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.