VH COPD Handbook by bob brocious

Living Well With COPD PATIENT GUIDE

Global Initiative for Chronic Obstructive Lung Disease (GOLD) GOLD is the recommended standards by which COPD is diagnosed and treated. It is endorsed by the National Institute of Health (NIH) and the World Health Organization (WHO). The information provided in this manual follows GOLD standard for the diagnosis and management of COPD. 7/2014

Table of Contents 1. COPD • What is COPD?.................................................................................................................................................. 5 • How Your Lungs Work...................................................................................................................................... 5 • Emphysema and Chronic Bronchitis.............................................................................................................. 6 • Causes of COPD................................................................................................................................................ 6 • Symptoms of COPD.......................................................................................................................................... 7 • What Can You Do About Your COPD?........................................................................................................... 7 2. Smoking Cessation • Quit Smoking................................................................................................................................................... 11 • Cigarette Dependence..................................................................................................................................... 13 • Readiness to Quit............................................................................................................................................. 14 • Smoking Triggers............................................................................................................................................. 16 • Sticking to Quitting......................................................................................................................................... 18 • Smoking Cessation Products.......................................................................................................................... 19 3. Medications • Maintenance Medicines.................................................................................................................................. 23 • Exacerbation Medicines.................................................................................................................................. 23 • Inhaled Medications........................................................................................................................................ 23 •O xygen.............................................................................................................................................................. 24 • Medication “to-do” List.................................................................................................................................... 24 • Sticking With Medications.............................................................................................................................. 26 4. Exercise and Nutrition •E xercise.............................................................................................................................................................. 31 a. Why Exercise?...........................................................................................................................................31 b. Stretching..................................................................................................................................................32 c. Aerobic......................................................................................................................................................34 d. Strengthening...........................................................................................................................................34 e. Exercise while sitting...............................................................................................................................36 •N utrition........................................................................................................................................................... 37 a. Healthy Eating..........................................................................................................................................40 b. Tips for Eating with COPD....................................................................................................................43 5. Managing COPD • Day to Day Management................................................................................................................................ 47 • Prevent Exacerbations..................................................................................................................................... 47 • Air Quality Index............................................................................................................................................. 48 • Flu and Pneumonia......................................................................................................................................... 49 • Conserving Energy and Controlling Stress.................................................................................................. 50 • Breathing Control............................................................................................................................................ 51 •E xacerbations................................................................................................................................................... 52 •D epression........................................................................................................................................................ 52 6. T raveling with COPD......................................................................................................................................... 57

SECTION 1

COPD

What is COPD?

How Your Lungs Work

COPD stands for Chronic Obstructive Pulmonary Disease. You can remember what these words mean by understanding their definitions

You have two lungs, one on the right and one on the left. They are located in your chest and protected by your ribs. When you inhale, air flows into your nose or mouth, through the trachea (windpipe) and bronchial tubes (airways), to the alveoli (air sacs) deep in your lungs.

Chronic means this disease will not go away. Obstructive means partly blocked. Pulmonary means in your lungs. Disease means sickness.

Oxygen (O2) passes through the air sacs and into the bloodstream. The blood carries the O2 to all the parts of your body. At the same time, carbon dioxide (CO2) passes from the blood vessels into the air sacs and is blown out of your lungs when you exhale.

The term COPD is used to describe a slowly progressing disease involving the airways in the lungs, lung tissues, or both. It is a long-term disease that will not go away. It may get worse over time.

Healthy Lungs — Breathing In

There are two diseases that make up COPD: Emphysema and Chronic Bronchitis. Some people may have either emphysema or chronic bronchitis, but many people with COPD have a combination of both of these diseases. People with COPD may sometimes have a worsening of symptoms called a flare-up or exacerbation.

through th

Inhale

People with COPD are at increased risk for heart disease. In COPD, oxygen (O2) levels in the blood fall and carbon dioxide (CO2) levels rise. This can cause tiredness, poor concentration, and heart strain. This strain can cause the heart to enlarge and lead to swelling of the legs and ankles, called edema. It is important to tell your healthcare provider if you are experiencing edema. Your healthcare provider may perform a variety of tests to diagnose and stage your COPD to determine the best course of treatment for you. These may include: • Pulmonary Function Test

Healthy Lungs — Breathing Out

through th • Chest X-ray • O2 Level Measurements • Blood Tests • Sputum (mucus) Culture • Exercise Tests

Exhale

COPD is a serious illness that can greatly affect your life, but it does not mean that you cannot enjoy your life. Together with your healthcare provider, you can learn ways to effectively cope with your disease, improve your breathing and level of fitness, prevent worsening symptoms, and slow the progression of your disease.

Emphysema

Lungs with Chronic Bronchitis

• With emphysema, the air sacs (alveoli) and small airways (bronchioles) are damaged and lose their elasticity. • When you breathe out, stale air becomes trapped inside air sacs. • Th is makes it harder for fresh air (containing oxygen) to come in and carbon dioxide to go out. • Th e blood vessels around the air sacs are also damaged, which prevents fresh air with oxygen from reaching the bloodstream and carbon dioxide from going out of the body.

Lungs with Emphysema

Chronic Bronchitis With bronchitis, the airways become swollen and produce large amounts of mucus. The swollen tissues and mucus can make breathing difficult because the inside of the airways become narrow or closed in. Lungs with bronchitis can become easily infected because it is difficult to cough out the mucus. A person with Chronic Bronchitis has a mucus-producing cough most days of the month, three months of a year for two years in a row without other underlying disease to explain the cough. After a long period of irritation: •E xcess mucus is produced constantly

Causes of COPD The most common cause of COPD is cigarette smoking, but there may be other causes or contributing factors. • Work-related dusts and chemicals (vapors, irritants, and fumes) and things in the environment, such as coal dust or silica. • I ndoor air pollution from fuels used for cooking and heating in poorly ventilated homes • S econdhand smoke may add to breathing problems and COPD •C hildhood respiratory infections (colds and viruses) may be linked to less lung function and more lung problems as an adult

• Th e lining of the airways becomes thickened • An irritating cough develops • Air flow may be troubled • Th e lungs become scarred

• Some patients who develop COPD have a rare inherited disorder called alpha 1-antitrypsin deficiency. This condition can be diagnosed by a blood test and is treatable. In the absence of other contributing factors, people with this disorder may never develop COPD, but it can lead to other health problems if left untreated. •C OPD is made up of two diseases: emphysema and chronic bronchitis. •E mphysema is caused by damage to the air sac walls. •C hronic bronchitis is caused by swelling, inflammation, and scarring in the bronchial tubes. • Th e two diseases often overlap, which means that many people with COPD have both.

Symptoms of COPD It is important to know the symptoms of your COPD in order to learn to control them. Controlling your symptoms will help to reduce the frequency of exacerbations, slow down the progression of your disease, and improve your quality of life.

What can YOU do about your COPD?

Symptoms include:

There are many things that people with COPD can do to feel better and lead productive and happy lives. The key is: IT’S UP TO YOU. You are in the driver’s seat and must stay in control. Here are some general ideas to make it happen:

• S hortness of breath with activity •F requent cough •C ough with mucus •P roductive morning cough

•F ind a healthcare provider who you can talk easily with. This will be an important relationship for you, since we know COPD is a progressive disease (it does not go away).

• I nability to maintain activity levels due to shortness of breath or tiredness ore frequent colds and respiratory infections •M •L imiting your activities because you get short of breath easily

• Your chosen healthcare provider will prescribe medications, perhaps oxygen if you need it, and help you if you become sicker. This is now a PARTNERSHIP and your are one half of it! •M ake an action plan with the help of your health care provider. This will help you stay on the path to wellness by setting real goals. •G et support from family and friends. They can help you achieve your goals.

You can live well with COPD. It is up to you to take control. 7

Here are some real and practical ways that you can improve and live well with COPD: •Q uit smoking •G et flu and pneumonia shots • Understand your COPD medicines •E xercise and get good nutrition • Conserve your energy •R educe stress •C ontrol your breathing

Action Plan

•U se oxygen therapy if your health care provier thinks it is necessary

A series of steps and you will plan with your health-care provider to help you succeed in living well with COPD.

anage acute COPD exacerbations (flare ups) — •M worsening episodes caused by infection

Notes

SECTION 2

SMOKING CESSATION

Quit Smoking

There are oral medications that can help you control the urge to smoke: • Wellbutrin (brand name), bupropion (generic)

If you have not quit, do it now. It is the best move you can make to improve your life with COPD.

•Z yban (brand name), bupropion (generic)

According to experts, these methods can help:

•C hantix (varenicline) — no generic available

Nicotine Replacement • Nicotine patch

•N asal spray

Speak with your health care provider to see if these medications would be right for you. While these medications have proven to be very helpful in helping patients stop smoking, they do come with side effects that need to be understood when making the decision to use them. Ask your health care provider and/or pharmacist to discuss the risks.

These products can help lessen the urge to smoke. Check with your health care provider first to make sure the one you choose will not interfere with other medicines and to select the correct dosage. Be especially careful if you have heart or blood vessel problems.

Get support and encouragement — your best chance of success is with the help of others •L earn how to handle and limit stress and urges to smoke.

•N icotine gum •N icotine lozenge • I nhalers

Valley Health Wellness Services has a tobacco cessation program. For more information call 1-800-662-7831

1. Effect of smoking on arterial stiffness and pulse pressure amplification, Mahmud A, Feely J. Hypertension. 2003:41:183 2. US Surgeon General’s Report, 1988, p. 202 3. U S Surgeon General’s Report, 1990, pp. 193, 194,196, 285, 323 4. US Surgeon General’s Report, 1990, pp. 285-287, 304 5. US Surgeon General’s Report, 2010, p. 359 6. A Report of the Surgeon General: How Tobacco Smoke Causes Disease – The Biology and Behavioral Basis for Smoking-Attributable Disease Fact Sheet, 2010; and Tobacco Control: Reversal of Risk After Quitting Smoking. IARC Handbooks of Cancer Prevention, Vol. 11. 2007, p 341 7. A Report of the Surgeon General: How Tobacco Smoke Causes Disease – The Biology and Behavioral Basis for Smoking-Attributable Disease Fact Sheet, 2010; and US Surgeon General’s Report, 1990, pp. vi, 155, 165 8. Tobacco Control: Reversal of Risk After Quitting Smoking. IARC Handbooks of Cancer Prevention, Vol. 11. 2007. p 11

Fagerstrom Test for Cigarette Dependence The Fagerstrom Test for Cigarette Dependence is designed to help you and your health care provider have a discussion about your need to smoke. Please read each question below. For each question check (9) the box that best describes your response. 1. H ow soon after you wake up do you smoke your first cigarette:

COPD and Smoking Quitting is the best medicine of all

After 60 minutes........................ 9 0

For patients with COPD…

31 – 60 minutes......................... 9 1

• S moking is the leading cause of COPD

6 – 30 minutes............................ 9 2 Within 5 minutes...................... 9 3

•Q uitting smoking slows the progression of COPD

2. D o you find it difficult to refrain from smoking in places where it is forbidden, e.g., in church, at the library, at the movies, etc?

• S econd hand smoke can worsen COPD symptoms

For anyone who smokes…

Yes................................................ 9 1

• S moking increases your chance of getting heart disease, having a stroke, and developing lung cancer

No................................................ 9 0

• Within 1 to 9 months after quitting smoking, most people cough less and are less short of breath

3. Which cigarette would you most hate to give up? The first one in the morning... 9 1 Any other.................................... 9 0

Quitting is hard for anyone who smokes. Here are some tips to help you stop smoking:

4. How many cigarettes do you smoke a day? 10 or less..................................... 9 0

•T ry…and try again. Even if you’ve tried before.

11-20............................................ 9 1

• S et a quit date and stick to it.

21-30............................................ 9 2

•F ind out what makes you want to smoke. Then plan how to deal with these triggers.

31 or more.................................. 9 3 5. D o you smoke more frequently during the first hours after wakening than during the rest of the day?

reate a quit plan: •C –Q uitting “cold turkey” may not work best for you. –C onsider enrolling in a quit-smoking program. – Ask a friend or family member for support.

Yes................................................ 9 1 No................................................ 9 0 6. D o you smoke even when you are so ill that you are in bed most of the day?

•M ake your home smoke-free. – Ask friends and family members to not smoke around you.

Yes................................................ 9 1 No................................................ 9 0 To find out your score, add up the numbers for each response. Higher scores may mean that you have a greater need to smoke. No matter what your score is, share this information with your health care provider.

Tell your health care provider you want to quit. He or she may be able to give you recommendations on how to quit. It’s never too late to quit smoking!

I Am Ready to Stop Smoking!

Quitting takes time…but I’m taking positive steps: Check each statement that is true

I know it takes time to stop smoking. I’ll take it one step at a time. I feel that I am ready to take my first step. The statements below can help me understand why I want to quit smoking and why I think this is a good time to quit.

9 I have decided to quit — but I am not ready to set a date

Check each statement that is true.

9 I have set a quit date and I will quit on

I want to stop because:

_____________________________________________

9 I do not want to have bad breath

_____________________________________________

9 I do not like my smoking habit 9 I am worried about my health

9 I smoked my last cigarette and have gone 24 hours without lighting up

9 I want to look better

9 I have removed cigarettes from my pockets/purse

9 I do not like the way my clothes smell

9 I have been a non-smoker for____________________

9 I want to quit smoking for my family

9 I request non-smoking rooms when I travel

9 I want to feel in control

9 I am proud of myself because____________________

9 Other reasons I want to stop

_____________________________________________

9 Other things I have done_______________________

_____________________________________________

I want to stop now because: I will celebrate the small steps! I will also:

9 I understand why I want to quit

Think about the reasons why I want to quit smoking.

9 My desire to stop smoking is strong

Ask for help if I need it.

9 I am able to manage this life change now

Talk with my health care provider.

9 I am coping with home and work demands 9 I feel good and I have lots of energy to do this 9 I can take some time for myself if I need to deal with withdrawal 9 It is also a good time for me to stop because _____________________________________________ _____________________________________________ _____________________________________________

Why is quitting so hard?

What may help you quit smoking?

Three things usually work together to make you want to smoke

9T alk to your health care provider about quitting smoking.

9 Nicotine addiction Nicotine is the drug in tobacco that causes addiction. At first, nicotine causes you to feel good and may distract you from unpleasant feelings. Why? Smoking nicotine releases “feel-good” signals to the brain. This good feeling does not last long, making you want to smoke again. Over time, your body requires more nicotine to feel the same, which leads you to smoke more.

9L ook at web sites such as www.smokefree.gov, which has information about quitting smoking. 9 J oin community programs for people who are trying to quit smoking. What are your ideas about what might help you? _____________________________________________ _____________________________________________

9 Habit Smoking can make you feel good, so you tend to do it over and over. Smoking also gives you something to do with your hands or mouth. As smoking becomes part of your routine, you no longer think about it — it is now a habit.

_____________________________________________ Talk to your health care provider about quitting. Make a plan. Stick to it. Get help if you need it.

9 Triggers Triggers are things that make you want to smoke — like driving the car, finishing a meal, or being with other smokers. There are many other triggers, too. Each person may have a variety of them. What are some of your triggers? _____________________________________________ _____________________________________________

What are your smoking triggers? Triggers are things that make you want to smoke. When you know what your triggers are, you can plan to deal with them. The urge to smoke usually lasts just a few minutes. Here are some examples to get you started with activities to do instead of smoking. Add your ideas and place a check beside triggers that make you smoke. Write in a way to help you deal with each of them.

My triggers

Instead of smoking I will…

9 When I wake up and start the day.

Take a shower immediately or go for a walk.

Your idea:

9 When I’m driving

Chew sugarless gum or sing along to music.

Your idea:

9 When I’m around other smokers.

Spend time in no-smoking places and with non-smokers.

Your idea:

9 When talking on the phone.

Hold a straw, doodle.

Your idea:

9 When I’m stressed

Exercise, take deep breaths, call a friend.

Your idea:

9 My morning coffee or tea

9 At work, during breaks

9 After each meal

9 Drinking or eating with friends

Knowing your triggers is an important first step toward quitting smoking. The next step is to work with your health care provider to find ways to deal with them.

My triggers

Instead of smoking I willâ&#x20AC;Ś

9 At the end of the work day 9 When I watch TV

9 When I am upset or have argued with someone.

9 When I am angry and cannot talk about it

9 When I am bored, nervous, or scared

9 When I feel lonely

9 After sex

9 When I am reading, writing, etc.

9 Other:

Try to stay away from your triggers. Ask your health care provider or a support person for help.

What will you use as a substitute?

Sticking to quitting… Seven steps to help you stop smoking

_____________________________________________ _____________________________________________

Quitting smoking is hard. Here are seven steps that may help you. Put a check mark beside each action that you plan to try, and discuss these steps with your health care provider.

5. C hange routines that include smoking. Think about the times you automatically reach for a smoke. Create a plan to do something different. For example, if you usually smoke while:

1. H andle stress without smoking.

9D rinking morning coffee — Change your morning routine. Drink tea or take a shower or a short walk before drinking coffee.

If you know about difficult times coming up at work, at school, or in your personal life, create a substitute plan for smoking during these times. For example:

9T alking on the phone — keep your hands busy by doodling or drawing.

9 Avoid the situation 9 Use a “quit-smoking” aid 9 Talk to a friend

9 Relaxing after meals — get up from the table right away, brush your teeth, take a walk.

What makes you stressed? How will you handle it?

What is your plan to do something different?

_____________________________________________

6. Do not make weight gain your main focus.

2. Drinking alcohol may affect your quit-smoking plan.

If the thought of gaining weight is keeping you from quitting smoking, think about all the benefits instead. Try these ideas to help prevent gaining weight:

Drinking alcohol may be a trigger for smoking. 9 I f you drink alcohol, talk to your health care provider about your plan to quit smoking.

9P lan time to exercise. Aim for 30 minutes of moderate exercise a day, 5 times a week 9 Drink water before and after meals

3. Stay away from smokers.

9 Chew sugarless gum or eat sugarless candy

It is harder to quit when you are around smokers. When you first quit smoking:

What will you try?

9 Try not to be near others that smoke 9A sk friends, loved ones, and coworkers not to smoke near you How will you try to stay away from smokers?

_____________________________________________

Cravings do not last long. They usually pass within a few minutes.

_____________________________________________ 7. Deal with cravings to smoke.

_____________________________________________

9 Stop what you’re doing and do something else

4. Keep substitutes for your cigarettes nearby.

What else can you do if you crave a cigarette?

You may feel you need to have something in your mouth when you quit smoking. These substitutes may help:

_____________________________________________

9 Sugarless candy 9 Bottled water 9 Toothpick

_____________________________________________ 18

Help Someone You Care About Quit Smoking

9 Keep your cigarettes, matches, and lighters out of sight 9 Th ink about quitting too. Quitting together could make it easier for both of you.

When someone you care about stops smoking, you may both become healthier.

You can also encourage your family member or friend to talk to his or her health care provider about the decision to quit. When someone you care about tries to stop smoking support them in this important decision!

Why? Smoking may be harmful to both smokers and those who breathe the secondhand smoke (smoke from someone elseâ&#x20AC;&#x2122;s cigarette). People who choose to quit smoking deserve all the help you can give them, because it is very hard to stop. So when someone you care about quits smoking, support them in this important decision!

Products to Help You Quit Smoking is a physical addiction and you may find that medications will help you quit. You may want to try over-the-counter nicotine replacement lozenges, gum, or patches.

How you can help Ask the person who is quitting what are the best ways you can help. Check the boxes for the actions that you will take to support him or her. 9 Say how well they are doing 9 Say how pleased you are that they are quitting 9 Say that it is OK to talk to you whenever they need to

E-cigarettes, also known as electronic cigarettes and vaporizer cigarettes are devices that emit doses of vaporized nicotine that are inhaled. Because e-cigarettes do not actually contain tobacco, they are not subject to U.S. tobacco laws. There is no data to support the effectiveness of e-cigarettes as an effective tool for smoking cessation. Long-term effects of the devices have also not been studied. The FDA and other regulatory agencies around the world are looking at these devices and considering restricting their use.

9E ncourage them to keep trying even if they are finding it hard to quit 9 S pend time doing things together to keep their mind off smoking 9 Help with chores or errands to lessen their stress 9 Celebrate milestones. Quitting is a big challenge! 9 Be there to listen

What is not helpful 9 Do not nag, preach or scold 9 I f they are grumpy from nicotine withdrawal, do not take it personally. Try to stay cheerful and listen. 9D o not assume they will start smoking again if they slip

You should ask your physician if prescription medication may be right for as you start your journey to a smoke-free lifestyle.

9 Do not offer advice. Just ask how you can help.

If you smoke 9 Never offer them a cigarette 9 Do not smoke near them

Notes:

SECTION 3

MEDICATIONS

Medications

Exacerbation Medicines Exacerbation medicine is COPD medicine that you take ONLY when your COPD symptoms have gotten worse. These medicines are also called Rescue Medicines. You need to start using your rescue medicines as soon as your symptoms start to become worse. It is very important to talk to your healthcare provider or someone on your COPD caregiver team as soon as possible when you start having more symptoms. Sometimes you will have to go to the hospital to get these medicines until you feel better. Some types of these medicines are:

COPD medicines are a very important part of keeping your COPD symptoms controlled and keeping you out of the hospital. There are a lot of different medicines that can be used to help you breathe better with COPD. They work in different ways. Your healthcare provider will determine which medicines are best for you depending on the stage of your disease, your symptoms, and your ability to obtain the medications. It is important that you know what medicines are prescribed for you, why you are taking them, and how to take them.

•F ast-acting Bronchodilators

There are two main categories of medicines: Maintenance Medicines and Exacerbation Medicines.

These work more quickly than your maintenance bronchodilators that you take every day. They give you immediate relief of your symptoms.

Maintenance Medicines Maintenance medicines are COPD medicines you take EVERY DAY even when you have no COPD symptoms and you feel great! These medicines help you continue to feel great. Some of these medicines may be in pill form, but most are inhaled (breathed directly into your lungs). Types of inhaled medicines that may be prescribed for you are: •L ong-acting Bronchodilators

• Antibiotics – “Anti” means against – “biotic” means bacteria Antibiotics help your body to get rid of an infection that is causing you to have worsening COPD symptoms. • Glucocorticosteroids Usually referred to simply as steroids, these medicines help to decrease the swelling in your airways. They work more quickly than the inhaled steroids that you may take every day.

– “Broncho” means lungs – “dilator” means to open up wide Bronchodilators are medicines to help “open up” your airways to make breathing easier. • Corticosteroids This is a type of medication that helps decrease swelling in your airways to make breathing easier Your maintenance medicines will not work well if you do not take them every day as directed. You may find it harder to breathe and your symptoms may become more frequent and severe resulting in exacerbation. It is very important to take your medicine every single day just as your healthcare provider has recommended to stay well and avoid an exacerbation.

– QVAR – Asmanex Combination Bronchodilator/Steroid – Advair – Symbicort – Dulera – Anoro Ellipta Rescue Medications – Atrovent – Albuterol (ProAir, Proventil, Ventolin) – Maxair – Xopenox – Combivent – Duoneb

Tips When Using Inhalers •M ake sure that your mouth is clean before using your inhalers so that you do not breathe food debris into your lungs

This list contains only some of the medicines that your healthcare provider may prescribe for your COPD. It is not a complete list of available medications.

•R inse your mouth after using your inhalers •C lean your inhalers regularly according to the manufacturer’s instructions

Oxygen

• Always carry rescue inhalers with you

Eventually, many people with COPD will need supplemental oxygen. It can improve your quality of life and may help you live longer. Oxygen is a medication. It requires a prescription and needs to be monitored regularly.

•H ave your inhaler technique evaluated by a member of your healthcare team at least once a year

COPD Inhaled Medications DAILY MEDICATIONS

Oxygen is ordered only if you meet criteria. Your oxygen levels (O2 Saturation) will be tested with a pulse oximeter, (a noninvasive device that is placed on your finger.) The pulse oximeter shows how much oxygen is being carried by your red blood cells. You will be tested on room air (without oxygen) at rest and with activity. If your O2 saturation is too low, you will be placed on oxygen and tested again. This test will help your healthcare provider decide if you need oxygen and how much you need.

Long-acting bronchodilators •L ong-Acting Beta Agonists – Serevent – Foradil – Brovana – Performist – Arcapta •L ong-Acting Muscarinic Antagonists – S piriva –T udorza Pressair

If you do need oxygen, you may not need it all the time. Some people with COPD only need oxygen with activity or at nighttime. Others need to wear it all the time. Your healthcare provider will let you know how much oxygen to use and when to use it.

Long-Acting Steroids – Pulmicort – Alvesco

It is important to use your oxygen as prescribed by your healthcare provider. 24

COPD Medication “to do” List

• Write “refill medicine” on your calendar a week before you run out

Every day:

• Make sure you have enough refills to last until your next visit with your healthcare provider

9T ake your medicine(s) as recommended by your healthcare provider

• Ask your pharmacy to send reminders when it is time to refill your medicine

9W rite down any questions you have that are not an emergency so you do not forget to ask them the next time you see your healthcare provider

Your Medicine Schedule

9M onitor your symptoms and call your healthcare provider or go to the hospital if they get worse

Work with your doctor to learn all you can about your medicines and how to use them effectively. It’s never easy to form new routines, but these tips can help you make and stick to a schedule for taking your medicines. Your goal is to use your medicines correctly every day to breathe easier and feel good.

9C arry a current list of your medications (including prescription, over-the-counter, herbals, and vitamins) 9 Carry a list of drug and food allergies

Every month: 9 Fill your medicine at the pharmacy

Match your medicines with an activity. Make a list of your medicines and the times they should be taken. Then place the medicine near a cue to help you remember to take it when you do a matching daily activity. For example, place an inhaler near your toothbrush to help you remember to use it in the mornings and evenings. Place other medicines on your table to remember to use them with your meals, or place them near your TV remote control. Use any cue that will help you remember. You may want to invest in a pillbox that has slots for the different times of day and for every day of the week. You would then pack the pillbox with a week’s supply of medicine.

9C heck your medicines to see if you have refills left. Call your healthcare provider to ask for more refills before you run out of medicine.

9U pdate your medication list and make copies to give to each of your healthcare providers

At each health care visit: 9T ell your healthcare provider about any side effects you are having 9T ell your healthcare provider about any other medications you have started or stopped taking, including any over-the-counter medication you are taking (OTC), herbals, or vitamins

Pay attention to problems. It may take time to form a schedule that works for you. Different things work for different people. Changes may have to be made. You may need to wear a wristwatch with an alarm set for your medication times. Or tape a small schedule to your telephone with brightly colored tape. Or place an inhaler near your car keys to remember to take some medicine with you when you leave the house.

9T alk to your healthcare provider about any questions or concerns you have regarding your health care or medicine(s)

Tips to Help You With Your Medicines • S et an alarm for the times that you need to take medicine. • Leave yourself a note on the bathroom mirror • Keep your maintenance medicines in a place that you will see them every day

• Th ink about the risks of not sticking with your medicine plan and write them down: __________________

Remember, it may not be easy, but in time, your medicine schedule will become part of your everyday routine.

Learn more about the medicines you take and how they may help you.

Quitting smoking and taking your medicines regularly and effectively are the two most important steps you can take to live better with COPD.

Stage 3: Preparation Example: “I’m ready to do

something.”

Am I Ready to Stick with my Medicines?

• You’re getting information and working on a detailed plan.

Making changes in life can be hard. Before you change, you must believe in what you are doing. You must also be ready to take the first step to achieve change. How ready are you to start taking your medicines as directed by your healthcare provider?

• You’re letting others know about your plan. • You’re already making small changes. For example, “I bought a pill box to organize my medicines.”

•R eview the 5 stages of change below to decide what stage you are in today.

• Write down specific details of your plan. Set small goals at first._________________

• Th en, on the ruler below, mark how ready you are to change today.

Your plan does not need to be perfect right away. Set a start date and try it.

• J ot down your ideas for moving from that stage to the next stage and discuss them with your provider. Not Prepared to Change

Stage 4: Action Example: “I’m doing it.”

•N ow you are actually doing what you said you would do.

Already Changing

• You will likely face fears and doubts. These feelings are normal. Ask family and friends for help.

Stage 1: Pre-contemplation Example: “I’m not ready

•M ake your plan specific. For example, “I will fill my pillbox every Sunday night before I go to bed.” Ask for help if you need it.

to stick with my medicine plan.”

• You may not be aware of the need to take your medicine as directed by your provider. • You may even deny that this is a problem.

• Write down how you can make your plan more doable_____________________

• Write down what it will take for you to move from this stage: _______________________

Don’t let slip-ups get you down. Reward yourself along the way.

You may need help from family and friends. But remember, it’s up to you.

Stage 5: Maintenance Example: “I’m still following

Stage 2: Contemplation Example: “I know I need to

• You’ve been at it for 6 months and you feel good about what you’ve done. In order to make a lasting change, don’t take anything for granted.

my plan.”

change. I’m just not ready.”

• You know there’s a problem and you are thinking about it.

•B e careful! Relapse (falling back into old habits) is always possible. Keep working at it. If you slip up you have not failed. Just start again.

•F ear of failure may be holding you back.

Notes

SECTION 4

EXERCISE AND NUTRITION

Exercise and Good Nutrition

of your disease. Cutting back on activity can cause a downward spiral to worsening lung disease. Shortness of breath leads to decreased activity. Inactivity leads to a decline in fitness. A decline in fitness leads to increased shortness of breath. It is a vicious cycle that affects your overall health.

COPD makes the lungs and heart work harder to carry oxygen to all parts of the body. Because of this, you should control your weight to reduce heart and lung strain.

Pulmonary Rehabilitation Pulmonary rehabilitation may help you reduce the impact of COPD by helping to control or reduce breathlessness and recondition the body so that you feel less short of breath. Pulmonary rehabilitation offers: • S tructured and monitored exercise training •N utrition advice •T echniques for reducing and controlling breathing problems •E ducation about maintaining and improving function •H elp to quit smoking

This cycle can be reversed. As you increase your activity, your fitness level will improve. Improved fitness will result in increased energy and decreased tiredness. With an increased energy level, you will find that you are able to increase your activity and perform more everyday tasks. Increased activity will further increase your fitness level. The result is improved health.

• I nformation about your disease and ways to cope •E motional and psychological support

You can benefit tremendously from pulmonary rehabilitation. Discuss it with your healthcare provider.

Exercise COPD poses many challenges including maintaining an exercise program. Many people with breathing difficulties think it is impossible to include regular exercise in their daily routine. This is not true. People with COPD must exercise! With planning and a few modifications, you can maintain an exercise program that will improve your quality of life. Why Do I Need to Exercise? Regular exercise will give you more energy, strengthen the muscles that you use to breathe, improve flexibility, preserve lung function, and slow down the progression

Getting Started Start slowly. Regardless of your current level of fitness, making exercise a part of your daily routine is possible. It’s OK if you can only take a few steps when you start. Small increases in activity do make a difference.

What type of exercise is best? Exercise can be broken into 3 basic categories: • S tretching •C ardiovascular or Aerobic • S trengthening. Ankle Pumping/Leg Circles Sit with your feet straight out in front of you. Keeping your heels on the floor, lift your toes up as far as you can. Hold for a count of five. For leg circles, rotate leg clockwise, then counterclockwise, as if drawing small circles. Repeat.

All of these areas should be included in your exercise routine.

Breathing during exercise Pursed lip breathing will decrease your shortness of breath and increase your ability to exercise. (see page 50 for instructions on pursed lip breathing) Consult your healthcare provider before starting an exercise program and ask if referral to Pulmonary Rehab may be appropriate for you.

Stretching Stretching is the slow lengthening of muscles. It is important to stretch before (warm-up) and after (cooldown) exercise to prepare your muscles for activity and prevent muscle strain and injury. Stretching does not require any special equipment and, if necessary, can be done from a seated position. General guidelines while performing these exercises: • Maintain good posture while performing these exercises — keep your back straight. Do not curve or slump your back.

Knee Straightening Raise your foot to fully straighten your knee out in front of you. Hold for a count of five. Lower your foot to the floor. Alternate legs. Repeat.

•M ake sure your movements are controlled and slow — avoid quick, jerking movements. Do not bounce. •D o not hold your breath during these exercises. If any of the following exercises causes pain, stop the activity and seek the advice of a physician, nurse or physical therapist.

Hip Bending Lift one knee up toward the ceiling. As you lower this knee, raise your other knee. Alternate each leg as if you were marching in place (while sitting). Repeat.

Single Shoulder Circles Bending one elbow, put your fingertips on your shoulder and rotate your elbow clockwise, then counter clockwise. Repeat with your other arm.

Overhead Reaching Raise one arm straight over your head, with your palm facing away from you. Keep your elbow straight. Slowly lower your arm to your side. Alternate arms. Repeat.

Single Arm Lifts Sit with your arms at your sides, fingers pointing toward the floor. Raise one arm out to your side, keeping your elbow straight and your palm facing down. Slowly lower your arm to your side. Repeat with your other arm. Repeat with both arms.

pollen levels, temperature, environmental irritants, and, if needed, resting areas. Indoor walking may be best depending on the severity of your disease. Mall walking is good way to get your aerobic exercise. Malls provide an environment with a controlled temperature. There are usually benches situated throughout the mall, so you can stop and rest if you need to. Another good indoor place to walk is in a grocery store or department store. You can use a shopping cart to help steady yourself and lean on it if you become tired. The goal of aerobic exercise is endurance, not intensity. Use your level of exertion and breathing effort to guide you. If you are not able to talk while you are exercising, you are working too hard. If you are able to speak easily with no additional effort, you are not working hard enough. Use the chart below to judge your activity level. You should try to exercise in the yellow zone. If you are in the green zone you are not working hard enough. If you are in the red zone, you need to slow down.

Calf Stretch Against Wall Stand facing the wall with your hands against the wall for support. Put one foot about 12 inches in front of the other. Bend your front knee, and keep your other leg straight. (Keep both heels on the floor). To prevent injury, do not let your bent knee extend forward past your toes. Slowly lean forward until you feel a mild stretch in the calf of your straight leg. Relax, then repeat with your other leg. Repeat

Aerobic or Cardiovascular Exercise Aerobic exercise is the steady use of large muscle groups. It strengthens your heart and lungs and improves your bodyâ&#x20AC;&#x2122;s ability to use oxygen. Regular aerobic exercise can decrease your heart rate and blood pressure, and lessen fatigue and shortness of breath. Aerobic exercises include walking, bicycling (stationary or outdoors), low-impact aerobics, and water aerobics. Walking is the best form of aerobic exercise if you have COPD and it can be done without a gym membership or any special equipment. If you are unable to walk distances, then start slowly. If you can only walk 30 seconds or 1 minute at a time, then do it 5 times a day. Once you are able to walk 5-7 minutes at a time, decrease the frequency to 4 times a day. When you are able to walk 10 minutes without stopping, you may do it only 3 times a day. Try to work up to walking 30 minutes without needing to stop. Your goal should be 30 minutes of walking daily. Walking can be done indoors or outdoors. If you are planning to walk outdoors, it is important to consider 34

Strengthening

•R est for 2-3 minutes between sets

Strengthening is the repeated contracting (tightening) of muscles until they become tired. Overall body strengthening is important, but upper body exercises are especially helpful for people with COPD as they include the muscles that you use to breathe. Strength training should be done 2-3 days a week. There are several simple strengthening exercises that you can do at home without a gym membership or any special equipment. Soup cans or water bottles can serve as free weights. Ankle weights can be made by filling a sock or sleeve from an old shirt with sand, rice, or pebbles.

•U se lighter weights and do more repetitions if you want to improve muscle endurance se heavier weights and do fewer repetitions if you •U want to increase muscle strength

Be sure to exercise all of the major muscle groups, including: •U pper body: arms, shoulders, chest, and upper back •M iddle body: stomach and lower back •L ower body: hips and legs

If you have not been doing strength training as part of your daily routine, you should start these exercises without using weights. Free weights and ankle weights should be added as your fitness level improves.

Start out slowly • Add exercises over time so that you are doing various exercises that cover all major muscle groups

Strength training basics

When starting out, you may benefit from working with a fitness professional to learn: •H ow to stick to your program

For most adults strength training is a safe and effective addition to an exercise program Strength training can:

•H ow to reduce the risk of injury during exercise

•H elp you burn calories

Talk to your healthcare provider before you begin an exercise program.

• I ncrease your muscle strength • I mprove balance, coordination, mobility • I ncrease the strength of your bones •H elp decrease symptoms of some chronic conditions including arthritis ave many benefits, especially as you get older •H

Strength training can be done using your body weight (like push-ups), free weights (dumbbells), machines, or resistance bands. The American College of Sports Medicine recommends strength training for adults 2 to 3 times a week. • 8 -12 repetitions for 2-4 sets is recommended •R epetition means how many times you lift the weight • A set is a group of repetitions

Strength training without a gym – Level 1

•R est for 1 or 2 minutes, then do this one more time

Wall push-ups

Strength training can help you feel stronger and healthier. Strength exercises help burn calories during and after exercise.

What you need: •G ood shoes (walking, running, or cross-training sneakers) •L oose, comfortable clothing (for example, a cotton T-shirt and cotton shorts or pants) •C hair •E xercise mat or towel over carpet Why: Strengthens arms, shoulders, and chest

Strength training can be done using your body weight (like push-ups), free weight (dumbbells), a medicine ball, or resistance bands.

How: ace the wall, lean forward with palms flat against the •F wall at shoulder width and height

Warm-up Warm up with 5-10 minutes of any activity that slowly raises your heart rate, like marching in place, jumping jacks, or walking up and down the stairs.

eeping your body straight, bend your elbows and •K slowly lean into the wall (do not move your feet) ause, then push back to a count of 2 •P

Exercises (Weeks 1 and 2)

•R epeat 10 times

Squat with chair

•R est for 1 or 2 minutes, then do this one more time

Toe stands

Why: strengthens hips, thighs, and buttocks How: When you first start this exercise, you may not be able to squat very far. You may use your hands to assist you, or squat only a couple of inches at first.

Why: strengthen calves and ankles

•H old your arms straight out in front of you, and lean slightly forward from your hips with your back flat

How: old onto a counter or chair back for balance •H

• S lowly lower yourself to a near sitting position to the count of 4, with most of your weight on your heels (do not let your knees go over your toes) • Pause,then slowly rise back up to standing to a count of 2

• S tanding with your feet shoulder-width apart, rise onto the balls of your feet to a count of 4, and hold for 2-4 seconds

•R epeat 10 times

• Th en lower your heels down to a count of 4 36

•R epeat 10 times •R est for 1 or 2 minutes, then do this one more time •K eep good posture and a straight back during the entire exercise

Exercise while you sit What you need: • A sturdy chair with no arms Waist: Sit with your feet flat on the floor. Sit forward a bit on the seat, keeping your back straight. Hold your arms up in an “L” position so your fingers are pointing up to the ceiling. Twist right then left from the waist. Do 1 set of 16 reps on each side.

•L ight hand-held weights. You can use any two same-size items, such as canned soup or water bottles. You can also do all of these exercises without weights. How to count your exercises: ach move is called a repetition (rep) •E •E ach series of reps is called a set Talk to your healthcare provider about a plan that is right for you. Stomach: While sitting on a chair with your feet on the floor, put your hands behind your head. Bend at the waist towards your knees. Sit back up straight. Begin with 1 set of 10 reps. Add one more set at a time until you feel you have reached your limit.

Shoulders: Pick up a weight in each hand. Start with your arms and weights down at your sides. Slowly raise the weights in front of you so they are at shoulder level. Your arms should stay straight, palms facing the floor. Lower them back down to the starting position. Do 1 set of 8 reps. Repeat 1 more set. You may also do this exercise one arm at a time.

Inner thighs: Place your feet together on the floor and let your knees separate. Place a hand on the inside of each knee. Try to close your knees while your hands try to keep them apart. Your knees should stay in the same position while you do this, as you count to 5. Repeat another count of 5. Later, lengthen the amount of time you do this press.

Shoulder rolls: Roll both shoulders back and around. Do this 4 times, then change direction and roll both shoulders forward 4 times. Now, lift the right shoulder up toward your ear, hold, and then let it drop. Repeat on the left side.

Chest: With elbows out to the side and chest high, hold the weights together in front of your face. Pull the weights apart, staying level, until your elbows can go no farther without going behind you. Return to starting position. Do one set of 8 reps. Repeat 1 more set. 37

Notes: _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Biceps: Sit up with your feet on the ground. Hold one weight in your right hand. Press your arm against your body for support. Starting at knee-level with your palm facing up, lift the weight until it almost touches your shoulder. Lower back to starting position. Be sure to keep your wrist straight. Do 1 set of 8 reps. Take a short rest. Repeat the set. Then do 2 sets of 8 reps with your left arm.

_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

Triceps (back of arms): With both hands extending above your head, hold a single weight with both hands. Keeping your upper arms still, bend your elbows to lower the weight behind your head. Now press the weight back up to the starting position. Do 2 sets of 8 reps.

Fitness facts and fiction

Lifting weights will make me gain weight and inches as I build muscle. False. You will probably not gain weight unless you eat more calories. Strength training helps you gain muscle and lose body fat. Because muscle is denser than fat, it takes up less room. So you may stay the same weight but lose inches. You may even lose weight as you burn calories.

Is there something that is keeping you from reaching your fitness goals? Find out what’s true and what’s not to help make your fitness program a success.

There is only one right way to exercise. False. You don’t have to exercise intensely for long periods of time. Exercising for 10 minutes 3 times during the day works as well as exercising for 30 minutes all at once. Try doing different exercises during each 10 minute period. Just be sure to keep your exercise level moderate to vigorous. In addition, you don’t have to exercise in a gym. You can also exercise at home or outdoors. Good choices include fast walking, bike riding, tennis, pushing a lawn mower, swimming, jogging, or running.

If I only have time to exercise a few minutes a day, it’s not worth doing at all. False. No matter what your age or health, any exercise is better than none at all. Benefits increase the more exercise you do. Regular exercise may help me live longer. True. Compared with leading a physically inactive life, exercising regularly can help reduce your risk for some chronic diseases, such as heart disease, high blood pressure, and diabetes.

If I exercise I can eat more and not worry at all about gaining weight. False. Losing weight depends on burning more calories than you eat. The best way to lose weight or maintain a good weight is to exercise regularly and eat proper portions of healthy foods. I’m already tired. Exercise will make it worse. False. Exercise may improve your energy level. Do not skip your exercise session because you feel tired. Exercise at a lower level. You’ll get the benefits of exercise and boost your energy level. If I do aerobic exercise more vigorously, I can exercise for less time and still get the health benefits. True. One minute of vigorous-intensity aerobic activity is about the same as 2 minutes of moderate-intensity aerobic activity. You know you are exercising vigorously if you can’t say more than a few words without pausing for a breath. If you are exercising at moderate intensity, you can talk but not sing. Health benefits result from 150 minutes a week of moderate-intensity or 75 minutes a week of vigorous-intensity aerobic physical activity.

• I nclude 2-3 servings of “good fats” daily. Good fats (monounsaturated or polyunsaturated) can be found in canola, olive, or corn oil, nuts, fish and seafood. Limit saturated fats found in beef, butter, lard, and fried foods.

Healthy Eating Good nutrition is important for managing any chronic disease, including COPD. Food provides your body with fuel to produce energy for all activities, including breathing.

•C ontrol your sodium (salt) intake. Too much sodium in your diet can cause you to retain fluids which may make breathing more difficult. Take the salt shaker off of the table. Don’t add extra salt while cooking. Try to limit salt to 140 mg or less per serving.

People with COPD may need up to 10 times more energy to breathe than people without COPD. Sometimes it is difficult to eat, especially when you are having an exacerbation, but good nutrition and maintaining a healthy weight are very important.

• I f you take diuretics (water pills), eat foods high in potassium like bananas, oranges, and tomatoes.

If you are overweight, your heart and lungs must work harder. Extra weight causes your body to need more oxygen. The extra weight also puts more pressure on your heart and lungs and makes it harder to breathe. A healthy diet can help you to reduce your weight and make breathing easier. Do not skip meals to try to lose weight! Skipping meals causes your metabolism to slow down and makes weight loss more difficult. If you are overweight, talk to your health care provider about starting a healthy weight-loss program.

• Avoid overeating. Eat 5-6 small meals a day instead of 3 large meals. Avoid foods that cause gas or bloating. Bloating and overeating make breathing more difficult. •L ook at the nutrition labels on food when you are at the grocery store. Understanding food labels will make it easier to choose healthy foods.

If you are underweight, you may feel weak and tired. If you are not eating a healthy diet, your body will burn muscle for energy (muscle wasting). Your muscles will become weak, including the muscles that you use to breathe. A healthy diet can help you gain weight, build muscle, and give you more energy. Do not skip meals! Skipping meals will cause you to become more weak and tired. Whether you are overweight or underweight there are some general diet guidelines that you should follow. •D rink 6-8 cups of non-caffeinated, low-sugar liquids daily. Drinking plenty of fluids will help to keep mucus thin so it is easier to cough up. •E at at least 6 ounces of lean protein every day. Eating enough lean protein will help prevent muscle wasting. •T ry to get 20-35 grams of fiber every day. Good sources of fiber are fruits, vegetables, nuts, beans, and whole grains. Fiber aids in digestion, helps control cholesterol and blood glucose levels, and provides important nutrients that help protect your body.

Food Label Facts In order to eat a healthy diet, you need to know what is in your food. Reading food labels is one way to ensure that you are getting enough of the nutrients that you need while limiting the less healthy nutrients. • S tart with the serving size. Many foods have more than one serving per container. All the nutrition information listed on the label is based on one serving of the food. •C heck the calorie count. Remember, the calories listed are per serving, not per package. •D aily Value (DV) –D aily values are based on a 2000 calorie/day diet. Your daily calorie needs may be different based on your age, health conditions, lifestyle, weight, and gender. Your health care provider can help you decide how many calories you need each day to be healthy. – Th e amount of each nutrient per serving is listed in grams (g) or milligrams (mg). The % DV tells you how much of your daily need of each nutrient you are getting in one serving.

Free, Low, Reduced In addition to the Nutrition Facts label on foods, you need to watch for words like FREE, LITE, LOW, and REDUCED. You need to know what these words really mean in order to make heart healthy choices.

If a food claims to be...

It means that one serving of the product contains...

Calorie free

Less than 5 calories

Sugar free

Less than 0.5 grams of sugar

Fat Fat free

Less than 0.5 grams of fat

Low fat

3 grams of fat or less

Reduced fat or less fat At least 25 percent less fat than the regular product Low in saturated fat 1 gram of saturated fat or less, with not more than 15 percent of the calories coming from saturated fat Lean Less than 10 grams of fat, 4.5 grams of saturated fat and 95 milligrams of cholesterol Extra lean Less than 5 grams of fat, 2 grams of saturated fat and 95 milligrams of cholesterol Light (lite) At least one-third fewer calories or no more than half the fat of the regular product, or no more than half the sodium of the regular product

Cholesterol Cholesterol free Less than 2 milligrams of cholesterol and 2 grams (or less) of saturated fat Low cholesterol 20 or fewer milligrams of cholesterol and 2 grams or less of saturated fat Reduced cholesterol At least 25 percent less cholesterol than the regular product and 2 grams or less of saturated fat

Sodium Sodium free or no sodium Less than 5 milligrams of sodium and no sodium chloride in ingredients Very low sodium 35 milligrams or less of sodium Low sodium 140 milligrams or less of sodium Reduced or less sodium At least 25 percent less sodium than the regular product

Fiber High fiber 5 grams or more of fiber Good source of fiber 2.5 to 4.9 grams of fiber

If you can’t remember the definitions of all of the terms, don’t worry. You can use these general guidelines instead: • “ Free” means a food has the least possible amount of the specified nutrient. • “ Very Low” and “Low” means the food has a little more than foods labeled “Free.” • “ Reduced” or “Less” mean the food has 25 percent less of a specific nutrient than the regular version of the food.

Granola bars Eggs Sandwiches Custard Crackers and peanut butter Cereal and half & half Yogurt and granola Fruit and cheese Cottage cheese and fruit Fruit or vegetables and dip

Tips for Healthy Eating with COPD Short of breath at mealtime or tiredness: • Clear your airways and rest before eating. •C hoose foods that are easy to chew and swallow. •E at slowly, take small bites, and chew well. Put utensils down between bites; breathe deeply while chewing. •U se easy-to-make recipes or ask for help from family and friends. •E at 5-6 small meals and snacks daily and don’t skip meals. • S it upright while eating and for 1-2 hours after meals. •D rink liquids after eating and between meals to reduce feeling bloating and full. •U se pursed-lip breathing.

Underweight or unintentional weight loss: •D rink milk or high-calorie ‘shakes’ between meals. •T ry supplements like Boost Plus, Ensure, or Carnation Instant Breakfast. • Avoid low-fat or fat-free foods; eat a moderate amount of fat daily. • Avoid sweets, sodas, and other ‘empty calories’. •D on’t skip meals. • I nclude some activity, about 30 minutes, to stimulate muscles. •U se ‘calorie boosters’ to add calories to your favorite foods.

Poor appetite: • Avoid non-nutritious liquids like large amounts of coffee, tea, and soda. •E at more protein and fat—metabolizing fats produces less carbon dioxide to exhale. •E at small, frequent meals and snacks. •E at larger meals earlier in the day when you have the most energy. • I nclude light activity to stimulate your appetite. •D on’t waste energy eating foods with ‘empty calories’ (candy, chips, soda). • I nclude favorite healthy foods at mealtimes. Eat with friends and family. •L isten to music while eating, use colorful placemats, and enjoy eating. •U se colorful garnishes like red or yellow peppers and parsley. •D rink liquids after meals instead of during meals. •T ry eating the high-calorie and protein foods on your plate first. •K eep high-calorie and protein snacks visible and in easy reach. •F reeze extra portions for easy and quick meals.

Calorie Boosters Whole eggs or yolk Non-fat powdered milk or evaporated milk Cream cheese Shredded/melted/sliced/cubed/grated cheese Mayonnaise, butter, margarine, sour cream Vegetable oils Peanut butter Nut dust (ground nuts) Jelly or jam Honey, maple syrup Overweight or unintentional weight gain: •D on’t skip meals. Eat frequent small protein-containing snacks. • Avoid sweets, sodas, and other ‘empty calories’. • I nclude some activity, about 30 minutes, every day. •E at more fruits, vegetables, and whole grains for fiber. •L imit sodium (salt) to reduce fluid retention. •L imit serving sizes to healthy portions. •D rink low-calorie fluids.

High-Calorie Snacks Pudding Cheese Ice cream 43

Notes:

SECTION 5

MANAGING COPD

Day-to-Day Management

Control your breathing

Stay away from smoke Exposure to second hand smoke poses the same health risks as smoking. Avoid areas where people are smoking. Ask your family and friends to step outdoors to smoke, or better still, encourage them to quit smoking.

Use pursed-lip breathing when you are short of breath or during physical activity.

Prevent Exacerbations (Flare-ups) COPD is with you all the time, but there are steps that you can take to reduce symptoms and prevent exacerbations.

Prevent infection Infections like a cold, the flu, or pneumonia may cause exacerbations. Some ways that you can help prevent infection are good hand washing, staying away from people that you know are sick, and getting vaccinated against flu and pneumonia.

Be Aware of Triggers in Your Environment • Cold Weather –D uring colder months you may be at increased risk for breathing difficulties and respiratory infections. Extremely cold air can be a shock to your lungs. It causes the muscles around your airways to tighten, narrowing them, making it more difficult to breathe. There are also more colds and flu during the fall and winter months. January and February are usually the coldest months of the year.

Understand your medicines Know when, why, and how! Take all of your maintenance medicines as ordered by your health care provider and know when to use your exacerbation (rescue) medications. Understanding why you take your medicines will help you remember to take them regularly. If you are on inhalers, it is important to know how to use them correctly in order for the medicine to do its job.

•H eat and Humidity – During warmer, more humid months you may be at increased risk for exacerbations. There are chemicals in the air that, when exposed to heat, release ozone. Breathing in too much ozone irritates the lungs in the same way that exposure to the sun causes burns. Humidity refers to the amount of moisture (water) in the air. Moist air is heavier than dry air and is harder to move in and out of the lungs making breathing more difficult. July and August are usually the hottest months of the year.

Stay physically active Regular physical activity helps make your muscles stronger. This may give you more energy to perform everyday tasks and help you to feel better. Eat well and maintain a healthy weight Being overweight or underweight can make it more difficult to breathe. Eating a healthy diet will help control your weight and make you feel better.

• I ndoor Air Quality –K eep the air in your home clean by doing things such as trying to cut down on dust accumulation and changing air filters regularly.

Energy conservation Conserving energy is important in managing breathlessness, especially during an exacerbation. Learn to pace yourself to avoid getting worn out throughout the day and use the energy conservation tips that you have learned.

•O utdoor Air Quality – When there is a lot of air pollution, dust, or pollen outdoors try to stay indoors with the windows closed. You can check the Air Quality Index (AQI) for conditions in your area.

Reduce stress Feeling stressed can make your breathlessness worse. Find ways to relax.

Avoidable Triggers

Try to Make Positive Changes in Your Life

• S moke

• S leep

– Staying away from smoke will decrease your symptoms. In addition to quitting smoking, try to avoid secondhand smoke and fireplace smoke.

– Poor sleep quality may contribute to an increase in symptoms. Talk to your doctor if you have problems sleeping. You should try to get 7-8 hours of quality sleep every night.

•M old

• Conserve Energy

– Exposure to mold may increase your risk of infection.

– Doing activities with less effort, such as sitting to do day-to-day tasks, may decrease tiredness.

•G oing outdoors on very hot or very cold days •O ther Irritants

•H and washing

– Try to avoid lung irritants such as dust, perfumes, and strong odors.

– Frequent hand washing is the single most important thing you can do to prevent illness. •M edicines – Using your COPD medicines as prescribed by your healthcare provider may improve everyday symptoms.

Air Quality Index (AQI) In over 900 counties across the nation, air pollution levels are measured daily and ranked on a scale of 0 for perfect air all the way up to 500 for air pollution levels that pose immediate danger to the public. The AQI further breaks air pollution levels into five categories, each of which has a name, an associated color, and advice to go along with it. You can find the current and forecasted AQI on line at http://www.airnow.gov/. Index Value

Name

Color

Advisory

0 to 50

Good

Green

51 to 100

Moderate

Yellow

Unusually sensitive individuals should consider limiting prolonged outdoor exertion

101 to 150

Unhealthy for Sensitive Groups

Orange

Children, active adults, and people with respiratory disease, such as asthma, should limit prolonged outdoor exertion

151 to 200

Unhealthy

Red

Children, active adults, and people with respiratory disease, such as asthma, should avoid prolonged outdoor exertion; everyone else should limit prolonged outdoor exertion

201 to 300

Very Unhealthy

Purple

Children, active adults, and people with respiratory disease, such as asthma, should avoid outdoor exertion; everyone else should limit outdoor exertion

301-500

Hazardous

Maroon

Everyone should avoid all physical activity outdoors.

None

Conserve Your Energy and Control Stress Most people with COPD must learn to pace themselves to avoid getting worn out throughout the day. Conserve energy with these practical tips, and you’ll get more accomplished without getting short of breath. • Move slowly to conserve energy and avoid breathlessness. •U se a cart with wheels to move dishes, tidy up, work in the garage, put away clean laundry, and so on. • S it to dress, undress, shave, put on makeup, and cook. Sit for as many tasks as possible.

Avoiding Getting Sick with Flu (influenza) and Pneumonia

• Arrange your house so that most things you use are at waist level or within easy reach.

Many people with COPD become very ill every year during flu season. The flu can greatly increase your chances of coming down with pneumonia.

•T ake rests after meals when your body is working hard to digest food. • I nvest in a shower stool and hose sprayer for bathing.

• Avoid germs! Stay away from people with colds and flu. The droplets in coughs and sneezes are full of germs. These germs end up on handrails, door knobs, shopping carts, and all the kinds of things people touch.

•U se assistive (“helping”) devices, such as a long handled reacher, for pulling on socks and shoes and for reaching things in high places.

• Wash your hands often to prevent the spread of germs. Carry alcohol-based hand sanitizer gel with you if you cannot get to soap and water. These are available in many stores and in small containers that fit into a purse or pocket. • Always ask your healthcare provider about getting a flu shot every year at the end of September or early in October because flu types change every year. Just because you had a flu shot last year does not mean you are protected this year. •F lu and pneumonia shots are not the same, but they are both very important for people who have COPD. • I f you are unable to get the flu shot (for example, people who are allergic to eggs cannot have a flu shot), make sure you get treatment as early as possible (there are special medicines available that are active against the flu virus).

Pursed-Lip Breathing for COPD

Control stress Feeling stressed can make your breathlessness much worse.

What is pursed-lip breathing? COPD can make it hard to breathe. When you feel short of breath, pursed-lip breathing is a method that may make breathing easier. It may help you feel less short of breath.

Learn to relax Stress is less likely to build up to anxiety if you know how to relax yourself when you start to feel tense.

How can pursed-lip breathing help me breath? Pursed-lip breathing helps you slow your breathing and use less energy to breathe.

Find what works for you. •T ry yoga, prayer, meditating, or listening to relaxing music. • S ome people like to get comfortable, and concentrate on things that relax them.

How do I do pursed-lip breathing? Follow these steps:

• S lowly tense and relax each part of your body. Start with your toes and work all the way up to your scalp. Breathe in as you tighten, and breathe out as you relax.

1. C oncentrate on relaxing your shoulders and neck muscles. 2. B reathe in (inhale) slowly through your nose as you count to two, taking in a normal breath. 3. P urse your lips as if you are going to whistle or blow out a candle. 4. B reathe out (exhale) slowly through your lips as you count to four or more. 5. R epeat until your breathing slows. Do not force air out. Do not hold your breath.

When can I use pursed-lip breathing? Use pursed-lip breathing when you start to feel short of breath. For example, when you: • Exercise • Bend •L ift things •C limb stairs •F eel anxious You can practice pursed-lip breathing any time. Try it a few times a day when: • You are watching TV • You are working on your computer • You are reading a magazine or newspaper Talk with your healthcare provider to learn more about when to use pursed-lip breathing. If shortness of breath continues or worsens, talk to your provider.

Diaphragmatic Breathing (Abdominal Breathing)

Techniques to Help Clear Mucus From Your Lungs

With COPD, trapped air in the damaged air sacs often causes lungs to over expand.

Ask your healthcare provider about different methods to help you cough up mucus. The Acapella™ and the Flutter® devices are two handheld devices that assist in clearing mucus from the lungs. Learning how to use these devices will make it easier to get rid of mucus in the lungs.

Step 1. Get into a comfortable position. Relax your neck and shoulder muscles.

HUFF Cough: Forced Expiratory Technique •R epeat this cycle two to four times

Step 2. Put one hand on your abdomen and one on your chest.

• S pit out the mucus that comes up Step 1. Sit comfortably in a chair. Take three to five slow, deep breaths using pursed-lip and diaphragmatic breathing.

Step 3. Inhale (breathe in) slowly through your nose to the count of 2. Feel your abdominal muscles relax. Your chest should stay still.

Step 2. Take in a normal breath. Step 4. Tighten your abdominal muscles and exhale (breathe out) while you count to 4. Feel your muscles tighten. Your chest should stay still.

Step 3. Squeeze your chest and abdominal muscles — open your mouth — and force out your air while whispering the word “huff” (sounds like a forced sigh). Some people find it helpful to press on the lower chest at the same time. Repeat once.

Step 4. Return to pursed-lip and diaphragmatic breathing.

Acute COPD Exacerbations (Flare-ups)

Know when to call 911. Discuss with your healthcare provider what to do if you become so sick that you need immediate help.

An acute COPD exacerbation is a worsening, or “flareup”, of symptoms. It may lead to less lung function and a step down in quality of life. Most importantly, it can be dangerous, as it may put you at risk for death. Often an exacerbation will land a person in the hospital.

COPD and Depression It is not uncommon for people with a chronic illness to experience depression at some point during the course of their disease. Almost half of people with COPD experience some level of depression. COPD causes many changes in your body. Some of the physical changes that you will experience over the course of your disease are shortness of breath, weight loss or gain, changes in sleep pattern, difficulty eating, and decreased energy. These changes may cause you to experience feelings of loss and can lead to depression.

Causes of COPD Exacerbations (Flare-ups) • I nfection caused by viruses and bacteria •C ertain cancers • Very hot or very cold weather • Asthma attacks • Air pollution • Heart failure

Signs of Depression • Tiredness, or lack of motivation • Memory loss • Difficulty concentrating or making decisions • Feeling irritable or angry towards others • Crying a lot or feeling sad for weeks at a time • Changes in sleeping patterns • Feelings of guilt or worthlessness • Being overly sensitive to criticism • Increased or decreased appetite • Unable to enjoy yourself or find humor in things • Feeling hopeless or like you want to harm yourself

Studies have found that smoking, lack of a pulmonary rehabilitation program, improper use of an inhaler, and not taking medications properly are all related to having more COPD flare-ups.

What Can You Do? You can prevent infections by doing your best to avoid germs for cold and flu. Catch symptoms early. If you are “tuned-in” to your symptoms so you can get a jump on controlling things from getting worse. What Will Your Health Provider Do During a COPD Exacerbation? COPD flare-ups are treated by changes in your medication, adding steroids, and/or antibiotics, sometimes oxygen. A serious flare-up may mean hospitalization and possibly steroids through an IV.

If you think that you may be depressed or are experiencing symptoms of depression, contact your healthcare provider. Your healthcare provider may be able to help. If you are having feelings of harming yourself call 911.

Some New Ways to Prevent COPD Exacerbations Since exacerbations are a very serious problem for people with COPD, doctors and researchers have been looking for ways to prevent them. Some healthcare providers believe that regular treatment with antibiotics will keep away COPD flare-ups. Ask your healthcare provider if this might be a good solution for you.

Living Well with COPD TAKE IMMEDIATE ACTION • Breathing faster and cannot catch breath • Too short of breath to talk • Skin color is ashen • Lips or nail beds look blue • Hear is racing • Chest tightness and wheezing at rest • Too short of breath to eat • Symptoms not improving with rescue medications YOU NEED TO BE TREATED — CALL 911

CAUTION

• More wheezy or breathless than usual • More sputum than usual or it is a different color • More short of breath with activity • Symptoms are affecting sleep • Coughing more than usual YOU MAY BE AT THE START OF AN INFECTION OR FLARE UP. USE RESCUE INHALER TO CONTROL SYMPTOMS. START “RESCUE PACK.” AVOID TRIGGERS THAT MAKE YOU FEEL WORSE. CALL YOUR DOCTOR FOR AN APPOINTMENT AS SOON AS POSSIBLE.

ALL CLEAR • At baseline breathing • Sputum amount and/or color is normal • Able to eat without difficulty • Sleeping patterns are normal • Able to do normal activities without difficulty EXERCISE DAILY, STAY HYDRATED, EAT A BALANCED DIET. TAKE ALL OF YOUR DAILY MEDICATIONS AS ORDERED. AVOID TRIGGERS THAT MAKE YOU WORSE

MY DOCTOR

DOCTOR’S PHONE #

Notes:

SECTION 6

TRAVELING WITH COPD

ave copies of current prescriptions, including your •H oxygen. You may need a letter from your healthcare provider verifying your prescriptions, oxygen, and medical equipment requirements. •C arry a list of all current medications and doses. •C arry the names and phone numbers of your emergency contact person, healthcare provider, pharmacy, and medical equipment provider. •C arry all medication and medical supplies in your carry-on luggage. Make sure that you have enough medication, oxygen, and batteries for the entire length of your travel. Plan for delays.

Traveling with COPD

Traveling by Car •D on’t allow anyone to smoke in the car. Oxygen is highly flammable.

Traveling with COPD requires advanced planning. 1. You need to make sure that you have enough of your medications to last the duration of your trip. 2. You may need to take medical equipment such as a CPAP machine or portable nebulizer. 3. T raveling with oxygen poses additional challenges. Using oxygen doesn’t mean you can’t travel, but it does mean that you have to plan ahead.

rack the car window. Portable oxygen tanks can give •C off gasses which may build up in small spaces. lace your oxygen tank upright beside you. If possible, •P secure the tank with a seatbelt. • Store additional oxygen tanks behind the seat flat on the floor. Never store tanks in the trunk or anywhere that may get too hot.

Traveling with Oxygen If you are traveling by car, you may use your own portable tanks or portable concentrator. If you are using other means of transportation, the individual companies may have their own regulations regarding oxygen use. It is important to check with your travel carrier in advance to see if you need to make special arrangements for your oxygen needs.

•D o not leave extra tanks in the car. Once you reach your destination, take extra tanks indoors where they will not be exposed to temperature extremes.

Travel Checklist •N otify your healthcare provider of your travel plans. If you have recently been hospitalized, obtain medical clearance before traveling.

Traveling by Bus or Train •C ontact your travel carrier 4-6 weeks in advance to see if there are any restrictions on traveling with oxygen. You will probably be allowed to use your own portable tanks or portable concentrator.

•M ake sure that you have enough oxygen to last your trip and any travel delays. • I f you are using a portable oxygen concentrator, make sure you have extra batteries.

• I f you use oxygen, notify your healthcare provider of your travel plans several weeks in advance. You may need special forms filled out in order to travel with your portable oxygen.

•R equest seating on a lower level. •M ake sure that you have enough oxygen to last your trip and any travel delays.

•N otify your oxygen provider of your travel plans several weeks in advance. They can help to arrange oxygen during your travel and when you arrive to your destination.

• I f you are using a portable oxygen concentrator, make sure you have extra batteries.

Traveling by Cruise Ship •C all the cruise line 4-6 weeks prior to your scheduled departure to see if there are any restrictions on traveling with oxygen.

Traveling by Airplane • Air travel requires an FAA-certified portable concentrator and a form signed by your health-care provider. Check with the airline and oxygen company at least 2 weeks prior to travel.

•M ake arrangements with your oxygen provider and cruise line to have tanks delivered directly to the ship before your departure.

•F AA regulations prohibit the use of personal oxygen tanks or liquid oxygen on all commercial airlines. e airline may be able to provide you with oxygen for • Th in-flight use only. Oxygen will not be provided to cover any time spent in the airport for layovers, changing flights, or delays. You may be charged a fee for using the airline’s oxygen.

•M ake sure that you have enough oxygen to last your trip and any travel delays. • I f you are using a portable oxygen concentrator, make sure you have extra batteries. •P lan for medication and oxygen needs for excursions off of the ship.

•M ake arrangements with your oxygen supplier before your trip for portable oxygen to use at the airport and once your reach your destination. •T ry to get a direct flight whenever possible. •B ook your flight as far in advance as possible. The number of seats allotted for oxygen dependent passengers may be limited. • Always reconfirm your oxygen arrangements 48-72 hours prior to your departure.

Notes:

Valley Health Programs to Help You Manage Chronic Disease

Notes:

Chronic Disease Self-Management Valley Health in collaboration with the Virginia Department for Aging and Rehabilitative Services offers a workshop to help you learn skills to lower the stress associated with having a chronic disease. During this 6-week program you will learn a variety of day-to-day management skills to help you live an active and fulfilling life. Workshop topics include: •G oal setting •P roblem solving •M anaging fatigue • Healthy eating •L ow impact exercising •E ffective communication This workshop will enhance the learning that you have received from the COPD Education Program and complement your healthcare providers recommended treatment plan. Ask your COPD Resource Nurse for more information.

Next Steps Valley Health offers this 8-week program to help you maintain regular, consistent exercise. It is a medicallybased, supervised program that includes: • Assessments at the beginning and end of the program • I ndividualized exercise plan •T wo 60-minute group workout sessions a week •U nlimited full access to the fitness center • A summary report provided to you and your physician •T ransition to full membership and waived enrollment fee at the end of the program You need a physician referral to participate in Next Steps.

COPD Resource Guide

Sources used American Lung Association http://www.lung.org/lung-disease/copd/

American Lung Association 1301 Pennsylvania Ave NW Suite 800 Washington, DC 20004 800-LUNGUSA (800-586-4872) www.lung.org

Living Well With COPD http://onebreath.org/document.doc?id=89 National Jewish Health http://www.nationaljewish.org/healthinfo/conditions/copd/

Global Initiative for Chronic Obstructive Lung Disease www.goldcopd.org

GlaxoSmithKline https://www.gsksource.com/gskprm/en/US/adirect/gskpr m?cmd=PatientByCondition&page=condition&pflag=tr ue&cflag=true#S

COPD Foundation www.copdfoundation.org

Global Initiative for Chronic Obstructive Pulmonary Disease, Inc. http://www.goldcopd.org/uploads/users/files/GOLD_ Report2014_Feb07.pdf

HealthCoach4Me Glaxo Smith Kline www.healthcoach4me.com

Boehringer Ingelheim Pharmaceuticals, Inc. Be Tobacco Free http://betobaccofree.hhs.gov/

Smoking Cessation Resource Guide

Healthline http://www.healthline.com/health/copd/depression

Freedom From Smoking American Lung Association www.lung.org

HealthCoach4Me GSK www.HealthCoach4Me.com Care Management Central GSK www.CareManagementCentral.com

Tobacco Quitline 800-QUIT-NOW (800-784-8669)

National Public Radio www.npr.org

Smoke-Less Support Group Front Royal, VA 540-636-0138

Mayo Clinic www.mayoclinic.org

Valley Health Quit For Good Program Front Royal 540-636-0263 Winchester 5 40-536-3044 Woodstock 5 40-459-1110 Smokefree.Gov http://smokefree.gov/

Funded in part by

Through generous contributions from donors, the Winchester Medical Center Foundation supports a variety of programs to benefit patients, the public and the medical community. For more information go to www.valleyhealhtlink.com/wmcf.

Chronic Disease Resource Center (540) 536-0518 www.valleyhealthlink.com