the HAE series: the Pulmonary system part III

Part III, and my favorite part to write, reviews the concrete steps we can take to prevent pulmonary disease and slow age-related changes to the lungs.

Lifestyle Factors

First and foremost, cessation of smoking and avoidance of second hand smoke is, of course, the number one lifestyle modification you can make to protect your pulmonary system. Smoking is the greatest risk factor for developing COPD. Those who smoke more than 10-15 ‘pack years’ (1 pack of cigarettes per day for a year is ‘1 pack year;’ 2 packs of cigarettes for 1 year is ‘2 pack years.’) are at higher risk to develop COPD and the exposure to secondary hand smoke and other environmental irritants and air pollution can also increase your risk. Visit SmokeFree.org for some amazing tools to help you or your loved one quit.

Exercise and the Pulmonary System

Exercise also can have significant impact on the risk of developing, and the management of, pulmonary disease. Both aerobic exercise and strengthening activities play a role in your pulmonary health. Participating in the recommended 30 minutes of moderate exercise most days of the week works to improve the way the body is able to access and utilize oxygen. Aerobic exercise strengthens the cardiovascular system; with a stronger heart and healthier vascular system, the blood stream can transport the oxygen-rich blood with increase ease and efficiency. Participation in a regular strengthening program improves gas exchange within the musculoskeletal system. When the blood stream reaches the muscle, a stronger muscle is able to more quickly and efficiently extract the oxygen, which it can then use to make energy and contract more successfully.

Lastly, focused breathing exercises can improve the muscle function of the structures responsible for the act of breathing. These include the diaphragm, located under the lung set, the intercostal muscles found between the ribs and the accessory breathing muscles, located throughout the neck and abdomen that help with the work of breathing. These muscles, in particular, tend to become overused and overdeveloped in pulmonary disease states that frequently lead to dyspnea or shortness of breath. Physio-pedia has an excellent set of videos that illustrates how these muscles work together to support the cycle of breathing here if you want to check it out.

Respiratory Training

There are three exercises I typically take my patients through to strengthen both breath control and respiratory strength. Pursed lip breathing, belly breathing and straw breaths all work to teach proper breath sequence, timing and help to strengthen the muscles responsible for the cycle.

To perform pursed lip breathing, try following these steps:

1. Take a slow inhale through your nose, counting to 3-4 seconds as you go.

2. Pause, then exhale this breath through pursed lips (like you’re holding a straw) trying exhale slowly, doubling the time you spent on the inhale. If you inhaled for 2 seconds, exhale for 4. If you made it 4 seconds, exhale for 8.

This exercise can be used proactively to strengthen, and also reactively, to address shortness of breath. You can watch a video of pursed lip breathing here. Pursed lip breathing is especially important to people with COPD; this extended exhale allows the breather to exhale trapped carbon dioxide more effectively, further normalizing the breathing pattern and improving the associated feeling of shortness of breath.

Diaphragmatic breathing, or belly breathing, helps to normalize the breathing pattern, and better utilize the diaphragm, leading to deeper and more effective breathing patterns. In states of respiratory distress, instinct tends to trigger short, quick, repeated breathing. However, this pattern is less effective than deeper, diaphragmatic breathing and tends to exacerbate the shortness of breath instead of alleviating it. Practicing this technique at rest is helpful, so it can be used more effectively in states of dyspnea with less effort and more ease. To perform a proper diaphragmatic breath, follow these steps.

1. Sit comfortably with feet flat on the floor, or lay down flat in bed. Place hands on your belly and try to relax your body.

2. As you breathe in slowly through your nose, imagine filling your lungs to the very bottom and watch your hands rise as your belly expands.

3. As you exhale, watch your hands fall back down and your belly return to resting state.

This video link will show you diaphragmatic breathing in action.

The third exercise worth mentioning is straw breathing. It is similar to the pursed lip breathing above, but can sometimes be a little easier to coordinate. To perform, find a plastic straw and sit comfortably in a chair. Breathe in slowly through your nose, then exhale fully with lips wrapped tightly around the straw. Try to repeat 5 times and rest.

All three of these exercises are best performed when you are calm and at rest. Try to choose a time to perform them each day to create a habit; spending 5 minutes focused on each one 3-5 times a day can be extremely beneficial and will make using these strategies with the onset of shortness of breath more automatic and let you return to a resting state with increased ease.

the HAE series: the Pulmonary System part II

Normal Changes with Aging

As with all areas of the body, with advancing age, the lungs can be come less efficient. The diaphragm muscle responsible for the inhalation and exhalation can become weaker, decreasing the amount of air you can take in and out each breath. With thinning ribs and arthritic changes, the rib cage can become less flexible and cause some restriction on your inhalation. Combined, these two changes can increase the work associated with breathing. Other accessory muscles involved with respiration can also become weaker, interfering with your ability to cough and in turn, clear your airway. With age also comes a weakening response of the immune system; the white blood cells that usually provide some defense to invading pathogens within the lungs become less effective putting your at increase risk of infections like community-acquired pneumonia Lastly, within the lungs, the alveoli lose their shape and this in turn makes gas exchange more difficult. Aside from the changes occurring naturally with age, I’ll review some pathology common in older adults. (But don’t fret, next week I’ll share how we can slow or reverse these changes through our actions!)

What Can Go Wrong

Pneumonia: As mentioned above, weakened immune systems can leave the pulmonary system at risk of infection. Infection within the lungs is called pneumonia. The result of inflammation at the alveoli, the gas exchange is impaired and the body can end up in a state of hypoxia, or decreased oxygenation. Other symptoms are typically cough, fever, back pain (typically near the site of the infected lung) and audible ‘crackles’ that can be heard through auscultation. More progressive cases can cause confusion, altered sleep and wake cycles and failure to thrive. Risk factors for pneumonia include immune compromise and immobility. The ability to move air throughout the lungs can help clear out pathogens and as such, it is of critical importance to use strategies like incentive spirometry or deep breathing during periods of immobility after a surgery, during a hospital stay or during a state of illness. Pneumonia is typically treated with an antibiotic if is caused by bacteria, however, some strains of pneumonia can be prevented prophylactically with the pneumococcal vaccine.

COPD: Chronic Obstructive Pulmonary Disease, or COPD, causes difficulty breathing by way of ‘air trapping.’ In the case of emphysema, destruction of the alveoli due to exposure to irritants like cigarette smoke, causes impaired air exchange and the trapping of carbon dioxide. With chronic bronchitis, inflammation within the bronchial tubes make it harder to inhale and exhale and with chronic asthma, the obstruction is due to inflammation within the airways causing bronchoconstriction, or narrowing of the bronchioles. These disease states leave the lungs less elastic and airways more prone to collapse and this combined, obstructs expiration. People experiencing COPD will have symptoms associated with hypoxia, or decreased oxygen, like coughing, difficulty breathing, confusion and fatigue. Treatment mainstays include keeping the airways open longer during the exhale phase with strategies like pursed lip breathing or spirometry, use of bronchodilators (inhalers) and supportive oxygen in later stages. 

Restrictive Lung Disease: As introduced above, disease and disorders that affect the muscles and bone structure can cause an external restriction in the ability for the lungs to expand. Restrictive disease can be classified as either intrinsic or extrinsic. Intrinsic causes include general fibrosis of the lung parenchyma and extrinsic causes involve the lung pleura, chest wall, respiratory muscles or neuromuscular disorders. Neuromuscular conditions like Parkinson’s Disease and musculoskeletal changes like rib fractures and thoracic kyphosis and scoliosis can cause structural changes to the rib cage and lost flexibility. Increased body weight and obesity can block the diaphragm from descending fully and can make both inhale and exhalation more difficult and cardiovascular causes, like pulmonary edema from heart failure can restrict lung expansion from the inside. Presentation involves dyspnea compensated for by rapid shallow breathing and patients will demonstrate a decreased total lung capacity, modestly preserved FEV1, increase airway resistance and a decreased FVC that results in a FEV1/FEV ratio greater than 80%, as well as a reduction in functional residual capacity (FRC), or the amount of air in the lungs that remains when respiratory muscles are fully relaxed.

Treatment for these conditions must address the etiology; stretching, range of motion and postural reeducation may help in cases that have not yet progressed to severe and treating the CHF through pharmacologic management and lifestyle modification will address the cause in the case of pulmonary hypertension. 

Pulmonary Hypertension: PH is a condition in which mean pulmonary arterial pressure is greater than 25 mmHG at rest. Pulmonary Arterial Hypertension (PAH) is a specific clinical condition of PH in absence of other causes of precapillary HTN. It is quite rare (1, 1000,000-1,000,000). PH is less uncommon, 1% of the population, and is often associated with other hypoxic cardiopulmonary disease like COPD and diffuse parehnchymal lung disease. In setting of hypoxia, pulmonary arterial smooth muscle contracts to cause vasoconstriction to promote ventilation matching, but in chronic hypoxic lung disease, the increased pulmonary vascular resistance resulting from hypoxic pulmonary vasoconstriction causes the development of PH. Symptoms usually include dyspnea, fatigue, general signs of cardiovascular dysfunction (syncope, angina, heart murmurs) and signs of pathologically elevated systemic blood pressure (ascites, edema, jugular distension). Exercise capacity is limited, and individuals with PH experience increased dyspnea due to inspiratory and expiratory muscle weakness.

HAE series: the Pulmonary system

The Basics

While the heart may seem like the most important organ in your body, it would be quite lonely without the pulmonary system to which it is attached. The pulmonary system is responsible for the critical task of gas exchange - or the transfer of fresh oxygen into the bloodstream, and the removal of carbon dioxide from it. Oxygen makes all the things happen. WIthout oxygen, there would be no energy. Without energy, there would be no functioning tissues, organs or muscles. In fact, the brain can only function about three minutes without oxygen and if cut off for any longer, will likely sustain some degree of brain death (*except in cases of severe hypothermia, but that’s a story for a different time.) All said and done, you inhale and exhale approximately 2000 times a day, exchanging 11,000 Liters of air by the time you start the next. 

This process occurs in four different stages. Pulmonary Ventilation initiates the cycle by drawing air into and forcing air out of the lungs. The muscle that forms the base below your lungs, the diaphragm, contracts and relaxes to create a vacuum effect; the oxygen rich air from the atmosphere is drawn in through the nose and mouth, and into your system by way of a series of pipes. The air first enters the pharynx, then passes into the larynx. The larynx becomes the trachea and the trachea splits into the two primary bronchi, which then each split into secondary bronchi, each of those then splitting into more and more segmental bronchi. This elaborate splitting and resplitting creates the tree-like shape that makes up each lung. The right lung is broken into three lobes; the upper lobe, the middle lobe and the lower lobe. The left lung only gets two, because it leaves a notch open where the heart sits and has an upper and lower lobe only. Each of the very last bronchioles in the tree ends at an alveolus. Multiple alveoli bunch together to form an alveolar sac. This is where the action happens. 

The alveolar sacs are responsible for the External Respiratory phase. Each sac looks like a tiny cluster of grapes and this is where the lung tissue connects to the blood stream. Blood leaves the right side of the heart by way of the pulmonary arteries and ends as capillaries who wrap around the alveolar sacs where they can proceed to transfer their gasses. (If you’re quick on the pick up, you’ll realize this is totally counter intuitive as arteries are usually associated with red, oxygen rich blood, but the term artery actually just indicates direction. An artery is simply a blood vessel which goes away from the heart, which in this case, it does.) During this gas exchange, carbon dioxide is deposited back to the lungs to be exhaled, and oxygen is transferred from the alveoli into capillaries to bind to hemoglobin and enter the blood stream. This, now oxygen-rich, blood travels along the pulmonary vein into the left side of the heart to be pumped out into the body. (Get the counterintuitive reference now? Though veins are usually oxygen-poor, these are oxygen-full because a vein simply indicates it is returning to the heart.)

The role of the elaborate vascular system is now to enable the Transit of Respiratory Gases. Blood travels throughout the body through arteries to every single muscle, tissue and organ in your body and provides the oxygen needed to created energy to keep those cells functioning. As these arteries turn into smaller capillaries and terminate at their designated tissue site, the fourth and final phase, the Internal Respiration completes the cycle. Oxygen transfers from the bloodstream into the tissues, and the tissues trade out the residual carbon dioxide that has been left there as a byproduct from energy production. I’ll leave you with a fun fact: Once that carbon dioxide is exhaled back into the air, it is used by plants for photosynthesis  - which then creates more oxygen for us to breathe. #CycleOfLife.

You can watch a pretty sweet Nat Geo video about the lungs here.

So, you got Covid-19…now what?

Fortunately, about 80% of people who get Covid-19 will experience only mild symptoms. However, the other 20% can experience more severe symptoms and 5% may experience critical illness as a result. Recovery from moderate to severe Covid-19 can take weeks, months or longer. Generally, the longer you were in the hospital, ICU or on a mechanical ventilator, the longer you may experience residual effects, and the more protracted your recovery may be. The APTA has provided physical therapists with a wonderful resource, the PACER series (Post-Acute Covid-19 Exercise and Rehabilitation project) to help us best prepare to care for patients as they recover from Covid-10 and I have pulled together some of the most relevant information I learned from this course here for you. If you contracted Covid-19, and still don’t feel yourself despite the ‘all-clear’ of a negative test, here are some things you may be experiencing, and some information on how Physical Therapy can help you continue along the recovery process.

WHAT TO EXPECT DURING COVID-19 RECOVERY:

• Fatigue and Decreased Endurance: You will likely find you are more tired than normal from moving around, walking, and performing activities of daily living. This can be due to deconditioning from the bed rest and hospital stay, due to dehydration, because of decreased blood volume, or related to impaired use gas exchange and ventilation (your ability to pull oxygen out of the air and into your lungs). Anemia is also possible after Covid-19 and should be assessed for by your doctor if you are experiencing these types of symptoms.

• Muscle Weakness: You may feel like your body is weaker than it was before or it is harder to carry heavy items. Muscle weakness can develop from prolonged bedrest or decreased activity, but it can also be more significant if you have been diagnosed with Critical Illness Myopathy (CIM) or Critical Illness Polyneuropathy (CIP) related to your Covid-19 illness.

• Shortness of Breath or Difficulty Breathing: As Covid-19 causes damage to the lungs, you may find you continue to be short of breath at rest or with activity while you recover. You may notice you have to lean forward to support yourself to breathe deep or find yourself taking shallow breaths or breathing more rapidly when you feel out of breath. This may be due to damage to the alveoli, in the lungs, where the oxygen is extracted from the air and drawn into the blood stream, or it may be due to scarring and fibrosis that has occurred within the lungs during their healing process.

• Signs of Cardiovascular Impairment: If you already had Cardiovascular disease prior to developing Covid-19, you may find your symptoms are now worse. If you suffered any cardiovascular damage during your illness, you may experience periods of angina (chest pain), a higher than normal resting heart rate, feelings of irregular heart rate or arrythmia or swelling in your legs or your feet. If you are experiencing any of these symptoms, it is important to report these to your doctor, so they can assess your need for further care. You also may experience lightheadedness when you stand up. Orthostatic hypotension is common after spending time in the hospital, and can be improved by drinking plenty of fluids, and taking extra time to come to standing, especially first thing in the morning or when you get out of bed.

• Difficulty with your Balance: Whether due to impact on your neurological system or simply due to weakness and deconditioning, it is possible you may feel more off balance or unsteady when you walk. If are having falls, or even feeling like you may fall, it is worth seeking physical therapy to improve your balance and keep you from sustaining any falls-related injuries that could further set you back.

• Increased Confusion, Memory Loss, Anxiety or Depression: Lastly, it is common to feel anxious or depressed after a hospital stay and especially after a hospital stay for Covid-19. If these feelings become overwhelming or are distressing, it is important to bring these to the attention of your doctor. It is also possible to have some degree of delirium or new onset memory loss after an ICU stay. This can take some time to improve, and you may benefit also from seeing a Speech Language Pathologist to help you learn recovery or compensatory strategies to address issues you may be having.

HOW PHYSICAL THERAPY CAN HELP YOU RECOVER AFTER COVID-19:

As a skilled Physical Therapist, I can help you work to get stronger after Covid-19. These are some things I would likely work with you on as part of your rehabilitation.

• Functional Mobility: I will help you improve the things you may be struggling to do at home. This may include the ability to get in and out of bed, transfer on and off various surfaces around your home and in and out of your car. We will also practice walking in your home, outdoors and in more complex environments to get you safer at home and more comfortable walking within your community.

• Strength and Flexibility: I will teach you exercises to improve the muscles that have become weaker. Most of these exercises will incorporate whole body functional movements that will also help make your mobility and activities of daily living feel easier. I will also teach you safe stretching exercises to address any impairments in flexibility you may have developed during your hospital stay or as a result of prolonged bedrest.

• Breathing, Pacing and Energy Conservation: To improve your ability to breathe comfortably, I will teach you specific exercises that will strengthen the muscles involved with the breath cycle like the diaphragm and the intercostals. I will also teach you ways you can pace yourself when performing self-care and household activities and coach you in ways you can save your energy for things you really need it for. If you have come home using oxygen, I will work with you to wean off, if approved by your doctor, and if not, can teach you how to manage your oxygen equipment and oxygen needs ongoing.

• Fall Prevention and Safety Awareness: By working on your balance and ability to use your balance reactions, I will help you prevent losses of balance, and teach you how to respond quickly if you do experience any. We will talk also about safety awareness; I will make recommendations to improve your safety at home and when you go out and about in the community.

• Aerobic Capacity and Activity Tolerance: While keeping a careful eye on your vital signs and response to activity, I will help you improve your endurance in safe and comfortable ways. It may start as small as laps around the house, but I will help you progress over time, with a goal of getting you back to doing everything you were doing before.

• Home Exercise Program and Discharge Planning: While we will work together on these areas during your Physical Therapy sessions, I will also be giving you work to do on your own. This will likely be a mix of walking, strengthening, stretching and balance activities and will be scaled to what you can do right now, then progressed as you can do more. When we finish with our course of therapy, I will make sure you have a program you can continue with on your own, or we can continue to work together on a Wellness basis ongoing.

Click here to learn more about our HAE/PT Covid-19 Action plan for infection control and patient safety.

If you have experienced Covid-19, but still don’t feel back to normal, please call or email to set up a phone consult or in-person evaluation so I can help you get better.

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