chronic obstructive pulmonary disease ebook

Wellness & Lifestyles Australia

CHRONIC OBSTRUCTIVE PULMONARY DISEASE E-BOOK

prepared by

Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE .................................................................................................................1 INTRODUCTION ......................................................................................................................2 DEFINITION ...........................................................................................................................3 CAUSES ................................................................................................................................3 DIAGNOSIS ............................................................................................................................4 EXACERBATIONS OF COPD AND COMPLICATIONS ...............................................................................6 DIFFERENCES BETWEEN CHRONIC BRONCHITIS AND EMPHYSEMA ............................................................7

Chronic Bronchitis ......................................................................................................... 7 Emphysema................................................................................................................. 9

TREATMENT OF COPD............................................................................................................. 11 TIPS FOR MANAGEMENT OF COPD............................................................................................... 14 PROGNOSIS ......................................................................................................................... 17 SUMMARY ........................................................................................................................... 18 CONTACT US ....................................................................................................................... 19

MANUAL LAST MODIFIED 11/04/2011

http://www.wellnesslifestyles.com.au Ph: +61 8 8331 3000 Fax: +61 8 8331 3002

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IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation. Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances. To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action. Copyright Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.


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INTRODUCTION Welcome to the W&L series of e-Books. You have chosen the edition on Chronic Obstructive Pulmonary Disorder (COPD). This resource will be beneficial to:

Anyone who is interested pulmonary system Anyone who wants to know how the disease process works Anyone who has COPD and wants to know how best to manage their health

This e-Book will cover information about the anatomy of the lungs, the changes that occur with the disease process and possible strategies for symptom management. The information provided is up to date and follows industry standard. W&L recommend that you continue to consult your doctor and physiotherapist so that your progress can be monitored and program tailored to your specific requirements.


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DEFINITION COPD stands for Chronic Obstructive Pulmonary Disease. This label is an umbrella term used to describe a disease with chronic airflow limitation. It is also often referred to as; COLD (Chronic Obstructive Lung Disease), COAD (Chronic Obstructive Airway Disease) or CAL (Chronic Airway Limitation). The World Health Organisation (WHO) has defined COPD as: ...a disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. (GOLD, 2003) This label is an umbrella term used to describe a disease with chronic airflow limitation. It is also often referred to as; COLD (Chronic Obstructive Lung Disease), COAD (Chronic Obstructive Airway Disease) or CAL (Chronic Airway Limitation). The World Health Organisation (WHO) has defined COPD as: ...a disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. (GOLD, 2003)

CAUSES

Smoking is the highest risk factor. More than 80-90% of smokers are at risk of developing COPD

Accessed 29th March 2011 http://www.helpmequitsmokingtips.com/wp-content/uploads/2011/03/1299564044-22.jpg

Other causes include:

Occupational hazards such as, fumes, dust, smoke, gases etc. Environmental pollution, e.g. passive smoking, air pollution Family history or genetics Socioeconomics status such as general health, diet, etc. Perinatal events & childhood illnesses such as, premature birth, chest infections during

childhood Recurrent infections


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DIAGNOSIS Early detection is usually difficult due to a lack of signs and symptoms initially. The development of COPD is often only apparent after major anatomical, physiological changes have taken place. Therefore it is often only first identified in sufferers over 40 years old. One in five Australians over 40 are estimated to have COPD but as many as may be unaware they have a problem. The elderly population are more susceptible and frequently suffer more as their disease can often be complicated by other medical conditions; particularly cardiac issues, recurrent infections and lowered immune resistance. Anxiety and depression have also been shown to contribute significantly to the overall exacerbation of symptoms and functional decline. COPD can often go undiagnosed, and hence, under-treated in elderly populations when compared with younger people, as their COPD can be disguised by the other conditions mentioned above.

Corbis Corporation (2002-2011), Accessed 29th March 2011 http://www.corbisimages.com/images/42-17323307.jpg?size=572&uid=3ad58b01-9c11-4a4e-82f7-4f467c91153e&uniqID=b81ed25d-

881a-48b9-8905-c3c94e203d12


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COPD is typically diagnosed with a lung function test call spirometry, although other tests may also be used in conjunction with this to confirm the diagnosis (such as chest X-rays, oxygen saturation levels, exercise tests). Spirometry is the gold standard for diagnosing and monitoring COPD. It measures how fast and how much air a person can breathe out into a machine. The results can be put into a graph called a Flow Volume Curve which interprets how obstructed and restricted a COPD sufferer's lung function is.

Shriber, A. (2009), Spirometry, Medline Plus, accessed March 29th 2011 http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1142.jpg

From these results, it can then be determined how severe a sufferer's COPD is. These categories are divided into; at risk, mild, moderate, severe and very severe.


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EXACERBATIONS OF COPD AND COMPLICATIONS COPD, once established, can be exacerbated by various factors such as:

an infection which can cause an acute inflammatory response, worsening the degree of obstruction. Each attack results in further damage to the lungs

medication changes (particularly steroid medication) environmental changes such as temperature or humidity exposure to allergens such as dietary changes , dust, animal hair alterations in general health such as injury to a limb, reduced appetite, reduced mobility.

Over time, these exacerbations become more frequent, closer together and harder to recover from. It becomes harder for the sufferer to return to their previous level of function.

People with COPD can often develop other complications in conjunction with their disease such as, heart failure, pneumonia and cancer.


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DIFFERENCES BETWEEN CHRONIC BRONCHITIS AND EMPHYSEMA Despite sharing the overall label of COPD chronic bronchitis and emphysema are two different conditions which affect the lungs in different ways.

Chronic Bronchitis Chronic Bronchitis had been defined as ....a disease characterised by a cough productive of sputum on most days for at least three consecutive months of the year for at least two successive years. (Brewis, 1991) In response to an irritant (e.g. smoke), there is inflammation, increased sputum production and tissue damage in the larger airways of the lungs. The diagram below shows the effect that chronic bronchitis has on the larger airways.

Shriber, A. (2009), Bronchitis, Medline Plus, accessed March 29th 2011 http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/17099.jpg


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Sufferer's of chronic bronchitis are sometimes referred to as Blue Bloaters due to the hypoxia and fluid retention it causes. As demonstrated in the picture below.

Williams, T. (2008), DrTedWilliams.net, COPD, accessed 29th March 2011 http://www.bronchitis.be/img/bluebloater.jpg

Chronic Bronchitis sufferer's can often develop a bluish tinge to their skin and lips due to the lack of oxygen their body is receiving. They can also develop a ruddy, flush look, particularly around their cheeks due to the amounts of carbon dioxide they retain. They also typically develop a rattly, chronic, smoker's cough productive of substantial amounts of sputum which initially presents as a morning cough but becomes more frequent throughout the day as the disease progresses. Other symptoms include; a barrel-shaped chest (due to over-inflation of the lungs, and changes in the position and action of the ribs and diaphragm), clubbing of their fingers (due to hypoxia), decreased exercise tolerance, breathlessness, fatigue, sinus congestion and halitosis. The picture below demonstrates clubbing of the fingers due to a chronic lack of oxygen (hypoxia).

Mitchell, S. (2008), ScienceNOW, The Case Of The Telltale Fingertips, accessed 29th March 2011

http://news.sciencemag.org/sciencenow/assets/2008/05/27/200852721.jpg


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Emphysema Mild emphysema can be present in non-smokers (mainly due to passive smoking or air pollution) but severe emphysema is typically only seen is smokers or those with certain genetic abnormalities. Emphysema causes inflammation and destruction in the alveoli leading to progressive degeneration of the elastic tissue throughout the lungs. This leads to large holes (or bullae) being formed. This dead space takes up an increasing amount of room, leaving precious little space for the working lung tissue. Additionally the remaining lung tissue has less structural support and poorer compliance, causing it to collapse when the person breathes out, trapping used air inside. The picture below shows a pair of severely emphysematous lungs with bullae (holes) throughout.

McKennitt, D. (2010), SteadyHealth.com, What are the Emphysema stages, accessed 29th March 2011 http://www.steadyhealth.com/about/img/pages/what_are_the_emphysema_stages.jpg


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The diagram below illustrates how the airways collapse when a person with emphysema breathes out (expiration).

HubPages Inc. (2011), Emphysema Symptoms and Treatments, accessed 29th March 2011 http://s1.hubimg.com/u/299408_f260.jpg

Sufferer's of emphysema are sometimes referred to as Pink Puffers as their faces can take on a pink tinge due to the increased amount of work they have to do trying to catch their breath. They are often very thin and underweight as they constantly expend a substantial amount of energy simply trying to breathe. They are usually extremely breathless, wheezy, have reduced exercise tolerance and suffer from fatigue, weakness, dizziness, confusion, anxiety and headaches.

Williams, T. (2008), DrTedWilliams.net, COPD, accessed 29th March 2011 http://www.bronchitis.be/img/pinkpuffer.jpg


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TREATMENT OF COPD COPD is not curable, but management can slow the progress of the disease and improve the quality of life of the individual. Encouraging a sufferer to quit smoking (if they do so) is a good start! Plenty of fluid, a healthy diet and avoidance of a polluted/infected areas can help. Doctors can prescribe various bronchodilators, corticosteroids and antibiotics as required. Continuous oxygen via a concentrator may be necessary depending on how advanced the disease is.

1st Class Medical (2009-2011), accessed 29th March 2011 http://www.portable-oxygen-concentrators.net/images/invacare_perfecto_2_v64z.jpg


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Physiotherapists are trained in techniques and exercises to manage aspects of COPD, such as airway collapse, sputum production and breathlessness. Physiotherapy treatment can include; teaching pacing and energy conservation, diaphragmatic breathing, active cycle of breathing techniques, forced expiratory techniques, percussion and vibrations, postural drainage, postural re-education and spinal mobilisations (as people with COPD can get very stiff through their mid and upper spine). Continence and pelvic floor retraining can also be taught if needed as many elderly people with COPD suffer from weak pelvic floors due to years of constant coughing. Positive Expiratory Pressure devices are typically handheld devices designed to provide positive pressure behind sputum to try and push it further up and out of the airways. They also are designed to reduce the trapping of air in lungs, optimise delivery of bronchodilators and reduce areas of collapsed lung. The picture below shows an acapella PEP, one of the more common types of positive expiratory pressure devices.

Smiths Medical (2011), Bronchial Hygiene, accessed 29th March 2011 http://www.smiths-medical.com/catalog/bronchial-hygiene/acapella/acapella.html


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Certain inspiratory muscle trainers can be provided if needed. These are small devices which can be used to retrain breathing muscles by increasing the pressure that breathing muscles have to generate per breath. They have been shown to increase the strength of the respiratory muscles by 20-25%. This means that additional muscles around the shoulders which often become overworked, don't have to work as hard.

Japan Entry K.K. (2008), accessed 28th March 2011 http://www.entry-japan.com/e/images/prod/wellness_plus_user.jpg

Pulmonary Rehabilitation is well established as an effective management tool for COPD and can also be an option for certain elderly people. Often people with COPD can become caught in a vicious cycle of breathlessness, fear of exercise, inactivity and, hence, decreased exercise tolerance. Pulmonary Rehabilitation is a multidisciplinary program which is individually tailored in order to optimise the physical and social performance of the COPD sufferer. As well as teaching how to manage symptoms and retrain breathing muscles correctly, pulmonary rehabilitation can provide psychological and nutritional advice, and teach exercises to strengthen the arms and legs and increase overall endurance, thereby improving one's quality of life. Sometimes surgical intervention is necessary as a last resort depending on the severity of the disease and the condition of the sufferer. This can involve; a bullectomy (removal of the large holes in the lungs that occur with emphysema), lung volume reduction surgery (removal of damaged tissue from the lungs) or even a lung transplant in very severe cases (damaged lung is removed and replaced with a lung from a donor).


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TIPS FOR MANAGEMENT OF COPD Here are some simple techniques which can be used to help residents with COPD manage their symptoms:

Encourage them to try to sit more upright in chairs and in bed rather than slumping down as this will help to get more air down into their chest.

Encourage them to take frequent, slow, steady breaths in through their nose and out through their mouth, breathing right down into their stomach as they do so (the stomach should expand slightly if done correctly). This is called diaphragmatic breathing and increases the work of the diaphragm, hence, increases air flow down to the bottom of the lungs which are often collapsed. This also decreases the work of the muscles around the shoulders, collar bone and between the ribs which often become over-worked and very tight in COPD sufferer's. Correct use of the diaphragm allows one to draw in more air with less effort. A good test to check if the exercise is being done properly is to get them to place one hand over the front of their chest and one hand over the stomach. If diaphragmatic breathing is done correctly the hand over the stomach should gentle rise and fall but the hand over the chest should stay relatively still.

Pfizer & Boehringer Ingelheim Pharmaceuticals, Inc. (2011), accessed 28th March 2011 www.knowcopd.com/pulmonary-rehab-tools.jsp

If they are having trouble clearing sputum from their chest, get them to sit or stand in an upright position, take a few deep breaths as described above, then take a breath in and hold for 3 seconds, then get them to try and 'huff' the air our rather than cough (as though they are trying to fog up a pair of glasses or a window) in order to clear the phlegm. This keeps the throat open, making it easier to clear the sputum. It is always better to try to cough up any sputum rather than let it sit in the chest, causing further airway blockage. If able, try to check the colour of the phlegm coughed up. If it is yellow or green, this indicates infection. If it is brown or red this indicates blood in the lungs and the resident's medical officer should be consulted.


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If they are suffering from a lot of breathlessness (if particularly anxious or walking a distance) try to get them to relax their shoulders (which can be difficult as most sufferer's of COPD are very tense through their shoulders and upper back), think about slowing their breathing down and encourage them to try 'pursed lip breathing' - breathing in through the nose and out through pursed lips (as though they're going to whistle or gently blow out over the opening of a bottle), taking twice as long to breathe out compared to breathing in. The breath should not be forced out. This helps to relax their respiratory muscles and splint the airways open allowing them to expel carbon dioxide and breathe more easily. Remind them that they are in control of their breathing and that their breathing doesn't control them. Pursed lip breathing can also be thought of as smelling roses and blowing out a candle.

The Cleveland Clinic Foundation (1995-2005), accessed 29th March 2011 http://my.clevelandclinic.org/PublishingImages/HIC/pursed%20lip-pucker.gif

There are several positions that can also help a COPD sufferer to manage their breathlessness. These include:

Sitting, leaning forward slightly, resting the hands or forearms on thighs. Try to relax the

shoulders down. Feet should be flat on the floor with knees rolled slightly outwards. Encourage pursed lip breathing as described above. Maintain this position until the rate of breathing slows and the person regains control of their breathing.

The Cleveland Clinic Foundation (1995-2005), accessed 29th March 2011 http://www.clevelandclinic.org/health/health-info/Pictures/sob-man%20sitting.gif


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Sitting with a pillow on a table in front, lean forward onto it with head resting on pillow. Encourage pursed lip breathing as described above. Maintain this position until the rate of breathing slows and the person regains control of their breathing.

The Cleveland Clinic Foundation (1995-2005), accessed 29th March 2011 http://www.clevelandclinic.org/health/health-info/Pictures/sob-sit%20table%20pillow.gif

Standing, leaning forwards on a table, wall or walking frame if appropriate. Relax the shoulders down. Encourage pursed lip breathing as described above. Maintain this position until the rate of breathing slows and the person regains control of their breathing.

The Cleveland Clinic Foundation (1995-2005), accessed 29th March 2011 http://www.clevelandclinic.org/health/health-info/Pictures/sob-stand%20table.gif


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Standing, leaning back against a wall. Feet placed slightly apart and shoulders relaxed. Encourage pursed lip breathing as described above. Maintain this position until the rate of breathing slows and the person regains control of their breathing.

The Cleveland Clinic Foundation (1995-2005), accessed 29th March 2011 http://www.clevelandclinic.org/health/health-info/Pictures/sob-stand%20%20at%20wall.gif

Encourage residents to practice diaphragmatic breathing and pursed lip breathing regularly. The more they practice, the easier and more natural it will become.

PROGNOSIS COPD as a single cause of death worldwide shares 4th and 5th places with HIV/AIDS. Currently it takes about 30 years of smoking to develop fatal COPD, which is why it is now seen so frequently in older people and throughout residential care facilities. Total deaths from COPD are projected to increase by more than 30% in the next 10 years without interventions to cut risks. This is why having an awareness of the disease, knowing what to avoid and knowing some simple techniques to help an sufferer manage their symptoms can help.


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SUMMARY In summary, COPD is an umbrella term used to describe a disease with chronic airflow limitation, with either a bronchitis or emphysema basis. Although the disease process is not a reversible one, regular input from both medical practitioners and physiotherapists can improve a sufferers quality of life. Adapting a sensible approach to exercise, maintaining your health and avoiding exacerbating factors can provide confidence in management of symptoms and slow disease progression. Please use this resource as a guide to COPD management in consultation with your specialist, medical practitioner and therapist. All the best for a speedy recovery, The W&L Team


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CONTACT US Wellness & Lifestyles Australia 2/59 Fullarton Road, Kent Town SA 5067 P: +61 08 8331 3000 F: +61 08 8331 3002 E: [email protected] W: www.wellnesslifestyles.com.au www.wleducation.com.au W&L services include: Physiotherapy Aged Care Funding Instrument (ACFI) Consultancy Podiatry Speech Pathology Dietetics Diabetes Education Occupational Therapy Psychology Physiotherapy Aide Diversional Therapy Aromatherapy Natural Therapies Massage Exercise Physiology Educational Training Staff Wellness Program Locum Services Medicare Billing Aged Care Funding Instrument Documentation Online Training W&L products include: Posters E-books E-learning modules

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