Pulmonary Rehabilitation Programme: Lung Conditions

Anatomy of the Respiratory System

Your two lungs fill your chest and sit on either side of your heart. The left lung is smaller than the right because it shares that side of the chest with your heart. The lungs are split into areas known as lobes, the right lung has 3 lobes and left lung has 2 lobes. This is to allow space for the heart.

A thin membrane surrounds your lungs and the inside of your ribcage, called the pleura, inside of which is the pleural cavity. Fluid inside the cavity provides friction free movement when you breathe and the lungs expand and relax.

Your windpipe – also known as your trachea – carries air into the lungs and out again when you breathe out. The trachea is supported and kept open by c shaped cartilage rings. As the airways progress down into the lungs they become less cartilage and more muscle.

The windpipe divides into airways called bronchi. These continue to divide into smaller and smaller airways. This is often referred to as the bronchial tree. At the end of these tubes are tiny air sacs called alveoli. This is where gas exchange of oxygen into the blood and carbon dioxide back out happens.

Bronchioles and Alveoli

• Bronchioles control flow of air in and out
• Alveoli have large surface area for gas exchange

The above diagram shows the airways getting smaller and finally leading to the alveoli air sacs.

Blood vessels are wrapped around these sacs and carry the blood allowing for the oxygen and carbon dioxide exchange to take place.

This needs lots of surface area and is the reason for lots of small air sacs.

Your airways also contain tiny glands that produce a small amount of phlegm. Phlegm helps to keep your airways moist, and traps the dust and germs that you breathe in. The phlegm is moved away by tiny hairs, called cilia, which line your airways (as shown in the diagram above).

How do I Breathe?

Your main muscle used to breath is your diaphragm, which sits below your lungs and divides your chest from your abdomen.

When you breathe in your diaphragm contracts and flattens. The rib cage and lungs expand, causing a reduction in pressure, drawing air into the lungs.

When the diaphragm relaxes, it returns to its dome shaped position and air is pushed out of the lungs.

Having gone through a basic overview of the anatomy of the lungs and working of the respiratory system, you can see that there are different structures and functions that can be affected by different conditions.

We are now going to provide a basic overview of some of the lung conditions and how these could affect your breathing.

Chronic Obstructive Pulmonary Disease

COPD stand for chronic obstructive pulmonary disease:

• Chronic means a long term condition
• Obstructive means that the airways are narrowed or blocked making it harder to breathe out quickly
• Pulmonary means affecting the lungs
• Disease is a medical condition

COPD is a group of conditions that affect your lungs making it difficult to empty air out of the lungs due to narrowed airways. The condition includes chronic bronchitis and emphysema.

Chronic Bronchitis

With chronic bronchitis, the airways are inflamed and narrowed, and there is an excess production of phlegm. As you can see in the diagram, the tube on the bottom represents an airway that is not smooth and clear, but more narrow and contains phlegm, compared to the healthier airway representation on the top.

Emphysema

In emphysema, the air sacs at the end of the airways known as the alveoli are damaged, and they are no longer round and plump. The walls of the sacs become baggy and unable to stay open, which means less surface area for the gas exchange to take place. If this damage affects a significant proportion of your lungs, gas exchange worsens, and therefore you may require oxygen to help keep the right concentration of oxygen reaching the lungs.

Symptoms of COPD

• Breathlessness; this may first be noticed on exertion, but people may find they get breathless on doing everyday activities
• Cough, which may last a long time
• Production of more phlegm than usual
• Wheezing
• Chest infections

Asthma

Asthma is an inflammatory condition, in which the airways are reacting to certain inhaled substances such as pollen, irritants or smoke. The airways become tightened making them narrower and it is therefore harder to get air in and out of your lungs. Initially there is reversible airway obstruction, caused by spasm of the muscles of the bronchiole airways. The airway lining can also being inflamed causing a build-up of phlegm.

Symptoms can include:

• Wheezing that comes and goes, depending on environment and irritants around
• Tightness in chest
• Coughing
• Shortness of breath

Chronic Asthma is where this inflammation and tightness is persistent.

ACOS

However, there is a group of patients that have the risk factors and clinical features of both COPD and asthma, and the concept of an ‘overlap’ syndrome has been proposed, known as ACOS. Best estimates suggest the overlap syndrome occurs in about 10% of people with airways disease, and in the overwhelming majority of patients a definite diagnosis can and should be made.

ACOS is characterised by persistent limited airflow with several features usually associated with asthma and several features usually associated with COPD.

Bronchiectasis

Bronchiectasis is a long-term condition where the airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection. The cilia, the tiny hairs that help to move the phlegm become less effective.

The most common symptoms of bronchiectasis include:

• A persistent cough that usually brings up phlegm
• Breathlessness
• Vulnerability to chest infections if phlegm is not cleared regularly, therefore there are breathing exercises that should be completed daily as part of this condition. If you have a diagnosis we would suggest that you also watch the separate Bronchiectasis Presentation that can be found on the main Pulmonary Rehabilitation Service web page

Interstitial Lung Disease/Pulmonary Fibrosis

Interstitial lung disease is a broad term used for a group of lung conditions that cause scarring of the lung tissue.

This includes conditions such as pulmonary fibrosis, sarcoidosis, asbestosis and pneumonitis. The scarring on the lungs reduces their efficiency as the lungs become stiffer and lose their elasticity, so they are less able to inflate and take oxygen from the air when you breathe in. In pulmonary fibrosis, there is scarring and inflammation, making it harder to exchange oxygen.

Symptoms for interstitial lung diseases can include breathlessness, a persistent cough and a feeling of tiredness.

Sarcoidosis

Sarcoidosis is where there is an immune response that forms granulomas, which is a group of inflammatory cells.

Instead of attacking foreign cells it starts attacking healthy tissue.

It can lead to scarring and damage to the tissue, causing long term problems such as breathlessness and poor oxygenation.

It can also affect multiple organs in the body.

Treatments

Because these respiratory conditions are not curable, the treatments are aimed at improving symptoms and different treatment options will differ depending on the condition. These treatment options could include:

• Smoking cessation
• Exercise
• Diet
• Vaccinations
• Inhalers: Short & long acting bronchodilators
• Steroid inhalers/Tablets – Bronchodilator Steroid
• Mucolytic medicines
• Antibiotics
• Oxygen
• Surgery

Research has shown if you stop smoking it reduces the rate the disease progresses, hospital admission and mortality rate. It is the most effective way to help the disease. It doesn’t matter what stage the disease is at, there is a massive benefit. However, it is also important to emphasise that not all respiratory conditions are the result of smoking.

• Exercise is important with all conditions and will be the reason why you were referred to this Pulmonary Rehabilitation programme. Please see the exercise information in this booklet or the presentation online for more information on this topic.
• A healthy diet and lifestyle is important for everyone. If you have a respiratory condition, a healthy diet can also help you with fighting an infection (see the Food Choices web page).
• Flu / pneumonia vaccination: To prevent severe infections and reduce your chance of hospital admission, you should have the flu vaccination every year. You can have the pneumonia vaccination, and after 10 years you may get a blood test to see if your vaccination is still present. If not, you are likely entitled to another vaccination.
• Inhalers – you may be prescribed inhalers for your condition. You need to take these as prescribed and ensure you know the correct technique.
  • Please see the Medication web page or online presentation for more information
• Steroid tablets are normally taken if you have chest infection for a short period. These tend not to be prescribed for longer term due to side effects however if there is seen to be significant benefit then the doctor may prescribe a long term steroid dose.
• Mucolytic medicines, for example Carbocisteine and NACSYS, are designed to help assist with the clearing of phlegm by trying to make it a thinner consistency.
• Antibiotics will be prescribed for an infection. These may also be part of a rescue pack that you have at home. Your doctor may also request a sputum sample to make sure the antibiotic is the right one to fight your infection.
• Surgery may be an option in some cases, such as removal of part of an affected lung or lung transplant. There is very specific criteria for this, and all other conservative treatments will have already been implemented with limited effect.
• Oxygen: Often oxygen levels are monitored during appointments to ensure your body is getting adequate oxygen. If there are concerns that it is low either at rest or when exercising you would be referred to the oxygen clinic for further assessment.

Oxygen

Oxygen is a prescribed medication and is used to treat low levels of oxygen in your blood and not shortness of breath.

However, due to low oxygen levels you may feel an increase in shortness of breath, which may improve when on oxygen treatment.

The referral to the oxygen clinic will be because you have a low oxygen level reading on the monitor at rest or after exercising. People have different oxygen requirements:

• Long term oxygen is used for a certain number of hours a day at a level prescribed
• Ambulatory oxygen is for use whilst doing activities or exercises
• Short burst oxygen is used for periods of 10-20 minutes as prescribed

Supply of Oxygen

Oxygen will be delivered to your home once it has been prescribed. Support with your oxygen will be provided by the Bedford Hospital Home Oxygen service. Arrangements can be made for holiday destinations to be set up with oxygen.

It is important that you recognise any signs of infection early and that you act quickly to ensure the correct treatment is started. These are some of the signs that you may have before an infection or exacerbation.