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).

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…

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.

Pulmonary Complications and Preoperative Pulmonary Evaluation

More pulmonary than cardiovascular complications

In general, any surgery imposes a risk to every system in our body. Most of the complications of surgery are related to cardiovascular events as well as infections. However Pulmonary complications after surgery are also frequent and probably more than the cardiovascular.

Which after-surgery complications in the lungs?

Typical pulmonary complications are local infections like pneumonia, disordered gas exchange with respiratory failure, bronchospasm (wit symptoms of asthma), marginal collapse of portions of the lungs (also called atelectasis), and/or exacerbations of previously existing pulmonary conditions (e.g. exacerbation of COPD).

What predisposes to pulmonary complications?

The nature of the pulmonary complications can be related to the surgical procedure itself or to the patient. The surgical procedure may be described according to site, duration, and anesthesia from which it may be expected that procedures close to the thorax, prolonged interventions, and general anesthesia are associated with subsequent pulmonary complications.

However, patients may also predispose to some risk of complications in the pulmonary structure and functions. Patients with chronic lung diseases tend to have more complications, especially patients with COPD. Age >60 years old, smoking condition, deficient health condition, and heart failure are potential elements of risk for pulmonary complications.

How a physician gather facts over issues to solve

These facts make it necessary to assess patients in plan of surgery for potential lung localized detrimental events. The interview of a patient under surgery program must include questions related to previous lung diseases, isolated respiratory symptoms, and smoking status. The physical examination must also be directed to find anomalies of the pulmonary area as well as trachea at the neck.

The laboratory studies of patients with positive findings in history of physical exam will mandate assessing with one or several of: pulmonary function tests (spirometry), arterial blood gas analysis, chest X-rays, and serum albumin.

Recommendations to the patient

After consideration of risk, patients would be able to receive instructions like: smoking cessation, COPD optimization of therapy, and some recommendations after surgery: lung expansion maneuvers, appropriate analgesia and prophylaxis of deep venous thrombosis. For some patients it may be required other methods of lung ventilation and controlled use of nasogastric tubes (indicating them just when really necessary and not as routine).

In summary

Patients are susceptible of lung complications when they go through a surgical procedure and an appropriate approach may minimize the occurrence of those complications.

The relevance of FEV1 measurement in COPD

 

FEV₁ is a key value to be known by smokers and COPD patients in order to assess the severity of the disease. FEV₁ means Forced Expiratory Volume in the First Second of a full forced exhalation after a full inhalation. It is obtained during the spirometry and represents the amount of air that leaves the lung when all the effort is put into exhalation. After the first second of a full exhalation there’s no much more opportunity to exhale additional amounts of air from the lungs.

 

How to get the FEV₁ value

 

It’s like blowing the candles in a birthday cake: the last ones require other inhalation to get turned off.

 

Although during the spirometry there’re no candles, the patient needs to exhale until he/she can not anymore and not breathing in. If there’s an interruption during FEV₁ measurement, this value will not be real and the interpretation will be wrong.

 

To obtain a FEV₁ value the continuous exhalation effort should last 6 seconds at least, when there’s no more flow from the lungs to the spirometer.

 

How different is FEV₁ value between COPD and asthma

 

FEV₁ gives a good estimate of obstruction in COPD and Asthma. In COPD, doesn’t revert so much. In most cases of asthma, it reverts when there aren’t any symptoms.

 

Everybody has a FEV₁ that modifies itself with aging. It increases until middle adulthood and starts to decrease 30 mL every year. In susceptible smokers, the rate of decrease of the FEV₁ is 60 mL every year which means that it is accelerated.

 

What’s the importance of FEV₁ value in research?

 

Dr. Robert Wise from John Hopkins University School of Medicine, Baltimore, Maryland, USA has been an advocate of the  FEV₁ relevance as a key value in the assessment of COPD (Am J of Med 2006:119;S4-S11).  This value represents the focus of investigations when evaluating the efficacy of approaches for the management of COPD.

 

Several years ago, in a famous, standard, reference publication Charles Fletcher and Richard Peto (Brit Med J, 1977:1:1645-1648) provided with data focused on FEV₁ change. Fletcher and Peto found that FEV₁ falls over time in London working men and this decline is accentuated in susceptible smokers. They also found that smoking cessation is the most effective measure to slow the acceleration toward the normal trend (particularly in those who stop smoking before 45 years old).

 

How the FEV₁value defines COPD severity

 

COPD stages are based on FEV₁ values and on how much it represents of the predicted value for gender, race, age, weigh, and height. For instance:

 

• Mild COPD exists when FEV₁ is 80% or more of predicted
• Moderate COPD exists when FEV₁ is 50% or more but less than 80% of predicted
• Severe COPD exists when FEV₁ is 30% or more but less than 50% of predicted
• Very severe COPD exists when FEV₁ is less than 30% of predicted or less than 50% of predicted with chronic respiratory failure (very low oxygen in blood and high levels of carbon dioxide)

 

Then… should we know the FEV₁ value in case of COPD?

 

Then, it’s good to know the FEV₁ to have a clear idea of the severity and change of the disease. This value is only obtained through spirometry and supports appropriate decisions for right measures to avoid rapid decline.

 

Remember: the most effective action to have a normal FEV₁ change during lifetime is quitting smoking as soon as possible.