My COPD notes

MY COPD NOTES
INTRODUCTION
1. PULMONARY REHABILITATION
2. TOWARDS MORE EFFECTIVE BREATHING
3. LUNG VOLUME REDUCTION USING ZEPHYR VALVES. MY EXPERIENCE AS A
PATIENT
4. ONE YEAR ON
5. ABOUT A SEMINAR AT LEEDS – MINIMUM INVASIVE TECHNIQUES FOR
EMPHYSEMA
6. AN EXPLANATION OF COLLATERAL VENTILATION
7. A STRATEGY FOR DEALING WITH STRESS
8. USEFULL LINKS
INTRODUCTION
About a year ago (time of writing, September 2013), I was asked respond to a question that
someone had raised on the British Lung Foundation Blog about valves being used in lungs. I was
asked because I was a recipient of this operation and had a really good result from it. I got a really
positive response to that first article, and that encouraged me to follow up with some more, all of
which have been well received. From the comments my articles generated, and questions that others
have put on the blog, I can only surmise that there is a void out there in the knowledge about COPD
and other lung diseases in general, and particularly about advanced treatments that are available. I
find very disappointing the implication that so many GP’s and specialist respiratory nurses don’t
know, or won’t admit there are advanced treatments and strategies available. Another aspect of this
situation that that is below what consider to be an acceptable standard is the fact that so many
doctors prescribe drugs without ensuring that the patient knows how and when to take them, and in
many cases omits to say what the drugs are supposed to do!
In an attempt to cover some of these shortcomings, I have decided to collect the various articles that
I have written, and put them into a booklet to be used as an education resource for patients
approaching the more advanced stages of lung disease. Prior to my contributions to the BLF Blog, I
had written an article about Pulmonary Rehabilitation (PR) for a friend to include in his blog about
living with COPD. He edited it fairly extensively to fit his style of writing for his blog while
keeping the essence of what I was trying to get across. I’ve included that article as PR is so
important for keeping fit and an excellent opportunity for patients to be educated about the
condition and how to live with it.
John Ratcliffe
September 2013
Pulmonary Rehabilitation.
The following is an account of Pulmonary Rehabilitation as seen through the eyes of John Ratcliffe.
WHAT IS IT?
A system of exercises aimed at fairly severely disabled people with the intention of increasing
fitness levels for a variety of reasons. These can vary from preparation for or recovery from a
serious operation, to trying to establish a lower demand at a personal level for certain drugs, or to
enable the person to continue to be able to live at home. There are probably as many reasons for
pulmonary ‘rehab’ as there are people doing it.
JOHNS EXPERIENCE OF IT
My local consultant who is managing my case, after a series of x-rays and MRI scans, and several
other tests, thought I might be a suitable candidate for a lung volume reduction operation. A
consultation session was set up with a more senior consultant surgeon at which it emerged that the
damage to my lungs was localised in such a way as to make me a good candidate for lung reduction.
BUT.. Against that, the consultant was of the opinion that my fitness level was so low that surviving
the operation was not likely because of low resilience and energy reserves. He refused to take me
on, but said, ‘Go away and come back a lot fitter and I’ll reconsider.’
That concentrated my mind somewhat. I had heard that my respiratory nurse specialist was involved
in trying to get a pilot pulmonary rehabilitation course going in my area. I managed to get on it by
begging and promising to do my best. It should be noted that there is a selection process to be gone
through to get on Pulmonary Rehabilitation Courses, and not everyone is suitable. For example,
some conditions such as unstable angina which coexist with COPD make it an unsuitable
intervention for all patients. In all cases where there are other conditions at play alongside COPD,
the health professionals have to make judgement calls on the suitability for inclusion on a course.
The course was set to run at a my local community hospital, on Tuesdays and Thursdays each week
for 8 weeks. Tuesdays were just exercise sessions to run from 10.30am till noon. Thursdays were
exercises in the morning, then a lunch, followed by one or two presentations on subjects relative to
the diseases/disorders that members of the group suffered..
The exercises were set up as a circuit of exercises using light weight equipment targeted towards
specific muscle groups in a way that after one set was used, it was rested while the next group got
attention. Emphasis was slightly biased towards chest and upper body groups over leg and lower
body so as not to pull O2 levels down too much. The circuit consisted of 16 stations which each
have a specific exercise, some of them involve a piece of equipment, others don’t.
Before starting our exercise session, readings were taken to note blood pressure, heart rate, and O2
saturation. We also had to declare how we felt in terms of breathlessness, and general well being,
any major changes in meds, or anything else that might effect our performance. We were being
monitored by quite a gang of people; the two local respiratory nurse specialists, a physiotherapist
training instructor (known as a TI) designated to be in charge of the group by the local Area Health
Authority (they provided funding for the trial), a occupational therapist with a good line in
relaxation techniques that proved to be valuable for calming down at the end of the session. We also
had a junior nursing auxiliary who was good at supporting one or two of of more unsteady
members. Regular visitors were the District Nurses when they had time. We all noted our
performance in terms of how many repetitions we did on each exercise, during a standard exercise
period of 2 minutes. Prior to each period, sats and pulse rate are measured and noted, so that
recovery times can be determined. Those who may have a particular risk will perhaps also have
blood pressure monitored regularly through the session. All in all, it became easy to see how our
fitness levels were improving week by week, and we could see when a set-back such as a minor
infection happened.
Thursday sessions after lunch (sandwiches and hot drinks provided by the hospital catering staff)
were an excellent addition. Talks and discussion sessions about many subjects ranging from the
medical aspects of COPD and related diseases to diet and nutrition to benefits and care options
available. We also had talks by people who had had COPD for a long time and how they managed
to cope, and the interactions between them and their carers. A Pharmacist also gave us a talk about
the drugs available and their delivery systems and the constraints each had in terms of the
progression of COPD. (In my opinion, this topic could have been explored in much greater detail.
The one hour allocated only touched very lightly on the subject, and most of us already had
knowledge of the subject to that level from our own experience.) The last session included a talk by
our local consultant specialist. Throughout the previous weeks of the course he was being briefed
by the respiratory nurse specialists about our progress. He was immensely pleased with the progress
we had made, and could see benefits gained not only in the increased mobility and fitness of most
of us, but he also explained how it all translated into cost savings for the NHS, largely in terms of
reduced hospital admissions,and after-care.
After the course, I had a couple of conversations with the respiratory nurse specialists about how
things were going forward towards the courses becoming a regular part of the treatment and therapy
offered to COPD patients. Several side issues came up. One was about the amount of monitoring
being done through the exercise sessions, some people (staff and administrators) wondered if the
monitoring was intense enough to become thought of as intrusive. My reply to this was that most of
us on the course were in such bad condition to start with, that not to monitor as was done would
have been risky, indeed, I don’t think it possible to have too much monitoring. Another issue was
the involvement of the district nurses and others who were not formally on the staff allocated for the
trial. There again, I see no problem so long as their normal duties were not neglected. Seeing what
was going on within the course, particularly getting involved with the monitoring gave them
insights into the care and needs of people that they may come into contact with in later months or
even years. Benefits all round as I see it.
THE FUTURE
Perhaps progress has been made. The British Lung Foundation is going to try and establish a
‘Breathe Easy’ support group at another of our local community hospitals. There is to be a
preliminary meeting I believe to establish how these meetings might be run. It is possible that some
of the administration staff from the Local Area Health Authority may be there to observe. I do hope
so. One of the local respiratory nurse specialists has asked myself and my wife to attend as we have
the experience of the previous course to call upon. I made the point that a meeting that was just talk
(as I believe most Breathe Easy groups seem to be), it is then just a social occasion. To give it some
real meaning and give it a real purpose then try and combine the meeting with an exercise session. I
would certainly see more point to making the journey. Real benefits could come from this approach.
For instance, members fitness levels would be established and could be tracked largely by the
person them self. The monitoring involved may pick up issues with the members’ health such as
blood pressure, weight fluctuation, incorrect use of specialist equipment like oxygen bottles, or
posture problems to do with certain movements or lifting. If some personnel from the Local Area
Health Authority do attend, then perhaps I can make these points to them in person, and challenge
them to show where they are not cost effective.
A future to look forward to? I do hope so
TOWARDS MORE EFFECTIVE BREATHING
First of all, what is ‘Breathing’? This is the means evolved by nature for animals to facilitate the
exchange between blood and air primarily of Oxygen and Carbon Dioxide. The lung developed in
early animals to do this job in a protected part of the body. The membranes and blood vessels
associated with the gas exchange are delicate. Another major function of breathing is controlling
how acid (PH level) our bodies are.
In a fit healthy person the lungs have the ability to service the body in extreme activity, while in
very challenging environments, such high altitude, bad weather, and bad air conditions caused by
chemical fumes, smoke or poor ventilation. At rest, this fit healthy person breathes very slowly, and
shallowly. This is as much as they need to do to maintain the body. They are probably using
between five and ten per cent of their lung capacity.
When a person’s lungs start to get damaged, whether through smoking, environmental conditions,
or illness, the reduction in capacity does not really get noticed until about fifty per cent of that
capacity has been lost. As we continue to lose capacity, the importance of breathing correctly so as
to make the most of what we have becomes more and more important.
When we consider how we breathe, think about posture. If we are sat, sagging forward with a curled
spine, then we are restricting our lungs ourselves, the bottom part of both lungs being unable to
expand, and our diaphragm cannot operate properly. When we hold our bodies straight,whether sat
or stood, with an erect spine, then the lungs and diaphragm have room to function.
The next thing to consider is that if we are not breathing, and are relaxed in an upright attitude, then
the neutral position of our lungs is that they are between half and three quarters full. Then it stands
to reason that the easiest first movement is to breathe out. So when in difficulty with breathing as
we get with COPD, we need initially to concentrate on breathing out, to make room for a useful
inward breath.
Now let us consider how we breathe in. When all is well, we are relaxed, not demanding much
oxygen, then we tend to breathe gently in and out through the mouth. This just uses the very top
part of the lungs, using chest expansion by the ribs and associated muscles. This is not very
efficient, but for most people at rest, it doesn’t need to be. Next, let us think about breathing gently
in through the nose and out through the mouth. This brings more of the lungs into play, and is
starting to get the diaphragm working. Better than mouth breathing, but when those of us with
severe COPD get into trouble, it is not enough to get sufficient oxygen into the blood stream, and
carbon dioxide out. To do that we need to breathe out through pursed lips. Think of trying to
whistle. Then shut the mouth and breathe in through the nose. Then out again through pursed lips.
Sit up straight. Shut the mouth. Breathe in through the nose. Practice this when we feel good. You
can feel the diaphragm working. Breathe long, and deep and slow. Those of us with a pulse
oximeter, if we put it on before practicing deep breathing, will see that our resting O2 level is
probably low to mid nineties. Now start deep breathing, it will take about a dozen or maybe as
many as twenty breaths to get full use of the lungs. Watch the meter, over a period of a few minutes,
you should see an increase of three or four per cent. Keep it up for ten minutes or so, and we feel
good, but this is taking effort. It is difficult to sustain for long periods, and concentration will start
to lapse. So doing it all the time is not what we need, neither is it natural. But for those of us with
limited lung capacity, it is a good idea to practice the technique when we are well so that when we
get breathless and struggle, we have something to help get us back on an even keel. Most of the
time, we have a wife, husband, partner or carer near us. If they know the technique, when our
breathing goes wrong, they will have something to help us with, getting us sat, reminding us to
breathe in through the nose, blow out through the mouth, watching us, telling us. When we panic, it
is difficult to think right, and we tend naturally to gasp through the mouth, and we need reminding
of the best way. Be tolerant of those telling us, they are trying to help us. If you are in the carer role,
be tolerant of your patient, in a breathlessness event, they are going through a difficult time.
While we are doing our good breathing technique, what is going on inside our lungs? Probably not
quite what you think. In the middle of a deep breathing practice session, each breath in takes about
four seconds, and a breath out about the same or a second or two longer. The diaphragm is working
properly. All is good. As we breathe in, there is some chest expansion and the diaphragm pulls
downwards, making the lungs expand and lowering the pressure in them, causing air to enter from
the atmosphere. This is important, the lowering of pressure, I mean. Because of the lower pressure,
carbon dioxide is encouraged to leave the blood stream, pass through the membranes into the
alveoli (the small sacs at the ends of the smallest airways where the gas exchange takes place).
When we breathe out, the chest contracts, and the diaphragm pushes up to make the lungs empty.
The pressure inside the lungs increases, especially if we use pursed lips to cause a constriction. This
is how we blow balloons up. Inside our lungs, the increased pressure pushes oxygen through the
membranes to be taken up by the blood stream. This is not how we normally associate our breathing
with our lungs and blood stream exchanging oxygen and carbon dioxide. Usually we think of it as
the other way around.
When we get a problem with breathing, it is usually because our technique falls apart, the
diaphragm not working properly being the usual reason. How can we help ourselves avoid
emergency situations due to breathing. Be self aware. When we first sense that something is going
wrong. Stop. Sit. Try and relax. When you can, if need be, move to where there is fresh air. Use this
deep breathing technique. Use your inhalers. If you don’t regain control quickly, get someone to call
an ambulance.
When ambulance staff or paramedics attend someone with breathing difficulties, their standard
procedure is to first of all get oxygen going into the patient, then to get a nebuliser going.
The nebuliser will normally be loaded with salbutamol (Ventolin) and Atrovent (Ipratropium
Bromide). Salbutamol works by acting on receptors in the lungs called beta 2 receptors. When
salbutamol stimulates these receptors it causes the muscles in the airways to relax. This allows the
airways to open. In conditions where there is narrowing of the airways, such as asthma or chronic
obstructive pulmonary disease (COPD, eg emphysema and chronic bronchitis), it is difficult for air
to get in and out of the lungs. By opening the airways, salbutamol makes it easier to breathe.
Ipratropium works in the lungs, where it blocks other receptors called muscarinic receptors that are
found on the muscle surrounding the airways. A natural chemical called acetylcholine normally acts
on these receptors, causing the muscle in the airways to contract and the airways to narrow.
Ipratropium blocks the muscarinic receptors in the lungs and therefore stops the action of
acetylcholine on them. This allows the muscle around the airways to relax and the airways to open.
This makes it easier for people with asthma or COPD to breathe. The combined action gives a rapid
response that quickly leads to easier breathing. With the return to more normal breathing, relief
soon brings a feeling of being back in control and you become calmer.
After you are stabilised, you will probably be taken to hospital for tests and observation. At the
hospital if infection is found you will be given appropriate antibiotics, and a drug regime
established or your current one reviewed. The most common result is you leave with a bag full of
drugs including Ventolin, Spiriva, Uniphylin tablets, and others to deal with side effects. The
important one with regard to the subject of this article is Spiriva. This is drug is closely similar to
Atrovent being intended to help your body maintain good control of your breathing. The difference
is that Spiriva is intended to be a one dose daily drug to give 24 hour cover, whereas Atrovent is
quick acting but short lived in the body. If you have Spiriva prescribed, take it, once daily. Do not
take Spiriva and Atrovent on the same day, except under medical supervision.
I hope this article help you as patients or maybe as carers to understand what goes on when we
breathe, and to be able to help ourselves or our charges when it goes wrong.
LUNG VOLUME REDUCTION USING ZEPHYR VALVES. MY EXPERIENCE AS A
PATIENT
The following is a transcript of a presentation that I gave at a seminar at The University of
Wales Hospital, Heath Park, Cardiff. This was held on November 13th 2012.
THANKS TO MY CONSULTANT AND THE TEAM
I would like to start by expressing my gratitude to my consultant and the team for the skill and
professionalism shown when performing the lung procedure on me, and in the aftercare shown in
the difficult time I had afterwards. Their confidence and cheerful attitude helped me no end. Thank
you all.
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GIFT OF TIME
This operation that I’ve had, the fitting of pulmonary valves into the upper lobe of my right lung,
has been of immense benefit to me, and my wife. Since the operation, my wife has told me that in
the opinion of various doctors who have seen me at Bronglais Hospital, Aberystwyth, that my life
expectancy was short. That was two years ago. Obviously I’m still here, and my opinion is that it is
all because of this operation. So what has changed? No diseased tissue was removed, no good tissue
was added. I am not a professional expert in these matters, but I have read quite a bit about lung
disease and various techniques and procedures used to try to bring about improvement in the lives
of those who suffer. It is my opinion that the procedure alters the the areas of lung tissue in play,
increasing the effectiveness of what good tissue we have. I think this is the best option we have
now, and will probably be so until someone gets lung tissue to repair or regenerate without
producing scar tissue. I hope that success in this is not far away. I live in hope that I will survive
until that success can be brought into general use, and applied to me. Until that happens, I benefit
from the greatest gift that my consultant and the team could have given me. Time.
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DESCRIPTION OF MY CONDITION PRIOR TO OP
A person who has become a good friend over the last couple of years who also has COPD,
described the condition as “Death by chair”. Prior to the operation that definition fitted me to a tee. I
was on oxygen, needing about five litres per minute at rest. I was having difficulty walking more
than a few yards, and would then need several minutes to recover. Talking for any length of time
was impossible. I would regularly have episodes where my breathing technique would fall apart,
leaving me gasping, very short of breath, and close to panic. Luckily,my wife learned how to put
together a nubuliser, loading it with salbutamol and iprotropium bromide, driving it with O2 at six
litres per minute to get me back to a stable state. There were times I think when I must have
terrified her.
In that period, I was taking a large quantity of drugs that needed to be taken at various times
throughout the day, so much so that I needed a spreadsheet on the computer to keep track, and make
sure I was getting the right drugs at the right time, in the right quantities. We also had to be aware of
possible conflicts between certain drugs, for example certain antibiotics and multivitamin tablets
containing trace metals. My life could only be described as “small”, and reducing.
About a year and a half prior to my op, my local consultant referred me to see a surgeon in Cardiff,
with a view to having Lung Reduction Surgery, involving the surgical removal of the most damaged
parts one or both lungs. At the end of the interview, he turned me down saying I was nowhere near
fit enough. He was quite sure that I would not survive an operation of that magnitude. He sent me
away saying that if I got myself fitter he would look at me again. I managed, with the help of my
respiratory nurse, to get onto a pilot pulmonary rehabilitation course that was being held at my local
community hospital. I considered that course to be a tremendous success. We had a series of what
for most people would have been very gentle exercises. For those of us who were participating, they
were stretching our abilities quite nicely. We also had various health professionals giving relevant
talks and holding discussion sessions. I see these as essential for patients in my situation, because if
you know what the problem is, then you can solve it, or at least reduce the effects. It is also
important that we don’t feel alone. COPD, because it makes us homebound, isolates us, and leaves
us lonely. These courses give much needed companionship. Unfortunately, at the end of that course
I was taken ill I think with a virus infection, that set me back.
With the knowledge gained from the rehabilitation course, and from ambulance paramedics, I have
learned to manage the COPD fairly effectively, in fact, enough to keep myself out of hospital even
though I was having breathlessness attacks quite frequently. I also keep antibiotics at home so that I
can start a course immediately I feel an infection starting, along with increasing my doses of
Prednisolone. My personal opinion about the year or so prior to my operation is that I was suffering
from a low level virus infection that did not show on any of the tests done on sputum or blood
samples taken through that period. It did seem to clear itself quite suddenly about two months
before the op. I just woke one morning feeling a lot better than when I went to sleep. I feel lucky
that it has not returned.
I am still not sure who referred me to my consultant but she saw me, and very kindly took me on
her list.
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EXPERIENCES IN HEATH HOSPITAL, CARDIFF REGARDING AFTER EFFECTS
When I awoke in the recovery room after the operation, I was told the operation had been
unexpectedly successful. Apparently, with most patients, the collapse of the part of the lung
operated on usually takes several days. In my case, it was pretty much complete by the time I came
out of the anaesthetic. As a result of this rapid reaction, I then suffered a pneumothorax, with a tear
in the upper lobe of the right lung. A chest drain was fitted, and I was hooked up to suction. I think
it was expected that the lung would start to heal over the next few days. This proved not to be the
case. At that time I was taking large doses of steroids, and using a nebuliser four or five times a day.
This, I was told, stopped the healing process. X-ray images taken over the next few days showed
that when off suction my lung fell away from the chest wall and my breathing became severely
restricted. While this setback was occurring, I was finding out the benefits of the operation. An
exercise bike was brought to my bedside, where the oxygen and suction could reach, and I found
that I was capable of doing what I considered then to be substantial sessions on it, five or six
minutes at a steady pace. For me that was a considerable achievement, bearing in mind that pre-op a
ten yard walk even with the benefit of O2 at 6 lit/min would leave me gasping and distressed for
several minutes.
About a week after the operation, X-rays showed that as well as no improvement in the
pneumothorax, the affected area of the chest cavity had migrated, meaning the chest drain was now
in the wrong place. A second drain was inserted, and after x-ray examination adjusted for best
placement. Two days later(?), as the pneumothorax was still not healing, it was decided to give my
chest a Doxycycline wash-out. Not a pleasant experience. Also it did not kick-start the healing
process. A second wash-out was tried a week later, successful result this time. I should mention here
that between the two wash-outs, after several requests by my consultant I had a consultation with a
steroid specialist. This consult resulted in a drastic reduction the amount of drugs I was taking.
Some being removed altogether, others being reduced. I believe this review of drugs was at least
helpful, if not being a major factor, in the success of the second Doxycycline wash-out. Several
days after the successful wash-out, after x-rays showed favourable improvement the drain was
removed. A few days later, when healing could be seen to be well established, I was discharged. An
expected stay in hospital of about eight to ten days actually turned out to be the whole of February.
Was it worth it? Absolutely! Would I go through it again, with all the complications? Definitely!
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DESCRIPTION OF MY CONDITION AND PROGRESS POST OP
The success of my operation can be seen in a number of different ways. Physically, what happened?
The placement of the valves caused a deliberate collapse of part of the upper lobe of my right lung.
Previously, the lung was hanging so low that the bottom of the lung was sitting on my diaphragm to
the extent that the lower part of the lung was compressed and not able to work very well. Post-op,
the lung is now hanging free above the diaphragm. The bottom part of the lung is now performing
as it should, and as the condition of the membranes is far better than the closed off section, my
breathing is now giving far better gas exchange. This is shown by the different results of tests pre
and post-op. An FEV1 test done in November 2011 gave a ratio of 16%. Another test done by the
same technician on similar equipment in early May 2012 gave a ratio of 31%. Almost 100%
improvement!! I think that since then further improvement has happened as the bottom part of the
lung cleared of rubbish and simply got used to being used again. Although I have not had
measurements done lately, I certainly feel that more improvement has taken place. Another major
benefit of lifting the lung free of the diaphragm is that the sheer effort of simply breathing has been
reduced from the major expenditure of energy that it used to be, often without the spare capacity to
even be able to say more than a few words. Now I have to be told to ‘Shut up’. Benefits come with
costs. I have paid for this improvement by gaining about 40 pounds in weight.
Another major influence on my performance has been that I have had cataract removal operations
on both eyes in the last few months. This required several weeks of inactivity after each operation
while the eyes were in a very delicate condition. Now that the eyes are healed, I can start fitness
work again. In the period after the lung operation, but prior to first eye operation, I went through a
period of several months rehabilitation fitness therapy at our local community hospital where my
performance was documented. I think my consultant was pleased to see these when I visited for a
follow-up consult in May.
Before February, I was using oxygen all day at approximately 5 lit/min when at rest. After a small
exertion, such as a visit to the bathroom, I would often increase the O2 to eight or even ten lit/min
for five minutes or so, to effect recovery, such was the state of my health at that time. I still use
oxygen, and the devices that I use are generally set at 4 lit/min. It is worth noting however, that all
use nose cannula and my portable equipment have cons ervers fitted, so they only supply oxygen
when I take a breath through my nose. I am by nature a mouth breather so I am weaning myself off
oxygen gradually.
Drugs and the nebuliser. After a spell in hospital about two years ago, I realised that Spiriva
(Tiotropium Bromide, a 24hour controlled release drug), wasn’t giving me the supposed 24 hour
cover. In fact, I doubt I was even getting 16 hours. So I asked my GPs if I could try Atrovent
(Iprotropium Bromide) via nebuliser instead, as it was one of the drugs the paramedics used, being
fast acting and, for me convenient to use. The GPs agreed and I then used the Atrovent combined
with Ventolin (Salbutamol) several times a day. This was much more satisfactory for me, although it
added to the complications of taking my drugs. In fact, for 18 months prior to the lung operation, I
was taking such a drug load that I needed to record my usage on a spreadsheet to keep track. The
consult with the steroid specialist while at the Heath Hospital was very valuable in reducing this
drug load. After discharge from Cardiff, I found I was needing to use the nebuliser less and less, and
very quickly relegated it and its drugs to be used only when necessary. I gave up using it at the end
of May altogether, just using pocket inhalers only when required. Taking my drugs now is only
about four or five minutes twice a day, instead of half an hour or more up to five times a day. For
me, that adds up to an incredible change, apart from what the savings in drug costs must be for the
NHS.
A further measure of the success of this procedure for me is the fact that I have just returned from a
trip to the West Coast of the USA. San Francisco in fact. Just that I could even consider such a trip
is fine testament, but to achieve it? Well I can only say that in the most literal sense of the word;
WONDERFULL. Because this trip was really for my sister’s benefit (she got married for the first
time aged 60). We had over 20 of my relations there for the occasion. I had to endure shopping trips
of industrial proportions, whirlwind sight-seeing trips, and parties that seemed to go on for days. I
came through it all OK. In fact, I learned that my resilience is far higher than I appreciated. Other
people who are not used to making allowances for my needs unwittingly caused me to let the
battery on my O2 concentrator to run flat several times. This proved not to be such a big deal if I
could sit quietly and move slowly to somewhere I could get plugged in. I have to say that I did not
meet one unhelpful person in all the time we were in the USA.
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IMPORTANCE OF A REHABILITATION PROGRAMME BEFORE AND AFTER THE
OPERATION
As I mentioned earlier, a good friend of mine, who also has COPD, refers to the condition as ‘Death
by chair’. I have to say that I agree with that statement. Because we get so breathless so quickly, we
become very reluctant to be out of our chair and moving about. An extension of this is the way we
convert our favourite chair or desk or place at a table into a kind of nest where we organize our
small lives into a comfort zone where everything is within arms reach. This is a kind of protection,
because when you are ill, who wants to deliberately make themselves breathless? We always
remember the last exacerbation, where breathlessness leads to great discomfort and panic. This then
becomes a kind of death spiral. Movement hurts. Don’t move. As a consequence, our bodies
become more unfit, and to do simple things require more oxygen and energy than a fit person to
perform the same activity.
If a patient is to undergo any surgery, then it is obvious that a fit person has a better prognosis for
recovery than someone who is not fit. But simply saying ‘Get fit’ to a prospective patient is not
enough. Few enough fit people could put a fitness programme together, and COPD patients are
unlikely to be fit. There are problems in dealing with COPD sufferers, motivation, equipment,
which exercises are appropriate, how much to do, monitoring, and more. So organised exercise
programmes are essential. So is education in other matters related to COPD, and the situation
patients find themselves in. The structure of a well run course such as the one I experienced a
couple of years ago, gives confidence as well as fitness. I found the social aspect of the course to be
beneficial. As well as exercise sessions organised as circuit training, we had talks given by
pharmacists, dieticians, oxygen technicians, occupational therapists, and others.
The fitness training part of the course was supervised by a very experienced physiotherapy
technician with help from other interested healthcare professionals. They always tried to get a one
to one ratio enlisting the help of patient family members where possible. The exercises were two
minute sessions of gentle exercise where the number of repetitions was recorded, as well as
saturated O2 levels and degree of breathlessness. Over a period of several weeks, it became easy to
see where fitness was improving, and also where people had problems, for example if someone had
a small infection starting, that was otherwise unnoticed. Getting the patient used to this type of
programme before surgery has the benefit that after the operation, they are ready to go on getting
fitter, and indeed, should be keen to do so.
My thoughts about rehabilitation courses is that they should involve both pre-operative and postoperative
patients. This would help with confidence as pre-op patients see the success that post-op
patients are enjoying, while going on to higher fitness levels. I would like to see rehabilitation
courses become permanent features of selected local clinics. From my perspective, not to would be
such a waste.
——————————————————————
IMPORTANCE OF A REVIEW OF STEROIDS AND OTHER MEDICATIONS AT SUITABLE
INTERVALS
Earlier I mentioned that while at the Heath Hospital I had my medications reviewed by a steroid
specialist. This was the first time that my medicines had been comprehensively looked at in total.
Because the treatment and control of advanced or severe COPD involves the taking of so many
different drugs, it is understandable that not all doctors have the knowledge to work out the
interactions between them, in particular, the steroids. By definition, GPs, who do most of the
prescribing, have a general knowledge of drugs. Specialised knowledge would only come from the
experience gained by treating patients with specific problems, and where they take a particular
interest. So it should be no surprise to learn that after several years of adjustments to my drug
regime, things had got a bit out of hand.
The recommendations that were made included:
Reduce Seratide dosage by half. This drug has a ceiling beyond which there is no further benefit,
but side effects do continue to rise.
Cut Pulmicort altogether. The effect this drug has is more than adequately covered by other drugs
that I was taking.
Pleased that I was using nebulised Atrovent (Ipratropium Bromide) instead of Spiriva (Tiotropium
Bromide), because of cost and effectiveness.
Recommended weaning off Prednisolone asap down to bare maintenance level.
I must say here that I have reduced my drug intake considerably since the operation mainly by
cutting all nebulised drugs. I have used my nebuliser for three doses since May. That was because of
an infection, and that was more for comfort rather than desperate need. For Salbutamol and
Atrovent, I now rely on pocket inhalers, but don’t even use those very much.
One of the effects of prolonged use of steroids at high doses is the production of cataracts. Since the
lung operation, I have had cataracts removed from both eyes, with complete success if I might say.
Increased heart rate and blood pressure are problems that other people have suffered, luckily I have
not been adversely affected in these ways. Obviously, there are other side effects from these drugs,
but I personally have no experience of them.
——————————————————————
CONCLUSION – ENORMOUS BENEFIT OF OPERATION TO PATIENT
To conclude, I would like to emphasise just how important this operation has been for me. Before
the operation, I was having a breathlessness attacks at least once a week. These are distressing
events, often involving a certain amount of panic. My wife and I learned how to manage these by
using nebulised drugs driven by bottled oxygen. These events sometimes happened while out
shopping, we must have frightened a few bystanders. Perhaps worthy of note is how rarely people
offered assistance. Just to stand up from sitting in a chair was a huge effort. Walking more than a
few yards was impossible.
Since the operation, I have managed with, the help of my wife, to regain my life. I am now more
able to do shopping, visit places of interest, do some cooking. I am starting to think about driving
again. In short, life is getting better for me.
What do I want in the future? I want a method to be found to facilitate tissue regeneration in our
lungs, so scar tissue can be replaced with healthy membrane that can pass the required molecules in
and out of the body.
In the mean time, I am more than happy to have what I have, thanks to my consultant, and the team,
and all the other people that have helped, and that is time, hopefully for the future to happen in.
ONE YEAR ON
This article was written in February 2013, and published on the British Lung Foundation
Blog.
ONE YEAR ON
12 months ago, I had 3 valves inserted into my right lung, in the upper lobe. This lobe had such
severe damage from emphysema, that large cavities had formed where there should be alveoli,
along with scar tissue. This lobe was not doing very much to help my breathing, in fact, it was
hindering the process.
Let me explain. The lungs depend for a large part of their operation on the fact that good lung tissue
(alveoli and minor airways, and the blood vessels) are elastic. When good tissue gets damaged,
either it heals with a good repair, and all is well, or if the damage is not so easy then scar tissue will
form. Think of a cut on your skin, if the edges can be kept nicely together and clean, then the
chances are that the skin will repair with no sign of scarring, and soon there is nothing to show that
there was any damage. But if the cut was a bit deeper, or on a part of the skin where it is hard to
keep the edges together, or the cut becomes infected, then the chances are that the repair will
involve scar tissue. Scar tissue in lungs is bad news. Firstly, it is not very elastic, and that interferes
with the ability of the lung to expand and contract. This seriously affects airflow in and out of the
lung. Scar tissue does not pass gas. So this affects the flow of oxygen into the blood, and carbon
dioxide and water vapour out. Like I said, scar tissue is bad news. I sidetracked. Back to the
beginning…..
12 months ago, I had 3 valves inserted into my right lung, in the upper lobe. These caused a
substantial part of the upper lobe to collapse. Done on purpose. Crikey I hear some of you saying.
Why would you do that? I’ll explain. Your lungs sit inside your chest cavity, right? Wrong. It’s more
like they hang there stuck to the inside of your ribcage courtesy of a gooey, sticky, slippery fluid
stuff that sticks the outer membrane of your lungs to the inside your chest wall, while allowing them
to slide up ad down at the bottom while being fixed in place at the top. In fit healthy lungs, this
allows the diaphragm (mostly, the other bit is chest expansion) to drive breathing, by pushing the
lungs up and then pulling down. Operating the bellows. So what holds your lungs in their shape,
while they are getting pushed and pulled? The internal structure, that’s what. In your lungs, the air
enters via the major airways that divide and divide again and again until the tiniest branches end in
little sacs called the alveoli, where gas exchange takes place. Also within your lung are blood
vessels that also divide repeatedly until they are capillaries alongside the alveoli. Add into the mix
nerves that sense what is going on, and muscles that control how open or restricted the airways are,
and the nerves that control them. All of these various and different parts of the lung have one thing
in common, they are elastic. Taken all in all, this tangle of strands has an integrity that gives it
sufficient rigidity that without any outside influence, it will just hang there in the correct place. OK.
That’s a good lung. In good shape. In good condition……. Now damage it. Give it a series of
infections. Pollute the air going in with smoke, fumes from fires, fumes from chemical processes,
fumes from traffic, dust from concrete, coal, asbestos, flour. Now add in maybe the odd parasite.
That lot all conspires(?) over your lifetime to damage the internal structure of your lung. Good
tissue gets replaced with scarring. Sometimes, bits of your lung, after being stretched, don’t go
back. They have lost their elasticity. Also, a lot of your alveoli are so damaged, that they have
merged to form cavities. Your lungs sag because of the loss of internal strength and structure. They
now sit on your diaphragm like a pair of tired bags. Your breathing now becomes laboured. Every
time you breathe out, your diaphragm doesn’t just have to squeeze your lungs to push air out, it has
to lift a substantial part of the weight of your lungs. Add in the loss of tissue that can transfer gasses
in and out of the blood, you have lost a lot of your breathing capacity. Congratulations!!! You’ve got
Emphysema. COPD. Welcome to my world. Oops! Sidetracked again.
12 months ago, I had 3 valves inserted into my right lung, in the upper lobe. These caused a
substantial part of the upper lobe to collapse. This caused a reduction in the volume of the lung.
Knock on effect of this is that the depth (top to bottom) of the lung was reduced, allowing it once
again to hang above the diaphragm. In its proper place. Once again, the bottom lobe was hanging
free, instead of sitting on the diaphragm with maybe half of it squashed to the extent that it was
useless in that it could not even expand or contract through lack of room. So I now have a lung that
is in the right place. Add to that, I have had a chunk of my lung that wasn’t doing much, taken out
of service, by being sucked shut. At the bottom of my lung, that bit that was sat squashed on my
diaphragm is now working again. Not only that, but that bit is in far better condition than the bit that
is now not working. The good part of this episode is that my FEV1 prior to having the valves put in
was measured at 16% a few weeks before the op. Several weeks after the op, it was measured again
at 31%. Figure out for yourself if that measures up to success or not.
So now, where am I? I’ve got three valves implanted in my right lung. That right lung is now
hanging pretty much where it should, and generally working pretty good. I have had a fairly heavyduty
operation (the only other way to get this result would be to have a chunk of lung cut out),
without the trauma of major surgery, which I have been told several times, I would not likely have
survived. Score one major plus point for my consultants. I am still using oxygen most of the time,
but probably actually less than even I think, my oxygen is fed to me via nose cannula, and I often
find myself mouth breathing, so not taking all the extra oxygen after all. I notice this when I move
after sitting for a while. I am far from optimum. My breathing is better, yes. Because my right lung
now does NOT sit on my diaphragm, a lot of the sheer effort of breathing has been reduced. Since
the operation, I’ve put on weight, mostly, I think because of that reduced effort. If I stay on my feet
for a while, say 10 or 15 minutes, while cooking or making a sandwich, or doing something similar,
I will end up huffing and puffing a bit, and have to sit and take a few minutes to recover. But that is
not panic gasping like I would have been doing before the operation. If I would even have
attempted something like that. Without my wife doing just about everything for me for those several
years, where would I have ended up? OK, so I’m better, but not ‘well’. I have been dragged back
from the brink of death, but, metaphorically, I’m still on my knees, close to the edge, but
considerably safer. Drug use. Much reduced, and I feel better for it. I haven’t used my nebuliser
since I can’t remember when. Do the mental adding up yourself. Was it worth it? You answer.
OK. I had an operation. My breathing is better, my quality of life is MUCH better, my wife is
happier. But what has actually changed? I have still got all the same tissue in my body, no bad stuff
taken away, no good stuff added. Just a change of emphasis really. Different bits of one lung
working. With a big effect. But don’t get carried away. My left lung, don’t forget that, is still
hyperinflated. Actually, it’s more hyperinflated than before. With the right lung now hanging right,
trim and slim, it’s actually taking up less room, which means that having shoved the heart and some
other bits out of the way, the left lung has expanded a bit more. That’s right, my heart and the parts
of the digestive tract that pass through the chest have been pushed sideways by about 40mm and all
the associated blood vessel etc. I now get funny questions when I have scans and x-rays. I am also
just as susceptible to infections, they knock my capacity for doing anything right back, and I take so
long to recover from doing so little when I’ve got one. So I do what most of you who know do, get
on the antibiotics and up the steroids for a few days. As I said before, no bad tissue was taken away,
so any extra damage from infection erodes what bit of good tissue I’ve got left. I have become wary
of situations that I consider dangerous to me. Doctors’ surgeries and places where children collect.
So what have I really gained in all this? Several possible answers to this, but I think the most
relevant one has to be —- TIME. Without having had the valves fitted, I might still be here, but
much poorer in health, or I might not. 50/50 either way I reckon. This extra TIME is giving me
more time to annoy my missus, see the girls (children), grand children, and great grand children
(two or three, depending on the delivery system at two thirds the way though February). I also have
enough spare energy to take up a hobby! Just a bit each week. Large scale modelling of narrow
gauge railway stuff. In the garden.
The extra energy means I can do a bit of cooking, and occasionally baking. My wife is perhaps not
too keen on this, I am a bit messy in the kitchen, and usually run out of energy before clearing up,
so someone else ends up doing that bit, guess who. Shopping is easier too. I still rely on my little
scooter when we know we will be a long time in a shop (think full trolley), but for shorter periods
(less than about twenty minutes) then I’ll push the trolley and lean on that. I’ve managed not to get
into trouble yet. Life is pretty good for me at the moment, compared to where I’ve been, I’m
grateful.
This little essay is my way of explaining to those of you who may be offered the valve operation an
in-depth look at what you might get. And also to put into context some of the effects that can
happen after the operation. All of the above is truly what happened to me, except that I also had a
big pneumothorax after the operation. But that was just a complication, it’s been described
elsewhere. And once sorted out takes nothing away from the success of the procedure.
What about failure? If the fitting of valves does not provide benefit, or indeed if it causes a problem,
which I believe is possible if the recipient has other major issues, what then? Well it is reversible.
The surgeon can use the same equipment to remove the valves as to fit them. Then you just end up
back where you started.
ABOUT A SEMINAR AT LEEDS – MINIMUM INVASIVE TECHNIQUES FOR
EMPHYSEMA
First published on March 31, 2013 by John Ratcliffe
ABOUT A SEMINAR AT LEEDS – MINIMUM INVASIVE TECHNIQUES FOR EMPHYSEMA
An interesting couple of days I’ve just had. Several weeks ago, I was invited to give a presentation
about my experiences as a COPD patient who has had Endobronchial Valves fitted, as part of a
symposium at St. James Hospital at Leeds, Friday, 1st March. This event was hosted by Mr. Kostas
Papagiannopoulos and his team, who are consultant surgeons in Thoracic Medicine on site at Leeds.
The event was organised and sponsored by Pulmonx, the company who make the Zephyr Valves,
and the Chartis System (a diagnostic tool). Also there giving presentations was Dr Ravi Mahadeva,
another chest consultant from Addenbrooke’s Hospital at Cambridge. The symposium was about
Minimum Invasive Techniques for Emphysema. Kostas and Ravi I have met before and I think of
them as friends. I think that they appreciate that although not a medical professional, in this area I
have done much research online, and I have read a lot of technical papers about COPD and
treatments, and can understand what they are talking about. It’s nice to be included by these people
who are so knowledgeable, and treated as an equal on a professional level. Both have been involved
in the early trials of pulmonary valves since they started in the UK after 2006. Attending this event
were just under fifty delegates, which I am told is a good response and indicates how the medical
profession is starting to appreciate the developments in treating lung disease. We had surgeons and
team members from places that are already doing the procedures, some recently qualified doctors
looking to progress to surgery, and others hoping to bring these operations into their areas.
We started early morning with a discussion about how to chose patients for whom these techniques
would be beneficial. Various qualifying questions were discussed, and reasons given for why a
patient at different stages should be accepted or rejected for treatment, or perhaps defer for decision
at a later date. Many of these were about related and complicating issues such as cardiac problems,
other lung diseases, or diabetes. It’s a long list.
Next was a discussion about the various treatments now available, and which would be most
suitable for a particular patient. These included Endobronchial Valves, sealants, and coils. In the
valve debate, two were considered, the Zephyr valve from Pulmonx, and the IBV valve from
Spiration. Of the two, the surgeons with experience of both, all came down on the side of the
Zephyr. The IBV is on older design that relies on one-way leakage between the valve body and the
airway wall, whereas the Zephyr has a valve built into the centre of the body. On sealants, Aeriseal
was the only product considered, but not wholeheartedly taken on board by those present. This is
new product, and there is not much information yet about trial results. It works by using a two part
polymer to create a foam. This is then introduced into the parts of the lung that are targeted for
reduction. Over a period of several weeks this first hardens then dissipates either out through the
airway or absorbed and expelled via internal routes. Once the foam has gone, the remaining film of
polymer then effectively glues the section of lung shut. Questions were raised about discharges in
the affected area and reversibility. I think the consensus was that more positive results are needed,
but it might prove to have some benefit later. Coils were also discussed. They have been used quite
a bit, but as a high number ( 10 or more) are used for each procedure, and they are somewhat
invasive, and difficult to remove, they are falling out of favour. It seems the treatment of choice for
now is the Zephyr valve.
After a short break, the next topic was a demonstration of procedure by video link from theatre. The
subject of the operation was a lady who had had valves fitted some months previously, but several
weeks ago, one had to be removed. She had developed a whistling wheeze, and on examination by
x-ray, it was thought that one of the valves may have displaced. Further examination by endoscope
proved that to be the case, and the valve was removed. Over the video link, we had a camera
showing the scene in theatre, able to be moved to show different aspects of what was going on in
there, another link showing the take from the scope camera, and two-way audio so the audience
could discuss the procedure with the surgeon. It had already been decided that this lady would not
have one valve put back into the same place, as that location had proved to be not as stable as
originally thought, but a little deeper into the lung, beyond the next branch, they were now to fit
three new valves. Techniques were shown of how the airways are measured so the correct size
valves are used, how they are loaded into the delivery catheter, then placed. Mention was also made
of how important it is to put them in in the right order. In the wrong order a previously fitted valve
can occlude the site intended for another. Before the scope was removed from the patient, a little
saline solution was used to check round the valves for leakage, and they were visually checked for
correct operation. The procedure took about forty minutes, and general anaesthetic was used to
sedate the patient.
Then came my turn, a presentation about COPD and in particular emphysema from a patient’s point
of view, before and after the fitting of valves. For those interested, I’ve written about them
elsewhere, and links are at the bottom of this article. After my presentation, we had a quite lively
Question And Answer session. Questions about how I dealt with my pneumothorax from a mental
viewpoint, and about the risks involved re the pneumothorax, and the operation as a whole.
Other questions about how I cope with infections, cold weather, rehabilitation courses, the
importance of a positive attitude, and so on.
Then came the lunch break, along with many comments from the delegates about how little
feedback they get from most patients, and my talk gave them insight into this and made them realise
how important this can be in patient care.
After dinner, and another theatre demonstration. This time, it was for a man with emphysema, but
also possible complications due to bronchiectasis. The target area was the lower lobe in the left
lung. The surgeon started off by showing us a CT scan from which we could see that the fissure area
was intact (This is the division between the upper and lower lobes of the lung. One fissure in the left
lung, two in the right.), so there is no air leakage between the lobes. Further down the scan, we were
shown where there may be bronchiectasis, which shows up on the scan as thickening of the airway
walls. The scope was fitted to the patient and first thing done was a Chartis system procedure. By
blocking off the airway to the lower lobe and then measuring airflow and pressures, it can be
determined if there is leakage between the lobes. If there should be, then that is an indicator against
using valves, because no seal can be made to isolate one lobe to deflate it. While this was
happening, the technician from Pulmonx, who was operating the Chartis system, explained the
graphs on the display, and the numbers on the readout, and how they were interpreted. As expected,
the result showed no leakage. After the Chartis tools were withdrawn from the scope, a deeper
visual investigation started, and at the site where the surgeon expected to find the bronchiectasis,
that was indeed discovered. Also present was a lot of mucus indicating irritation. Samples of the
mucus were taken for culture and testing. The surgeon decided to go no further with the patient at
this time, and the scope was withdrawn. It was explained that because of the mucus from an
unknown source, and the bronchiectasis, the fitting of valves would have induced too high a risk of
pneumonia. Therefore the procedure was stopped.
A third patient who had been scheduled for treatment had been cancelled because of infection.
The day finished off with a discussion about dealing with funding committees and cost benefit
arguments, and a short presentation about complications and resolving or avoiding them.
The conclusion everyone agreed on was that valves are the favoured solution to advanced
emphysema at present, and the other methods may have their uses in particular cases. Thanks were
given to all who made presentations and were involved in the theatre demonstrations.
AN EXPLANATION OF COLLATERAL VENTILATION
First published on July 24, 2013 by John Ratcliffe
Recently, on another blog, there was a question where someone was asking for a good description
of Collateral Ventilation in relation to lung disease. The following is the answer I gave. I have
repeated it here in the hope that someone else may benefit from it.
Let’s see if I can help explain this for you. It may be a bit long-winded, so please bear with me.
In the lungs of a normal, healthy person, there is one single route inwards and out again for each of
the alveoli (alveoli are the tiny cavities at the end of the airways where the gas exchange with the
blood happens). Think in terms of a bunch of grapes. Alveoli are the grapes, the airways are the
stalks.
When the lungs get damaged, whether through disease or pollution or irritation, if the membrane
suffers extensive damage, then some of that membrane is replaced, as part of the healing process,
with scar tissue. If there are repeated episodes of disease, or sustained exposure to pollution or other
causes of irritation, then the amount of scarring can become significant.
Scar tissue is not as elastic as the original membrane. It also does not permit gas exchange. As our
lungs expand and contract, if the sites where scarring has occurred have become a significant size,
then some tearing can happen. This tearing is minute, and is no cause for concern in terms of day to
day wear and tear. It is the long term combined effect over years that is the problem. This is where
we now jump to, several year down the line. Imagine that two adjacent alveoli have a lot of
scarring, and another inflaming infection takes hold, and one particular breath is deeper and heavier
than normal, and it causes a tear that goes through the tissue between the alveoli. You now have a
hole that will not close. The tissue will heal, but leaves an enlarged cavity because that requires less
stretching than the original formation. For the bunch of grapes, two grapes have been replaced by
one damson fed by two stalks. After several more years, a number of damsons have formed, and
some of those have merged into much larger plums. This is now advanced Emphysema, with some
large cavities (called bullae), and we are at the point where medical intervention is required. One of
the things that has to be considered to determine which operation is best to go for is how this
damage presents itself.
The structure of the lungs is that they are divided into zones called lobes, three in the right, and two
in the left. Thinking in terms of the bunches of grapes, consider that each lobe is home to one
complete bunch whose only contact normally is through the main stem (the main airway). If the
damage within the lungs is confined within the individual bunches, in other words, does not cross
the boundaries between the lobes, then there is no collateral ventilation. Collateral ventilation
occurs when the the tissue damage permits the passage of air between the lobes through holes
between the lobes.
As the damage progresses, as the cavities form, so the internal support structure of the lungs gets
reduced. This allows the lungs to become longer and they over inflate because of the loss of
elasticity. They sit on the diaphragm, the bottom lobe of each lung gets compressed and generally
cannot continue to work properly. The diaphragm now has to lift this extra weight with each breath
taken. Through a day, that adds up to a lot of extra hard work. Taken with the loss of alveoli, and the
presence of frequent infections etc., the lungs are now operating at maybe as low as 15% of their
full capability when in good condition. The patient is permanently fatigued and needs lots of
medication to keep the airways open. Often oxygen is needed. At this point, the consultant decides
that surgical intervention is required. The first choice at the moment for most consultants is to use
pulmonary valves. They are easy to fit, they allow the blocked off part of the lung to continue to
pass CO2 and the lungs natural secretions out. Most importantly, they are reversible (if need be,
they can be removed easily). The biggest deciding factor in choice for or against valves is whether
or not there is collateral ventilation. If there is none, or is very minor, then valves could be
considered. If there is collateral ventilation, then the usual decision is to go for lung reduction
surgery.
As you can see, at the stage where there needs to be a choice made, the presence or not of collateral
ventilation is important.
A STRATEGY FOR DEALING WITH STRESS
First published on August 8, 2013 by John Ratcliffe
At some point, all of us get into some sort of a stressful situation. Maybe we’ve done too much too
quickly, or had a shock of some sort. We end up with low oxygen levels, panting and panicky, and
our heart rate goes up. We’re in trouble.
First thing to do is STOP. Whatever it is we’re doing STOP… NOW…. Find somewhere to sit (best
option), or at least something to lean on. Take your rescue drugs (for me Ventolin and Atrovent).
Start pursed lips breathing (most ‘old hands’ will do this automatically). Concentrate on blowing
out more air than you breathe in. If you have a pulse/oximeter, use it. After about five minutes, if
you are still struggling to get to regular breathing, repeat the rescue inhalers. All rescue drugs are
safe for repeated use if needed. If another five minutes passes and you are not on the road to
recovery, GET SOMEONE TO CALL AN AMBULANCE!!!! It could be that you need nebulised
drugs and oxygen to get you to stabilise. If your breathing is still ragged and you are struggling, you
do need help. There is nothing to gain by being a hero.
That’s the breathing side dealt with, what’s the heart doing meanwhile? Probably going like the
clappers. I know that if I get into trouble, my heart rate goes up, a lot. My normal PR (Pulse Rate) at
rest is about 105. A short walk will take it up to 120. Doing pulmonary exercises can take my PR up
to just over 130. A panic attack? 150/160. Serious, and not good.
How to deal with this? Use a relaxation technique. The benefits of doing this was shown to me and
others on the course when I attended a Pulmonary Rehabilitation course about two years ago. It was
used as part of the exercise programme as a part of the finishing set. We all said that we felt the
benefit. One the Occupational Therapists would lead this by reading a script about five minutes
long, usually describing a gentle journey through a tranquil landscape. We would sit, close our eyes,
a try to imagine ourselves following this journey. We all learned from this that we COULD in some
way control our heart rate, and slow it down quicker than a ‘normal’ recovery. What made this work
was the rhythm of the words, changing from fairly fast gradually to a good bit slower, along with a
change in how the view was described. Clever writing! But, for me, this had a flaw, the scripts were
too long, too much to remember when in a difficult situation. So I came up with a slightly different
way of doing it, which did not need me to recall a long script. Here it is.
Imagine a ball. It’s about the size of a football. It’s red. It’s bouncing. One bounce for each of your
heart beats. Feel your heart beat. Match the bounce. A low bounce is faster than a high bounce.
When you have got the bounce right (with practise, you will do that in a few seconds), change the
colour of the ball to orange, and make the bounce of the ball a little higher to slow it down a
fraction. Be careful not to slow the ball too much, or you will lose the synchronisation with your
heart beat. At the same time, do pursed lips breathing. In a few seconds (10 to 20) you should feel
that your heart has slowed a little. Change the colour of the ball again, to yellow. Make the bounce a
little higher again to slow it again. When you get your heart beat to match the bounce again, change
the colour again, and so on. I find that I can usually slow my heart rate down by about 5 beats per
minute using this, so from about 140 down to 110 takes 6 or 7 minutes, which I think is pretty good
going. The colours. I go through the colours of the rainbow Red to Violet, because it’s easy to
remember, and using the same sequence gives a comparison to previous times so you know how it’s
going THIS TIME. If your recovery is much longer than usual, it’s often an indication of something
wrong that needs to be seen to. The ball. Not important, just something comfortable that you can
bounce in your mind.
Remember, Red … Orange … Yellow … Green … Blue … Indigo … Violet.
When you have gone through the colours, if it’s not enough, start again.
Like many other exercises for helping out when we’re not so good, this needs to be practised when
we’re OK, and on an even keel.
USEFULL LINKS
Original Articles.
These links go to the original articles. They are provided so that those readers who so
wish can see the comments that the articles generated.
1. PULMONARY REHABILITATION http://bitz-and-bobz.co.uk/copd/pulmonaryrehabilitation-
contributed-by-john-ratcliffe/
2. TOWARDS MORE EFFECTIVE BREATHING
https://healthunlocked.com/blf/posts/616837/breathing-techniques-explained
3. LUNG VOLUME REDUCTION USING ZEPHYR VALVES. MY EXPERIENCE AS A
PATIENT https://healthunlocked.com/blf/posts/611571/lung-volume-reductionusing-
pulmonary-valves-my-experiences-as-a-patient
4. ONE YEAR ON https://healthunlocked.com/blf/posts/801732/one-year-on
5. ABOUT A SEMINAR AT LEEDS – MINIMUM INVASIVE TECHNIQUES FOR
EMPHYSEMA https://healthunlocked.com/blf/posts/836613/about-a-seminar-atleeds-
minimum-invasive-techniques-for-emphysema
6. AN EXPLANATION OF COLLATERAL VENTILATION
https://healthunlocked.com/blf/questions/130020831/can-someone-explain-collateralventilation-
in-simple-terms-please-thank-you-davy (Note – this article first
appeared as an answer to a question. The link is to the question, my answer is the fifth one
in the following comments
7. A STRATEGY FOR DEALING WITH STRESS
https://healthunlocked.com/blf/posts/130027720/a-strategy-for-dealing-with-stress
Other Useful links
1. http://www.youtube.com/watch?v=7C6CGqXLtuM
This is a link to a video released by Pulmonx, the company that produces the ‘Zephyr’ valve.
It explains how the procedure of fitting the valve is done. There is also a pretty good
explanation of what emphysema is and how it progresses.
2. http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf
This link will take the reader to a rather large PDF file (you need Adobe Reader to open
this). This is the annual report for 2013, issued by the Global Initiative for Chronic
Obstructive Lung Disease, Inc. It states the current international position regarding treatment
of COPD. Of particular interest is the list of drugs currently in general use, and descriptions
of how they work. Remember that in the UK, in most areas we are a little ahead of the rest
of the world, but in some countries, in some aspects, they maybe a little ahead of us.
Therefore, it is fair to say that although this paper has superb information in general, perhaps
some back-up research maybe in order to prove the information is correct for the UK. That
said, I still consider the report to be an excellent resource.

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