patient education guide -...

Patient Education guide

Table of Contents1. Breathing Skills 5

• 1.1 Pursed Lip Breathing 5

• 1.2 Diaphragm Breathing 5

2. Exercise and Balance Skills 7

• 2.1 Aerobic Exercise 7

• 2.2 Stretching 8

• 2.3 Strength Training and Sit to Stands 9

3. Oxygen Therapy 10

• 3.1 Benefits of Oxygen 10

• 3.2 Oxygen Equipment Usage 11

4. Medication 14

• 4.1 Types of Medication Prescribed by your Physician 14

• 4.2 Delivery Methods of Medication 17

5. Disease Process 22

• 5.1 Understanding COPD 22

• 5.2 Managing Triggers and Disease Progression 25

• 5.3 PIKO Meter Daily Breathing Test 25

6. Exacerbations: (Flare-ups) 28

• 6.1 Steps to Take During a Flare-up 28

• 6.2 Signs of an Emergency 28

7. Infection 29

• 7.1 Signs and Symptoms of Infection 29

• 7.2 Antibiotics 29

• 7.3 Bronchial Hygiene Through Lung Clearance 30

8. Nutrition 31

• 8.1 Importance of Healthy Eating and Hydration 31

• 8.2 Foods to Include in Your Diet 31

• 8.3 Foods to Limit in Your Diet 32

• 8.4 Fluids to Include in your Diet 32

9. Environment 34

• 9.1 Environmental Triggers and Irritants 34

• 9.2 Unhealthy Environments and Travel 34

10. Resilience 35

• 10.1 Conserving Energy 35

• 10.2 Controlling Stress 35

• 10.3 Support Networks 36

• 10.4 Setting Goals 36

11. Sleep 37

• 11.1 Importance of Sleep 37

• 11.2 Getting a Good Night’s Sleep 37

• 11.3 Sleep Apnea 38

12. Smoking 40

• 12.1 Benefits of Quitting Smoking 40

• 12.2 Smoking Cessation Strategies 41

Appendices 42

• 1.1 Printable Collateral 42

• Patient Health Information form 43

• Daily Respiratory Action Plan 44

4 Nexus Home Silver: Patient Education Guide

Welcome to Nexus HomeBy participating in this disease management program with nationally recognized respiratory care

protocols, you will be able to develop confidence in your ability to help manage yourself, regain your

independence, and improve your quality of life, while avoiding unnecessary emergency room visits.

Along with support from your respiratory therapist, you will be working through the instructional mod-

ules in this disease education and skills training workbook with the goal of achieving the following four

badges of competency:

ActivityConfidence in ability to strengthen your body through exercise, manage oxygen ther-

apy, and increase overall activity level.

BreathingConfidence in ability to use breathing exercises and techniques to enable your lungs

to work more efficiently and to manage flare-ups and control anxiety.

MedicationConfidence in ability to understand what your different medications are for and how

to administer them effectively.

Self-ManagementConfidence in ability to manage your environment, follow a healthy diet and sleep

pattern, and recognize signs of infection, flare-ups, and when to call a healthcare

professional.

Directed by your respiratory therapist you will complete a self-assessment several times throughout

this program to help determine your level of confidence and when you have mastered each competen-

cy to be awarded that badge.

Each instructional module may correlate to more than one competency. All related competencies will

be displayed on each page of instruction.

5Nexus Home Silver: Patient Education Guide

1. Breathing Skills

1.1 Pursed Lip Breathing

Pursed lip breathing is a way to control shortness of breath by helping you get more air in and out of

your lungs. You should practice this type of breathing 4 or 5 times a day while at rest until you are com-

fortable enough with the technique to rely on it during exercise or when you need it most.

Pursed Lip Breathing, or “Inhale and Pucker,” Technique:

• Relax your neck and shoulder muscles.

• Take a normal breath in (inhale) slowly through your nose while counting to two.

• Pucker or “purse” your lips as if ready to whistle or blow out a candle.

• Breathe out (exhale) slowly through your pursed lips while counting to four.

In addition to relieving shortness of breath, other benefits of Pursed Lip Breathing

are:

• Releases trapped air in your lungs and makes way for new air to enter

• Keeps airways open longer allowing your lungs to work more efficiently

• Slows breathing rate and causes general relaxation

1.2 Diaphragm Breathing

Learning to breathe from your Diaphragm is a way to make your breathing more efficient so you may

use less effort and energy to breathe. You should practice this type of breathing for 5-10 minutes

about 3-4 times per day so that breathing from your diaphragm becomes easy and automatic.

Competency: Activity and Breathing


Diaphragm Breathing Technique:

• Lie on your back on a flat surface or in bed and support your head (and knees) with a pillow.

• Place one hand on your upper chest and the other below your rib cage so you may feel your diaphragm move as you breathe.

• Breathe in slowly through your nose keeping the hand on your chest as still as possible while your stomach pushes up against your other hand.

• As you exhale through pursed lips (See “Pursed Lip Breathing”), tighten your stomach muscles and let them fall inward with the release of your breath.

• As you gain more comfort with this technique, you may try it while sitting in a chair.

In addition to more efficient breathing, deep belly breathing (from the diaphragm) has the following

benefits:

• Strengthens the diaphragm, giving you more power to empty your lungs

• Slows your breathing rate, making breathing less difficult

• Decreases oxygen demand

2. Exercise and Balance Skills

With increasing shortness of breath many people with COPD become sedentary. Lack of physical

activity can result in decreased strength, muscle mass, and heart function. This can lead to depres-

sion and social isolation. It has been proven that maintaining flexibility through stretching as well as

strength and endurance through exercise can help you physically and mentally.

Be sure to discuss any exercise program with you physician before you begin. You should always use

your oxygen during physical activity (if it has been prescribed). If you have been instructed to turn your

oxygen up a bit for exercise, make sure you do that.

If you experience any of these signs and symptoms during and after exercise, stop immediately. If they

last longer than five minutes, call your physician.

Possible signs of overexertion:

• Heart palpitations (heartbeat pounding out of your chest)

• Dizziness or light-headedness

• Dramatic increase in shortness of breath

• Nausea

• Chest pain radiating to neck, jaw, or down your arm

2.1 Aerobic Exercise

Aerobic exercise is the most important type of exercise. To accomplish aerobic exercise you need to

maintain the activity for 20 minutes at least 3 times each week. You should go at a pace that makes

you a little short of breath, but not so fast that you can’t do it for close to 20 minutes. If you cannot do

the activity for 20 minutes, do the best you can and increase the time a few minutes each week. After

a few months you should experience less shortness of breath during many activities. In the beginning

you may want to have another person with you for support.

Note: Taking advantage of a pulmonary rehabilitation program is strongly recommended as they offer guidance and support to your exercise efforts. Most people really enjoy the social aspect as well.

Competency: Activity


2. Exercise and Balance Skills

With increasing shortness of breath many people with COPD become sedentary. Lack of physical

activity can result in decreased strength, muscle mass, and heart function. This can lead to depres-

sion and social isolation. It has been proven that maintaining flexibility through stretching as well as

strength and endurance through exercise can help you physically and mentally.

Be sure to discuss any exercise program with you physician before you begin. You should always use

your oxygen during physical activity (if it has been prescribed). If you have been instructed to turn your

oxygen up a bit for exercise, make sure you do that.

If you experience any of these signs and symptoms during and after exercise, stop immediately. If they

last longer than five minutes, call your physician.

Possible signs of overexertion:

• Heart palpitations (heartbeat pounding out of your chest)

• Dizziness or light-headedness

• Dramatic increase in shortness of breath

• Nausea

• Chest pain radiating to neck, jaw, or down your arm

2.1 Aerobic Exercise

Aerobic exercise is the most important type of exercise. To accomplish aerobic exercise you need to

maintain the activity for 20 minutes at least 3 times each week. You should go at a pace that makes

you a little short of breath, but not so fast that you can’t do it for close to 20 minutes. If you cannot do

the activity for 20 minutes, do the best you can and increase the time a few minutes each week. After

a few months you should experience less shortness of breath during many activities. In the beginning

you may want to have another person with you for support.

Note: Taking advantage of a pulmonary rehabilitation program is strongly recommended as they offer guidance and support to your exercise efforts. Most people really enjoy the social aspect as well.

Competency: Activity


Aerobic Activities

• Treadmill - First make sure you have no trouble with balance while walking. Hold on to the hand rails and attach the “kill clip” to your clothing, which stops the treadmill if you move too far back on the platform..

• Walking in your home or outdoors - Choose a flat, even area. Use a walker or a quad cane if you have any balance problems.

• Stationary bicycle - Make sure the bike is stable. Adjust the seat so that the leg has just a slight bend in it when at the bottom of the pedal stroke. Adjust the resistance to a point that causes mild shortness of breath but not so much that you can’t do it for as close to 20 minutes as possible.

2.2 Stretching

Difficulty breathing may cause you to develop a hunched over posture, resulting in shortened chest

muscles that restrict the ability to fully expand your lungs. Performing stretching exercises can length-

en your chest muscles and improve your posture, giving you more room to breath.

Pec Stretch

1. Standing in an open doorway, place your hands on either side of the door frame.

2. Lean forward until you feel a slight stretch across your chest.

3. Hold the stretch for 5 seconds.

4. Repeat 2 to 3 times.

5. Breathe as you stretch

6. Try to stretch deeper over time

Torso Stretch and Twist

1. Sit in a straight back chair with your feet flat on the floor, shoulder width apart.

2. Place your arms straight in the air, behind your head, elbows facing forward and hands clasped and hold for 2-3 seconds.

3. With arms still raised, twist your head and body from the waist to one side and hold for 2-3 seconds.

4. Return to the original position and repeat by turning to the other side.


2.3 Strength Training and Sit to Stands

Exercising your leg muscles daily can increase endurance, energy levels, and balance, which can help

prevent falls.

Seated Knee Extensions

1. Sit in a straight back chair without arm rests with your feet flat on the floor, shoulder width apart.

2. Straighten one leg and hold it out in front of you for 5 seconds.

3. Return the leg to its original position and repeat with the other leg.

Sit to Stand Technique

1. Sit in a straight back chair without arm rests.

2. Cross your arms in front of you against your chest at the wrist with hands on opposite shoulders.

3. Keeping your feet flat on the floor, your back straight, and your arms crossed against your chest, rise to a full standing position and then sit back down again.

4. Repeat this for 30 seconds.


3. Oxygen Therapy

3.1 Benefits of Oxygen

Many people with COPD will eventually need supplemental oxygen. Oxygen therapy can improve

energy and breathing so that your quality of life is better. Having too little oxygen in the blood, called

hypoxemia, can cause sleepiness, morning headaches, irritability, poor concentration, worsening

breathlessness, fluid retention, and can put a strain on your heart.

Note: You may not feel better immediately with oxygen use, but make sure you continue to use it as prescribed because your body needs an adequate amount to function optimally.

New developments in oxygen equipment make it much easier and convenient to use. Tanks are more

portable and lightweight. Oxygen systems are available either as continuous flow or intermittent flow.

Intermittent Flow

Intermittent flow systems are called conserving devices and are breath-activated. The oxygen in the

tank will last longer than with continuous flow. This means that the oxygen tank can be used for longer

periods of time without the need to refill or change the tank.

Continuous Flow

Some patients need to have constant flow, especially when they are asleep and cannot trigger oxygen

flow by breathing. These systems provide a constant supply of oxygen and are not turned on and off

depending on your breathing.

Competencies: Activity and Self-Management


3.2 Oxygen Equipment Usage

Types of Oxygen Delivery Equipment

Compressed Gas in Cylinders (Portable)

Can be used outside the home on shoulder straps or on a wheeled cart. Lighter weight ambulatory gas

cylinders are also available, and are designed to be carried with a shoulder strap.

Portable Liquid Oxygen

Can be used outside of the home on shoulder straps or on a wheeled cart. Typically, a liquid oxygen

portable is the same weight as a lightweight gas cylinder. Liquid oxygen, unlike gas in cylinders, will

evaporate when filled and unused, therefore stationary liquid reservoirs act as a “refill” station to dock

and refill the liquid portable.

Portable Oxygen Concentrator

A smaller version of the stationary concentrator used at home. It can run on electricity, battery power

or your car’s DC outlet (cigarette lighter). It can also be used for airline travel by plugging the power

cord into a special outlet near the airplane seat or run off the battery in the unit. It concentrates the

oxygen in the air to a level that meets your doctor’s prescription, however each unit must be tested to

see if it provides enough oxygen for your particular oxygen prescription

Stationary Oxygen Concentrator That Extracts Oxygen From the Air

Most commonly used in the home and also at night. It runs on electricity, and concentrates the oxygen

in the air to a level that meets your doctor’s prescription.


Methods of Oxygen Delivery

• Nasal Prongs

• Face Mask

• Tracheostomy Tube

• Transtracheal Oxygen Therapy

• In-line With Other Equipment (CPAP, BIPAP, NIV, Ventilator)

Flow Rate (Amount of Oxygen You are Receiving)

Oxygen is prescribed as a flow rate in liters per minute. Make sure you use it at the flow rate prescribed

by your physician. Using too much can be dangerous. Often you will be given a different flow rate of

oxygen for when you are sleeping and for when you exercise. It is important to know your oxygen pre-

scription and adhere to it.

My Oxygen Prescription

lpm Delivered

by at rest

lpm Delivered

bywith exercise (ADL’s)

lpm Delivered

bywhen sleeping

Traveling with Oxygen

When traveling make sure you plan ahead so that you take enough oxygen and all prescribed medica-

tions with you. Consider such factors as portability of oxygen equipment, how long and where you will

use it, and location of oxygen suppliers in the area in case you run out.

If you will be traveling by plane, train, or bus, make arrangements with your doctor, oxygen supplier,

and the transportation agency ahead of time to ensure you have what you need. For example, if you

travel by plane, arrangements will need to be made ahead of time with the airline to make sure you


have the correct device for the altitude.

Using Oxygen with Caution

Be careful not to use the oxygen near a flame of any kind, including a lighted cigarette or gas range.

The plastic tubing on your equipment may catch fire. Oxygen will not explode or burn, but it does cause

other things to burn faster.

Do not use aerosol sprays, such as air fresheners, hair spray, vapor rubs, or petroleum-based jelly near

your oxygen unit. These items are all very flammable.


4. Medication

Since COPD is a chronic, progressive disease, you most likely will be taking respiratory medication daily

in different combinations. It is important for you to understand what you are taking, how often, and

how the medication affects you in order to better manage your disease.

4.1 Types of Medication Prescribed by your Physician

Rescue Respiratory Medications

This type of medicine is used to make your

breathing passages larger so that you can get air in

and out more effectively. It immediately relieves

or eliminates the symptoms you are having. This

type of medicine takes effect within minutes of use

and on average lasts between 4 and 6 hours. This

medication may need to be taken before exercise

or when your symptoms worsen.

Brand Name Generic Name Delivery Type

Ventolin, Proventil Albuterol MDI or Nebulizer

Xopenex Levalbuterol Nebulizer

Combivent Albuterol+Ipratropium Respimat inhaler

DuoNeb Albuterol+Ipratropium Nebulizer

Atrovent Ipratropium Bromide Nebulizer or MDI

Competencies: Medication


Everyday Maintenance Respiratory Medications

This type of medicine is used to keep your symptoms under control and needs to be taken daily for

maintenance. It is important to take these medications as prescribed because they have a cumulative

preventative effect over time (are not rescue medications) and last between 12 and 24 hours.

Note: This medication should not be taken more often than prescribed for shortness of breath.

Long-Acting Bronchodilator- Beta Agonist (LABA)

This everyday maintenance medication helps to open up your breathing passages, providing day-to-day

coverage for shortness of breath.

Brand Name Generic Name Delivery Type Typical daily use

Serevent Salmeterol Diskus -Dry Powder Twice a day

Striverdi Olodaterol Respimat inhaler Daily

Arcapta Indacterol Dry Powder-Neohaler Daily

Foradil Formoterol Dry Powder Twice a day

Brovana Aformoterol Nebulizer Twice a day

Long-Acting Antimuscarinic Anticholinergic (LAMA)

This everyday maintenance medication works on the muscles around the larger airways by preventing

them from tightening up.


Spiriva Tiotropium Respimat inhaler, Dry Powder Daily

Incruse Umeclidinium Dry Powder- Ellipta Daily

Tudorza Aclidinium Dry Powder- Pressair Twice a day


Combination Everyday Maintenance Medications- LABA/LAMA

This combined everyday maintenance medication works on both the large airways and small airways

for more effective coverage for people that need it.


Stiolto Olodaterol +Tiotropium Respimat inhaler Daily

Anoro Vilanterol +Umeclidinium Dry Powder- Ellipta Daily

UtibronIndacaterol +Glycopyrro-

lateDry Powder- Neohaler Twice a day

Bevespi Glycopyrrolate + Formoter-

ol fumarate

Pressurized MDI

(pMDI)Twice a day

Corticosteroids/Anti-inflammatory (Long-Acting or Preventative)

This everyday maintenance medication stops swelling (inflammation) in your lungs and can reduce the

number of flare-ups (exacerbations).

Note: It is important to rinse your mouth after taking inhaled steroids to prevent an oral yeast infection.


Pulmicort Budesonide Inhaler or Nebulizer Twice a day

SymbicortFormoterol +

BudesonideInhaler Twice a day

Advair Salmeterol + Fluticasone Diskus inhaler Twice a day

Breo Vilanerol + Fluticasone Ellipta inhaler Once a day

Flovent FluticasoneDiskus inhaler or MDI

HFATwice a day

Qvar, Beclo-

vent, VancerilBeclomethasone MDI HFA or MDI Twice a day


Oral Corticosteroids (Prednisone)

This type of medication may be ordered by your physician during an exacerbation (flare-up).

Note: Refer to your Daily Respiratory Action Plan (see Appendix) for symptoms that may indicate you are hav-ing a flare-up.

An oral steroid may be prescribed during an infection and in conjunction with an antibiotic and in-

creased rescue inhaler usage. A typical course of treatment is 7-14 days, depending on your improve-

ment. This medication is often very effective in treating a flare-up, so take it as prescribed.

This type of medication is taken orally and has an immediate effect on your entire body, which varies

with the dosage. Some side effects include: increased blood sugar levels, increased appetite, irrita-

bility, fluid retention, and weakened bones and reduced immunity with long term use. You may also

experience relief of existing joint and muscle pain.

Note: If you are diabetic you may require a brief increase in your diabetes medication due to increased blood sugar levels. Follow your physician’s instructions carefully when taking an oral steroid.

Other Medications for COPD

Theophylline (Theodur) is a pill that may be added to your mother medications to help your breathing.

Dailresp (roflumilast) is occasionally used to reduce flare-ups, but it doesn’t have any real effect on

shortness of breath. Proventil (albuterol) comes in pill form but is seldom used.

4.2 Delivery Methods of Medication

Inhaled respiratory medication is delivered by liquid or powder depending on the medication and

delivery device used. Your respiratory therapist will help you improve your technique to ensure you are

taking your medications correctly and getting the most benefit from them.

Metered-Dose Inhaler (MDI)

This handheld device delivers a measured dose of medicine, usually in aerosol form, directly to your


lungs. The type of medicine in your inhaler could be a fast-acting or long-acting bronchodilator, or an

inhaled corticosteroid if you have continuous symptoms and moderate or severe COPD.

An inhaler can be used with or without a spacer (chamber).

Using an Inhaler Without a Spacer

1. Remove the cap, shake the inhaler well, and exhale.

2. Place the mouthpiece tightly between your lips.

3. As you press down on the canister slowly breathe in as deeply as you can.

4. Hold your breath for 10 seconds before exhaling to allow the medicine to fully reach the lungs.

5. Repeat steps 2-4 for each puff ordered by your doctor. Wait 1 minute in between puffs.

If you have trouble using your MDI inhaler, a spacer can be added to make the medicine easier to take

in (slowly and with more control, getting more medication into the lungs). If you have a spacer, you

should always use it when you take your inhaler.

Using an Inhaler With a Spacer

1. Remove the cap from the inhaler and spacer, shake the inhaler well, and insert it into the open end of the spacer (opposite of the mouthpiece).

2. Follow Steps 2-5 above.

3. If you hear a whistling sound when breathing in through the spacer you are breathing too quickly and should slow down.

4. Rinse your mouth after using a corticosteroid medicine.

5. Clean your spacer by moving the parts around in warm water with a mild soap. Rinse in clean water and let air dry before putting the spacer back together.


Respimat Soft Mist Inhaler

The Respimat inhaler has three simple steps for daily use. To help remember the

steps, just think T.O.P:

T = TURN the base of the Respimat inhaler

O = OPEN the cap and close your lips around the mouthpiece

P = PRESS the dose release button, and inhale

Before the first use you need to insert the cartridge and prepare your inhaler.

Your inhaler provides one month’s supply of doses.

Dry Powder Inhaler (DPI)

This handheld device holds dry-powder medication. Some have a built-in counter that shows you how

many doses of medication are remaining.

Using your Diskus:

• Hold it in the palm of one hand and put the thumb of your other hand on the thumb grip.

• Push the thumb grip until it clicks and exposes the mouthpiece.

• Slide the lever as far as it will go to load the medication, keeping the device level.

• Breathe out away from the device, then place your lips around the mouthpiece.

• Breathe in quickly and deeply, pulling in the medicine.

• Move the device away from your mouth and hold your breath for 10 seconds to allow the medicine to fully reach your lungs.

• If another dose is prescribed, repeat Steps 3-6 above.


• Check the counter to make sure the correct number of doses are left. If you lose a dose before inhaling, reload it and try again.

• Rinse your mouth with water.

• Clean the Diskus with a dry cloth (do not get it wet).

Note: Never blow into your Diskus inhaler. Blowing air into the device can moisten the medication and make it harder to inhale into your lungs.

Turbohaler / Dry Powder Inhaler (DPI)

Using your Turbohaler:

• Unscrew the cap and remove it.

• Holding the device upright, twist the colored grip until it clicks.

• Breathe out away from the device, then place your lips around the mouthpiece.

• Breathe in quickly and deeply, pulling in the medicine.

• Move the device away from your mouth and hold your breath for 10 seconds to allow the medicine to fully reach your lungs.

• If another dose is prescribed, repeat Steps 3-6 above.

• Some Turbohalers have a counter that shows doses remaining.

• If you lose a dose before inhaling, reload it and try again.

• Clean the Turbohaler with a dry cloth (do not get it wet).

Note: Never blow into your Diskus inhaler. Blowing air into the device can moisten the medication and make it harder to inhale into your lungs.

Nebulizer

A home nebulizer machine changes liquid bronchodila-

tor medication into mist form for you to inhale through a

mouthpiece or mask. A nebulizer can be used in place of a

metered dose inhaler (MDI). A nebulizer machine has an air

compressor and requires power. Most nebulizers plug into

an electrical outlet, but the portable ones run on batteries.


Using a nebulizer:

1. Place the nebulizer on a sturdy surface and plug in the cord (if not portable).

2. Wash your hands thoroughly before handling the parts.

3. Plug the hose into the nebulizer and into the bottom of the medicine cup.

4. Remove the cap from the top of the medicine cup.

5. Squirt the prescribed medicine into the medicine cup.

6. Replace the top of the medicine cup and connect the mouthpiece or mask attachment to it.

7. Keep the medicine cup upright so it doesn’t spill.

8. Turn the power switch to the ON position. The medicine will begin coming out of the mask or mouthpiece as a mist.

9. Put your lips around the mouthpiece or position the mask securely on your face and begin breathing through your mouth.

10. The treatment will last around 10 minutes, but make sure the mist is gone before you turn the machine OFF.

11. If you need to take a break in the middle of the treatment, turn the machine OFF and then resume.

12. After you are finished with the treatment take several deep breaths and cough into a tissue to clear any secretions.

13. Disassemble the medicine cup and the mouthpiece or mask and rinse them in 1 part white vinegar and 3 parts warm water between each use, allowing them to air dry. Do not clean the tubing.


5. Disease Process

5.1 Understanding COPD

Q: What is Chronic Obstructive Pulmonary Disease (COPD)?

A: COPD is a broad term used to describe particular types of progressive lung conditions, or

diseases. COPD is a condition that affects the lungs and makes it difficult to exhale “used, or bad” air

from the lungs, making less room for “clean, or good” air to enter. This results in oxygen entering your

bloodstream more slowly and a buildup of carbon dioxide, which is one of the body’s waste products.

Carbon dioxide (not to be confused with carbon monoxide) is a major cause of shortness of breath.

Note: Asthma is a condition that is similar to, but not the same as, COPD. Asthma generally develops before age 30 and, unlike COPD, is a condition that is typically completely reversible with medications. There is no destruction of lung tissue with asthma as with COPD. As a general rule, if a person has smoked more than 20 years before developing symptoms, it is COPD. Often people are misdiagnosed as having asthma when, in fact, it is COPD. Occasionally both conditions can be present at the same time.

Q What are the primary diseases that make up COPD?

A: Chronic Bronchitis: With bronchitis your airways are inflamed and swollen, producing large amounts

of mucus and phlegm. You may notice a persistent cough with phlegm production, wheezing and short-

ness of breath. Most people who have Chronic Bronchitis also have some amount

of emphysema.

Emphysema: With emphysema the air sacs that move the good air into the bloodstream and bad air

out become damaged and eventually destroyed. The main symptom is shortness of breath. Many

people who have emphysema also have chronic bronchitis, making it even more difficult to breathe.

Q: What are the symptoms of COPD?

A: The Symptoms of COPD are:

• Shortness of breath.

• A cough that produces mucus and won’t go away.

• Tightness in the chest.

• Feeling tired, especially during activity.

Competency: Activity, Breathing, Medications, and Self-Management


• Wheezing

Q. How is COPD diagnosed?

A. A breathing test known as Pulmonary Function Testing (PFT), or Spirometry, is required to confirm

the diagnosis of COPD and is also used to track the progression of COPD.

COPD is diagnosed when the PFT test shows a FEV1/FVC ratio of <70%. To assess and track the progres-

sion of the disease, the FEV1 number from the PFT test is used, which is the amount of air you can blow

out in one second and is a percentage of lung function you have available.

Because of the difficulty exhaling with COPD the output of air will be progressively diminished and the

FEV1 percentage will change over time and indicate the severity of disease progression. The FEV1 per-

centage is categorized into stages from 1-4 ranging from Mild to Very Severe:

Stage Category FEV1 (disease progression)

1 MildYou can blow out greater than or equal to 80%

of your air

2 Moderate You can blow out less than 80% of your air

3 Severe You can blow out less than 50% of your air

4 Very Severe You can blow out less than 30% of your air

Q. What do the disease stages mean to me?

A. When you were born you had 100% of your lung function to breathe with. Everyone has a decline

in their lung function as they age. Those with COPD or those who smoke will have an increase in the

decline of their lung function.

Note: Much of your shortness of breath comes from the inability to exhale enough air before you feel the need to take another breath in. Trying to speed this up by pushing more air out will make you more short of breath. Instead, try pursed-lip breathing, which does help get more air out (See Breathing Skills section).

The lung function you have left is like a “pie.” You were born with a whole pie, being able to blow out

most of your air in 1 second (FEV1). Now you are only able to blow out ___% in 1 second. This is how

much pie you have left. Once some of the pie is gone, you never get it back, but you can help manage

your disease by using your medications consistently, avoiding smoking, and recognizing and treating

your flare-ups early to slow down your loss of lung function.


Q: What causes COPD?

A: COPD is mainly caused by cigarette smoking, but pollution and occupational irritant exposure can

contribute as well as hereditary factors, such as a family history of early-onset emphysema.

Note: The hereditary disease Alpha-1 Antitrypsin Deficiency occurs when the body doesn’t produce enough en-zyme that protects the lungs. AAT Deficiency causes emphysema (which is the major component of COPD) and is diagnosed by a simple blood test. This condition is very rare and usually results in COPD before age 50.

Q: Is there a cure for COPD?

A: COPD is a progressive disease that gets worse over time. Although there is no cure, there are steps

you can take to lessen the effects of the symptoms and improve your quality of life. Being a part of a

disease management program can help you better manage flare-ups, reduce hospitalizations, and slow

the disease progression.

Note: Once a person with COPD quits smoking the rate of decline is much closer to the effects of age. Avoiding frequent flare-ups also slows down loss of lung function.

Air Exhaled in One Second: FEV1

Retained Air

60%40%

Lung Function with COPD. Example of “moderate” COPD

FEV 1 > 80%

100%

Normal Lung Function - FEV of 80-100%


5.2 Managing Triggers and Disease Progression

Every day you should follow your Daily Respiratory Action Plan that was developed with you by your

healthcare professional (see Appendix).

In addition, the following strategies will help you be able to recognize triggers and adapt to the disease

progression while maintaining the best quality of life possible:

• Practice breathing skills and relaxation techniques

• Keep all physician appointments

• Follow your prescribed medication and breathing treatments

• Maintain healthy eating habits

• Build or increase your flexibility and strength with an exercise regimen or Pulmonary Rehab, if prescribed by your doctor

• Don’t smoke

• Schedule yearly flu and pneumonia vaccines

• Avoid environmental irritants

• Perform a PIKO breathing test daily

5.3 PIKO Meter Daily Breathing Test

Occasionally a physician or other healthcare provider may recommend that

you monitor your breathing with a home spirometer, such as a PIKO meter.

The PIKO meter breathing test is a simple test you can use daily to monitor

your lungs and provide an early indication of trouble.

Because the test relies on effort to assign a number, in order to obtain opti-

mal results it is imperative that you use your best efforts when blowing into

the PIKO device. For the test to be an effective management tool, you need to

do the test daily and according to the instructions provided.

After the first month, where your numbers trend and your “personal best” can be assessed. Your

personal best can then be used in conjunction with the zones in your Daily Respiratory Action Plan (see

Appendix) to manage your disease.


PIKO Meter Instructions for Use

1. Take the PIKO peak flow meter out of the plastic case.

2. There is one button on the side of the PIKO peak flow meter. This is the button you will push to perform the different functions using the PIKO.

3. If the display is blank, press the button once. The display will show the most recent test results.

4. Stand up (or sit up straight). Hold the PIKO meter so you don’t cover the vent holes. The vent holes are at the top of the PIKO Meter behind the mouthpiece.

5. Press the button once. You will hear a short beep. Wait to hear a second beep. The display will look like this: 0- -.

6. Take a deep breath in.

7. Place the mouthpiece in your mouth and close your lips around the mouthpiece. Do not put your tongue in the mouthpiece.

8. Blow out as hard and as fast as you can without bending over. Blow for at least two full seconds.

9. Look at the display. Your test results will appear in the display right away. The test results will change from PEF to FEV1. If your zones have been set, an arrow will point to the zone you are blowing in—green, yellow or red.

10. If you hear a long beep or see an exclamation (!) mark after your number on the PIKO Meter, something was wrong with your technique and you will need to redo the test to get the best results. If you are still having problems, let your respiratory therapist know and they can review the instructions and your technique and make suggestions.

11. Repeat steps 3 through 8 two more times within three minutes of the first test. (The PIKO Meter will select and save the highest of the three best results if the tests are completed within three minutes but will automatically turn off if not used in three minutes).

12. The highest number from the three tests will be your result for that day’s test.

Cleaning your PIKO Meter

Keep your PIKO meter clean to obtain accurate test results.

1. Take off the clean plastic mouthpiece by moving it sideways.

2. Wash the clear plastic mouthpiece in liquid dish soap and cold water. Rinse, shake off the excess water, and dry thoroughly. Do not place any parts in the dishwasher.

3. The Piko top section (not the display section) can be cleaned with low-flow water at room temperature. Shake off the excess water and dry thoroughly. Do not immerse the display section in water.

4. Check the metal liner under the mouthpiece and clean with an alcohol pad if dirty.

5. Replace the mouthpiece by snapping the mouthpiece into place. The mouthpiece should face straight out once replaced


Tracking Disease Progress with your PIKO Meter

Determining Zones

Once your personal best is determined from using the PIKO Meter breathing test for about a month, it

may be helpful for you and your health care provider to establish zones that cross-reference with your

Daily Respiratory Action Plan (see Appendix) and indicate how well you are breathing and what steps

you should take. The zone system can be compared to the colors of a traffic light—green, yellow and

red.

Green Zone (often 80%-100% of personal best) signals ALL CLEAR. This indicates good lung function.

Follow your routine treatment plan for managing your COPD

Yellow Zone (often 50%-80% of personal best) signals CAUTION. You may need more aggressive

medical management for your COPD. This may include a temporary increase in quick-relief medicine,

antibiotics, or oral steroid medicine, as prescribed by your doctor and outlined in your Daily Respiratory

Action Plan.

Red Zone (often 50% or less of personal best) signals a MEDICAL ALERT! You may need immediate

treatment. Consult your Daily Respiratory Action Plan for other signs and symptoms that you are in the

Red Zone and notify your doctor or seek emergency care if you have other signs and symptoms in the

red zone.


6. Exacerbations: (Flare-ups)

An exacerbation occurs when you have a flare up of your COPD and have a notable increase in symp-

toms. It is important that you follow your Daily Respiratory Action Plan (see Appendix) daily in order to

recognize when you need help.

6.1 Steps to Take During a Flare-up1. Use your oxygen.

2. Breathe in through your nose and out through your mouth (pursed lip or diaphragm breathing).

3. Use your inhaler or nebulizer

4. Increase your fluid intake if under no fluid restrictions

If you have the following symptoms call your healthcare provider:

• Shortness of breath (most-significant indicator), usually associated with wheezing.

• Sputum is thicker or stickier

• Coughing up more phlegm than usual.

• Sputum changes to green, yellow, or brown for more than 12 hours

• Fever is greater than 100 degrees F for more than 24 hours

6.2 Signs of an Emergency

If you develop the following symptoms you need to be seen right away:

• Blood in your sputum ( not slight blood tinge of sputum but when sputum is mostly or all blood)

• Extreme chest tightness or wheezing

• Struggling to breathe

• Drowsy and confused

• Blue fingernails or lips

• Sudden onset (within 15 minutes) of shortness of breath or chest pain

Competency: Activity, Breathing, Medications, and Self-Management

7. Infection

7.1 Signs and Symptoms of Infection

If you get lots of infections, try to “tune in” to when one might be beginning so that you can get antibiot-

ics early if your doctor thinks you need them.

Taking an infection seriously can prevent a flare-up, or exacerbation, and can help you avoid an emer-

gency situation. Most flare ups are due to infection and treatment for both is commonly ordered.

You may be developing a chest infection if you notice any of the following:

• Increase in breathlessness

• Increased cough

• Phlegm increases in amount

• Phlegm increases in thickness

• Phlegm changes color

• Phlegm begins to smell bad

• Fever

7.2 Antibiotics

Antibiotics are used to treat bacterial infections (not useful for viral infections, such as colds and flu).

Bacterial infections of the lungs and airways (pneumonia or acute bronchitis) are very serious for peo-

ple with COPD. They can cause further lung damage and make breathing even more difficult.

When you have to take antibiotics for an infection:

• Finish the entire prescription, even after you start feeling better. Quitting antibiotics before the course is finished can allow some of the bacteria to survive and cause another, more severe, infection later.

• Tell your doctor if you are having a rash or other reaction to your antibiotic, especially if it is making it difficult for you to take them.

Competency: Medications and Self-Management


7. Infection

7.1 Signs and Symptoms of Infection

If you get lots of infections, try to “tune in” to when one might be beginning so that you can get antibiot-

ics early if your doctor thinks you need them.

Taking an infection seriously can prevent a flare-up, or exacerbation, and can help you avoid an emer-

gency situation. Most flare ups are due to infection and treatment for both is commonly ordered.

You may be developing a chest infection if you notice any of the following:

• Increase in breathlessness

• Increased cough

• Phlegm increases in amount

• Phlegm increases in thickness

• Phlegm changes color

• Phlegm begins to smell bad

• Fever

7.2 Antibiotics

Antibiotics are used to treat bacterial infections (not useful for viral infections, such as colds and flu).

Bacterial infections of the lungs and airways (pneumonia or acute bronchitis) are very serious for peo-

ple with COPD. They can cause further lung damage and make breathing even more difficult.

When you have to take antibiotics for an infection:

• Finish the entire prescription, even after you start feeling better. Quitting antibiotics before the course is finished can allow some of the bacteria to survive and cause another, more severe, infection later.

• Tell your doctor if you are having a rash or other reaction to your antibiotic, especially if it is making it difficult for you to take them.

Competency: Medications and Self-Management


7.3 Bronchial Hygiene Through Lung Clearance

When you feel a buildup of mucus in your lungs during an infection (or after exercising), you may use a

technique called the “huff cough” to help get the mucus out.

Huff Cough Technique:

1. Sit comfortably in a chair with your feet on the floor, shoulder width apart.

2. Breathe in through your nose slowly and deeply 3-5 times, using pursed lip or diaphragm breathing.

3. Cough gently to loosen the mucus.

4. Cough again while squeezing your abdominal muscles and forcing air out of your open mouth (it may help to say the word “huff” while expelling air). This cough should be forceful enough to get the mucus up.

5. Spit the mucus into a paper towel (do NOT swallow it).

6. Repeat 2-4 times or as needed.


8. Nutrition

8.1 Importance of Healthy Eating and Hydration

Eating healthy and drinking enough water can may help your immune system and ability to breathe

more easily. Individuals with COPD have different dietary needs. It is important to maintain a healthy

weight. This may mean losing weight, maintaining weight, or gaining weight depending on your height

and weight.

Note: If you cannot obtain and prepare your food due to your severe breathing symptoms, financial limita-tions, or have weight loss associated with loss of appetite, please notify your therapist.

Tips for Eating with COPD:

• Manage food portions by eating smaller amounts more often

• Avoid gas-causing foods

• Reduce processed foods

• Eat foods high in fiber

• Drink enough water to avoid thirst (which may help keep mucus thinner)

• Increase protein and cut down on simple carbohydrates in your menu

• If you are underweight and have been told you have severe COPD, it’s okay to increase the amount of fat in your diet

8.2 Foods to Include in Your Diet

Foods that are high in fiber and complex carbohydrates:

• Fresh or frozen whole vegetables

• Cooked dried peas and beans (may be gas-causing)

• Whole-grains

• Bran

Competency: Self-Management


Protein:

• Fish

• Poultry (turkey is highest in protein)

• Beef

• Eggs

• Dairy products (Greek yogurt)

• Peanut and other nut butters

8.3 Foods to Limit in Your Diet

Gas Causing:

• Carbonated beverages

• You may wish to reduce the amount of fruits, vegetables, and beans that cause you gas or bloating

Starchy foods and sugars:

• Pasta

• White breads, rolls

• Cereals

• Cakes and pastries

• Potatoes

• Chips and snack foods

8.4 Fluids to Include in your Diet

Many people with COPD have thick, sticky mucus that is hard to cough up. Keeping hydrated by drink-

ing enough fluid during the day will help this mucus thin out and become easier to clear.

If you are on a fluid restricted diet, or are taking a diuretic, please follow your healthcare provider’s

instructions. (Be advised that if you are taking a diuretic—water or liquid pill—drinking excess water

undoes any benefit of that medication.)


Good Sources of Fluids

• Water (around six 8-ounce glasses a day, if not drinking other types of fluids)

• Broths

• Fruit juices (avoid added sugars)

• Fresh fruits and vegetables

Caffeine Use

If you already drink caffeinated beverages as part of your daily routine you don’t need to stop. Howev-

er, if you notice palpitations, anxiety, sleeplessness, or jitters you should reduce the amount of these

beverages you consume.

Note: You should avoid caffeine if taking these medicines: Clozapine, Lithium, and Riliuzole. Do not mix caf-feine with other stimulants such as ephedrine, dexedrine, or phentermine.


9. Environment

9.1 Environmental Triggers and Irritants

Avoid tobacco smoke as a top priority, but also try to avoid other environmental elements that trigger

flare-ups. During humid, windy, or cold weather, shorten time spent outside. These conditions can

irritate your airways, making you cough more and making your breathing more difficult. If you must go

out in cold or windy weather, hold a light handkerchief over your nose and mouth.

Be careful when coming into contact with irritants such as dust, hairspray, perfumes, cooking sprays,

or any other type of aerosol. Make sure the room is well ventilated and leave the room quickly where

aerosol was sprayed, being careful not to inhale.

9.2 Unhealthy Environments and Travel

Pollution

The air quality in our homes can be worse than that outside. This can be due to many things including

dust, pollen, dander, and fumes from paint and cleaning products.

Improving Air Quality Indoors

• Make sure your home is well ventilated.

• “Go Green” with cleaning products.

• Arrange for someone to clean when you are out of the house.

• Reduce dust in home by dusting often and washing bed linens.

• Consider an air purifier if you are extremely sensitive.

Travel

Avoid areas where heavy amounts of air pollution are present. Check the air pollution level before

going out or traveling.



10. Resilience

10.1 Conserving Energy

To avoid getting worn out throughout the day and to get more accomplished without getting short of

breath, conserve your energy with the following practical tips: If you are prescribed oxygen, always use

it when active.

• When not exercising move slowly enough to avoid severe breathlessness. Some shortness is normal and not harmful. It may be helpful to use pursed-lip breathing when walking.

• Use a cart with wheels to move items such as dishes and laundry, which will reduce your trips back and forth and lessen the burden of carrying heavy loads.

• If you have been told you have very severe COPD it may help to sit for as many tasks as possible, such as to dress, shave, put on makeup, or cook. Use a shower stool and hose sprayer to sit while bathing.

• Bending and lifting may cause shortness of breath. Make sure to breathe when bending or lifting. If your breathing is severely limiting you might consider arranging your house so that the things you use most are at waist level or within easy reach. Long-handled reachers or tongs can help you reach things or pick things up without bending.

• Take rests after meals when your body is working hard to digest food. It is common for patients with COPD to get short of breath when eating a large meal. It may help to eat smaller amounts more frequently.

10.2 Controlling Stress

Feeling stressed can make breathlessness much worse. Anxiety can cause you to breathe even faster,

tax your chest muscles, and cause panic.

Learning relaxation techniques can help you avoid allowing stress to build to anxiety.

Here are some suggestions to try as you find what works for you:

• Yoga, meditation, or listening to relaxing music.

• Close your eyes and imagine you are in your favorite place. For example, picture a warm breeze on your face or sand under your feet.

Competency: Activity, Breathing, and Self-Management


• Relax your body by slowly tensing and then relaxing each part. Start with your toes and work all the way up to your scalp. Breathe in as you tighten, and breathe out as you relax. This is a good time to practice pursed-lip and diaphragm breathing.

10.3 Support Networks

Don’t allow yourself to become isolated. In addition to family and friends, try reaching out to others

who are living with COPD to share experiences and tips. If you are comfortable with the Internet you

may wish to join an online support group.

Pulmonary rehabilitation classes are available in a group setting directed by a healthcare professional.

This is another way to connect with other patients living with similar challenges and share experiences

as you learn more about different exercises and coping techniques.

10.4 Setting Goals

Pick one goal to work towards:

Set a motivation goal—what would YOU like to accomplish in the next 30-60 days?

Learning how to manage your activity level, your breathing, and your medications will allow you to

achieve your goal as well as master new skills and create new goals.

Set small goals along the way:

Continue to set small, manageable goals with your healthcare professional and work toward them with

a positive attitude.

With an understanding of your disease plus confidence in your ability to manage it, you will reach a

greater level of independence and satisfaction in your daily life.


11. Sleep

11.1 Importance of Sleep

According to the American Thoracic Society, close to 50% of COPD patients report significant sleep dif-

ficulty. They go on to say that this most likely relates to daytime symptoms of chronic fatigue, lethargy,

and the overall impairment of quality of life that many COPD patients experience.

Getting a good night’s sleep is important to your immune system working properly, especially with the

lack of energy and strain on your heart and lungs that COPD causes.

11.2 Getting a Good Night’s Sleep

Determining why you can’t sleep can help you get a better night’s sleep. Possible issues for COPD pa-

tients are:

• Sleep position

• Medications

• Acid Reflux or heartburn (try elevating head of bed)

• Anxiety

• Dyspnea (Shortness of breath)

• Sleep apnea

Tips for improving sleep:

• Have a bedtime routine

• Sleep in the same place every night.

• Don’t eat a lot right before bed

• Take anti-anxiety and sleep medications as prescribed by your physician

• If you suspect sleep apnea, talk with your physician



11.3 Sleep Apnea

If you suffer from recurrent awakenings at night, snoring, or insomnia, you may suffer from sleep

apnea. Sleep apnea is a serious sleep disorder that can be common in people with compromised lung

function, such as COPD.

If you have the following symptoms, you should talk to your doctor about sleep apnea:

• Snoring

• Daytime sleepiness or fatigue

• Sudden awakening with a sense of gasping or choking

• Dry mouth or sore throat upon awakening

• Forgetfulness, irritability, or difficulty concentrating

• Depression or anxiety

• Night sweats

• Sexual dysfunction

• Morning headaches

In order to diagnose sleep apnea, the physician will order a sleep study (PSG or HST) to be given.

Treatments for Sleep Apnea

Conservative Treatment

• Overweight people can benefit from losing weight

• Nasal sprays

• Breathing strips

• Pillows or devices that encourage side-sleeping

Note: These treatments may not be very effective for people with COPD.

Mechanical Therapy

With Continuous Positive Airway Pressure (CPAP) therapy, patients wear a mask over their nose and

mouth while sleeping. An air blower gently forces air through the nose and/or mouth to prevent airway

closure.


Surgery

Sometimes surgery can be performed to help people with sleep apnea. If you have OSA, you need a

referral to a doctor that specializes in Ear, Nose, Throat (ENT) medicine to determine whether or not

you are a candidate for surgery.


12. Smoking

Cigarette smoking can cause many complications in addition to COPD, including lung cancer, heart dis-

ease, and poor circulation, to name a few. If you have COPD and are still smoking you are accelerating

the decline in your lung function. Your shortness of breath will worsen much sooner.

12.1 Benefits of Quitting Smoking

Extend your life and improve the quality of your life by avoiding smoking

Your body will not be able to repair the damage already done to your lungs by smoking, but you can

stop further damage from smoking. With your airways more open, you will be able to breathe easier,

cough mucus up better, and your lungs will be able to capture more oxygen, allowing you to feel more

energetic. Your blood circulation and sense of taste and smell will also improve. Smoking is related to

many other diseases in addition to lung disease. A few examples are heart and blood vessel disease

(vascular), in addition to several cancers other than lung cancer.



12.2 Smoking Cessation Strategies

Start a journal

• Write down the reasons you smoke and other ways you could satisfy those needs.

Make a decision to quit.

• Write down a quit date and share that with your doctor and family.

• Set up an appointment with your doctor to discuss smoking cessation aids and programs.

Make a change

• Change the habits that you associated with smoking.

• In preparing to quit, find ways to make smoking a less pleasurable experience.

Think positive

• Visualize yourself as a non-smoker and remind yourself you can get past the hardest part.

• Don’t think about never smoking again. Every time you get the urge to smoke, tell yourself that you can wait a while and repeat this to yourself every time you get urge. Most people find this to be a more bearable way to deal with cravings

Join a smoking cessation group

• You may be able to find a support group by calling your local hospital or asking your doctor.

Celebrate the small victories

• Every cigarette you don’t smoke is a victory.

Don’t give up

• If you have made a plan to quit and have a cigarette, don’t become discouraged and quit trying. Many people have relapses but through perseverance go on to be successful.

• It is common to continue to think about smoking for many months or even years after quitting (this is the fundamental nature of any addiction). Usually this thought will pass after about 10 minutes.

What to Expect After You Quit

As your body tries to clear out the tars and other substances you may cough more for a few days, but

this effect will lessen and disappear.


Other symptoms that you may experience after quitting are related to nicotine withdrawal—such as

anxiety, irritability, and increased appetite—should go away within the first month.

Appendices

1.1 Printable Collateral• 1.1.1 Patient Health Information Form (PDF)

• 1.1.2 Daily Respiratory Action Plan (PDF)

patient education guide -...

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