TWO ANDA HALF YEARS ON, AN UPDATE.

As some of you know, back in February 2012, I had 3 Pulmonx valves fitted to the upper lobe of my right lung, as a means to achieve a reduction in lung volume. The op was an enormous success, giving me a huge increase in my capacity to live a life. Basically my FEV1 increased from 16% to 32%. I’ve written about it, and you can find that in other articles on this blog
I thought it was time for an update, so here we go………

The new life takes some getting used to. I found that the best way is to forget about fast breathing, as it only causes some air trapping, that then needs some controlled breathing to get rid of. It’s only useful when doing a function test, and then only for checking the elasticity of the lungs. For me, it’s long slow deep breaths, but concentrating more on getting a good , steady out-breath, and every so often at the end of the blow, blow out a tiny bit more. Low air pressure, associated with bad weather systems affects me, increasing the need to blow out using ‘pursed lips’, to increase the pressure in my lungs. Breathing in looks after itself, just try to do it through your nose.
For those thinking about going forward for this, or any other procedure, this is not a cure. It is an intervention intended to give an increase in capacity by shutting down a bad part to allow the better parts more room to operate. Remember that the damage to your lungs will continue, due to inflammation and infection. So avoid doctors’ surgeries and children!!!! (As if you can, ha ha).
The aftermath of the valve op, and indeed, the use of coils is largely uncharted territory. There aren’t very many of us yet, and the aftercare is largely guesswork. GP’s as yet have nothing to guide them, so I see my docs treating me as a patient with fully functioning (or nearly so) lungs. So a sputum test result which shows a ‘normal’ loading of bacteria or fungus spores is put down as ‘of no consequence’, whereas, for me with about 25% of my lungs working, it actually translates to 4 or 5 times more serious than for a ‘normal’ patient. That, I call significant, to me.
Keeping as fit as you can is important, as is pacing yourself. I am finding that as this progresses, more changes are happening. Some of the drugs I was taking before the op, I have dropped off, as the symptom they were treating has changed. I find that taking a NSAID morning and night helps to reduce lung inflammation with little or no side effects, just as well as steroids did with side effects (cataracts, aggression, and appetite). In fact, I would recommend that everyone with advanced COPD get a drug review every two years or so. Symptoms change over time, and so does the need for specific drugs.
Now, how am I? I’m feeling pretty good. But (always a ‘but’ isn’t there?) the damage continues. I did another seminar at Cardiff in May, and as part of the day’s proceedings, a CT scan that I had the week before was put up before the delegates. Wow. What a revelation. This was discussed by a couple of very eminent Professors of Thoracic Surgery, (one from France, Prof Pison from Grenoble Uni Hosp), my consultant, and about ten other surgeons in the audience of approx 60 medic professionals. Most noticeable was the difference between the depth of the lungs, because of the valves. But also the degree to which the damage had continued. I now have big cavities in both lungs (a bit bigger than golf balls), so the discussion centered on where to go from here. The final consensus was actually to do nothing, having considered valves, coils, reduction surgery, Bullectomy, and finally transplant. So here I am, not feeling bad at all, but aware that my condition can best be described as ‘Brittle’. I reckon I am probably two years past my ‘Throw it in the bin’ date. So me and the family are definitely winning.
Would I go through the op again? Oh yes. Absolutely!!!!
Would I recommend it? Yes, provided it is suitable for the patient, and that the patient is suitable for the op, Whether it be valves, coils or reduction surgery.
May I wish you all, similar long term success, whether it comes from drugs or surgery, or just plain keeping fit and eating well.

All of you out there, breathe easy.

John

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Breathing Techniques

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.

Remember, breathe easy,

John
PS. I am not a medical professional. I am writing this to try and fill a gap in general knowledge about COPD. If I have written something wrong, say so. We all have something to learn, especially me.
PPS. The PS above was proven when a comment made me check The actions of Ventolin and Atrovent. I have now amended the article to give the correct information.