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Breathe Out

Breathe Out

by Mary Callahan Rn
BREATHE OUT THROUGH PURSED LIPS! Those words are golden for persons with chronic lung disease. Once mastered, the technique can help with everything from going up stairs to picking up a grandchild, all without shortness of breath.

That advice and so many more practical tips for getting through the day and getting through life are contained in the pages of this book.


BREATHE OUT THROUGH PURSED LIPS! Those words are golden for persons with chronic lung disease. Once mastered, the technique can help with everything from going up stairs to picking up a grandchild, all without shortness of breath.

That advice and so many more practical tips for getting through the day and getting through life are contained in the pages of this book. Understanding how lungs work in good health and bad is the key to avoiding symptoms, preventing complications and staying independent.

The book is based on the very successful series of classes, called the Respiratory Disease Self-Care Classes, provided for many years by the New Mexico Lung Association.

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Breathe Out Living Life to the Fullest, with Emphysema, COPD, or Smoker's Lung

By Mary Callahan AuthorHouse Copyright © 2007 Mary Callahan, RN
All right reserved.

ISBN: 978-1-4343-4855-5

Chapter One Normal Lungs

Something to think about

As organs of the body go, the lungs are fairly simple. They have only one job, and that is gas exchange: in with the good air, out with the bad; in with the oxygen, out with the carbon dioxide. Oxygen is what every organ and tissue of the body needs to stay alive. Carbon dioxide is the waste product of breathing. If you are wondering what a waste product is, think about the other things the body needs to stay alive:, food and water. They have waste products too.

The lungs have two major structures you need to know about, the air sacs and the bronchial tubes. The air sacs are where the gas exchange happens. The bronchial tubes deliver the air to the air sacs.

The interesting thing about the air sacs, also called alveoli, is that they are so small. In normal, healthy lungs there are 300 million of them, and they can be seen as individual sacs only under a microscope. Each one has tiny blood vessels, called capillaries, surrounding it that pick up the oxygen and drop off the carbon dioxide.

The bronchial tubes are like branches of a tree. They start with one big one, the trachea (or windpipe), and quickly start dividing and dividing and dividing again until there are thousands of them and they are very small as well. But the bronchial tubes are not just like garden hoses. They do more than deliver the goods. They also treat the air on its way to the air sacs.

The air sacs of the lungs, being small, are fairly fragile. They have to be kept warm, moist, and clean. The air we breathe is not always warm or moist enough. It is never clean enough. The lining of the bronchial tubes as well as the cavities behind the nose work to warm the air as it goes by and add humidity.

That is the easy part. The tricky part is filtering the dirt, pollution, and germs out of the air before it gets to the air sacs. As you can imagine, germs in the air sacs means infection, and that infection is called pneumonia. The bronchial tubes are called the defense mechanism of the lungs because they keep germs out of the air sacs and prevent pneumonia.

They do that because they have a very special lining. The lining produces a blanket of mucus that catches anything it touches like flypaper catches flies. As useful as it is to catch the germs before they can get to the air sacs, it is not good enough. The bronchial tubes also have to transport the germs out of the lungs.

They are able to move the mucus with the germs attached out of the lungs because of hairlike projections called cilia under the mucus blanket. They move like a field of wheat in the breeze, always beating upward. You may cough the bits of mucus out, but most of the time you swallow it without even knowing. It is normal and natural, and we all do it every day.

I have just described how healthy lungs work, but there is a little bit more to the respiratory system. To start with there is the mouth and nose. They are a part of the system because the air passes through them on the way to the lungs. The nose is part of the warming, humidifying, and filtering system. There are structures behind the nose: sinuses, nose hairs, and these curly bits of cartilage called turbinates that increase the surface area touched by the air on the way down. All that surface area begins the processes that are continued by the bronchial lining.

If you are a mouth breather, there is obviously less surface area for the air to touch on the way down, but there is still enough. The only real problem with breathing through your mouth is that you get a dry mouth out of it.

After the air goes through the nose or mouth, it heads toward the windpipe, also called the trachea. At a certain point there is a fork in the road, so to speak. There is a choice of going down the windpipe to the lungs or going down the esophagus toward the stomach. The air usually makes the right choice because there is a vacuum pulling the air into the lungs.

Food, drink, and saliva, meant to make the other choice, to go down the esophagus into the stomach, are more likely to make a mistake than air is. The vast majority of the time, they go the right way because a tiny flap called the epiglottis closes over the top of the windpipe every time you swallow, blocking entrance to the lungs. But from time to time, the epiglottis doesn't move fast enough and we get something "down the wrong pipe." For people with normal, healthy lungs this is an embarrassment, at worst. You cough and choke for a minute, and everyone jokes about doing a Heimlich maneuver on you.

If you already have breathing trouble, this coughing spell can be frightening. You may need a few minutes to recover when it is over, but it will be over. It is still just a little something "going down the wrong pipe."

The only thing you need to know about the windpipe is that it gets a little bigger around when you breathe in and a little smaller around when you breathe out. This is important because all the rest of the tubes leading into the lungs do the same, all the way down to the tiniest ones. Remember that when we talk about diseases of the lungs.

Another crucial part of the respiratory system are the muscles of breathing. Understanding how they work will help a great deal with symptom control.

The major muscle of breathing is the diaphragm. It is a large dome-shaped muscle that separates the chest cavity from the abdominal cavity. It sits high and rounded when you are resting between breaths. When the brain signals that you need another breath in, the diaphragm pulls down, lower and flatter, increasing the size of the chest cavity and creating a vacuum filled by the incoming air.

Breathing out is just the diaphragm moving back into its resting position.

In normal resting breathing, the diaphragm does almost all of the work. Other muscles that help a little are in the upper chest, between the ribs. When you are really working hard to breathe, like running a marathon, you might call on muscles in the neck and shoulders as well. All those muscles of breathing that ARE NOT the diaphragm are called the accessory muscles of respiration. They are extra help, there when you need them.

Lastly, when it comes to breathing, the brain plays a role. It tells you when to take each breath and how deep a breath it should be. This all goes back to what the job of the lungs really is: gas exchange. The brain controls your breathing so you exchange just the right amount of the gases, oxygen and carbon dioxide. You don't have to think about it. It all happens automatically.

The most important thing to remember about the role of the brain in breathing is that the brain will never scream, "Breathe out! Breathe out!" If you are short of breath, your brain will be screaming, "Breathe in. I need more oxygen," even if that is not what you really need.

Chapter Two Basic Breathing Exercise, Parts 1 and 2

Something to Do

This chapter contains the most important information in the book. Seriously. If you learn nothing else but how to control your shortness of breath with breathing techniques, then you have still learned enough to change your life.

I call the exercise the "basic" breathing exercise because it is the heart of so many other things you will learn. When you learn how to improve your exercise tolerance, this exercise will be basic to it. When you learn how to control stress, this exercise will be crucial to it. When you learn how to carry groceries in the house without shortness of breath, guess what? This exercise is how you'll do it.

It is a three-step exercise. The first two steps are easy. If you don't already know them, you will learn them quickly. In spite of that, I recommend that you practice just those two steps for a few days before you add the last step. You may have used the technique to rescue yourself from shortness of breath, but you probably haven't used it to prevent shortness of breath. With practice you can learn to use the technique in a calm, controlled manner any time you see trouble coming.

Here goes:

Step 1-Pursed-lip breathing

Pursed-lip breathing means breathing out against lips that are partly closed, creating a back pressure felt all the way down into your lungs. It helps because that back pressure holds bronchial tubes open so you can exhale completely. You will learn that in COPD breathing tubes have a tendency to collapse, trapping air behind them and making it difficult to get the next breath in. Sometimes mucus plugs play a role in the air being trapped. Sometimes swelling makes things worse. It doesn't matter what causes the problem. Pursed-lip breathing is the answer. It can get you out of trouble when you are short of breath. It can prevent episodes of shortness of breath.

So sit back and relax in your favorite chair. Take in a nice deep breath, and then let it flow back out through lips that look like you could be whistling or kissing. It doesn't matter how you get the air in, mouth or nose. It only matters that there is slight back pressure slowing the breath as it leaves your lungs.

Once you have been practicing for a few minutes, add Step 2.

Step 2-Slowed exhalation

What makes this step so easy is that you are probably already doing it. Just using pursed lips slows your exhalation, and if you pay attention, you will probably find you are already breathing out for about twice as long as you breathe in. You can test the theory by counting to yourself. Breathe in to the count of three and out to the count of six.

That's a good place to start. It is not important that your ratio be exact. Everyone is unique, and you should find the ratio that is right for you. The point is that it should be somewhere around 3:6. If your ratio is more like 3:3, you are probably not really relaxing enough and not getting the full benefit of the breathing technique. If your ratio is more like 3:24, then you are missing about three breaths in and you will feel it!

Still easy, isn't it?

I have found that it is a good idea to spend a few days practicing just this part of the basic breathing exercise before you add the third, more difficult step. A good time to practice is while you are watching TV or reading. If you connect practice with something that happens almost every day (reading the paper, maybe?), then eventually you don't even have to think about it. Practice will just come naturally when that activity occurs.

If you never move on to the third step, or if you find the third step too difficult, you still have a skill that will be useful every day. How is that? Well, slow pursed-lip breathing will help you walk farther without shortness of breath. Slow pursed-lip breathing will help you move a chair or pick up a grandchild more easily. Slow pursed-lip breathing may even get you up a flight of stairs that you never thought you would go up again. Slow pursed-lip breathing is what you go to when an emotional upset sends you into just the opposite: rapid, shallow breathing.

Maybe most important, once you master slow pursed-lip breathing, you never have to be afraid again. You will always know that you have a tool to get you out of shortness of breath. You can stop the cycle of shortness of breath that leads to panic, which leads to more shortness of breath, which leads to more panic, and so on.

We will go into all of these in more depth later. For now, I just want you to be motivated!

Chapter Three When Good Lungs Go Bad

Something to Think About

As demonstrated by the first chapter, the lungs are fairly simple and easy to understand when they are healthy and doing their job. They are more complicated in disease, of course, but one thing remains simple. The lungs have only three ways to demonstrate that they are in trouble. No matter what is wrong with the lungs, what part of the system is affected, or how it is affected, there are only three possible symptoms.

Those three symptoms are 1) shortness of breath, 2) mucus production and coughing, and 3) low blood-oxygen level. You may be thinking 1 and 3 sound like the same thing, but they are not. They often go hand in hand, but not always. You can feel very short of breath from working hard to breathe, but a test of oxygen level shows that you are succeeding with all that hard work. The flip side is that some people get used to a low oxygen level and don't experience it as shortness of breath.

Things get complicated when we start talking about what problems can cause those symptoms. The most common problems fall under the label COPD.

COPD stands for Chronic Obstructive Pulmonary Disease.

C stands for "chronic," which means the problem is going to stick around for a long time. It is not curable and not fatal (at least not for a long time), so it is chronic.

O stands for "obstructive," which will be explained next.

P stands for "pulmonary," which means related to the lungs. (They tried calling it COLD for a while, but that just sounds silly.)

D means "disease," and most people know that means illness.

COPD. Most of it is easy to understand. It is just the "O" that needs explaining. It stands for "obstructive" and that means there is a problem or obstruction to breathing out. Most lung diseases are obstructive.

The opposite of obstructive is "restrictive," and that means the problem is breathing in. Now, you may be thinking that you must have the restrictive type because your problem is breathing in. But remember, the brain never screams, "Breathe out! Breathe out!" It always demands another breath in, even if the reason you can't get a breath in is that you haven't cleared enough space by breathing out.

In obstructive lung diseases, which are by far more common, it is hard to breathe in because the lungs are still partly filled with the last breath. On top of that, the fresh air that does get in has to mix with the stale air left behind, so the oxygen level is lower.

This is very important information, because you can learn to override the brain's message and work on getting the last breath out BEFORE you take the next breath in. That is a huge part of symptom control. Very often an episode of shortness of breath, which can be so frightening, can be resolved quickly just by simple pursed-lip breathing, the technique you learned in the last chapter.

There are three common obstructive lung diseases and one less common one. The first three are emphysema, chronic bronchitis, and asthma. The fourth is called bronchiectasis. Simply put, emphysema is damage to the air sacs. Chronic bronchitis is damage to the bronchial tubes. Asthma is an abnormal reaction in the bronchial tubes. Bronchiectasis is just like chronic bronchitis, but with a different cause and worse symptoms.

Now we'll go into them in more depth.


To understand emphysema, we have to go back to learn more about the air sacs themselves. They are tiny air-filled sacs at the end of the bronchial tubes where the real work of the lungs takes place. Each one is surrounded by tiny blood vessels that pick up the oxygen out of the air and drop off the carbon dioxide. In normal, healthy lungs, there are 300 million of them.

That number is three times what you need to breathe completely comfortably. We all lose air sacs every day, because we are all getting older every day. But with normal wear and tear on the lungs you will never lose enough of them to be symptomatic. Unfortunately, smoking is not normal wear and tear on the lungs.

Smoking, and sometimes inhaling secondhand smoke, speeds the aging process in the lungs. Air sacs are destroyed more quickly, and you can lose two-thirds of them and have symptoms of shortness of breath.

The shortness of breath is caused by two things that are going on in your lungs when you lose air sacs. One is that there is not enough surface area left for gas exchange. By surface area I mean where air sacs meet blood vessels and oxygen crosses.

That sounds like a pretty big problem, but it is not really the biggest problem. The biggest problem is that the air sacs are used to help hold the bronchial tubes open, and with fewer air sacs the bronchial tubes lose support.

To understand this, you have to picture the inside of the lungs as more complex than just tubes leading to balls, the "bunch of grapes" picture we often have in our minds. A truer picture of what the lungs look like, if you were looking through a microscope, is a sponge or a slice of bread. The two major structures, the air sacs and the bronchial tubes, are all intermingled and wrapped around each other. They are so tiny and fragile that they need the surrounding tissue (each other) to remain open.

When the bronchial tubes don't have the support they need to stay open, they can collapse. But they don't collapse when you are breathing in. The rush of air itself keeps them open. They collapse when you are breathing out because, although you still have air moving that might keep them open, you have the chest wall coming down on them as well. Some bronchial tubes, not all, will collapse before you have finished breathing out.


Excerpted from Breathe Out by Mary Callahan Copyright © 2007 by Mary Callahan, RN. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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