copyright 2008 Cheryl K. Hosken, BSN, MS Psych.
Walter Miller had been a heavy smoker since his teen years. His wife said that he smoked more than anyone could imagine. She encouraged him to stop smoking, but did not nag him about it. He did try stopping over the years, but he was so addicted that he could not stop. Increasingly Walter began to experience shortness of breath and fatigue symptomatic of chronic obstructive pulmonary disease. He was 55 years old.
However, Walter would not go to a doctor because the doctor told him to stop smoking. One fall, he had been ill with a cold for 3 weeks but still refused to see a doctor. He decided to work in the garden on a Saturday afternoon. His wife went to find him after an hour, but he was not in the garden. She found him in the house in bed with chills and fever. She asked if he wanted to see the doctor. He agreed to go to the emergency room and found that he had emphysema and pneumonia in both lungs. The doctor asked how he got into the hospital. He told the doctor that he walked in.
The doctor said, "You could not have walked in!" He had so little oxygen in his blood that the doctor did not know how he survived. He was given 2 liters of oxygen per minute immediately and was hospitalized for five days. He was connected to oxygen for the rest of his life. He lived for another eight years.
Meditate Word By Word On These Verses:
Luke 14:21-24.
Have you ever physically exerted yourself so that you were left gasping for breath and feeling as though you could not move another muscle? If so, you know what it can be like to suffer from obstructive pulmonary disease. For some patients with this progressive, incurable disease, physical activity becomes a memory as they edge toward death.
The name Chronic Obstructive Pulmonary Disease (COPD) is a group of diseases that slowly stops airflow to the lungs. The process of breathing fresh oxygen in and out takes 4 seconds. Everyone's ability to move air in and out diminishes with age, but with obstructive pulmonary disease there is a profound loss of respiratory function. A person with only 30 percent of lung capacity may be able to lead a relatively normal life, whereas another person with 60 percent lung capacity may be completely incapacitated.
Usually chronic bronchitis and emphysema are both present is diseased lungs. Emphysema breaks down the elastic walls of the alveoli and leaves behind large, useless pockets called bullae. When the air sac collapses because of the bullae formation, useless and stale air is trapped in the lungs. Chronic bronchitis causes constriction of the airway to the lungs. It also makes excess mucus in the lungs that interferes with the exchange of air in the alveoli.
Combined, these two diseases cause imbalance of gas exchange between the air sacs and the blood vessels. Two things happen then: the overburdened respiratory muscles can no longer propel air through the surviving alveoli causing hypoventilation of the lungs. The air sacs and the blood vessels used to exchange air cannot do so and the blood stream is short of oxygen and high in carbon dioxide.
Question 1: What are the two conditions that are called obstructive lung disease? Do you think this is a problem in your country?
Causes of Obstructive Lung Disease
The first and foremost cause is smoking. It is believed that smoke from cigarettes has an enzyme that breaks down the elasticity of the lungs. There is a small number of people who have a genetic deficiency of a protein in the blood that cannot protect the body from the enzyme that decreases elasticity in the lungs.
Early Symptoms
Chronic bronchitis often precedes emphysema and obstructive pulmonary disease first emerges as a mild, nagging "smoker's cough" in the morning. Usually, there is also sputum of clear phlegm. If this happens for six out of 12 months in a year, the bronchitis is considered chronic.
Another early warning sign of obstructive pulmonary disease is feeling short of breath and fatigued after minimal exertion. People often ignore these symptoms. They say, "I am out of shape" or "I am getting older." By the time they go for a medical examination, the damage to the lungs is done and the damage is irreversible.
Pulmonary function tests, chest x-rays, and blood gas analysis (these are repeated blood tests to measure the concentration of oxygen and carbon dioxide in the blood and its acidity-alkalinity.) People with obstructive pulmonary disease have low oxygen and high carbon dioxide levels and a high acidity of the blood.
Advanced Obstructive Pulmonary Disease and Its Symptoms
Often, it is pneumonia or some other emergency that bring people to the doctor. Usually, the disease is already far advanced. Then the goal of treatment is to control symptoms, make people more comfortable, and prolong their lives. Stopping smoking and rehabilitation help the condition. The survival time for such patients is 8-10 years.
Shortness of Breath
Hunger for air or dysapnea is a fact of life for most people with COPD. When the disease becomes more severe, people are dramatically short of breath. Mrs. Miller recalls that there were times when her husband simply could not breath and she rushed him to the hospital for medications and inhalants for a few hours.
This symptom is managed by giving up cigarettes. Although stopping smoking cannot undo the damage to the lungs, it does slow down the disease process. If a smoker quits before the condition turns serious, he will have almost normal lungs. However, the majority of COPD persons have smoked all their lives and for them to give up tobacco completely is extraordinarily rare. The psychological and physical cravings are so overpowering that not even the prospect of death will be an incentive.
Question 2: What can be done about the smoking habits of people in your country?
(Select the best answer.)
Forbid the advertising and sale of tobacco products.
A quick bullet to the head.
Quarantine smokers so they don't spread their harmful habit.
Pulmonary Rehabilitation
This type of rehabilitation is focused on helping a person breathe better. Abdominal breathing or controlled deep breathing is a way to help the diaphragm use its maximum capability. Usually the person with advanced disease often has a flat, weak diaphragm. The person with COPD must learn these exercises so they become second nature to him. This will help him through times of respiratory distress. For example, if the person with COPD has pneumonia and cannot breathe, the abdominal breathing helps to calm him and get more oxygen into his lungs. Talking quietly to him and helping him focus on relaxing his muscles also helps.
There are also the general exercise programs that resemble the cardiac rehabilitation programs. Although they are not as intense in nature, the goal is to try and help the person with COPD increase his exercise tolerance and keep his body fit. One thing to remember is not to push the person beyond his endurance.
Drug therapy
Broncodilators are drugs that open constricted passages by relaxing the smooth muscles. The names for some of these drugs are theophylline, metaproterenol, and isoproterenol. These drugs also come in a liquid solution that is poured into a nebulizer that mixes the drug and air into a mist. The nebulizer treatment can last for 10-15 minutes. Usually, the treatments are 4 times daily.
Cortisone may be used to reduce inflammation in the airway. The side effects from steroids are many and they must be used with caution. Among the side effects are mood swings, indigestion, ulcers, and bone fractures. Walter Miller's back fractured every month during the last 6 months of his life since he was on prednisone.
It is not uncommon for these patients to also take tranquilizers to ease anxiety about lack of breath.
Oxygen Therapy
These patients may also need supplemental oxygen. This is necessary because hypoemia can progress to hypoxia - a state where body cells start to die due to lack of oxygen. Oxygen is given 24 hours a day from 1-4 liters per minute.
Question 3: What is the key necessity for the body that this disease inhibits?
Putting a person on oxygen extends his life. The added life doesn't lack quality either. During the first 7 years that Mr. Miller was on therapy, he and his wife had an active lifestyle. When Mr. Miller went on oxygen, the color of his skin turned from gray to a healthy tone. He put his oxygen tank in the back of his car when they traveled. There are also oxygen backpacks and oxygen carts that can go everywhere with a person.
Oxygen is given through a nasal cannula that fits into the nostrils. The steady stream of oxygen however, dries out the mouth, nose, and throat. The dryness can be irritating and makes the person more susceptible to infection. More and more, a tracheostomy is the preferred route for delivering oxygen to people with obstructive disease. This administration is preferred because the oxygen can be humidfied before it enters the patient's throat. Some persons are also on mechanical ventilators at home.
Question 4: How is the body inhibited from getting this necessity?
Chronic Coughing
The nagging cough that begins with obstructive disease rarely worsens over time. However, there may be violent hacking that prevents them from catching their breath and leaves them sore and frightened. In the middle of these coughing fits, the person may sometimes lose control of bowel and bladder.
Chronic obstructive pulmonary disease patients need to cough to rid the respiratory tract of mucus. But if the coughing is causing pain and interfering with sleep, a cough suppressant is needed. For the problem of urinary incontinence, an adult diaper may be used. This prevents embarrassment and keeps the person dry.
Difficulty Expelling Secretions
As the disease advances, the sputum from the lungs turns thick and gummy, making it extremely difficult for a person to clear his throat and bronchi. The problem increases because people with obstructive disease cough ineffectually. The effort exhausts them and over time, they give up trying to cough.
This is problem is managed by using a suction machine. Inhalation therapy again helps. The person can inhale a weak solution of soda and saline to loosen secretions. Expectorant medications have similar effect on secretions to loosen them so they can be coughed up.
Make sure that your patient gets enough fluids. These may be water, fruit juice, boullion, or fruit teas. Extra fluid liquifies mucus and restores fluid loss because these patients lose fluids through increased respiratory rate and mouth breathing. Moist air also makes coughing up phlegm easier, so you may put a wet towel on a hot radiator to put moisture into a room.
Question 5: What are the effects of coughing on the body?
(One or more of the following answers may be correct.)
Lack of sleep.
Loss of weight.
Constipation.
Urinary incontinence.
Appetite Loss
Emphysema is one of the diseases that severely wastes the body. Appetite loss can be a major problem for these patients and they lose a lot of weight. Mr. Miller, at the end of his life, had gelatine and an enriched milk drink for his daily diet. The reason for the loss of appetite is that the lungs are only partially inflated and press down on the stomach. This leaves little room for food. If the stomach is full of food, it compresses the lungs and interferes with breathing. To this is added persistent coughing, fatigue, shortness of breath, and disagreeable taste in the mouth from medications. It is easy to see how a person can become discouraged from eating.
Once the body depletes its reserves of fat and glycogen, it begins to burn the muscle tissue for fuel. Therefore these people need a diet high in protein - meat, eggs, fish, dairy products, beans and lentils, that build muscle tissue. Try not to pressure the patient too much about eating but try to make good choices for his menu.
It is best to serve them 6 smaller meals per day than the customary three so that the stomach is not too full. In order to digest a large meal, oxygen is diverted from other parts of the body to the stomach. Since these people have too little circulating oxygen, the less time and energy digestion takes, the better.
Insomnia
Most persons with obstructive disease can only dream of sleeping through the night. They waken frequently, short of breath and must sit up to cough. They often sleep in a semi-sitting position. A second obstacle to sleep is that too little oxygen and too much carbon dioxide in the blood alert the brain and waken the person to try and get more oxygen.
Depression
Obstructive disease is a terminal illness. Depression may come because life is so changed from normal and this change goes on for years. Mr. Miller became depressed about having to be on oxygen and have a tank with him at all times. He also felt tremendous guilt about having smoked for so long and this disease was the result. His wife didn't berate him for smoking, just gave him infinite compassion and love.
Question 6: How is nutrition affected by obstructive disease?
Treatment for Chronic Obstructive Disease
The patient's only hope for long-term survival is a lung transplant and there is little chance and great risk in such operations. Most of these patients are too sick to survive such a surgery.
There are two other surgeries that are done occasionally. One is called bullectomy. If a bulla is large and compressing the lung tissue, removing it can provide some breathing relief for the patient. Another surgery is to reduce the diseased sections of lung. The physician excises the bulla and those parts of the lung that are not functioning anymore.
Potential Life Threatening Complications
Walter Miller's condition declined sharply at the end of December and he was in and out of the hospital for the next six months until his death. He also had prostate cancer. Walter and his wife agreed that he would die at home. He could not walk to the bedroom and he slept and lived in a reclining chair in the kitchen. During the spring months, he was rolled out to the balcony to see the birds and his favorite dog was nearby.
His skin became increasingly delicate and the visiting nurse called saying that his bedsore were getting too large. He would have to get a hospital bed. The new bed arrived at his home and Walter cried. He knew he was at the end stage of his illness. His wife cried with him, but there was no other choice.
Pulmonary Infection
Pneumonia inflames the lungs, and when respiratory function is failing, such an infection can mushroom into a life-threatening crisis. Any of the following early signs of infection should alert you immediately:
- change in color of mucus from clear to yellow or green
- the person complains of a foul taste in his mouth
- fever
- unusual odor
Respiratory Acidosis
Carbon dioxide circulates through the blood stream in the form of carbonic acid. The body rids itself of this and other acids in two ways: through the air expelled by the lungs and through the urine excreted by the kidneys. Respiratory acidosis refers to the over-accumulation of acid in the blood stream, which happens when there is an infection in the lungs.
Blood gas analysis must be done to determine the carbon dioxide levels. This is a painful procedure since it is an arterial procedure done at the wrist. These are done every 15 to 30 minutes until the supplementary oxygen and injections allow enough oxygen to the bloodstream again. Ventilation of the lungs either by natural means or a mechanical respirator is necessary to restore oxygen to the blood.
Secondary Polycythemia
In response to the shortage of oxygen, the body steps up the production of red blood cells. This is beneficial to a point and then the overabundance of red cells makes matters worse. The blood thickens and its flow decreases decreasing blood supply to vital organs. The brain is especially affected with dizziness, headache, fainting, and irritability. It produces to identifiable signs: clubbing of the fingertips and toes (increased size at the ends of the fingers and toes) and cyanosis. It also may cause thrombosis and/or heart attack. To keep the number of red blood cells within normal limits, oxygen through the nose or tracheostomy helps the body regulate the number of red blood cells.
Respiratory Failure
This is the condition where the heart and lungs can no longer supply enough oxygen to the body even when it is at rest. The warning signs of such failure are not different from late-stage of the disease. They are dysapnea, wheezing, fingernail beds and lips turning dark blue, and a bluish tinge to the body. As the condition progresses, neurological symptoms emerge. There is confusion, drowsiness, and coma. Oxygen therapy is used to correct this problem, but if the person is at end stage, death occurs. Walter Miller, at the end of his life, did not remember the rooms of his own house where he lived every day. His wife drew a plan of the rooms so that he would know where she was when she was not at his bedside.
Right-Sided Heart Failure
The symptoms are the same as those of congestive failure: profuse perspiration, palpitations and chest pain. Excess fluid that is not filtered by the kidneys builds up in the lower extremities. Treatment for such a condition is bronchodilators, digitalis to strengthen the heartbeat, and duiretics to diminish the edema.
Walter Miller died quietly at home with his wife at his side. His body was tired and weakened from the disease brought on by smoking.
Question 7: What attitudes do you have toward this disease and people who have it?