supplement level needed to resolve your hypoxia problem. Partial diagnostic sleep studies may be done at home, using only recording oximeters, and follow-up studies may define whether or not your oxygen supplement level is appropriate.
High Altitude Hypoxia is rather difficult to define, as it really depends on whether your lungs and Oxygen Saturations are normal, and whether or not the altitude stress is acute or chronic. With altitude there is less atmospheric pressure to drive oxygen into the body, in essence creating a situation of relatively less available oxygen.
Normal people in Denver (altitude about 5000 feet, the "Mile High" city) have oxygen levels in the mild hypoxia region, and they get along just fine. However, people with COPD and low or marginally normal levels of Oxygen Saturation, may be significantly hypoxic if they go to altitudes of 1000 to 2000 feet above sea level. Commercial aircraft are artificially pressurized to a level of about 5000 to 8000 feet, and obviously COPD patients at risk must take oxygen precautions when flying. In the COPD Links module you will find advice about travel by air, and the problems of how to provide for oxygen so you can travel safely. If there is any question about your ability to fly safely, you should have a test called the Hypoxia Altitude Simulation Test (HAST), also referred to as the Hypoxia Inhalation Test (HIT). This test involves breathing a low oxygen gas that simulates the low oxygen levels during commercial air travel, and permits a definition of how much supplemental oxygen you will need to travel safely.
Hard and prolonged coughing attacks, especially if they induce choking spells, may cause acute hypoxia, and precautionary temporary oxygen may be advisable.
Bronchitic Exacerbations, and other cardiac and pulmonary problems frequently make patients hypoxic. Unexplained and progressive hypoxia can be an early warning signal of a developing COPD complication requiring medical attention.
Looking at all these potential hypoxic situations one must ask, how is it possible to be certain you are getting adequate supplemental oxygen, and particularly so for the patients on continuous Long Term Oxygen Therapy ("LTOT"). The answer to this question is the development of the portable personal oximeter, for individual use, and therefore the immediate availability of O2 Sat readings whenever one is in doubt. With a price of just over $200 they are an excellent investment for the COPD patient who has any questions about their oxygen needs. A simple and reliable oximeter is the Nonin Onyx 9500 Digital Fingertip Pulse Oximeter. Ordinarily these devices are dispensed via a medical prescription and may be purchased from multiple medical supply sources. The Med1Online web site http://www.med1online.com sells this device without a prescription.
Oxygen is not only vital to your health, it is also expensive. It is now well documented that many hypoxic COPD patients may increase their Oxygen Saturation levels about 4 to 5% with proper breathing patterns. And there is anecdotal evidence of some more severely hypoxic patients who are able to increase their O2 Sats as much as 8% with appropriate breathing strategies.
Think about the implications of this very carefully. If you run out of oxygen, or feel the need for more oxygen, correct breathing may bring your O2 Sats up to an acceptable level. And as to cost savings for expensive oxygen, the ability to reduce your oxygen flow by even 1/2 to 1 liters per minute is going to make quite a savings over a year or so.
It makes a lot of sense for the COPD patient on oxygen therapy, and particularly those on continuous Long Term Oxygen Therapy, to master efficient breathing patterns. As discussed in previous modules, experiment with the Breathing Trainer adjustments and find a comfortable COPD breathing pattern with a slower respiratory breathing Rate, a larger Tidal Volume breath size, and a longer Expiratory Time of at least 60% or more. Then, try increasing the End-inspiration Pause time from about 5% to 10% or 15% and see if your O2 Saturations improve.
*********************************************************************************************************************************
Chronic shortness of breath ("dyspnea") is a heavy burden of constant discomfort, and dyspnea exacerbations for whatever reason can be extremely distressing and frightening. And dyspnea limitations that force patients to withdraw from favorite activities with friends and family often causes COPD patients to feel withdrawn and isolated, and suffer from feelings of hopelessness. It is therefore perfectly understandable that anxiety and depression is a common added burden for many COPD patients.
This module will give you some guidelines to help you work through these problems.
Remember, there is an intimate link between anxiety, and particularly anxiety that produces so-called "Panic Attacks," and the production or worsening of acute dyspnea attacks. This is because anxiety often produces rapid breathing (as part of the "Rescue Breathing Pattern") which in turn causes the physiologic "Dynamic Hyperinflation" problem, which makes breathing much more difficult. Be sure to again review the module on Dynamic Hyperinflation if you are uncertain about this critically important topic.
The general linkage between severe COPD and anxiety and depression goes something like this:
* First your dyspnea begins to restrict heavier exertion activities, and you give up your exercise and leisure recreational activities such as stopping playing golf and taking long walks.
* Then your breathing gets worse, and you are restricted with even mild activities, and you become concerned and anxious.
* Then your breathing gets much worse, and necessary activities of daily living become difficult, and dyspnea attacks become feared. Anxiety deepens, and frequently depression develops.
* You now become very limited in activities, and essentially confined to a chair or bed. Inactivity causes your leg and other muscles to deteriorate, and any effort produces painful dyspnea. Fear of acute dyspnea attacks makes you avoid any effort. You feel helpless, and perhaps unworthy, and depression deepens.
* Your weakened muscles now require much more effort for any activity, and you must breathe even more for these weakened muscles to work.You are now severely limited, depressed and anxious.
The end physical result is chronic shortness of breath, acute dyspnea attacks with effort, and deconditioned leg and other peripheral muscles that work inefficiently, and as a result require more ventilation for a given level of effort.
The question then becomes one of: how do you reverse these physical problems, in order to reverse these normal and understandable psychological anxiety and depression problems.
Essentially, from a physical point of view, what you have here are two problems:
1.) Breathing problems, of two general types:
A.) Chronic breathing problems, and
B.) Acute dyspnea attacks, usually brought on by exertion.
2.) Deconditioned and weak muscles, mainly leg muscles, that make getting about difficult, and requiring an excessive amount of breathing if you do move about.
These two general problems are related and intertwined among each other, and produces a classic "What came first, the Chicken or the Egg" situation. Or in this case, what is the priority problem, and what do we do first to correct the situation.
The majority of formal pulmonary rehabilitation programs have a primary exercise focus, to recondition the legs and other peripheral muscles, make these muscles more efficient as to oxygen needs and getting rid of waste carbon dioxide, and thereby require relatively less breathing with exertion to satisfy these oxygen and carbon dioxide requirements. Considerable research has been done in this approach, and there is no question that this is an effective strategy to get patients ambulated, and to reduce their overall level of dyspnea. And as patients feel more comfortable, and are able to get about more easily, there is a powerful positive influence on the anxiety and depression situation.
The other general approach, and the one that I personally favor, is a primary breathing training strategy. Ask COPD patients what their major concern is, and very few will complain about the inability to exercise, though indeed exertion is a very common reason for acute dyspnea. COPD patients dominant concern is mainly about shortness of breath ("dyspnea"), and the large majority here are concerned about acute dyspnea attacks. Acute dyspnea is a very distressing experience, and COPD patients live in constant fear of these attacks. It makes logical sense that initial therapy should therefore concentrate on the patient's primary complaint of dyspnea, and in particular acute dyspnea attacks.
Remember Willie Sutton, the famous bank robber? As Willie Sutton allegedly said, when asked why he robbed banks, ".....Because that's where the money is." Think of the primary breathing control focus in COPD re habitation as the Sutton approach to pulmonary rehabilitation.
Teach COPD patients breathing control and their overall breathing comfort improves. But more important, If patients know how to recognize an impending acute breathing attack and prevent the attack, or if having an attack how to control the attack, they will then lose their fear of exerting themselves. If patient feel they are in control of their breathing, it then takes only a little encouragement to get them to be more active, because patients usually want to be more active. And with increased activity, their leg and other peripheral muscles will become reconditioned, and strength will improve, and their overall rehabilitation program be therefore enhanced.
Chronic dyspnea, and especially acute dyspnea attacks, are psychologically very debilitating. Perhaps even more psychologically debilitating is so-called psychological "loss of control." Improve the breathing comfort for a COPD patient, and restore their physiologic control over their dyspnea, and this will greatly restore their psychological loss of control. In turn, this will usually have a very powerful positive influence on their anxiety and depression.
However, this will not resolve the anxiety and depression problems in all patients. These patients should be referred for appropriate professional psychiatric or psychology help, such as consultation and possible psychoactive medications, or referral to appropriate support services.
And there is on-line information and help in this matter of COPD anxiety and depression. I would suggest you visit the web site of psychologist Dr. Vijai Sharma. Dr. Sharma has a particular interest in COPD, and counseling patients with COPD. His general web site also has much information about a variety of psychological topics at http://www.mindpub.com/
COPD patients with concerns about anxiety and depression should be sure to look at his extensive (59 pages) downloadable PDF file "Anxiety and Panic Attacks in Emphysema & Other Chronic Obstructive Pulmonary Diseases (COPD)." at: http://www.mindpub.com/PanicAttacksinCOPD.pdf Anxiety and depression, and self-help measures to deal with these problems are thoroughly discussed, and much of what Dr. Sharma describes intermingles with what has been previously discussed under the topics of the Rescue Breathing Pattern and Dynamic Hyperinflation.
***********************************************************************************************************************************
Occupational Therapy ("OT") is a therapy discipline that teaches patients how to best get along in their particular environments with whatever medical problems they have. It teaches patients with a wide variety of medical disabilities various physical tricks, to optimally work around their physical disabilities. There is also an emphasis on treating the patient in a comprehensive manner, including social, psychological and spiritual considerations.
The COPD and Emphysema patient generally has not only physical dyspnea problems, and often a number of related physical problems such a weight loss and weakness. And there are frequently psychologic or psychiatric problems, such as anxiety and depression.
In addition these combined physical and psychological problems can bring social problems into the overall picture, such as tensions within the home environment related to the patient and their caregivers, who in turn may be stressed with the responsibilities of caring for the patient. The COPD home care situation would seem to be ideal for Occupational Therapy consultation and advice. Surprisingly however, Occupational Therapy services oriented to pulmonary rehabilitation needs, seem to be quite uncommon in most pulmonary rehabilitation programs. Regardless, a general Occupational Therapy consultation is an option that should be considered.
Examples of how Occupational Therapy ("OT") might help the COPD patient are many. For example, how to efficiently make a bed. Or how to set up a kitchen for efficient use. And if a chair bound patient needs mobility, how to use a wheelchair or even a motor driven scooter, and in this case to make kitchen modifications to accommodate these devices. Simple bathroom devices such as a raised toilet seat, or safety handrails around the toilet or bathtub, or a non-slip safety mat in the shower can provide much convenience and added safety. Communication devices, and for the patient who is alone for substantial times, emergency communication devices might be suggested. And in the two story home with the bedrooms on the second floor, a relatively isolated patient who is unable to climb stairs can be brought back into the family experience of eating at the regular dinner table and enjoying entertainment and social activities by simply relocating the patients bedroom to the first floor.
The list of living suggestions and clever assistive devices goes on and on. Even if your pulmonary rehabilitation program does not offer this service routinely, requesting an Occupational Therapy consultation, including a home inspection and evaluation as to your particular problems and needs, might indeed provide invaluable advice.
Occupation Therapy is also much concerned about efficient and coordinated general body movements. But it is also important for the COPD patient there be appropriate coordination and timing of breathing with the general body movements and various specific tasks. Here a consultation and working relationship with a Chest Physiotherapist can be very productive in the overall rehabilitation program.
Also of interest in this area is the COPD specific Yoga program "Stretching Breathing Exercises for People With Severe COPD" by Dr. Vijai Sharma ( www.mindpub.com ). Dr. Sharma is trained and credentialed in Viniyoga, one of the several Yoga disciplines. Viniyoga emphasizes adaptability to individual needs, and has a strong emphasis on coordination of breathing with general body movements.
**********************************************************************************************************************************
The more you know, the better you will do in managing your COPD.
COPD information and resources.
**********************************************************************************************************************************
COPD and Emphysema Self-Care (Part 1)
The second in this series is in a separate Knol entitled:
COPD and Emphysema Self-Care (Part 2)
The third of this series is a separate Knoll entitled:
COPD and Emphysema Self-Care (Part 3)
***********************************************************************************************************************************
Oxygen and Medications
OXYGEN and MEDICATIONS
This web site is mainly devoted to chest physiotherapy and breathing training, and will not be discussing COPD oxygen and medication therapy in detail. These modalities are generally derived from prescriptions written by your physician. Questions about oxygen or your various medications should be referred to your doctor. In the COPD Links module a number of references will be given that discuss these topics in greater detail.
As to medications, it is important that you take them regularly, in the prescribed manner. It is surprising how many patients take their medications irregularly, or confuse one medication for another. And with regard to your inhaled aerosol drugs or Metered Dose Inhalers, previous modules have stressed the importance of exhaling effectively. You must do this in order to correct Dynamic Hyperinflation and lung overinflation problems, in order that you may achieve a larger breath volume, to more effectively carry the medication deep into your lungs. This is particularly important if you are having an acute episode of increased dyspnea.
Oxygen therapy needs to be discussed in greater detail, as adequate oxygen is now known to be critically important to your general health, and in fact how long you will survive. Unfortunately, oxygen deficiency and the need for supplemental oxygen therapy can be subtle, and quite variable, and dependent on various circumstances which you need to understand.
Remember, the lungs have two basic functions. The first is to get waste Carbon Dioxide removed from your body, and much of our discussion of breathing training up to this time has been concerned with this function. The second is to get the vital energy source of Oxygen into your body, and this process has been linked to breathing patterns.
As previously discussed, it has long been known that slower breathing, with a larger Tidal Volume breath volume generally improves oxygen transfer into the body, and biofeedback training with oxygen measuring devices have been used to alter breathing patterns to improve blood Oxygen Saturation. Furthermore, an end-inspiratory breath hold pause should improve oxygenation, by means of improved alveolar collateral ventilation, at least in some patients with a low blood Oxygen Saturation. It has become apparent that breathing patterns play a small but significant role in improving blood oxygenation.
It is critically important that the adequacy of your oxygen level be diagnosed, as clinical diagnosis of a low oxygen level is very difficult and unreliable, except in severe levels of blood Oxygen Desaturation, called Hypoxia. It is very easy to miss a diagnosis of moderately severe, but clinically important hypoxia.
This may present some difficulties. The most accurate way is a direct Arterial Blood Gas analysis. The simple common venous blood sample unfortunately is not adequate for blood Oxygen and CO2 measurement. If the oxygen level is sufficiently deficient while you are resting quietly, the diagnosis of hypoxia (i.e. low oxygen) is easily made. Hypoxia may also be diagnosed indirectly, by sampling through the skin or a fingernail, by a device known as an Oximeter, which measures the so-called Oxygen Saturation (or commonly referred to as the "O2 Sat") of the blood, expressed as a percent saturation. Oximeters are very convenient, though slightly less accurate, and avoids the sometimes uncomfortable direct sampling required when putting a needle into an artery. Fortunately small portable Oximeters suitable for home use, and reasonably priced, have become available.
However, to complicate this situation, an adequate level of oxygenation while you are resting quietly does not completely exclude the diagnosis of significant hypoxia. At the present time, based on some old studies, hypoxia is diagnosed to be qualified for oxygen therapy reimbursement by blood oxygen levels at rest. There is widespread concern in the pulmonary physician community that some patients would benefit by broadening the definition of hypoxia for different circumstances other than simple resting hypoxia. Recommendations of an expert study group for further research in this area were published in July 2006, and hopefully future research will clarify these issues.
Hypoxia may be present under the following common conditions:
* When you are exerting yourself.
* When you are sleeping.
* If you go to a higher altitude (including commercial aircraft flying).
* After hard and prolonged coughing attacks.
* If you become ill with a Bronchitic Exacerbation, or other medical problems.
Exertion Hypoxia is common, and to diagnose this situation requires a controlled exercise stress. Exercise stress may be safely provided by walking (e.g. the Six Minute Walking Test, or similar tests), Stair Climbing, Bicycle Ergometry (i.e. a specially calibrated stationary exercise bicycle), or a stationary exercise walking Treadmill. Your physician and other trained personnel monitor you continuously with safety precautions. And if a Bicycle Ergometer or Treadmill is used, as an extra precaution, a continuous Electrocardiogram (EKG) of your heart is commonly performed, along with continuous Oximetry measurements. Should significant hypoxia develop, supplemental oxygen may be provided, and the exact amount necessary may re determined.
Sleep Hypoxia is also fairly common, and may be due to other problems than COPD which may need to be treated. The various conditions may be diagnosed with a formal "Sleep Study." This requires you to spend the night at a Sleep Laboratory. Multiple sensors may permit a more detailed diagnosis as to why hypoxia is developing, and a more specific therapeutic program, in addition to defining the oxygen supplement level needed to resolve your hypoxia problem. Partial diagnostic sleep studies may be done at home, using only recording oximeters, and follow-up studies may define whether or not your oxygen supplement level is appropriate.
High Altitude Hypoxia is rather difficult to define, as it really depends on whether your lungs and Oxygen Saturations are normal, and whether or not the altitude stress is acute or chronic. With altitude there is less atmospheric pressure to drive oxygen into the body, in essence creating a situation of relatively less available oxygen.
Normal people in Denver (altitude about 5000 feet, the "Mile High" city) have oxygen levels in the mild hypoxia region, and they get along just fine. However, people with COPD and low or marginally normal levels of Oxygen Saturation, may be significantly hypoxic if they go to altitudes of 1000 to 2000 feet above sea level. Commercial aircraft are artificially pressurized to a level of about 5000 to 8000 feet, and obviously COPD patients at risk must take oxygen precautions when flying. In the COPD Links module you will find advice about travel by air, and the problems of how to provide for oxygen so you can travel safely. If there is any question about your ability to fly safely, you should have a test called the Hypoxia Altitude Simulation Test (HAST), also referred to as the Hypoxia Inhalation Test (HIT). This test involves breathing a low oxygen gas that simulates the low oxygen levels during commercial air travel, and permits a definition of how much supplemental oxygen you will need to travel safely.
Hard and prolonged coughing attacks, especially if they induce choking spells, may cause acute hypoxia, and precautionary temporary oxygen may be advisable.
Bronchitic Exacerbations, and other cardiac and pulmonary problems frequently make patients hypoxic. Unexplained and progressive hypoxia can be an early warning signal of a developing COPD complication requiring medical attention.
Looking at all these potential hypoxic situations one must ask, how is it possible to be certain you are getting adequate supplemental oxygen, and particularly so for the patients on continuous Long Term Oxygen Therapy ("LTOT"). The answer to this question is the development of the portable personal oximeter, for individual use, and therefore the immediate availability of O2 Sat readings whenever one is in doubt. With a price of just over $200 they are an excellent investment for the COPD patient who has any questions about their oxygen needs. A simple and reliable oximeter is the Nonin Onyx 9500 Digital Fingertip Pulse Oximeter. Ordinarily these devices are dispensed via a medical prescription and may be purchased from multiple medical supply sources. The Med1Online web site http://www.med1online.com sells this device without a prescription.
Oxygen is not only vital to your health, it is also expensive. It is now well documented that many hypoxic COPD patients may increase their Oxygen Saturation levels about 4 to 5% with proper breathing patterns. And there is anecdotal evidence of some more severely hypoxic patients who are able to increase their O2 Sats as much as 8% with appropriate breathing strategies.
Think about the implications of this very carefully. If you run out of oxygen, or feel the need for more oxygen, correct breathing may bring your O2 Sats up to an acceptable level. And as to cost savings for expensive oxygen, the ability to reduce your oxygen flow by even 1/2 to 1 liters per minute is going to make quite a savings over a year or so.
It makes a lot of sense for the COPD patient on oxygen therapy, and particularly those on continuous Long Term Oxygen Therapy, to master efficient breathing patterns. As discussed in previous modules, experiment with the Breathing Trainer adjustments and find a comfortable COPD breathing pattern with a slower respiratory breathing Rate, a larger Tidal Volume breath size, and a longer Expiratory Time of at least 60% or more. Then, try increasing the End-inspiration Pause time from about 5% to 10% or 15% and see if your O2 Saturations improve.
*********************************************************************************************************************************
Anxiety and Depression
ANXIETY and DEPRESSION
Chronic shortness of breath ("dyspnea") is a heavy burden of constant discomfort, and dyspnea exacerbations for whatever reason can be extremely distressing and frightening. And dyspnea limitations that force patients to withdraw from favorite activities with friends and family often causes COPD patients to feel withdrawn and isolated, and suffer from feelings of hopelessness. It is therefore perfectly understandable that anxiety and depression is a common added burden for many COPD patients.
This module will give you some guidelines to help you work through these problems.
Remember, there is an intimate link between anxiety, and particularly anxiety that produces so-called "Panic Attacks," and the production or worsening of acute dyspnea attacks. This is because anxiety often produces rapid breathing (as part of the "Rescue Breathing Pattern") which in turn causes the physiologic "Dynamic Hyperinflation" problem, which makes breathing much more difficult. Be sure to again review the module on Dynamic Hyperinflation if you are uncertain about this critically important topic.
The general linkage between severe COPD and anxiety and depression goes something like this:
* First your dyspnea begins to restrict heavier exertion activities, and you give up your exercise and leisure recreational activities such as stopping playing golf and taking long walks.
* Then your breathing gets worse, and you are restricted with even mild activities, and you become concerned and anxious.
* Then your breathing gets much worse, and necessary activities of daily living become difficult, and dyspnea attacks become feared. Anxiety deepens, and frequently depression develops.
* You now become very limited in activities, and essentially confined to a chair or bed. Inactivity causes your leg and other muscles to deteriorate, and any effort produces painful dyspnea. Fear of acute dyspnea attacks makes you avoid any effort. You feel helpless, and perhaps unworthy, and depression deepens.
* Your weakened muscles now require much more effort for any activity, and you must breathe even more for these weakened muscles to work.You are now severely limited, depressed and anxious.
The end physical result is chronic shortness of breath, acute dyspnea attacks with effort, and deconditioned leg and other peripheral muscles that work inefficiently, and as a result require more ventilation for a given level of effort.
The question then becomes one of: how do you reverse these physical problems, in order to reverse these normal and understandable psychological anxiety and depression problems.
Essentially, from a physical point of view, what you have here are two problems:
1.) Breathing problems, of two general types:
A.) Chronic breathing problems, and
B.) Acute dyspnea attacks, usually brought on by exertion.
2.) Deconditioned and weak muscles, mainly leg muscles, that make getting about difficult, and requiring an excessive amount of breathing if you do move about.
These two general problems are related and intertwined among each other, and produces a classic "What came first, the Chicken or the Egg" situation. Or in this case, what is the priority problem, and what do we do first to correct the situation.
The majority of formal pulmonary rehabilitation programs have a primary exercise focus, to recondition the legs and other peripheral muscles, make these muscles more efficient as to oxygen needs and getting rid of waste carbon dioxide, and thereby require relatively less breathing with exertion to satisfy these oxygen and carbon dioxide requirements. Considerable research has been done in this approach, and there is no question that this is an effective strategy to get patients ambulated, and to reduce their overall level of dyspnea. And as patients feel more comfortable, and are able to get about more easily, there is a powerful positive influence on the anxiety and depression situation.
The other general approach, and the one that I personally favor, is a primary breathing training strategy. Ask COPD patients what their major concern is, and very few will complain about the inability to exercise, though indeed exertion is a very common reason for acute dyspnea. COPD patients dominant concern is mainly about shortness of breath ("dyspnea"), and the large majority here are concerned about acute dyspnea attacks. Acute dyspnea is a very distressing experience, and COPD patients live in constant fear of these attacks. It makes logical sense that initial therapy should therefore concentrate on the patient's primary complaint of dyspnea, and in particular acute dyspnea attacks.
Remember Willie Sutton, the famous bank robber? As Willie Sutton allegedly said, when asked why he robbed banks, ".....Because that's where the money is." Think of the primary breathing control focus in COPD re habitation as the Sutton approach to pulmonary rehabilitation.
Teach COPD patients breathing control and their overall breathing comfort improves. But more important, If patients know how to recognize an impending acute breathing attack and prevent the attack, or if having an attack how to control the attack, they will then lose their fear of exerting themselves. If patient feel they are in control of their breathing, it then takes only a little encouragement to get them to be more active, because patients usually want to be more active. And with increased activity, their leg and other peripheral muscles will become reconditioned, and strength will improve, and their overall rehabilitation program be therefore enhanced.
Chronic dyspnea, and especially acute dyspnea attacks, are psychologically very debilitating. Perhaps even more psychologically debilitating is so-called psychological "loss of control." Improve the breathing comfort for a COPD patient, and restore their physiologic control over their dyspnea, and this will greatly restore their psychological loss of control. In turn, this will usually have a very powerful positive influence on their anxiety and depression.
However, this will not resolve the anxiety and depression problems in all patients. These patients should be referred for appropriate professional psychiatric or psychology help, such as consultation and possible psychoactive medications, or referral to appropriate support services.
And there is on-line information and help in this matter of COPD anxiety and depression. I would suggest you visit the web site of psychologist Dr. Vijai Sharma. Dr. Sharma has a particular interest in COPD, and counseling patients with COPD. His general web site also has much information about a variety of psychological topics at http://www.mindpub.com/
COPD patients with concerns about anxiety and depression should be sure to look at his extensive (59 pages) downloadable PDF file "Anxiety and Panic Attacks in Emphysema & Other Chronic Obstructive Pulmonary Diseases (COPD)." at: http://www.mindpub.com/PanicAttacksinCOPD.pdf Anxiety and depression, and self-help measures to deal with these problems are thoroughly discussed, and much of what Dr. Sharma describes intermingles with what has been previously discussed under the topics of the Rescue Breathing Pattern and Dynamic Hyperinflation.
***********************************************************************************************************************************
Occupational Therapy
OCCUPATIONAL THERAPY
Occupational Therapy ("OT") is a therapy discipline that teaches patients how to best get along in their particular environments with whatever medical problems they have. It teaches patients with a wide variety of medical disabilities various physical tricks, to optimally work around their physical disabilities. There is also an emphasis on treating the patient in a comprehensive manner, including social, psychological and spiritual considerations.
The COPD and Emphysema patient generally has not only physical dyspnea problems, and often a number of related physical problems such a weight loss and weakness. And there are frequently psychologic or psychiatric problems, such as anxiety and depression.
In addition these combined physical and psychological problems can bring social problems into the overall picture, such as tensions within the home environment related to the patient and their caregivers, who in turn may be stressed with the responsibilities of caring for the patient. The COPD home care situation would seem to be ideal for Occupational Therapy consultation and advice. Surprisingly however, Occupational Therapy services oriented to pulmonary rehabilitation needs, seem to be quite uncommon in most pulmonary rehabilitation programs. Regardless, a general Occupational Therapy consultation is an option that should be considered.
Examples of how Occupational Therapy ("OT") might help the COPD patient are many. For example, how to efficiently make a bed. Or how to set up a kitchen for efficient use. And if a chair bound patient needs mobility, how to use a wheelchair or even a motor driven scooter, and in this case to make kitchen modifications to accommodate these devices. Simple bathroom devices such as a raised toilet seat, or safety handrails around the toilet or bathtub, or a non-slip safety mat in the shower can provide much convenience and added safety. Communication devices, and for the patient who is alone for substantial times, emergency communication devices might be suggested. And in the two story home with the bedrooms on the second floor, a relatively isolated patient who is unable to climb stairs can be brought back into the family experience of eating at the regular dinner table and enjoying entertainment and social activities by simply relocating the patients bedroom to the first floor.
The list of living suggestions and clever assistive devices goes on and on. Even if your pulmonary rehabilitation program does not offer this service routinely, requesting an Occupational Therapy consultation, including a home inspection and evaluation as to your particular problems and needs, might indeed provide invaluable advice.
Occupation Therapy is also much concerned about efficient and coordinated general body movements. But it is also important for the COPD patient there be appropriate coordination and timing of breathing with the general body movements and various specific tasks. Here a consultation and working relationship with a Chest Physiotherapist can be very productive in the overall rehabilitation program.
Also of interest in this area is the COPD specific Yoga program "Stretching Breathing Exercises for People With Severe COPD" by Dr. Vijai Sharma ( www.mindpub.com ). Dr. Sharma is trained and credentialed in Viniyoga, one of the several Yoga disciplines. Viniyoga emphasizes adaptability to individual needs, and has a strong emphasis on coordination of breathing with general body movements.
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COPD WEB LINKS
An Internet search on "COPD" or "Emphysema" will turn up literally millions of web sites. Not all of this information is reliable. This module will suggest sites that provide reliable information and good patient care instruction material, and sites that may otherwise be of assistance in helping with your COPD.
There are many good web sites out there that can provide good COPD advice such as general medical and health information, medication details, disease and complication specific information, nutritional advice, test and procedure information, and various resources such as respiratory organizations and patient and caregiver support groups. Use them to your advantage, to enlarge on the knowledge you have gained from this series on pulmonary rehabilitation.
Pulmonary Education and Research Foundation (PERF) http://www.perf2ndwind.org/
An excellent and authoritative source of COPD information
Essentials of Pulmonary Rehabilitation
http://www.perf2ndwind.org/Essentials.html
From PERF --- An extensive COPD manual --- Highly recommended
American Thoracic Society 'Best-of-the-Web" http://www.thoracic.org/sections/clinical-information/best-of-the-web/pages/obstructive-disease/copd-disease-management.html
An excellent and authoritative source for Web links about COPD and Disease Management.
COPD-Alert http://www.copd-alert.com/
A leading patient advocacy and self help site.
Stretching Breathing Exercises for People with COPD http://www.mindpub.com/
Dr. Sharma's home video Yoga program specifically for COPD. Excellent Psychology resources.
American Thoracic Society http://www.thoracic.org/sections/copd/
This is a pulmonary professional web site.
An excellent patient information section may be seen from the main menu "For Patients and Their Families."
European Respiratory Society http://www.ersnet.org/
This is a pulmonary professional web site. There is a good patient information section.
Canadian Thoracic Society COPD Guidelines http://www.copdguidelines.ca/
This site has excellent patient information.
American College of Chest Physicians http://www.chestnet.org
This is a pulmonary professional web site.
National Institute for Clinical Excellence (NICE) http://www.nice.org.uk/CG012NICEguideline
This is a pulmonary professional web site from the United Kingdom. Detailed COPD guidelines.
An excellent version for patients is at www.nice.org.uk/CG012publicinfo
Global Initiative on Obstructive Lung Disease (GOLD) http://goldcopd.com
An international organization concerned about COPD. Brief patient information section.
Alpha-1 Association http://www.alpha1.org/home/index.asp
An organization devoted to COPD patients with the Alpha-1 Antitrypsin deficiency.
Alpha-1 Foundation http://www.alphaone.org/
An organization devoted to COPD patients with the Alpha-1 Antitrypsin deficiency.
National Jewish Medical and Research Center http://www.nationaljewish.org/
A leading pulmonary center, with patient information resources.
National Jewish Lung Line http://www.nationaljewish.org/contact/lung/index.aspx
A free phone and e-mail advice service from the National Jewish Medical and Research Center.
American Lung Association http://www.lungusa.org
General information about lung diseases and resources.
National Lung Health Education Program (NLHEP) http://www.nlhep.org/
COPD advocacy group. News. Some instructions and resources.
National Emphysema/COPD Association (NECA) http://www.necacommunity.org/
COPD advocacy group. Patient self help mission. Good newsletter with news and COPD tips.
National Heart Lung and Blood Institute http://www.nhlbi.nih.gov/index.html
The NIH has a huge site with information on all sorts of health issues.
American Association of Cardiovascular and Pulmonary Rehabilitation http://www.aacvpr.org
The professional American association most concerned with Chest Physiotherapy.
California Society for Pulmonary Rehabilitation http://www.cspr.org
California therapist pulmonary rehabilitation resources.
American Association for Respiratory Care http://www.aarc.org
Respiratory Therapist national web site.
National Home Oxygen Patients Association http://www.homeoxygen.org/
Oxygen therapy advice.
Portable Oxygen Website http://www.portableoxygen.org/
Long term portable oxygen, from a user's perspective.
TRAVEL O2 http://www.travelo2.com/
Commercial oxygen provider for the travelling COPD patient.
SeaPuffers Pulmonary Cruises http://www.seapuffers.com/
Cruises catering to the COPD patient on oxygen.
US COPD Coalition http://www.uscopd.org/
Patient advocacy organization. Information and resources.
Let's Get Fit http://www.copd-letsgetfit.com/
COPD exercise advocacy.
EFFORTS (Emphysema Foundation For Our Right To Survive) http://www.emphysema.net/
Patient advocacy organization. Information and resources.
Health Compass http://websites.afar.org/site/PageServer?pagename=HC_homepage&JServSessionId
General health advice.
COPD-Support http://www.COPD-Support1.com
COPD information and resources.
Family Caregiver Alliance http://www.caregiver.org/caregiver/jsp/home.jsp
Advice and support for the caregivers of COPD patients.
National Emphysema Foundation ; http://emphysemafoundation.org/
COPD information and resources.
COPD information and resources.
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