Do you need Pulmonary Rehabilitation?

When to start?
The fact is that real Rehabilitation starts in the very mind of the patient. If the patient do not take the opportunity to help his/herself, the chances are low that rehabilitation works.

How to realize if it is necessary
First, think about what you used to do and for how long. Many patients just adapt to a lower quality of life due to symptoms. They do not see the difference unless they make a well felt comparison between current and old days. When asked about “how have you been doing?” be sure to consider if it better than 10, 5, or 1 year before.

The long-term comparison
“Has your quality of life improved?” and “What aspects have been impacted?” are key questions to consider when reporting your well being to your doctor. Your symptoms may be fine but you are less active, you don’t go upstairs, or you are “taking it easy”.

What is Rehabilitation for?
Rehabilitation is designed to reintegrate you the potential of belonging to your active role in your life and for society. Our nature is to be active because it is about survival since prehistoric times. Walk to look for food or run to be alive.

What can you do?
So this may apply to COPD. Walk to stay alive and belong to society. When you consider the time you are spending resting and compare with previous years, then you may request some advice in terms of rehabilitation beyond medicines.

Has it proven to help?
Rehabilitation has proven to help you breathe stronger. Some clinical trials has shown the fact that when patients under maintenance therapy also receive rehabilitation, they improve their lung function more than if they don’t take the active sidewalk.

Where to start?
There are many programs around the country that are led by outstanding professionals. Several sessions may help your knowledge so you can eventually implement at home too.

What happens in the Pulmonary Rehab Programs?
There are complete programs of pulmonary rehabilitation. They include breathing exercises, stretching, strength, and aerobic dynamics. During these activities, your body simulates what a normal person typically do or should do. Your oxygen requirements increase and your lungs start to readapt to the requirements (as well as your cardiovascular system). The result is a rehabilitation for a better physical performance.

What else you should do
Think about it again. Think about your activities and how your breathing problems have impacted them. Look for pulmonary rehabilitation tips to help you manage the disease. Later you will thank yourself for taking the decision to stay active (always under medical advice).

Some facts about COPD you should know

What you should be aware of

What is fact and what is fantasy in the world of CODP? There are several things patients need to be aware of when having discussions about their disease with their doctors. The chronicity, the obstruction, the treatable feature, the progression, and the prevention, has been outstanding topics in the literature for physicians. That without talking about the complications and other diseases frequently associated to this disease.

How and why it is chronic

The disease is chronic which means that it is not acute, it didn’t happen suddenly and is the result of a long time of progressive damage. With that said, we can’t not reverse it to normal as soon as we can start therapy. It’s awful to say that “damage is done” because is an over-simplification of the fact that damage can continue if we don’t take appropriate actions. What we can say is “It’s not too late” to start taking control of some domains of the disease. So, let’s be sure that we all understand that one medication, one exercise, one visit to the doctor will be enough. Let’s be sure that we understand that it started some time ago and it may take some other time to be under control.

What obstruction means

Obstruction is a kind of complicated. The reasons for this is because, in pulmonology, obstruction means any reduction in the caliber of the airway. We (the complicated-in-physiology pulmonologists) have one word that prefer not to use (occlusion) because it may imply that the airway is closed or blocked indefinitely. The latter can happen with some tumors in the space of the airways and can be an undesirable mess. Obstruction in COPD, however, is complex because the continuous contraction of the very muscles around the lung airways lead to strong/permanent contraction and it can be complicated with the excessive  mucus production of some patients (like long term asthmatics and chronic bronchitis). However, not all patients produce excessive mucus (which is associated to a particular type of inflammation) which leads us to think that the main therapy for COPD should be a long acting bronchodilator (airway muscle relaxant).

Worthy to treat

The disease has been shown to be treatable. Give that “some” of the mechanisms associated to obstruction in the airways has been described, several medicines and non-pharmacological interventions have shown to be of benefit reducing the bronchospasm (obstruction) as well as improving different outcomes related to this (like power to inhale, physical and social engagement, etc.). Even more, if the patient has stopped smoking the probability to get more control is outstanding.

Oh, no! … progressive

The progression shouldn’t make us feel scared. The disease is progressive, it’s true but aging is also progressive, hair loss is also progressive, skin wrinkling is also progressive, as well as some vision changes and it doesn’t mean that the worst will happen no matter what you try. Let’s face it: rehabilitation, medications, control of other factors may help in the delay of the progression although mathematical-scientific data can’t show it sometimes.

Prevent

Prevention definitely works because if you don’t smoke or are not exposed to the factors involved in the development of the disease, you don’t develop it. So, it is key to stop smoking, to avoid risk factors, to control associated diseases (e.g. asthma) to help the physician’s efforts to put you in your best shape.

So, don’t forget it: be realistic but not unnecessarily pessimistic. Help your doctor understanding where you are and getting more of their directions for coping in the best way with your disease.

Swine flu outbreak and potential risks for COPD patients

What flu is this?

Media have overcrowded with a lot of reports about a potential pandemic “Swine flu”. A strain of influenza that hadn’t seen before affecting humans is killing people in Mexico and has infected more than 1000 others. It is impacting other countries and has visited New York. But, what about the disisease? How does it look alike? Is it possible to get this disease in COPD?

Is this Swine flu the same Flu we are used to?

The typical influenza is a very contagious disease and ussually is tranmitted by the respiratory route rather than objects. That is the reason why you may find the use of a mask as an appropriate measure. There are several types influeza viruses. The ones most found in humans are called type A and type B (not easy to differentiate in the patient). Type C influenza tends to produce minor illness.

From Avian to Swine Flu

The outbreak in the news is a type of influenza that affects pigs. They can become infected from the avian influenza (the one that affects birds). Pigs may contaminate each other (while the virus changes a little bit) but now there are contaminated humans.

At this point, we have an new influenza affecting humans that will have same features as the “traditional” influenza but with different outcomes. Some of them well known thanks to “out-of-control” media news.

How this Flu looks alike?

These viruses tend to replicate in the layers of airways for a period of 4 days. After this period, the disease becomes apparent and is marked by a sudden onset of symptoms. The symptoms are: nasal congestion, swollen throat, conjunctivitis (red eyes), and the symptoms of bronchitis (cough and sputum production).

The issue is that, although the respiratory system is the most affected, other systems may be involved like digestive, headaches, muscle pain … the patient just want to be on bed.

Are COPD patients more vulnerable?

In terms of COPD, the Flu affects this population and that’s the reason why expert guidelines recommend vaccination before seasonal outbreaks. If this will provide with profilaxis for the current outbreak is still unknown. Given the lung condition it is expected that COPD may include a predominant population to be affected. These viruses affects seriously the respiratory tract.

Since the risk factors for contracting the disease are typical: patients in semi-closed environments (hospitals, nursing homes, schools, prisons, and crowded-close environments during epidemics … it seems reasonable to make some of social distancing at this point.

Recommendations for COPD patients to avoid risks of Swine Flu

I would recommend to my patients some of the things that media are not saying (but creating panic in the population). If you are a stable COPD patient avoid:

1. Avoid visits where there are kids (they exchange viruses between each other easier than anybody) 
2. Do not go to parties in close houses or apartments
3. Avoid unnecessary visits to doctor’s offices (talk to your doctor before)
4. Don’t use public transportation during rush hours
5. Be hydrated and try to cough efficiently (if you are a frequent cougher)
6. Air travel is not a good option now (particularly the long ones)
7. Concerts, movie theaters, theaters … ussually people go there because they don’t feel well and want to have a quiet entertainment
8. Listen to NPR

Your respiratory medications

It is important to keep using your medicines. If you are under therapy with inhaled steroids, you may want to be sure you’re not exposed to people with acute respiratory illneses.

Signs of alarm

If your respiratory symptoms get worse and you have fever and other symptoms of flu, you really need to talk to your doctor since there is a risk for having influenza or being infected with the current swine flu (based on your contacts).

What should you do?

Don’t be scared. Just be smart and protect yourself of become infected. If you have to go to out side places to eat, pick them appropriately (keeping in mind the kind of people who ussually go there).

My best regards.

From Smoking to COPD: what’s going on in the middle?

Doubtful association
It has been said that there is no a definite correlation between the spirometric standard FEV1 and the clinical manifestations in COPD. The FEV1 may be extremely low but the patient may be doing well. So where is the real assessment of the condition? Why COPD seems to be a big puzzle for doctors and patients?

Smoking and a show of symptoms
A long time ago smoking has been linked to development of serious health conditions. Symptoms have been associated with the smoking behavior but some say that it may not be any disease.

What is normal?
This is the most enigmatic perspective about a disease: symptoms being considered normal when we all know that smoking is not normal, coughing frequently with or without sputum is not normal, a development of exaggerated breathlessness with less extenuating efforts is not normal.

Some Learning

This is what teaches us that some times (if not every time) it is better to hear the patient, to assess them from a more clinical (humanitarian) perspective than relying in para-clinical procedures. Making diagnosis only based on technical methods may bring huge disastrous consequences. Particularly when it is expected to find changes in numbers more than in the body that can be assessed with appropriate developed strong skills. When it may be easy to evaluate a patient more physically than going into an algorhythm that may simplify the “clinical” decision making process but waiting for cold results. 

What to do to start?
Smoking cessation is fundamental based on clinical scientific data but we also know that symptoms associated to the continuous irritation of the airway don’t go away after smoking cessation.

Looking at the patient beyond the tech
Given these two considerations (smoking related symptoms and their persistence) we should look at the COPD patient as a real patient. It seems to be disregarding from the medical side that there is an abnormal condition due to COPD and maybe FEV1 will not be the best or definitive assessment to follow the disease up.

How to look at a COPD patient
Patients need to be considered more than a scientific set of individuals, a population to be seen from a statistical standpoint. Patients need to be seen individually and treated according to what has been shown in clinical trials but adjusted to the individual clinical reality.

History to be written
So… it is still required to look for a more clear and fair standard to monitor smoking and its effects. I hope that beyond FEV1 physicians are starting to take into account the sufferer.

Evolving Definition of COPD

Challenges of a disease

Experts from around the world have been challenging the burden of COPD since a couple of decades ago. However, one of the most relevant challenges has been the education on the disease and what it really represents not only for the medical community but for the very patient.

The history

Years ago, scientists didn’t see light in the chronicity of the disease. It’s perpetuating agressive cycle was like a ghost that physicians didn’t want to deal with and so… the patient. The decline in lung fuction no matter the measures was deppressing and the pulmonologist was like a priest at the end of life.

Words

The word emphysema meant the worst thing a person could suffer (after cancer of course). Patients considered that it was their fault and didn’t want to see a doctor since the only solution would be smoking cessation and some unproductive support.

Advances

Recently, due to research and a careful assessment of sufferers, the definition of COPD has evolved. Traditionally it was considered relentless, lethal, no effective measures allowed… Now we define the disease in terms of airflow obstruction, chronic but partially reversible and, said this, treatable.

Armamentarium of opportunities

Bronchodilators, the corner stone for airflow obstruction management started to show their benefits. Pulmonary rehabilitation opened a window to better health related quality of life. Oxygen for advanced stages was found to help too. Antiinflamatory drugs started to be formulated in inhalers. The disease was reorganized according to spirometry measurements and evidence based recommendations.

And now: a treatable disease

These days we can now talk about a chronic treatable disease associated to cigarette smoking among other risk factors. More opportunities for the patient to find out what to do. More resources to understand their doctors (with their typical limited time). And more investigations on progress on the field.

Work in progress

Although there’s a long way to walk through, never it’s to late to understand that diseases may occur but our empowerment is fundamental to confront them with good will, appropriate medical support, and self education well controlled. Great that we all can deal with problems…

Who’s smoking this days?

COPD and its associations
Chronic Obstructive Pulmonary Disease is associated to cigarette smoking in more than 70% of cases. However, COPD is only one of the consequences of smoking. Everybody knows that this behavior is also associated to lung cancer, a wide spectrum of cardiovascular diseases, other cancers, and many other conditions.

Measures against smoking
Here in New York it has been adopted the measure of banning smoking in almost everywhere. Airports around the world understood that they are closed spaces and need clean air to breath. Buses, trains, planes, etc also need clean air (as well as apartments, corridors, stairs, sidewalks, etc).

Origins of smoking behavior
Many years ago smoking was a male behavior. Men were then affected by its related conditions in a higher rate than women or younger populations.
When it was announced that smoking was not the best choice for an off moment, the target of marketing changed to women and the youngest (just see the publicity from the 60s, 70s, and 80s).

The change
The nightmare just then started. This days it is known that COPD has changed its population too. COPD is currently affecting more and more women than ever. In 2000 the number of hospitalizations associated to COPD in women outnumbered those for men and women also started reporting more than half of cases by 2004. The sad part of the unnecessary tale is that COPD deaths almost tripled in women from 1980 to 2000. Of course this is another evidence that smoking incidence has increased in women.

More than a woman
COPD has started to create a burden for younger population. Patients with less than 65 years old are increasing in number at medical offices and hospitals. It has also seen that COPD is as common as diseases of younger crowds like asthma and diabetes in those between 45 and 54 years old.

Affecting the working population

The pain that this give to the society is aggravated by the reality that this age range is the working population. The bitter reality of all this is that 70% of patients with COPD are younger than 65 years old.
It’s then important to realize that everybody needs smoking cessation counseling as well as educational efforts should never stop being aggressive as they can.

Effort requested
Every minute accounts in the medical office to chat about smoking and its effects on the health and its related quality of life. Every effort at home to ban smoking and educating about cigarette smoking and illness may be so relevant that its results will provide with sense of feeling grateful for the years ahead. Parents talk frequently about candies, vicious snacks, hand washing, etc but they should talk openly about smoking and its associated decline in lung health and general well being.

Finally
So… women, girls, and boys: no smoking please. A condition called COPD is being reported more in all of you and it’s not by coincidence.

Behind the Best Treatment for COPD?

Many Components

COPD is a multifactorial disease. Thinking about its treatment requires to consider this reality. It’s not a knot in the hair that you can cut and nothing else happens. Since most of the cases are associated to cigarette smoking there’s no doubt that the best management starts with this measure. However, its several components need to be addressed when planning its follow up.

… cigarette-cigarette: stop doing that!

After taking into account the reality of cigarette smoking as the physical and chemical element responsible for the origin, it’s necessary to consider the response of the organism as a target for management. The classical response of the organism after a repetitive injury is the protection. In case of lungs what they can do (if we accept the similitude with an entire being) is to close the airways.

Closing the door to protect

Although there’s no doubt that the irritation leads to some type of inflammation, the persistent feature will be the airways closure (bronchoconstriction). If this is the situation, the most open we can keep the airways the most we help to ease breathe. Medications which mechanism of action implies the relaxation of the muscles around the lung airways are called bronchodilators.

Bronchodilators

It seems reasonable that as soon as a diagnosis of chronic airways obstruction in the lung is made, it should be initiated therapy with bronchodilators. The point of sensitivity with bronchodilators is that they should be inhaled to allow a most effective local action and less general consequences. Guidelines have been recommended to start with bronchodilators soon after diagnosis. Unfortunately, the scientific evidence has not been enough to support an early continuous therapy with bronchodilators and they are being suggested to be used as on a needed basis (as if there were not chronic disease).

Bronchodilators can be of short action or long acting. Short acting agents only help to relieve sudden symptoms while long acting point toward a prolonged relieve. Since the disease is chronic and progressive, all COPD patients will require long acting bronchodilators to maintain their symptoms under control.

Effects of Bronchodilators

Bronchodilators have shown to increase the airflow in and out of the lungs. This effect is seen in the improvement of FEV1 values. The improvement in FEV1 will eventually lead to reductions in the air trapped inside lungs that is said to be responsible for breathlessness. If the air trapping is reduced, dyspnea decreases and patients may tolerate more physical activities, which has been demonstrated in trials associating increases in airflow and exercise tolerance in the laboratory.

More than bronchodilators

However, it’s also relevant to mention that the complex nature of the disease may require adjustments of therapy according to patient responses, incidence of exacerbations, presence of other diseases (comorbidities), etc.

Said this, it should be consider that some patients may require more than one medication to cope with excess risk of exacerbations, infections, physical attiude, etc.

So..

So, let’s keep in mind: there’s no better treatment for COPD but key elements to cover followed by the consideration of the complexity of the illness and individual features that will help address the different aspects of the disease.

COPD: Basic Steps to help

Just Dyspnea and It’s my fault

The COPD patient complains of breathlessness when cough and (sometimes) phlegm have been present for a longer period of time. Some experts have considered that when breathlessness is already installed there are chances for improvement. There are options and no space for regrets. Although the self blaming changes the perspective of some patients, physicians and other health care givers may reinforce the power of the patient.

Patients need to consider their own will since not all the control is on health system’s hands. So what a patient can do?

Understanding the basic: Chronicity

Patients with COPD must understand the chronicity of the disease. It’s not by coincidence that it occurs or develop. More than a lotto result is one of the potential reactions to continuous exposure to noxious particles and gases. Although this exposure happened a long time ago there is a trend in our organism to keep living and the immunological reactions continue. 

The risk factors

Smoking is a key risk factor and of course the most important. However, our current environments are polluted and there is some concentration of population in big cities or industrial areas where it’s easier to inhale low quality air. At the same time, there are some occupations that predispose to continuous inhalation of bad air.

Old “Normal” Symptoms

The COPD patient develops symptoms progressively. The progressive appearance of symptoms allows certain level of adaptation. Most of the patients consider their symptoms as normal and tend to accept them as natural until they become bothersome not only for them but for people around. It’s not the cough what bothers people as much as somebody breathing with difficulty continuously.

Education as basics

Considering the relevance of self education in the management of the disease, an appropriate interaction of the patient with themselves, and with information sources, care givers, health system, may help them to cope better with the disease. Some patients may prefer an academic source, while others tend to go to news or friendly scientific writers, but the important issue is to select a few that answer and help according to the individual needs.

It may be good to create regularity visiting some sources of getting information from certain books. However it is the patient who must choice to get the most of the current evolving knowledge on COPD.

Some considerations on self education

As general recommendations, given the constant flow of information, there are some basic things that COPD patients may do to help in their health support:

1. Understand the basics of the disease
2. Conceive it as chronic and progressive
3. Identify the cause and modify it
4. Precise a few sources of written information based on individual needs
5. Stick to the physician directions in terms of medication and office visits

In a next post let’s define more features that may help in the selection of written sources of COPD information.

COPD: Changing and not the Same for all Sufferers

Heterogeneous Disease

COPD has shown to be a heterogeneous disease. As with any other disease, there seems to be very unique and common features to help physicians in the diagnostic process as well as in therapeutic decisions. Long time ago, COPD was considered to be a syndrome based on a reaction to the continuous aggression by cigarette smoking imposed against the beautiful lung airway structure. Patients were considered to have one of two typical expressions of consequences: chronic bronchitis or emphysema.

Santa Klaus maybe had COPD (because of the chimneys?)

There are some patients with more features of chronic bronchitis but we never forget the classical emphysematous patient: skinny, always smoking, with their head among shoulders instead of above them, dry cough, etc, etc. In the meantime, the chronic bronchitis patient was fatter, smiling, coughing and producing sputum, and breathing with difficulty (just imagine Santa Klaus after he inhaled smoke while working…).

Question

The big question is: why some patients show one or other predominant characteristic of the disease? why ones are emphysematous while others have predominant chronic bronchitis?

Some help but different

That reminds us that categories help but are not definite. That reminds physicians that each patient is different to the other although key features may be common. Not all patients respond the same to cigarette smoking injure so they maybe don’t have to respond equally to same therapeutic measures. They even neither have the same behavior nor have the same attitude during the medical office dialogue. Understanding the actual or potential differences may help support a better approach to disease management.

More differences

So, will everybody have same adverse events? will they have same set of surrounding diseases? (which we call comorbidities). Maybe not and perhaps some may be followed up with spirometry, while others need to be followed up with activity levels, or breathlessness (dyspnea) scales, or symptoms exacerbations, or oxygen levels changes, just for mentioning a few couple of parameters.

Changing focus of investigations

These considerations, fortunately, have led some investigators to start talking about different phenotypes of COPD. Although it challenges our current understanding of the disease, already considered complex and under continuous evaluation to make it look simpler, patients and multiple clinical trials have been shown that the damage is not as homogeneous as we could have thought in the population.

Similarities

We also know that in metabolic diseases some patients present different complications (e.g. diabetics with more renal impairment than neuropathy). In hypertension, some have stroke while other have heart predominant damage. They all have different medical approaches and require different directions: some need to loss weigh, others have to change diet, others respond to a drug better than others, etc.

A Disease in evolution

COPD is starting its own cycle of research, adjustment according to the evidence, natural evolution of the crowd of patients, new and contradictory trends in management, followed by more research and so forth. The present is here and now and the hope is increasing thanks to the investigators who have given passion to this issue. Each patient is different because, simply: individuals are not the same.

Patients with earlier COPD: appropriate attention?

Patients less severe?

According to the Global Initiative for Obstructive Lung Disease (GOLD), there are patients con COPD with minimal changes in the standard method for diagnosis: spirometry.

Spirometry is the only way a doctor can tell a patient if they have COPD and how severe it is. The Forced Expiratory Volume in the first second (FEV₁) helps in the classification of severity. The maximal amount of air exhaled after 6 seconds in a forced maneuver in called Forced Vital Capacity (FVC) and when the FEV₁ is less than 70% of FVC the obstruction in the airway is considered to be present.

Relevance of even early Spirometry 

Obtaining these values is really helpful. The goal to get the factual numbers i to be in the best status of open airways. That’s the reason why patients are asked to inhale a bronchodilator (rescue inhaler) and then they perform the spirometry. The numbers obtained are called post-bronchodilator FEV₁ and FVC.

Interestingly, FEV₁ needs to be compared to the predicted value according to other demographic variables like gender, height, weight, etc. If the FEV₁ is more than 70% of the predicted value, patients are considered to have mild COPD even with an FEV₁/FVC ratio less than 70%.

Guidelines and Early COPD

GOLD guidelines recommend rescue inhalers for these cases. Some doctors wonder if we could do the same with mild hypertension (management of crisis only) knowing that the disease is there anyway. There are some other measures to be taken for mild COPD patients like avoiding risk factors (smoking), annual vaccinations, changes in lifestyle and, I would say, continuous education.

Anything to do for less advanced COPD?

COPD is a progressive disease that need to be treated anyway. If we all know that it leads to an accelerated loss of lung function, which means a more rapid decrease of FEV₁ each year, it may be advisable to start looking at the disease seriously since its diagnosis.

Symptoms vs. Spirometry

Spirometry is a key indicator for the presence and severity of the disease but some symptoms may remind patients and physicians that something is not working appropriately in the lungs earlier. The presence of cough and some sputum production, breathlessness with some activities in the frame of fumes, dust, or any continuous noxious gas exposure should alert about COPD.

Looking for Patients’ Health Benefits

The good news is that we know more and more about the disease each year. There are more patients in earlier stages of the disease who are not receiving any medical intervention (including education). An engagement into the reality of the progressive nature of the disease may help to have a better quality of life when we all know that something can be done. Think about the quality of care all patients need and how they could get more benefits of life and health just understanding a little bit more of their disease.