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COPD THE DISEASE
COPD THE DISEASE
How do the lungs normally work?
The chest contains two lungs, one lung on the right side of the chest, the other on the left side of the chest.
Each lung is made up of sections called lobes. The lung is soft and protected by the ribcage. The purposes
of the lungs are to bring oxygen (abbreviated O2), into the body and to remove carbon dioxide (abbreviated
CO2). Oxygen is a gas that provides us energy while carbon dioxide is a waste product or “exhaust” of the
How do the lungs protect themselves?The lungs have several ways of protecting themselves from irritants. First, the nose acts as a filter when breathing in, preventing large particles of pollutants from entering the lungs. If an irritant does enter the lung, it will get stuck in a thin layer of mucus (also called sputum or phlegm) that lines the inside of the breathing tubes. An average of 3 ounces of mucus is secreted onto the lining of these breathing tubes every day. This mucus is “swept up” toward the mouth by little hairs called cilia that line the breathing tubes. Cilia move mucus from the lungs upward toward the throat to the epiglottis. The epiglottis is the gate, which opens allowing the mucus to be swallowed. This occurs without us even thinking about it. Spitting up sputum is not “normal” and does not occur unless the individual has chronic bronchitis or there is an infection, such as a chest cold, pneumonia or an exacerbation of chronic obstructive pulmonary disease (COPD).
Another protective mechanism for the lungs is the cough. A cough, while a common event, is also not a normal event and is the result of irritation to the bronchial tubes. A cough can expel mucus from the lungs faster than cilia.
The last of the common methods used by the lungs to protect themselves can also create problems. The airways in the lungs are surrounded by bands of muscle. When the lungs are irritated, these muscle bands can tighten, making the breathing tube narrower as the lungs try to keep the irritant out. The rapid tightening of these muscles is called bronchospasm. Some lungs are very sensitive to irritants. Bronchospasms may cause serious problems for people with COPD and they are often a major problem for those with asthma, because it is more difficult to breathe through narrowed airways.
How does air get into the body?To deliver oxygen to the body, air is breathed in through the nose, mouth or both. The nose is the preferred route since it is a better filter than the mouth. The nose decreases the amount of irritants delivered to the lung, whilst also heating and adding moisture (humidity) into the air we breathe. When large amounts of air are needed, the nose is not the most efficient way of getting air into the lungs and therefore mouth breathing may be used. Mouth breathing is commonly needed when exercising.
After entering the nose or mouth, air travels down the trachea or “windpipe”. The trachea is the tube lying closest to the neck. Behind the trachea is the esophagus or “food tube”. When we inhale, air moves down the trachea and when we eat, food moves down the esophagus. The path that air and food take is controlled by the epiglottis, a gate that prevents food from entering the trachea. Occasionally, food or liquid may enter the trachea resulting in choking and coughing spasms.
The trachea divides into one left and one right breathing tube, and these are termed bronchi (or bronchus for singular). The left bronchus leads to the left lung and the right bronchus leads to the right lung. These breathing tubes continue to divide into smaller and smaller tubes called bronchioles. The bronchioles end in tiny air sacs called alveoli. Alveoli, which means “bunch of grapes” in Italian, look like clusters of grapes attached to tiny breathing tubes. There are over 300 million alveoli in normal lungs. If the alveoli were opened and laid out flat, they would cover the area of a doubles tennis court. Not all alveoli are in use at one time, so that the lung has many to spare in the event of damage from disease, infection or surgery.
Which muscles help in the breathing process?Many different muscles are used in breathing. The largest and most efficient muscle is the diaphragm. The diaphragm is a large muscle that lies under the lungs and separates them from the organs below, such as the stomach, intestines, liver, etc. As the diaphragm moves down or flattens, the ribs flare outward, the lungs expand and air is drawn in. This process is called inhalation or inspiration. As the diaphragm relaxes, air leaves the lungs and they spring back to their original position. This is called exhalation or expiration. The lungs, like balloons, require energy to blow up but no energy is needed to get air out.
The other muscles used in breathing are located between the ribs and certain muscles extending from the neck to the upper ribs. The diaphragm, muscles between the ribs and one of the muscles in the neck called the scalene muscle are involved in almost every breath we take.
If we need more help expanding our lungs, we “recruit” other muscles in the neck and shoulders. In some conditions, such as emphysema, the diaphragm is pushed down so that it no longer works properly. This means that the other muscles must work extra hard because they aren’t as efficient as the diaphragm. When this happens, patients may experience breathlessness or shortness of breath.
What Is Chronic Obstructive Pulmonary Disease (COPD)?Chronic obstructive lung disease (COPD) describes a group of lung conditions (diseases) that make it difficult to empty the air out of the lungs. This difficulty can lead to shortness of breath (also called breathlessness) or the feeling of being tired. COPD is a word that can be used to describe a person with chronic bronchitis, emphysema or a combination of these. COPD is a different condition from asthma, but it can be difficult to distinguish between COPD and chronic asthma.
Two people may have COPD, but one may have more symptoms of chronic bronchitis while another may have more symptoms of emphysema. It is helpful to understand the difference between the two conditions, as COPD means a person may have some chronic bronchitis as well as emphysema.
How do I know I have COPD?Cough, sputum production or shortness of breath that will not go away are all common signs of COPD. These signs and a history of smoking will usually indicate the need for a test called spirometry, which measures if you have airway obstruction or not.
How does my healthcare provider know I have COPD?Your healthcare provider will decide if you have COPD based on both your reports of symptoms and test results. The single most important test to determine if you have COPD is spirometry. The most important things you can do to help your healthcare provider in determining if you have COPD is to: 1) be honest about your smoking history; 2)share your exposures to pollutants and chemicals; and 3) remember, as best you can, when your symptoms first started.
How is COPD treated?The first most important treatment if you are a smoker is to stop smoking. As well as helping you quit smoking, your healthcare provider may prescribe medicines that widen the breathing tubes (bronchodilators), reduce swelling in the breathing tubes (anti-inflammatory drugs) or treat infection (antibiotics). Medications have been shown to help stabilize the breathing passages and decrease swelling. In order to provide control of your COPD, these medications must be taken every day, probably for the rest of your life.
Currently, there is no treatment available to restore damaged bronchi from bronchitis or alveoli affected by a large amount of emphysema. Unfortunately, the damage that has been done to the alveoli is permanent. In some parts of the world, surgery (lung volume reduction) can be performed as a way of removing some (but not all) areas of the lungs with large amounts of emphysema.
With COPD you can learn to use the lung power you have more efficiently. You should learn as much as you can about your condition. Attending groups or enrolling in a Pulmonary Rehabilitation Program can be helpful. Pulmonary rehabilitation may also be recommended so that you can learn to be in control of your breathing, instead of your breathing controlling you.
What causes COPD?COPD can be caused by many factors, although the most common cause is cigarette smoke. Inhaling irritating particles, such as smoke or air pollutants, can cause the mucus glands that line the bronchial tubes (bronchi) to produce more mucus than normal, and can cause the walls of the bronchi to thicken and swell (inflame). This increase in mucus causes you to cough, frequently resulting in raising mucus (or phlegm). COPD can develop if small amounts of these irritants are inhaled over a long period of time or if large amounts are inhaled over a short period of time.
Environmental factors and genetics may also cause COPD. For example, heavy exposure to certain dusts at work, chemicals and indoor or outdoor air pollution can contribute to COPD. The reason why some smokers never develop COPD and why some never-smokers get COPD is not fully understood. Family genes or heredity probably play a major role in who develops COPD.
What is asthma?Asthma is a condition of chronic swelling of the airways. These airways are sensitive to stimulation by a number of things, such as infection, cold air, exercise, pollens, etc. The swelling may produce an obstruction of the airways, similar to COPD. Some people with COPD also have asthma.
What is bronchiectasis?Bronchiectasis is a permanent enlargement of the bronchi and bronchioles. The enlarged airways produce abnormal amounts of mucus, which can block (obstruct) the breathing passages. Bronchiectasis may occur after severe pneumonia. While bronchiectasis may at first appear to be COPD, the evaluation and treatment are different.
What is bronchiolitis?Bronchiolitis is characterized by swelling of the small airways (bronchioles), usually resulting from inflammation or infection. This condition is more commonly seen in children after severe lung problems and in adults after lung transplantation. The narrowing of the breathing passages can be confused with COPD.
What is chronic bronchitis?Chronic bronchitis is a constant swelling and irritability of the breathing tubes (bronchi or bronchioles) and results in increased mucus (phlegm) production. Chronic bronchitis is diagnosed when a person reports cough and mucus on most days for 3 months during 2 consecutive years when other lung conditions have been eliminated as a cause. This means that other conditions (and there are many) that may cause sputum production or cough are not the cause. Airway obstruction occurs in chronic bronchitis because the swelling and excessive mucus production causes the inside of the breathing tubes to be narrower than normal. The narrowing of the airways prevents the normal amount of air from reaching the lungs. The amount of narrowing is measured with a breathing test called spirometry.
What is emphysema?Emphysema is a disease that involves the alveoli (air sacs) of the lung. Normally there are over 300 million alveoli in the lung. These alveoli are stretchy and springy, like little balloons. Like a balloon, it takes effort to blow-up a normal alveoli, however, it takes no energy to empty the air sac because the alveoli spring back to their original size. In emphysema, the walls of some of the alveoli have been ruined. When this
happens the alveoli become stretchy and act more like paper bags. A paper bag is easy to blow-up, but
you need to squeeze the bag to get the air out. So, instead of just needing effort to get air into the lungs, it also takes energy to squeeze the air out. As it is difficult to push all of the air out of the lungs, they do not empty efficiently and therefore contain more air than normal. This is called hyperinflation or air trapping. The combination of constantly having extra air in the lungs and the extra effort needed to breathe, results in the feeling of shortness of breath.
The “obstruction” in emphysema is because the breathing tubes tend to collapse on exhalation, preventing you from getting the normal amount of air out of your lungs. This is a result of the loss of stable alveolar walls, which normally hold the breathing tubes open as your exhale. Airway obstruction is measured with spirometry (a breathing test). Several other tests can be performed that can tell your provider if it is likely that you have a lot of emphysema causing your COPD.
Will COPD ever go away?The term chronic in chronic obstructive respiratory disease means all of the time, therefore, you will have COPD for life. While the symptoms sometimes are less after you stop smoking, they may never go away entirely. Improvements in symptoms depend on how much damage has occurred to your lungs.
What Are the Signs and Symptoms of COPD?COPD can cause breathlessness (also called shortness of breath or dyspnea), cough, production of mucus/sputum/phlegm and tiredness (also called fatigue). Symptoms such as breathlessness and fatigue cannot be seen or easily measured because they are sensations or feelings that you experience. Only the person experiencing the symptom can describe these sensations and how badly they make them feel.
When symptoms first occur, most people ignore them as they think that they are related to smoking, i.e. “It’s just a smoker’s cough” or “I’m just winded/breathless from being out of shape”. These symptoms can worsen to the point that people are motivated to stop smoking in order to control the symptoms. Others let the symptoms control them. These signs and symptoms of COPD (breathlessness, tiredness, cough and sputum production) are an indication that the lungs are not normal, even though the lungs are actually responding “normally” to the irritation. Many people with COPD develop most, if not all, of these signs and symptoms.
Is coughing a symptom of COPD?Cough can be expected with COPD. Cough is a natural reaction of the airways to try and remove mucus or it can be a reaction to protect the airways from inhaled irritants. Coughing is therefore a good thing when it results in moving sputum or phlegm out of the breathing passages. For this reason, you will sometimes find your healthcare provider unwilling or hesitant to give you anything to prevent you from coughing. Conversely, cough resulting in airway spasm is not useful over a long period of time, but can be controlled with cough “suppressants”. While a person with COPD will often cough, coughing does not mean you have COPD.
What can I do to treat cough? Cough due to irritants can sometimes be controlled with “over-the-counter” (not needing a prescription) remedies like throat lozenges and cough syrups. Cough due to smoking will probably not go away unless the person stops smoking. If treatment with over-the-counter medications does not control the cough, your provider may prescribe medication. Coughs that are due to thick, sticky mucus can be treated by drinking plenty of fluids. Fluids can help loosen and thin the mucus. If fluids do not work, a cough expectorant or mucolytic may loosen the secretions. Coughing that produces spasm may require an inhaled bronchodilator and/or inhaled steroid. Coughing that does not produce mucus or that becomes violent and difficult to control will usually subside with cough suppressants (also called antitussives) such as codeine. Many people forget that simply drinking more fluids is often the best treatment for a cough.
When should I call my healthcare provider about my cough? Most coughing is not dangerous. People without COPD should consider seeing their provider if they have a cough that has lasted several weeks
or a cough without a known reason (for example, the common cold). In addition, people with certain conditions, such as a collapsed lung or hernias, may be advised by their provider to control their coughing with medications.
Incontinence (inability to control passing urine during cough) may be another problem caused by coughing. Urinary incontinence during cough may occur more frequently in men who have had their prostate removed. Controlling the cough will reduce incontinence. Emptying the bladder more frequently than usual (e.g. every 2 hours) may also reduce incontinence. Pelvic muscle exercises are available and have been found to be useful in those with chronic problems with incontinence.
Unexplained cough or coughing that causes you to “pass out” should be reported to your healthcare provider. Cough that does not go away with inhaler treatment should also be reported.
Is shortness of breath (breathlessness) a symptom of COPD?Yes, shortness of breath, also known by the term breathlessness or the medical term of dyspnea, is a common symptom of COPD. Breathlessness is a feeling occurring when the lung changes from working in the way it was normally designed to work, to working differently. If the lung senses that it takes more work or effort to move air in and out of the lungs, a feeling of breathlessness will be experienced. While this feeling can be very uncomfortable to the person with COPD, it does not mean that the person is further damaging their lungs by doing things that make them breathless. Unfortunately, people try to avoid this feeling by doing fewer activities or activities less often. This strategy of avoiding activities to avoid breathlessness may work initially, but eventually avoiding activities leads to getting out of shape or becoming deconditioned. Becoming deconditioned can result in even more shortness of breath with activity. One of the greatest challenges for people with COPD is learning to continue leading an active life in spite of the difficulties breathing. Pulmonary rehabilitation programs are useful in helping people learn strategies to reduce this feeling of breathlessness with activities. An important principle for people with COPD to learn is to never avoid an activity because it causes breathlessness. To do so means COPD has taken control of you and you have lost control over your breathing problem.
What can I do to treat breathlessness? If you and your provider find that your breathlessness is from your COPD, you can do several things. First, be sure you are taking your medications when and how prescribed, even if you don’t “feel” that they are helping. Secondly, begin a regular program of exercise to build up your strength. Thirdly, learn about paced breathing and ways of breathing more efficiently with activities. These techniques are taught in pulmonary rehabilitation programs. Fourthly, if you find the support of others with the same problem helpful, enroll in a pulmonary rehabilitation program or begin attending breathing support groups offered by your local lung association or clinic.
When should I call my healthcare provider about my breathlessness?Anytime a person has a new symptom, or the symptom worsens for no known reason, you should consider calling your healthcare provider. Describe to your provider when the breathlessness started, how long it lasts and what makes the breathlessness better or makes it worse. Providing information of this kind can help your provider determine the best steps to take in making you more comfortable.
Is sputum production a symptom of COPD?Sputum production, also called phlegm or mucus production, can also be a symptom of COPD. Sometimes, people confuse sputum with the mucus coming from their nose, which has drained from their sinuses. Sinus drainage from the nose may drip down the back of the throat to the trachea, where it may “mix” with mucus coming from the lungs. When your provider asks about sputum production, they are usually asking about the amount coming from your lungs, not your sinuses.
It is normal for the airways to produce several ounces of sputum a day. This mucus is needed to keep the breathing passages moist. When the lungs are bothered by irritants, they try to protect themselves by producing additional mucus to trap any inhaled particles from entering the lungs. Constant attack by irritants, such as smoke, however, makes these glands enlarge and produce two to three times the normal amount of mucus. Chronic irritation also causes a problem with the natural cleaning system in the airways provided by the cilia.
Cilia are destroyed by smoking. Smoking also causes any surviving cilia to become paralyzed for at least 20 minutes following inhalation of cigarette smoke. The result is a poorly working sweeping system that doesn’t clear the air passages very well.
Clearing mucus can be a problem for people who are very weak from illness or if they take medications that make them sleepy. Sometimes medications are needed to loosen the mucus so that the mucus can be coughed out more easily. It is possible that sputum that is allowed to accumulate in the lungs may “grow” bacteria, which can cause acute bronchitis or pneumonia.
What can I do to treat my problem with sputum? The first thing to remember is that sputum needs to be coughed up. Swallowing small amounts of sputum is not known to cause health problems. However, it is better to cough the sputum into a disposable tissue so that you can see the color of the sputum. Knowing the color and amount of sputum you raise on a daily basis is helpful to the person treating your COPD.
There are usually three types of treatment needed for sputum problems:1. expectorants, which make the sputum easier to cough out;2. mucolytics, which thin thick mucus and;3. antibiotics, which treat infections in the lung.
A person with COPD may not need any of the three treatments listed above. A common problem for people with COPD is thick sputum, making sputum difficult to cough up and out. Thick sputum may come from a need to increase your fluid intake. The most natural way of thinning mucus is by drinking any type of non-dehydrating liquid, such as water, juices, etc. These will help make the sputum thinner and easier to cough. Since alcohol, coffee and tea are dehydrating; they should be avoided as a means of liquefying mucus. A person with sputum production should drink at least eight glasses (2 quarts/liters) of liquid a day.
If this natural way of thinning mucus does not work, then medications may be used. Expectorants are medications that may help make the mucus looser. Not all medical scientists, however, are convinced that they work. The most common type of expectorant is a substance called guiafenesin. Another approach is to use medications that break up the sputum molecules, called mucolytics. The most common type of mucolytic is a medication called N-acetylcysteine. This medication is available in inhaled form and must be delivered by a nebulizer. N-acetylcysteine is more commonly prescribed to patients in European countries than in the USA.
The use of antibiotics is reserved for sputum that is infected. Sputum that is clear in color is usually not infected. Sputum that is colored light brown, but which you can see through, may be discolored from diet, such as drinking coffee. However, infected sputum (and therefore infected lungs) is likely if the sputum is a deep yellow color that cannot be seen through. Other colors that may indicate an infection is developing are green, brown or reddish mucus.
When should I call my healthcare provider about changes in sputum? Generally, a change in the color and the amount of sputum is a sign that there is some abnormal activity in your lungs. In some instances, these changes are so predictable (occurring once or twice a year) that the patient with COPD and their provider can establish a system of treatment that the patient can start at home. For example, seven days of antibiotics and steroids may be prescribed for the patient to begin as soon as signs and symptoms of an infection begin. In most instances, the sputum can tell the person a great deal about what is happening in their lungs, maybe even hours to days before a severe infection develops. It is believed
that people who can recognize and treat an infection early can avoid a more serious problem needing hospitalization.
Is tiredness or fatigue a symptom of COPD?While tiredness or fatigue can be very uncomfortable, it is not dangerous since it is not damaging your lungs or other organs. Tiredness may, however, be a symptom of another condition. Like breathlessness, tiredness is an uncomfortable feeling. It is a common symptom in people with COPD. Tiredness is a feeling of loss of energy or stamina. Generally, breathlessness and tiredness go hand in hand and they are, for some people, difficult to tell apart. Tiredness discourages a person from keeping active, which leads to greater loss of energy, which leads to more tiredness. When this cycle begins it is sometimes hard to break. It is estimated that for every day a person is hospitalized, it takes 3-4 days to regain their stamina. Tiredness, like breathlessness, can be prevented or reduced by keeping active and learning how to do activities with less effort.
What can I do to treat tiredness? If you and your healthcare provider find that your tiredness is from your COPD, you should take the same measures as with breathlessness; make sure you are taking your medications as prescribed, begin a regular program of exercise to build your strength, learn about paced breathing and ways of breathing more efficiently with activities and consider learning from others with the same problem by attending breathing support groups offered by your Lung Association or enrolling in a pulmonary rehabilitation program.
When should I call my healthcare provider about my tiredness? Call your healthcare provider when unexpected tiredness occurs and does not go away. Ask yourself similar questions that you would with breathlessness. Have you ever had this type of tiredness before, what happened? Anytime a person has a new symptom, or the symptom worsens for no known reason, they should consider calling their healthcare provider. Describe to your provider when the tiredness started, how long it lasts, what makes the tiredness better or makes it worse. If you have ever had this type of tiredness before, what happened? Did any medication help or did you need to be hospitalized? Providing information of this kind can help your provider figure out the best ways to make you more comfortable.
Is wheezing a symptom of COPD?Wheezing is a sign that air is trying to flow through a narrow passage and it may indicate that the lungs are getting out of control. Airway narrowing can occur from spasms, swelling or mucus accumulating in the airways. Sometimes, when a person with COPD develops an infection in their lungs, wheezing may occur. This wheezing should be controlled with medications so that the wheezing lessens and finally is no longer present. If wheezing worsens or cannot be controlled with medication, call your healthcare provider.
What can I do to treat wheezing?Taking your bronchodilator medication regularly should control wheezing. Avoid things that cause wheezing, such as smoky places or, if cats or other things cause you wheezing, avoid them. Usually wheezing does not go away without treatment.
When should I call my healthcare provider about my wheezing? If wheezing and breathlessness do not go away with the medication you have been given, call your healthcare provider. If these symptoms become severe, seek emergency treatment.
How Can I Stay Healthy?For anyone with COPD it is important to keep as healthy and active as possible. You can do many things to
keep yourself healthy. Quitting smoking and rigorous activity are the most important.
Do I really need to stop smoking?Smoking is the single greatest reason people develop COPD, but smoking itself is also a condition that requires special treatment. It is well known that smoking can cause lung cancer, heart and lung disease. About 90% of people with COPD get COPD from damage caused by smoking. Nevertheless, stopping smoking can help patients, even in severe cases. For example, everyone loses lung tissue as they get older. People with COPD who smoke, however, lose lung tissue at a much faster rate. Stopping smoking can slow the rate of loss to a normal rate. In addition, smoking causes swelling and irritability in the breathing passages. Some of these changes will no longer happen or will be less severe when smoking is no longer irritating the breathing passages.
Is it too late to stop?No, it is never too late to stop for the reasons mentioned above. While stopping smoking will not make the lungs normal again, stopping smoking slows the damaging process from getting even worse.
What are some tips that can help me to stop smoking?Tip 1: for those who are having trouble stopping smoking on their own, medication can help. Tip 2: no single treatment is right for everyone. If the first approaches you take fail, try to figure out why. Speak with your healthcare provider about other options. Tip 3: don’t be discouraged if your first attempts to quit fail. It may be that you need a different form of treatment, or that you weren’t quite ready to give up smoking. Tip 4: avoid being in situations where people are smoking until you feel strong enough to resist the temptation. Tip 5: never give up trying to stop. Most smokers try several times before successfully quitting for good!
Tell me more about the process of stopping smoking? Stopping smoking is a two-part process. One part is the nicotine dependence developed from smoking; the other is the habit of smoking. Nicotine leaves the body 24-48 hours after the last cigarette, but withdrawal symptoms may continue after the nicotine has left the body. Usually, cravings are less frequent and less strong after 2 weeks. The other part that smokers need to deal with is the connections their brains have made with multiple doses of nicotine throughout the day. Someone once said “anything you do 500 times a day, 365 days a year has got to be addictive, regardless of what it is!”. While most people who smoke stop smoking by their own method, some do better with the help and support of family and healthcare providers, and medication.
What treatments are available to help me stop smoking? Smoking cessation support groups are available through many hospitals, clinics or other sites. Studies show that smokers benefit most from the combination of a support group and medication. It is well known that the more support you receive when quitting smoking, the better success you will have. While therapies such as biofeedback and hypnosis have also been used to treat smoking, their usefulness is less clear. Ask in your community if a “Quit Line” is available. Having telephone access to support is very helpful.
What medications might help me stop smoking? Medications to help people stop smoking vary and the cost can be a factor for some people. When considering the cost of a treatment or medication, however, the smoker should consider the ultimate cost they will pay by continuing to worsen their chronic lung condition.
Nicotine replacement therapy includes gum, lozenges, patches, nasal spray and inhalers. Nicotine gum and patches are often available over the counter, while the nasal spray and inhalers are available by prescription,
depending on where you live. Nicotine replacement therapy provides low levels of nicotine in order to decrease the withdrawal symptoms from nicotine addiction. Heavy smokers may require higher doses. This low dose of nicotine gives the smoker time to adjust to stopping smoking.
Because nicotine replacement can affect your heart and blood pressure, these medications should not be taken if you have had a heart attack in the past month or have significant heart irregularities. Discuss the use of these products with your provider if you have recently experienced a heart attack, have chest pains, heart irregularities or you are having difficulty controlling your blood pressure.
You should stop smoking when using these substances, since the combination of smoking and these medications reduce your chances of stopping successfully. You and your provider may find that using two types of nicotine replacement products (for example using the gum along with patches) helps control your desire to smoke. This combination therapy should be done under the supervision of your provider.
What is nicotine gum? Nicotine gum (Nicorette, Nicotinelle) is a way of providing the body with nicotine without the harmful effects of smoke. Nicotine gum releases nicotine slowly when chewed. Gum must be chewed until a tingling sensation in the mouth occurs, the gum should then be “parked” between the cheek and gums until the tingling or taste goes away. Repeat the chewing until the tingling reappears. Repeat this process for 30 minutes, and then discard the gum in a safe place, away from children and animals. Continual chewing may cause the jaw to be sore, upset the stomach, cause hiccups or a sore throat.
What is a nicotine inhaler? Nicotine inhaler (Nicotrol inhaler, Nicorette inhaler) is another way of providing the body with nicotine without the harmful effects of smoke. This inhaler is different from bronchodilator inhalers. It is a small tube containing a cartridge of nicotine. The individual slowly inhales on the tube/holder and the nicotine is absorbed in the mouth. It is not inhaled into the lungs. This delivers a low level of nicotine similar to nicotine gum. Some people find that holding something in their hand and putting a tube in their mouth is helpful during withdrawal. This can be used at regular times throughout the day or when one anticipates a craving.
What is a nicotine patch? Nicotine patches (Habitrol, Nicoderm CQ, Nicotrol, Nicorette, Nicotinell, Niquitin CQ and ProStep) are a way of providing the body with nicotine without the harmful effects of smoke. How often you use them will vary. Most patches are worn for 24 hours, except for Nicotrol, which is worn for 16 hours. The patch provides a low level of nicotine over time and “takes the edge off” withdrawal symptoms. Since the nicotine dose delivered at night may interfere with sleep, patches are sometimes removed at bedtime. However, nicotine craving on awakening is then worsened. While patches are well tolerated, skin irritation is a common problem. This problem can be reduced by placing the patch at a different place on the skin every day.
What is a nicotine spray? Nicotine nasal spray (Nicotrol NS, Nicorette) is a way of providing the body with nicotine without the harmful effects of smoke. The spray delivers nicotine through a spray and is absorbed in the nose. It is not inhaled like other nasal sprays. One to two doses are used per hour as needed. Most need nine to 12 sprays per day. The spray should be used for at least 3 months but for no longer than 6 months.
What are nicotine lozenges? Nicotine lozenges (Niquitin CQ, only available in some European countries, Commit is available in the US) deliver nicotine through a tablet. The tablet is placed under the tongue when the desire to smoke arises and is allowed to dissolve. One to two lozenges can be taken every hour, with a maximum of 20 lozenges a day. Lozenges should be taken for 3 months, when the number of lozenges used daily should
be reduced. Lozenges should be stopped when only one to two lozenges per day are being used.
Are there other medications besides nicotine replacement that can help me to stop
smoking?Yes, two other medications have been used to help individuals stop smoking.
Bupropion (Zyban) was originally used as a medication to treat depression. It was later found to be particularly helpful for people trying to stop smoking. This medication does not contain nicotine. It is a tablet taken once or twice a day. You and your healthcare provider will decide the best amount for you.
Generally, 2-3 months of treatment are needed. Those who should not take this medication include those who are at risk for seizures, eating disorders or use MAO inhibitors (a special class of medications to treat depression). If you are taking any medication to treat depression, including Bupropion, tell your physician before you begin taking Zyban.
Clonidine (Catapres) and nortriptyline (Aventyl, Pamelor) have also been used to assist smokers stop smoking, but these drugs have not had as wide a use and study as bupropion.
These medications can be used alone but may be more effective if used with some form of nicotine replacement.
Where do I get help to stop smoking? Many organizations want to help. In addition to the clinic or hospital where you are being seen, call your local Lung Association, or refer to the following sites:
Should I get the flu and/or pneumonia vaccination?Unless told otherwise by your healthcare provider, and you are not allergic to eggs, you should receive both the flu and pneumonia vaccination. The flu shot is available each fall and you should get one every year. There are no live viruses in the shot, so you will not get the flu from the shot. As with any shot, it may make your arm tender.
You should get the pneumonia shot at least once a lifetime. If you have had the pneumonia shot 6-8 years ago or have had pneumonia since you first got the shot, ask your healthcare provider if you should get another one. Like the flu shot, there are no live viruses in the shot, but it may make your arm tender.
Is it normal to get depressed?Having COPD and being unable to do what you want to do because of shortness of breath can be a reason for depression. Depression is a treatable condition and should not be ignored. Some patients find that being enrolled in a pulmonary rehabilitation program and having contact with others can lessen depression. Others require medications to treat their depression. Discuss your feelings with your healthcare provider. Depression is not a condition that is always obvious to those caring for you.
What should I know about osteoporosis?You should know that both men and women get osteoporosis (weakening of the bones). This occurs in many people as they grow older or because of medication. A common medication taken by patients with COPD, steroids, can increase your chances of getting osteoporosis. Your healthcare provider can monitor the strength of your bones (bone density) with a bone density scan. There are medications that can slow the progress of bone loss and in some cases actually strengthen the bones.
Is there a special diet for patients with COPD?There is no special diet for people with COPD. At one time, it was felt that people with COPD should avoid carbohydrates found in sugars and starches. This theory has never been shown to be true for patients not hospitalized. In addition, people with COPD can experience two very different problems with weight. Some people with COPD gain weight and others have difficulty maintaining their weight.
While COPD does not cause weight gain, some medications used to treat COPD, such as steroids, may cause some people to gain weight. Being overweight will make the symptoms of COPD worse. Carrying the added weight requires more work for the body and keeps the lungs from expanding fully. The result can be greater breathlessness and increased tiredness because the person is less active. People who are overweight often lose their motivation to exercise. The challenge for these patients is to lose weight and exercise. Those needing to lose weight should be actively involved in a weight loss program that is no different than a person without lung disease.
Some people with COPD may have serious problems maintaining their normal weight. Weight loss comes from not having enough calories to simply keep up with the daily demands of the body.
Additional calories are needed to make up for those they burn with the act of breathing. They, therefore, do not have any “extra” calories to use in order to maintain their normal weight. The challenge for these patients is to eat enough calories to maintain their weight. Those who are underweight need to consume as many calories as possible. Therefore, foods that are high in calories, but easily swallowed and digested, are best. In some instances, medications to stimulate the appetite may be needed.
Whether a person with COPD is overweight, underweight or their ideal body weight, they all can lose muscle function from nutritional imbalance and lack of exercise. The way to reverse this process is to exercise and eat a balanced diet.
Are there activities that I should not do?After stopping smoking, keeping active is the second most important thing you can do to help your breathing problem. The kind and amount of activity is almost limitless, for example play golf, shop, take hikes or garden. In order to do these exercises without causing severe breathlessness, you need to learn to pace your breathing with the activity. Paced breathing helps you breathe in coordination with your activity. One of the biggest adjustments patients with COPD must make is to pace their breathing, economize their motion and slow their pace. These techniques are taught in pulmonary rehabilitation programs and at COPD support groups.
It is very unusual for people with breathing problems to “over exert” themselves. Usually, people who feel that they are over exerting are experiencing the normal symptom of breathlessness. With the exception of activities that may expose you to environmental irritants or a cold or flu, you should be involved in physical activities every day.
Can I travel?People with COPD should not avoid traveling because they have a breathing problem. In some cases, those with COPD are advised to avoid traveling to higher altitudes (elevation) because of decreased oxygen levels at altitude. They may be prescribed oxygen when traveling at altitude. If you choose to travel to a higher altitude, discuss your oxygen needs with your healthcare provider.
Flying does not “hurt” the lungs. The major concern is the pressure in the airplane and your need for oxygen in flight. If you are receiving oxygen for any reason, discuss the possible need for oxygen with your provider before flying (see Oxygen section).
Why do I sometimes have trouble sleeping?COPD sometimes affects a person’s sleep. People with COPD may experience sleep problems for a variety
of reasons, including sleep apnea, low levels of oxygen at night, medications and cough. Low oxygen levels may disrupt sleep. Those with disrupted sleep because of low oxygen levels may or may not be aware of a low oxygen level. Your healthcare provider may refer you for a sleep evaluation. There are a number of medications that are used to treat COPD that may interfere with sleep. Most bronchodilators including beta-agonists and theophylline are stimulants. Taking these medications near bedtime may make it difficult to fall asleep. Cough may awaken patients resulting in disrupted sleep. Coughing that awakens you should be discussed with your healthcare provider so that they can evaluate and treat it. Patients with severe difficulty breathing may develop fears of falling asleep. This should also be discussed with your healthcare provider since it is easy to develop poor sleep habits.
Signs of sleep problems that should be discussed with your healthcare provider include difficulty getting to sleep or staying asleep, awaking with headaches, awaking with shortness of breath and complaints by your sleep partner that you stop breathing during sleep. When evaluating your sleep problem, your provider will want to know all medications you take before going to sleep.
What about sex?Your lung disease does not directly affect your sexual ability. However, the symptoms of your lung disease, such as shortness of breath, fatigue and the emotional reactions of having a chronic disease, may interfere with your ability to perform and enjoy sexual activity. Many people with COPD have concerns about the effect of sexual activity on their lungs. Sex, like other physical activities, is not harmful to your lungs.
The medications you are taking for your lung disease, such as bronchodilators and steroids, have not been documented to cause difficulties with sexual functioning. Other medications you are taking for other health problems could possibly cause difficulty with sexual activity. Pulmonary rehabilitation programs usually have a class that discusses issues related to sexual functioning or you can discuss your concerns with your healthcare provider.
How often should I see my healthcare provider?Your healthcare provider will schedule regular visits with you, either every year or every 2-3 years, depending on how well your COPD is under control. Between these regularly scheduled visits, you should see your healthcare provider when you have an increase in your symptoms that you are unable to control with your “action plan”.
What is an “action plan”?An “action plan” is a strategy that you and your healthcare provider develop to handle increased symptoms, such as increased shortness of breath, increased cough or greenish sputum. This plan should outline how often you can use your bronchodilators, when and how much steroids to take, and specifically when you should call your healthcare provider.
What Is an Exacerbation?Exacerbation means worsening or a “flare up” of COPD. An exacerbation can be from an infection in the lung, but in some instances it is never known why people have a worsening of symptoms. An exacerbation is usually treated with antibiotics even if the reason for the exacerbation is not known. Some healthcare providers believe that early treatment with antibiotics may prevent the process from getting worse. Whatever the reason for your exacerbation, you should contact your healthcare provider if your symptoms worsen (breathlessness, cough, sputum production).
How do I know I’m having an exacerbation?Signs and symptoms of an exacerbation are similar to those of an infection or pneumonia. The amount and color of your sputum is important to note. A change in the amount of sputum (either bringing up more or
bringing up less than usual), a change in the color of your sputum from clear to deep yellow, green, brown or red, and increasing shortness of breath are typical signs and symptoms of an exacerbation.
If I am hospitalized, what can I expect?If you are hospitalized for complications of your COPD, you will probably be given antibiotics (and other medications intravenously), oxygen, have chest-x rays taken and several blood tests. These tests help guide your healthcare provider in how best to treat you. Sometimes, despite all treatment, the lungs are unable to adequately take in oxygen. In this case, you may require a ventilator to help you breathe (see Planning for the Future). Once on a ventilator, it may be a slow process removing you from the ventilator. In some cases, when the infection begins to go away, a person can be removed from the ventilator in just a few days. At other times, it may take weeks or months for the lungs to gain the strength needed to breathe without the help of a ventilator. There are also times when the person is not able to breathe again without a ventilator. This condition is called ventilator dependency. You, your family and your healthcare provider should discuss what you would like do if you are ever in a position where you will require a ventilator temporarily or permanently. Your views and preferences for a ventilator or any other therapy can be outlined in documents called advanced directives.
Will I be admitted to the hospital?While you may experience more shortness of breath than usual with an exacerbation, acute bronchitis or pneumonia, these conditions do not necessarily require hospitalization. Many medications are now available to prevent hospitalization. Your provider will determine whether you need to be hospitalized based on your history and symptoms.
How Do I Know I Have Pneumonia?For people with COPD, it is sometimes difficult to know if their respiratory infection is the flu, a cold, a respiratory infection (acute bronchitis) or pneumonia. Acute bronchitis is the sudden swelling of the bronchial tubes from infection. Often, your provider may not be able to tell you what organism has caused the bronchitis, but antibiotics control the problem quickly. Conversely, pneumonia may begin like bronchitis, but does not go away with usual treatment. Common signs of pneumonia are more shortness of breath than usual, cough, increase (or sudden decrease) in the amount of sputum, a deep yellow, green or red color to the sputum, coughing blood, fatigue (extreme exhaustion), or fever. A chest x-ray is needed to diagnose pneumonia.
Pneumonia can develop in the lungs from an infection caused by any of several organisms (also called “germs” or “bugs”). These organisms can be a virus, bacteria or fungus. Organisms can grow in the lungs if the person’s immune system is too weak to fight off the organism’s growth. Our lungs, like our mouth and nose, normally contain organisms, but they are either harmless or are too few in number to be harmful. Harmful organisms are termed pathogenic (they cause infection whether in small or large amounts). People developing pneumonia are either not able to control the growth of these organisms or have inhaled pathogenic organisms that are quick to cause pneumonia.
Is pneumonia dangerous?Pneumonia can be dangerous, especially if the person is already very weak. People with COPD often become weak because of lack of exercise or nutritional problems. If pneumonia does occur, it can usually be treated at home with antibiotics. Sometimes your provider has to change the antibiotic if the organism does not go away with the first antibiotic. If you get too weak, or unable to breathe adequately because of the infection in the lungs, you may need to be hospitalized. Occasionally, people with pneumonia need to have their breathing assisted or controlled with a ventilator until the infection is controlled. Some people are too weak to fight the infection, even when a ventilator is used, and die from pneumonia. Pneumonia can be very dangerous if not treated early.
What can I do to treat the pneumonia?When antibiotics are prescribed, take them as directed, no more or no less than prescribed (unless they are causing side-effects). That means not only the dosage (for example “one tablet twice a day”), but also for the length of time outlined by your healthcare provider (for example “take for 7 days”). The length of time you are prescribed antibiotics varies with the medication and your provider’s evaluation. Therefore, some antibiotics are for 5 days and some for 14 days. The important thing is not to stop taking antibiotics because you “feel better”. There is no single antibiotic that is considered the “best” to treat all pneumonias. Your healthcare provider will decide which is best for you based on your history and chest x-ray. It is likely you will need to use your inhalers more frequently and possibly use inhaled steroids or steroid tablets for a short period of time in order to help you recover from the pneumonia.
When should I call my healthcare provider about pneumonia?You should call your healthcare provider if you suspect that you may have pneumonia. Signs of pneumonia are dark yellow or green sputum production in larger amounts than normal, a feeling of congestion that won’t go away, increasing shortness of breath, fever and increasing tiredness. Your provider will determine if you have pneumonia with a chest x-ray and antibiotics will be prescribed if you have. You should call your provider if the sputum does not improve in color or amount after several days of antibiotics. You should also call if your breathlessness worsens or fever does not improve. You can expect to be weak from pneumonia. Weakness, however, that worsens despite treatment should be brought to the attention of your healthcare provider.
How Do I know If I Have the Flu?The flu is caused by the influenza virus and can be confused with a cold or a respiratory infection. The flu is different from a cold in that the symptoms begin very suddenly. The most common signs and symptoms of the flu include more shortness of breath than usual, fever, extreme exhaustion, muscle aches (called myalgias) which can last 2-3 weeks, stomach upset, severe coughing without raising sputum and headache. The flu is easily transmitted between people. Like a cold, the flu can be transmitted in the air, or by touching something or someone contaminated with the virus. For example, the flu can be transmitted by inhaling the air near a person with the flu who coughs or sneezes. The flu can also be transmitted by shaking hands with someone with the flu and then touching your nose or eyes. Besides avoiding people with the flu, a person with COPD should be careful to wash their hands after having contact with people with the flu or people suspected of having the flu.
How do I prevent the flu?Since avoiding people is not very practical, getting a flu shot can reduce your chances of getting the flu. The flu shot must be “renewed” every year because the type of virus causing the flu changes from year to year. The flu shot protects you from the types of viruses that are likely to cause the flu for that year. The shot is no guarantee that you will not get the flu, but it does reduce your chances of getting it.
Can I get the flu from the flu shot?No, you cannot “get” the flu from the shot. While in the past the flu shot contained the “live” or active form of the virus, this no longer occurs. The way the flu vaccine is now processed does not give people the flu. Sometimes, however, people who were already exposed to the flu get the flu after a shot, but this is a coincidence. It takes 1-2 weeks after you get the shot for the vaccine to give you protection. Soreness where the needle entered the skin or mild aches can occur for 1-2 days after the shot. The flu shot is no guarantee you will not get the flu, but if you get the flu, the seriousness of the flu is often less.
Is the flu dangerous?The flu can be dangerous for those who are weak or those who get serious respiratory infections easily.
People with very severe COPD should be careful not to expose themselves to the flu and should seek
immediate medical attention if they have the flu.
What can I do to treat the flu?You should discuss the treatment of flu with your healthcare provider. Some may want to see you at the first sign of the flu and prescribe medication. If your healthcare provider feels you can handle the flu, you should treat the symptoms by drinking eight glasses of liquids a day, taking acetaminophen/paracetamol for fever, headache and/or muscle aches, resting for exhaustion, and using your inhalers for chest discomfort/tightness.
When should I call my healthcare provider about the flu?Call your healthcare provider if your symptoms worsen despite treatment or if you cough up sputum that is deep yellow/green in color.
How Do I Know If I Have a Cold?It is sometimes difficult to figure out if a respiratory infection is a cold or the flu, or a respiratory infection for another reason. A cold or flu can often be the first sign of an exacerbation. The most common signs and symptoms of a cold start gradually and can include a runny nose, watery eyes, sneezing and/or a sore throat. You may or may not experience a fever, headache or extreme exhaustion with a cold. A cold is an infection caused by a virus. Colds are easily transmitted (passed from one person to another) between people who are infected. A cold is transmitted either by contaminated air we breathe, or by touching something or someone with the virus. For example, a cold can be transmitted by inhaling the air of a person with a cold who coughs or sneezes near you. A cold can also be transmitted by shaking hands with someone with a cold and then touching your nose or eyes. Besides avoiding people with colds, a person with COPD should be careful to wash their hands after having contact with people with a cold or suspected of having a cold.
Are colds dangerous?Respiratory infections from a cold are generally not dangerous. However, people who get a cold who have COPD, people who are very sick (receiving chemotherapy) or people who are weak (elderly) may become more ill if they get a cold
What can I do to treat a cold?For most people, treating their symptoms of the cold is the best and only treatment that is needed. For example, if a cold causes your sputum to become thickened, drink large amounts of fluids. If your nose becomes congested, use a decongestant or nasal spray. Nasal decongestants should only be used for several days. Avoid giving your cold to others by not having contact with others for 3-4 days.
When should I call my healthcare provider about my cold?Call your provider if the symptoms continue to worsen. Signs of worsening are when the mucus from your lungs turns deep yellow, your shortness of breath becomes more severe than usual and won’t go away, you develop a fever, or you are suddenly unable to get out of bed.
Information taken from
SRI SIDDHARTHA MEDICAL COLLEGE TUMKUR A CONSTITUENT COLLEGE OF SRI SIDDHARTHA UNIVERSITY, Papers Published in Indexed (Scopus) Journals ISSN (P) / ISSN E 1. Vijayaraghavan. R, Chandrashekar R, Belgavi CS .Inflammatory myofibroblastic tumour of appendix. J of Clin Pathol. 2006;59:999-1000. 2. Vijayaraghavan. R, Chandrashekar, Sujatha.Y , Belgavi CS . Hospital outbreak of a ty
I am continually amazed when I go to patients chart to track a particular event, change in condition etc.and I find less than adequate documentation. It is scary actually, because all nurses have had it drilled into our heads that "if its not documented, it wasn't done!" The most recent was just last week. Report was given that a patient had received 120mg I.V. Lasix STAT the night bef