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.

Core Values

I attended a webinar last night the speaker asked us to identify our core values. What I found particularly interesting, is she specified that our core values should be both relevant to our personal lives and our business practices, because contrary to popular belief that you should keep your professional and personal life separate, a business can be most successful and fulfilling when these values align. As an independent practitioner, I found this concept resonated with me longer, as one of the things I value most so far about running my own practice is that I get to do things MY way. While I started HAE/PT simply as a way to be able to continue to work while meeting the unusual demands I now face at home due to the pandemic, it has transformed into something else entirely. It has given me an opportunity to to use my skills and experience in the best way I know how to help my patients in more meaningful ways. In thinking about it in this light, of course my personal core values should line up with my professional ones, and I can see how making these a regular part of the way I do my business will be the best path to success.

The core values, and the values I strive to live my life by and design my business around, are Strength, Support and Stability.

Strength:

I’ve always found myself striving to be strong. As a person, in my athletic pursuits as a swimmer and as a physical therapy clinician. Strength fosters resilience. When life becomes challenging, physically or emotionally, it is your strength that helps you remain resolute, that helps you achieve your goals and remain whole when you emerge on the other side. This is a value I work on daily in myself. It is an attribute I work on at each visit with my patients. And it is a value I wish for as I develop my business.

Support:

I’ve been in the ‘helping’ field as long as I can remember. My first job was a mother’s helper when I was somewhere around nine or ten. I started volunteering at eleven as a swim teacher for kids with disabilities. I continued in this role until I left for college. I worked at various camps and recreation programs for people with disabilities from my teens into my early twenties and when it came time to choose a career, it felt like a given to make a choice within the helping professions. There certainly weren’t any other careers that piqued my interest, and the only jobs that felt worthwhile to pursue were ones that would allow me to support other people. I strive to support my friends and family when they struggle, and I feel like being able to support my patients as they recover from illness and injuries is best part of my job. In opening my own practice, I have given myself the flexibility to expand the ways I support my patients. I have developed programing to support patients before, during and after physical recoveries and under a greater umbrella of health and wellness, and can now provide support during my visits without the constrains of productivity standards and other factors that limit how I choose to spend my time.

Stability:

Stability is successful maintenance of balance. Stability has far reaching implications in all areas of health - mental, physical, emotional and spiritual. While some people yearn for freedom, flexibility, or adventure, and while I also value all of those things, I believe that you can only truly grow when you have a stable base to keep you grounded. I’ve always been drawn to images of trees with giant sprawling roots, and wear a necklace each day with that depicts a tree of life, embellished with my children’s initials. I feel most at peace in the woods, among tall trees, in fresh air, on a clear fall day. While I can’t completely put into words how why I feel this way, I can tell you how it makes me feel. It makes me feel calm. It makes me feel like I can see the ‘forest for the trees’ - it helps me put my problems in perspective and see my world on a larger scale. When I’m stressed, or overwhelmed, I can take a walk in the woods and emerge feeling renewed and optimistic. While I don’t consider myself spiritual, per say, there is a passage that always catches my eye during the high holidays each year. Paraphrased, it reads:

“Will you be troubled every passing wind or be the calm within the storm?”

I strive to live my life as the calm within the storm - and want the very same for my patients. I want for them to experience stability in their health by providing them with an education beyond what a physical typical therapist may provide. I want them to be stable, literally, so they can avoid falls and remain free from injury. I want to be able to support each of them, to help them develop the strength and the stability they need to age successfully. I believe these values, my core values, are what makes HAE/PT special and I look forward to sharing them with you.

STRESS!!! Three Easy Changes You Can Make Today to Decrease your Stress and Improve Your Health

Anyone out there feeling extra stressed lately? No? Just me? Great…

In reality, I think I’d be hard pressed to find someone who hasn’t been unusually stressed out this year. 2020 has been a veritable buffet of stressors - there’s been something for absolutely everybody. Job insecurity? Check. Overworked and underprotected? Check. Fear for your children? Check. Fear for your aging parents? Check. Fear of death or disability from a mysterious illness no one fully understands that is spreading like wildfire through the world? CHECK!  Loneliness, isolation or stuck in the house with your entire family for months on end? Check, check and check. For even the most stoic of individuals, 2020 has shaken us to our core, and more than likely, given each of us more than our fair share of things to worry about. 

Stress is a fact of life. In fact, some stress is actually helpful. Our bodies are designed to respond to stress in a way that keeps us safe in the presence of impending threat or danger. But while the experience of stress is natural and unavoidable, stress is meant to be experienced in the acute state: ‘Oh, is that a bear? I better prepare to run. Body: Send blood to my extremities, shut down my immune system and digestion. Get my heart pumping and let’s get some extra glucose circulating so I can move even faster.’ However, the body is not designed to react in an adaptive way to chronic stress. All the physiologic reactions to stress (increased cortisol, glucose and adrenaline release) act to shunt resources away from non-essential functions like the immune and digestive systems, to redirect the body’s resources to systems involved in response to the present physical threat. The cardiorespiratory system revs up, increasing the heart rate to pump more blood into circulation and triggers you to breathe faster to increase oxygen uptake to respond to increased energy demands. Blood (and the oxygen and glucose circulating within the blood) is sent to the extremities and large muscle groups to prepare to run or fight. While these physiologic reactions are super helpful when you’re face to face with a bear, they can be quite maladaptive and destructive to your body when they don’t shut off after the source of stress has been resolved (like in response to chronic anxiety) - or in the case of 2020, if the stressors just keep coming. 

Exposure to chronic stress results in an increased state of systemic inflammation. And again, while inflammation can be a good thing (it is how we heal from a cut or virus or other invading pathogen), chronic inflammation is associated with nothing but bad outcomes. Chronic systemic inflammation has been linked to increase risk of cardiovascular disease, metabolic syndrome, diabetes and cancer. It is associated with the development of arthritis, Alzheimer’s, IBS and a host of other bodily dysfunctions. It is one of the primary theories linked to aging in general. And also, it makes you feel like crap. Chronic inflammation increases aches and pains, disrupts your sleep and increases anxiety and depression. So, if you haven’t been feeling yourself this year, you can probably chalk it up to chronic stress, systemic inflammation and the fact that your entire life and physiologic sense of homeostasis is TOTALLY OUT OF WHACK. 

Now, (and I say this with total lack of judgement because I 100% fall into this camp) some of us think that ‘we can handle it’ or that living a busy, stressful life is simply your status quo. While this may be true, this doesn’t mean your body is handling it any different then the rest of us frazzled, stressed out hot-messes (I also fall into this camp sometimes, too. Lucky me.) Whether you’ve got your make-up on, kids out the door (or at their zooms) and to-do list half finished by 7am, or you’re simply struggling to find the motivation to pour a cup of coffee and deal with the mess you’ve left from the night before, under the surface, we are all the same. When we don’t address how we respond to stress, our body experiences inflammation. No matter what. And as I briefly explained before, inflammation causes disease and dysfunction. So what do we do about this? How do we stop the cycle?

Personally, (and I’m writing this partly to give myself a concrete stress-reduction plan) I suggest trying to reduce stress in two ways. First, I think it is critical to find ways to interrupt the stress-response cycle. This requires two steps - learning to identify when you are experiencing stress, and making the choice, then and there, to ‘change the story’. Second, it is important to minimize the state of systemic inflammation throughout your body, not only to promote improved health, but also to set yourself up to better respond to stress in the first place.

Interrupting the stress-response cycle:

The first step in interrupting the stress-response cycle is to identify that you’ve begun to feel a reaction to stress. Note that I didn’t say identify the stress. The stressor itself is immaterial, it doesn’t matter if it’s a bear or a work deadline. Your body responds in the same exact way (though in variable degrees of severity). Try to notice next time you encounter a stressor what happens in your body. Do you get tense and find your shoulders riding up to your ears? Does your heart race? Do you get a headache or experience nausea? Some people get strong somatic responses - increased heart rate, flushing, muscle tension, headaches or other bodily responses. Other people (myself included) experience more emotional responses. You may feel angry, overwhelmed, irritated or worried. Try to make a list of your specific stress responses and then try to be mindful of these throughout the day. The first step in interrupting the stress-response cycle is simply identifying when you are experiencing it. 

The second step is to change the story. In my experience, this is the most helpful thing you can do right now to reduce the effect of stress on your body. By consciously changing the way you react to the stressor, you change the way your body perceives it. This is the key to stopping the cascade of the physiological responses that lead to systemic inflammation and the physical effects of stress. I learned to use this technique when I experienced sudden onset tinnitus last year. Everytime my ears would start to ring, I’d panic. The anxiety and panic would worsen the experience of the tinnitus, and the worsening of tinnitus would increase the feelings of anxiety. See the problem here? The key to curbing my tinnitus was not getting rid of the stressor (as often, we can’t), but changing my reaction to it. When I would notice the ringing, I taught myself to stop and listen to it. I’d simply identify it for what it was, literally tell myself this is a symptom, not a crisis. This is a sound, not a bear. Then, I’d take a few minutes to listen to the ringing while taking slow deep breaths. Within a few days of practicing this behavior, the ringing didn’t trigger the panic response anymore, and eventually, the tinnitus improved. Even though I still am aware of the tinnitus at times,  it no longer initiates the stress, panic, inflammatory cycle for me, it’s just simply ‘there.’

You can adopt this two-step stress reduction plan to address any stress you encounter. Whether it’s pain, background noise, or demanding coworkers or children - when you identify the onset of the physical effects of stress, stop. Stop and identify the stress for what it is and remind yourself this is not a crisis, or a threat or an oncoming train. Then, take whatever actions best help you retrain your body to enter a state of calm, instead of a state of fight or flight.  If the deep breathing works, great. If you respond well to meditation, use that. Take a walk, go outside, read a book, write in your journal. Whatever you associate with calm, substitute that behavior for your instinctual response to the stressor. It takes practice, but your body will adapt and you can extinguish this response, despite how automatic it may initially be.

Decreasing systemic inflammation: 

Lastly, find ways to lower your systemic inflammation. According to the American College of Sports Medicine, there are four methods to decrease systemic inflammation. First is to take anti inflammatory medications. Second is to ingest antioxidant foods and supplements. Third is by caloric restriction. And the fourth is to exercise. Guess which is the most effective? Exercise. No joke. How great is that? The most effective solution to reduce inflammation is something you can do on your own, for free, right now. It doesn’t even need to be aggressive exercise! Low impact steady state cardio has been shown to reduce cortisol levels and is great for stress-reduction. More moderately intense exercise has even greater benefits on your mental and physical health. Effects start right after you exercise and last hours, and are cumulative over time. There is literally no downside to making exercise part of your regular routine. There is also substantial evidence there are benefits in following an anti-inflammatory diet (like the Medeterranean diet), getting adequate sleep and practicing habits like gratitude, yoga and other mindset-shifting activities daily. You don’t need to follow a guru or pay thousands to a health coach to get in these habits either. Just sit down, in the morning, and try to write a few things you’re grateful for. Make time to exercise. Drink plenty of water. Go to sleep on-time. 

So, am I writing about this because I am a stress-management expert? No. I’m writing this because I’m a frazzled, stressed out control-aholic trying to manage my home, my children, my career and my life in the middle of a dumpster fire of a year. I’ve turned to my vices more often than I’d like to admit, found myself grumpy, irritable, achy and run down and I know perfectly well that this is because I’ve been letting my reaction to stress run the show, instead of using these strategies to change the story. 

I hope you find this information useful and these strategies helpful. Not only do I find that these techniques help me, but these are skills I teach to my patients who struggle with pain management and anxiety related to physical dysfunction and disability. Of course, my advice does not take the place of the advice of your doctor or other clinical professional, and if you feel like your level of stress is unmanageable, please reach out to those individuals for help. And if you see me somewhere staring off into space taking nice slow breaths, now you know why:)

#justtryingtokeepmyishtogetheroverhere