Introduction

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The National Lung Health Education Program (NLHEP), is a new healthcare initiative designed to identify and to treat patients in the early stages of emphysema and related chronic bronchitis. Together, emphysema and chronic bronchitis are known as chronic obstructive pulmonary disease (COPD). Approximately 110,000 to 115,000 Americans die of COPD each year as we enter the new millennium! COPD is now the fourth most common cause of death in the U.S.A. COPD is the only disease among the top ten killers in America that continues to rise in the number sick days and deaths.

By contract, great progress has been made in reducing the number of people who become sick or who die from major diseases, such as heart attack, stroke, and many cancers because of early identification and treatment programs.

The NLHEP is directed to both primary care physicians and to patients. Many societies and governmental agencies within the United States help sponsor the NLHEP. Financial support for the NLHEP comes from unrestricted grants from the pharmaceutical and medical equipment industries. The NLHEP enjoys a partnership with the American Association for Respiratory Care (AARC), a professional organization representing 50,000 respiratory care professionals. Together, the NLHEP and the AARC are planning a new attack on emphysema, a common disease which results in suffering and early death.

We are launching the National Emphysema Prevention Program (NEPP). Please learn how you can work with your doctor and help prevent emphysema! We aim to reduce the social and the economic impact of this important problem. We believe that through education to the public by professional and governmental agencies, the problem of emphysema can finally be prevented and solved. Please visit our web sites for current information.

Thomas L. Petty, M.D.

Dennis E. Doherty, M.D.

Co-Chairs,

National Lung Health Education Program (NLHEP)

Save Your Breath, America!

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This booklet is dedicated to people who live and breathe, and who either have or may develop chronic obstructive pulmonary disease (COPD). This group of diseases, often known simply as “COPD,” includes asthmatic bronchitis, chronic bronchitis, and emphysema. COPD affects an estimated 32 million Americans, but has only been “diagnosed” in about half of those who actually have COPD, largely due to a lack of awareness.

Save Your Breath, America! is a companion to a booklet written for physicians, “Prevent Emphysema Now!” It provides the most current information on the causes and treatment of asthmatic bronchitis, chronic bronchitis, and emphysema. Based upon 30 years of study of these closely-related diseases, it is offered as advice for persons who:

Smoke now or who have smoked in the past,
Have a long-term cough, excess mucus, shortness of breath, or wheeze,
Have family members with COPD.

Remember, the symptoms of COPD, including emphysema, may not show up for 30 or more years. This gives you and your doctor a good chance to determine if a breathing problem is present, or will be present in the future. You may need treatment to stop the disease before it gets serious enough to cause symptoms that affect your lifestyle. If you notice a change in your ability to breathe as you perform ordinary daily routines, don’t delay. See your doctor. A major part of this booklet is devoted to the steps you can take to save your breath and prevent emphysema!

Breathing is essential for life. Your body needs the oxygen in the air you breathe to create the energy that keeps you alive. Your respiratory system carries the oxygen to your lungs, where it enters your bloodstream to travel throughout your body. The bloodstream also carries the "used" air, which is mostly carbon dioxide, back to your lungs so that you can breathe it out.

When fresh air is breathed in through the nose and mouth, it is pulled through the windpipe or trachea and into the lungs. There it moves through two large passageways, called the bronchi.

Then a complex system of much smaller tubes or bronchioles branch out to carry oxygen to the "working parts" of the lungs -- millions of air sacs or alveoli. These small sacs (like tiny folded balloons) have very thin walls that are full of blood vessels. The walls are so thin that the oxygen in the air can pass through them to enter your bloodstream and travel to cells in all parts of your body. Oxygen is required to “burn” food for the energy required by every organ of your body.

What is COPD?

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What does the term COPD mean? It stands for chronic obstructive pulmonary disease and refers to a problem with breathing air out from your lungs. If you have difficulty breathing "used" air out of your lungs, not enough space is left for oxygen-rich air to enter your lungs.

Until recently, most people who had COPD were grouped together and considered to have one disease. We now know that several different diseases cause this difficulty in providing oxygen to the body and releasing air from the lungs. Asthmatic bronchitis, chronic bronchitis, and emphysema are three of the major diseases that are grouped together as COPD.

Asthmatic and Chronic Bronchitis

Both asthmatic and chronic bronchitis occur when the large breathing tubes of the lungs, or bronchi, are inflamed and swollen. Imaging what happens to your skin when you've gotten an insect bite and it becomes swollen, red, and painful. This same idea can be applied to the swelling that occurs with bronchitis. The lining of the air tubes becomes swollen and produces large amounts of mucus. Because mucus clogs the airways, it complicates the problem, much like pus infects and irritates a wound and delays healing.

The muscles that surround the airways may tighten when they should not, causing spasms of the bronchi, or bronchospasm. These narrowed airways prevent all the "used" air from leaving the lungs. Bronchospasm, inflammation, and swelling all make the space inside the airways smaller. This reduces the amount of air that can flow in and out of the lungs. It is like breathing through a straw.

The first symptom of chronic bronchitis is a persistent cough that brings up mucus. This is often followed by wheezing, shortness of breath, and frequent chest infections. The symptoms of bronchitis can usually be relieved or improved with treatment.

Emphysema

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Emphysema develops when many of the small air sacs in the lungs are destroyed. This reduces their ability to get bigger and smaller, so they pass less oxygen into the blood and remove less carbon dioxide from the blood.

Shortness of breath is the major symptom of emphysema. At first, this difficulty in breathing may occur only with heavy exercise. Later it happens with light exercise and, still later, even when walking or engaging in other everyday activities. Do you notice that you no longer can keep up with friends your own age without getting out of breath? Do you get more tired with less exercise than you did a year ago? If so, tell your doctor about these gradual changes, and ask your doctor to check your lungs. Many people who have emphysema also have chronic bronchitis. The mucus produced by these inflamed airways makes breathing even more difficult.

In most cases, the lungs can take a lot of abuse. It may be 30 or more years before someone who has emphysema notices a change in his or her health. However, when emphysema is diagnosed early, more can be done to treat it. By stopping smoking and using appropriate treatments or medication, persons with emphysema can generally lead a comfortable life.

What Causes COPD?

Asthmatic bronchitis, chronic bronchitis, and emphysema develop as a result of one or more of these factors: cigarette smoking, family susceptibility, or inhaling large amounts of dust at work or at home.

Other conditions that can make these diseases worse are frequent colds or infections in the nose, sinus, throat, or chest. It is also known that emphysema can be hereditary. In some families this might be due to a lack of normal lung "defenses" that fight damage within the lung. It may also be because certain habits are passed along to other family members. For example, if parents smoke, there is a good chance that their children will smoke. Since 90% of COPD is caused by smoking, persons with family members who smoke are at greater risk of getting these diseases.

Early Detection

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Early discovery of a breathing problem and appropriate treatment can prevent the disease from progressing to the point that it seriously affects the way you live and work.

Anyone who has an ongoing cough or shortness of breath, even if it seems minor, should see his or her doctor. Morning cough, for example, is not normal. It is a result of smoking and indicates that there is irritation and swelling within the lung. Shortness of breath while exercising, climbing stairs, or walking can also be a sign of a breathing problem. Many people simply feel that they are "out of shape”, slowing down, or getting older when, in fact, they are working harder to breathe.

A spirometer can tell whether your breathing is normal. It takes only a couple of minutes to blow into this machine, which can detect a change in your breathing ability even before you do. Fortunately, many physicians have a spirometer in their offices. The next time you see a doctor, ask for a spirometry test (lung function test), if you think you might have COPD or asthma.

Remember, when you take a spirometry test, no needles are involved. You don’t have to take off your clothes. This test is not painful, and will not cause you any discomfort. All you have to do is fill your lungs completely. Then you pause and blow out all the air you can in six seconds. This test will give two numbers for you and your doctor to understand together. The first number is the forced expiratory volume in one second (FEV₁). This is the amount of air you blow out in the first second that you force out your breath. The total amount of air you blow out in the six seconds is called the FEV₆. In six seconds most people can blow all or most of the air out of their lungs.

“Test Your Lungs, Know Your Numbers” is the motto of the NLHEP. Most people know their blood pressure and cholesterol numbers and can tell if these numbers get higher or lower. You also should record your spirometry test results for future comparisons. Spirometry will help you determine if you do have or don’t have any amount of airflow abnormality. If you have any abnormal airflow, this would mean that you’re on the pathway to develop emphysema or related chronic bronchitis. Prevent emphysema now and you will not have to face it later.

Breathing tests should be done on anyone who may be at risk for developing COPD, such as those who smoke or who have family members with one of these diseases. Here is a checklist that will help you decide if you should see your doctor about having a breathing test.

1. Does asthmatic bronchitis, chronic bronchitis, or emphysema run in your family?

2. Do you smoke or formerly smoked?

3. Are you short of breath more often than other people?

4. Do you cough?

5. When you cough, do you cough up yellow or green mucus?

6. Are you exposed to someone else’s smoke?

If the answer to any of the above questions is yes, you should see your doctor for a breathing test.

After taking the test, you can ask your doctor these questions:

7. Are your breathing measurements normal or abnormal?

8. How abnormal are they?

9. Is the problem one that can be treated with drugs and/or by stopping smoking?

10. Is the abnormality worsening? If so, how quickly?

11. What exactly should your do for your problem?

Treatment

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What can you do if you have an early stage of asthmatic bronchitis, chronic bronchitis, or emphysema? Certainly you should change any behavior that can make it worse. The single most important thing you can do for yourself is to stop smoking. In fact, if you don't stop smoking, none of your other efforts will be as effective as they could be, and your COPD will get worse.

Stopping smoking is a complex matter. If you decide that you want to quit, no matter what, you will succeed. People with COPD and emphysema are often very addicted to the nicotine in tobacco. Nicotine replacement products are available to help deal with the uncomfortable symptoms of nicotine withdrawal that many patients experience when they try to quit smoking. Nicotine gum and nicotine patches are available at drug stores without a prescription. Both can be used together. Nicotine nasal spray and nicotine vapor inhalers that work like a cigarette are available by prescription. An antidepressant drug called bupropion (Zyban®), can help you stop smoking.

You must decide to quit and pick a specific quit date. Quit completely all at once (“cold turkey”). Start nicotine replacement on your quit date. If your doctor prescribes Zyban®, it should be started two weeks before your quit date. Zyban® can be used only with nicotine replacement.

If you fail, wait a week or so. Don’t get discouraged. Try again. Many heavily addicted smokers succeed after several attempts to quit smoking. Quitting is the most important thing that you can do for your health, and for the prevention of emphysema. In addition, you will decrease your risk for having a heart attack, a stroke, or developing lung cancer.

As a COPD patient, you need clean air. Therefore, you should also avoid being around smokers and fume-laden air. During fog or smog, try to stay indoors with windows closed. If possible, fumeless appliances should be used for heating.

Polluted air also can irritate your breathing passages. Try not to go out when the air quality is rated poor. But if you cannot avoid excessive air pollution, protecting your mouth and nose with a mask may improve your breathing.

You should see your doctor on a regular basis to have a physical and to have your lungs checked with spirometry, especially if you have a chest cold or any time you cough up mucus. It is also important to guard against catching the flu by getting an influenza vaccine each fall, well before winter starts. A pneumonia vaccine should also be given to anyone over age 50, and to all persons with COPD.

There are many different types of treatments that can help you cope with a chronic lung disease and live your life to the fullest. Next, we will discuss some of these treatments. Your doctor will select the ones that will be most helpful for you.

Clearing Your Lungs

Coughing has an important "cleaning action" and is something you should do every morning and evening. You must learn to cough in such a way that you can clear your lungs of mucus with two or three coughs. There are many ways to do this. Your doctor will teach you the way to cough that is best for your particular problem.

As an aid to this cleaning, your doctor might recommend breathing moist or humid air, and drinking plenty of fluids every day. This helps to thin out the mucus so that you can cough it up more easily.

Your doctor might also recommend inhaled bronchodilating drugs or anti-inflammatory drugs that open your airways and help increase the normal flow of mucus out of your lungs.

Medications

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Many different medications are used as treatment for asthmatic bronchitis, chronic bronchitis, or emphysema. Your doctor will decide which medicine is best for you based on your medical history, breathing tests, and laboratory tests.

To help you breathe easier, your doctor may give you bronchodilator drugs. Bronchodilators relax the muscles that surround the breathing tubes and widen them, letting air travel in and out more easily.

Your doctor may also prescribe drugs to liquify the mucus in your lungs, or even drugs called steroids, which reduce the swelling in your breathing tubes. If you have an infection in your respiratory system, your medications may include antibiotics.

These medications may be available in many different forms. In addition to pills or syrups, your doctor may prescribe a metered-dose inhaler (MDI), which has medication that you breathe in. You must learn to use your MDI correctly (see below).

A device called a spacer or extender can also be used to make it easier to take your medication. This device catches the mist produced by a metered-dose inhaler and holds it so that you can breathe it in at a slower rate.

Proper press-and-breathe technique for MDI Use

Metered-dose Inhalers (MDI)

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Most of these devices, which deliver medication to your lungs as a spray, require a prescription from your doctor. The medication in a metered-dose inhaler that can be bought without a prescription such as Primatine Mist^TM is adrenaline, a short-acting drug which may be dangerous for persons with heart disease. It is inadequate to treat COPD.

To get the maximum benefit from the medication, it is important that the inhaler be used properly. Here are some helpful tips for using a metered-dose inhaler:

New Developments

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Progress is continually being made in the treatment of asthmatic bronchitis, chronic bronchitis, and emphysema. A bronchodilator medication (an anticholinergic), is available in metered-dose devices. The other major type of inhaled bronchodilator is called a beta agonist. Both medications can be used together. Both are sold in a metered-dose inhaler (separately and mixed together for convenience). Since these bronchodilators work on the respiratory system in different ways, they can be used together to treat COPD.

A new treatment that may be effective in a rare hereditary form of emphysema is being tested on volunteers. A replacement for the inherited deficiency of alpha antitrypsin is commercially available. Although it restores a protective material in the lungs, its effectiveness in preventing the progress of emphysema remains to be proven.

Surgery which removes areas of major lung damage is called lung volume reduction surgery (LVRS), may make breathing for people with emphysema easier. In some patients, this operation can improve shortness of breath and quality of life. The mechanisms behind this improvement are complex. By reducing overinflation of diseased parts of the lungs, the curve of the diaphragm muscle may be restored. The upper parts of the lung (apices), are often the most destroyed parts. The upper lungs take up a lot of space for expansion of the rest of the relatively normal lung, but don’t play a very important part in breathing. Extensive evaluations must be done through scans and tests of heart function to determine good candidates for LVRS. At the present time, Medicare does not reimburse for this operation. This may change depending on the results of the National Emphysema Therapy Trial (NETT). This study compares the results from lung surgery following a period of pulmonary rehabilitation compared to pulmonary rehabilitation alone. It will be five years or more before the results of NETT are known. Qualified surgeons are now offering this operation to selected patients on an individual basis when patients have ways to pay for the surgery other than through Medicare. Patients should be evaluated by pulmonologists and surgeons, working together before going ahead with this treatment.

The Future

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Today, doctors and scientists have a better understanding than ever of the nature of asthmatic bronchitis, chronic bronchitis, and emphysema. These diseases are viewed as damage to the lungs as a result of two factors. First, is outside conditions such as smoking, air and environmental pollution, and in some cases, frequent infections. The second factor is the hereditary loss of certain lung defenses, which leaves lungs easier to damage. The future promises more advances in understanding why patients get asthmatic bronchitis, chronic bronchitis, and emphysema.

Diagnosing any breathing problem by spirometry at an early stage is most important. The treatments and medications discussed in this document can help stop the progression of COPD, in addition to making your life as comfortable as possible. The earlier this is done, the better your health will be. Diagnosing asthmatic bronchitis, chronic bronchitis, and emphysema early can save your breath, America!

For Additional Reading:

Carter R, Nicotra B, Tucker JV: Courage and Information for Life With Chronic Obstructive Pulmonary Disease. New Technology Publishing, Inc. Onset, MA, 1999, 264 p.

Hodder R: Every Breath I Take. A Guide to Living with COPD. Stoddard Publishing Company, Limited. Park Centre, Toronto, Canad, 2001 244 p.

Petty TL, Nett LM: Enjoying Life With COPD. Laennec Publishing, Cedar Grove, NJ, 3^rd Edition, 1995, 199 p.

Web Sites to View:

American Association for Respiratory Care:

National Emphysema Prevention Program: www.nepp.org

National Lung Health Education Program:

Test Your Lungs, Know Your Numbers!

DATE	FEV₁/FEV₆	FEV₁

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Doctor’s Name

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Doctor’s Phone Number

Printing and distribution has been made possible by educational grants from:

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National Lung Health Education Program (NLHEP)

1850 High Street

Denver, CO 80218

Fax: 303-832-5137

E-mail: nlhep@aol.com

Web Site: nlhep.org

Asthmatic and Chronic Bronchitis

Emphysema

What Causes COPD?

Early Detection

Clearing Your Lungs

The Future

For Additional Reading:

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