Understanding Breathing Disorders: A "Primer" for Yoga Practitioners
My reason for writing this article
I have written this article for my fellow yoga practitioners who may have a recognized or unrecognized minimal to moderate level of respiratory challenges. Looking back, I had mild shortness of breath (SOB) since childhood that only manifested upon exertion such as running, jogging or competitive sports. I opted out from such activities because something about these activities didnít feel like much fun. I had frequently occurring colds and respiratory infections that would last for weeks with lingering cough and excessive mucus. My family and I attributed my SOB and accompanying heart racing to sub-optimal health or some weakness of heart and never suspected a lung problem. Finally, in 1994 I was diagnosed with emphysema. Looking back I understand I had sub-clinical asthma and untreated asthma, indoor pollution and biogases and smoking over years progressed to Chronic Obstructive Pulmonary Disease (COPD).
Chronic lung disease such as adult recalcitrant asthma, chronic bronchitis or emphysema take many years to develop and we go on with our lives best we can. Consciously or unconsciously we might avoid exertion that would cause breathing discomfort. In yoga workshops I have occasionally encouraged fellow practitioners with mildly belabored breathing. They had attributed it to such factors as the age, weight, pain, etc, but it turned out to be a compromised lung function.
If there is a breathing issue, check it out. Hope this article would be of some help to you personally or a loved one of yours with compromised lung function.
Current medical perspective of the chronic lung disease is discussed including the signs and symptoms and their impact on a person's overall health. Emphysema and COPD and some forms of chronic adult asthma are increasingly being viewed by pulmonary experts as progressive systemic (body wide) disorders. Yoga being a comprehensive mind body and breath system can be a viable self-care and collaborative care program for such lung conditions. This article is an attempt to create a framework and a language in which a meaningful dialogue could be developed between the yoga community and medical community. Process of inhalation and exhalation in the healthy and impaired lungs along with experiential tips for appreciation of the chronic obstructive breathing are provided so a person with breathing impairment can meaningfully collaborate with the health professionals. Basic self-care steps for protection of the lung function and quality of life are outlined which can be utilized by anyone with or without yoga orientation. Breath coordinated spinal directional movements along with relaxed breath awareness and skillful breath management are at the heart of the personal practice proposed here. Suggestions for specific adaptations in the traditional yoga poses and breathing techniques are provided so the individuals with yoga orientation can design a personal practice to support their lung function and overall health.
With global warming and ever increasing indoor and outdoor pollution, respiratory disorders are widespread. In 2005, estimated 22.2 million had asthma at the time of the survey and an estimated 32.6 million people had ever been diagnosed with asthma during their life time. In 2001 estimated 35 million suffered from diagnosed or undiagnosed Chronic Obstructive Pulmonary Disease (COPD). COPD is currently the fourth leading cause of "chronic morbidity and mortality" in the United States. Many baby boomers who smoked in their youth are now middle aged or older when aging lungs might be more vulnerable to the smoking related health consequences. Smoking and second hand smoking reduced in North America is still a major problem and growing in the third world countries. History of smoking and second hand smoking is "best studied COPD risk factor" and one of the common risk factors for asthma. Furthermore, asthma and COPD can overlap and today's chronic, untreated or uncontrolled asthma can be tomorrow's COPD.
Chronic lung disease is a serious global problem. The exact number of people afflicted by the lung disease is not established yet. However, prevalence surveys carried out in a number of countries, using standardized methods estimate that up to about 25 % of 40 years and older adults may have mild or more severe level of COPD . Asthma too is one of the most common chronic diseases, with an estimated 300 million individuals affected worldwide.
Why Should You Know about Lung Disorders?
In order to understand breathing impairment more fully let us first review the process of healthy lung breathing.
Inhalation: Air enters through the nose into the windpipe (trachea), flowing through the large airways (bronchial tubes) and then down the small airways (bronchioles) into the air sacs (alveoli) attached to the small airways. Diaphragm, the primary breathing muscle contracts to expand the chest, creates negative air pressure and thus draws air into the lungs. Oxygen (O2) from the air passes through the air sacs into the blood vessels and the blood then carries the oxygen to all parts of the body.
Air flows in without obstruction or restriction in the healthy lungs because of the following: 1) airways are unblocked and undamaged 2) air sacs are elastic, that is, expand and come back to original position 3) the diaphragm muscle is strong and flexible, that is, can contract effectively and 4) the ribcage and chest muscles are strong and flexible to expand and elevate to allow room for the lungs to expand.
Exhalation: Diaphragm relaxes and the chest contracts to force waste air out of the lungs. Waste air including carbon dioxide (CO2) is carried by the blood vessels back to the air sacs and expelled through the airways and out through the nose. Air flows out unobstructed because of the following: 1) the diaphragm is flexible enough to relax 2) chest and ribcage muscles are strong and flexible to release and restore to the original position 3) Air sacs are able to return to normal, that is their pre-inhalation size to expel the air and 4) airways are elastic and open and do not collapse during exhalation.
Lung impairment can be divided into two categories:
1. Restrictive-when patients have difficulty in getting the air IN because the lung or the chest is stiff and hard to move
2. Obstructive-when the airways are narrowed and patients have difficulty in getting the air in and out, but mainly getting the air OUT.
Examples of restrictive disease: Pulmonary fibrosis, lung cancer or pneumonia.
Examples of obstructive disease: Chronic bronchitis, chronic obstructive bronchitis, emphysema and asthma.
Note: Progressively deteriorating asthma observed in some adults is sometimes a combination of restrictive and obstructive disease.
What is helpful for obstructive breathing can be harmful for restrictive breathing. Therefore follow these guidelines:
1. Don't ask people with pulmonary fibrosis (restrictive disease) to "Breathe slowly!" They have to take short and rapid breaths for their oxygen-starved body because that is the most mechanically efficient way to breathe with this condition.
2. Ask people with COPD and asthma to slow the breathing and lengthen exhalation because they tend to have more difficulty breathing out and the lungs may become too full or the stale air already in the lungs allow little room for the fresh inhaled air.
3. Don't ask people with COPD to "Take a deep breath" because they might not be able to get rid off of the excess air and with a few such deep breaths may experience breathing discomfort.
1. In order to experience inspiratory obstructive breathing, take a stirrer with a narrow hole or a straw pipe and pinch it to put a kink in it. Breathe in a few times through the coffee stirrer/straw pipe. Breathe out a few times through the same in order to experience expiratory obstructive breathing.
2. Recall the last time you went to a high altitude point and perhaps experienced shortness of breath, fatigue, reduced stamina and perhaps even severe headache. It is because the oxygen saturation in blood is at a very low level. Oxygen saturation refers to the amount of oxygen in the arterial blood oxygenated by your lungs. At sea level, oxygen saturation is 96-98% for a healthy young adult. However, at 14000 ft. above the sea level, the oxygen saturation for a healthy young adult, who has not yet had a chance to adapt, is only 75-80%. If you have been to Pike's Peak or Machu Pichu, which is roughly at the height at 14000 feet, you can imagine the breathing discomfort a person with severe or very severe COPD would feel even at the sea level. They have to use supplemental oxygen to maintain adequate oxygen saturation level.
3. Perhaps, you experienced moments of great emotional excitement, shock or fear when you might have felt your breathing out of control. People with COPD, often express their breathing discomfort in such terms as "I have to try so hard to breathe;" "can't catch my breath" "I feel I am hungry for air" or "gasping."
The knowledge and understanding of COPD is continually evolving. Beginning 2001, each year a panel of top international lung experts on Global Initiative of Chronic Lung Diseases (GOLD) issues a consensual document reflecting the latest understanding, treatment and research on COPD.
GOLD 2006 provides the following "working definition" of COPD:
Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.
Let's now review the implications of the working definition of COPD.
"COPD is a preventable and treatable disease"
The phrase "preventable and treatable" was added in 2006 to provide a positive outlook and motivate people with COPD to stop smoking and go for treatment, rehabilitation and self-care, and to encourage the health professionals to take a more active role in helping people with COPD. There was a time when COPD was considered an "irreversible disease." Many people with COPD were elderly and severely sick. Some viewed COPD as a "self-inflicted disease," because they were smokers. Many patients and professionals were too discouraged to work hard on self-care or rehabilitation. Fortunately, there is a change in the right direction.
"COPD has some significant extrapulmonary effects that may contribute to the severity in individual patients."
The phrase, "extrapulmonary effects" means that the lung disease is not merely a disease of lungs; it has far reaching effect on other organs and systems of the body because every cell in the entire body needs oxygen and must have waste carbon dioxide removed. GOLD consensus document goes on to say that "Weight loss, nutritional abnormalities (e.g. loss of desire to eat--author) and skeletal muscle dysfunction (e.g. muscle weakness-author) are well-recognized extrapulmonary effects of COPD." COPD patients are at increased risk for myocardial infarction, angina, osteoporosis, respiratory infection, bone fractures, depression, diabetes, sleep-disorders, anemia, and glaucoma. COPD increases the risk for other diseases" (GOLD 2006, p.3).
Thomashaw and Walsh CO-Morbidity survey of over 3000 people with COPD indicates that people with COPD on average have 6 co-morbid disorders. 60 to 80% of them take 5 to 10 medications and 15-25% take more than 11 prescribed medication. These medications are for such problems as high blood pressure, heart disease, osteoporosis, arthritis, GERD (Gastro-esophageal Reflux Disease), sinus disease, sleep apnea, weight loss, muscle weakness as well as depression and anxiety. COPD affects multiple organs and systems of the body and the relative impairment thereof determines the severity of the disease for that person.
It appears pulmonary community is moving towards recognizing COPD as a systemic ("body wide") problem.
1. Yoga is a holistic system that engages the mind, body and breath. When adapted to the specific needs of a person with COPD and practiced safely, it can provide a more comprehensive physical and mental self-care system than a narrowly defined self-care or rehabilitation program such as a set of exercises and/or breathing techniques. A mind-body system is ideal for a mind-body condition!
2. It is the hope and speculation on part of this author that if breathing impairment was diagnosed earlier and benefits of yoga fully exploited, the physical and emotional and extrapulmonary effects could be attenuated and slowed down.
"Pulmonary component (of COPD) is characterized by airflow limitation that is not fully reversible."
What that means is that even after bronchial dilation medications are given, there remains structural damage to the airways and ongoing airway obstruction problems. Refer to the section, Healthy Lungs in order to more fully appreciate the implications of the airflow limitation.
Chronic airflow limitation is caused by chronic inflammation of the lungs which results into the following:
1. "Airway disease," which refers to the structural changes and the narrowing of the small airways, also called, "obstructive bronchiolitis." (Bronchioles=small airways).
2. "Parenchymal destruction. The term "parenchyma" refers to "tissue mass" hence, the "destruction of the lung mass." Parenchymal destruction translates into two major problems: a) loss of alveolar attachments. Air sacs are attached to small airways, which are called "alveolar attachments." Loss of alveolar attachments results into significant loss of support for the small airways; b) "decrease of elastic recoil" of the lung, and therefore further difficulty in getting stale air out of the lungs. In order to appreciate this change, picture the air sacs as tiny balloons or rubber bands. Balloon inflates when the air is filled and it deflates when the air is released. Likewise, rubber band stretches when pulled and snaps back when released. When the air sacs lose their elastic recoil means that after taking the air in and inflating, they don't "snap back" to their normal size.
Yoga/Self-Care Tip: Airway disease and parenchymal destruction significantly reduce the ability of the airways to remain open during exhalation. In COPD it helps to work on exhalation. More specifically, you may benefit from developing a breathing pattern of slower and longer exhalation to empty the lungs more efficiently according to your capacity.
"The airflow limitation is usually progressive"
Airflow limitation is usually progressive but that progress can be slowed down by optimal utilization of treatment, exercise, nutrition and self-care and avoiding all tobacco smoke and other noxious agents. Many people with COPD have an asthmatic component as well. This problem may be helped by bronchial dilator medications. Airflow limitation caused by asthma related inflammation is reversible. Reversal of the reversible airflow limitation should be a target of every individual afflicted with breathing impairment.
Yoga/Self-Care Tip: Because the airflow limitation is slowly progressive, people with COPD, health professionals and self-care specialists should make optimal use of the treatment, rehabilitation program, exercise, breathing training, meditation, relaxation, nutrition, support groups and self-management to slow down the "progress" of the disease and reverse the reversible airflow limitation.
"(airflow limitation is) associated with an abnormal inflammatory response of the lung to noxious particles or gases"
Utmost care should be taken to avoid or minimize exposure to the harmful agents such as smoking or secondary exposure to tobacco smoke, occupational dusts and chemicals, indoor pollution such as bio fuels, outdoor pollution, seasonal factors such as pollen and above all take all precautions against respiratory infections. Inflammation of asthma is very different from that of COPD, but many people have a mixture of COPD and asthmatic inflammation. Asthmatic inflammation is more amenable to treatment.
"Is it Chronic Bronchitis, Emphysema or COPD?"
National Institute of Health (NIH) states that "In the U.S., the term COPD includes "chronic bronchitis," "chronic obstructive bronchitis," or "emphysema," or combinations of these conditions. We will first discuss the specific meaning and distinction between these terms and then the question if they have outlived their usefulness.
In chronic bronchitis, airways remain chronically inflamed and swollen producing large amount of mucus which can make breathing difficult. The insides of the swollen airways become narrow or closed in. Mucus may remain trapped in the swollen and narrowed airways. Prolonged exposure to tobacco smoke and/or other noxious chemicals and gases can irritate the airways and cause them to secrete extra mucus. The "smoker's cough" of current or past smokers may be a symptom of chronic bronchitis. The warning signal of "morning smokers cough" even a mild one, should never be ignored.
Chronic bronchitis should not be confused with acute bronchitis, which is often caused by chest cold or respiratory infection that normally lasts only for a week or two. Chronic bronchitis, on the other hand is defined as the "presence of cough and sputum production for at least 3 months in each of 2 consecutive years," and is not necessarily associated with airflow limitation.
When chronic bronchitis is associated with airflow limitation, it is called chronic obstructive bronchitis.
The word, "emphysema" is derived from a Greek word which means "inflation." In emphysema lungs are inflated or enlarged because the patient is only partially able to get the air out of the lungs. The air sacs like the tiny balloons are "blown" with old and stale air trapped inside them. This makes it harder for fresh air to get in and the stale air much harder to go out. Air sacs and small airways (bronchioles) are impaired and lose their elasticity. As a result, air sacs are never able to return to their normal size. The blood vessels around air sacs are also diminished and impaired which prevents oxygen from reaching the blood stream and carbon dioxide from getting out of the body.
Previous definitions of COPD included the terms "chronic bronchitis" and "emphysema," but the GOLD panel of experts say that these term are not interchangeable with the term "COPD" for the following reasons:
1. Emphysema describes only one of several structural abnormalities present in a person with COPD
2. Chronic bronchitis does not reflect the major impact of airflow limitation on morbidity and mortality in COPD patients.
3. GOLD document further states that chronic cough and sputum, chief characteristics of chronic COPD, do not always precede the development of airflow limitation; some patients develop significant airflow limitation without chronic cough and sputum production." (GOLD 2006, p.3)
In summary, "COPD" is the term we all should use because it is a more accurate description of the impairment in the lungs and its impact on the rest of the body. The term COPD is inclusive of emphysema and chronic bronchitis.
"Is It Asthma or COPD?"
If there is no overlapping between asthma and COPD pathology, that is, the "purest form," we can differentiate asthma and COPD as follows:
1. Airflow limitation is reversible in asthma but irreversible or only partially reversible in COPD.
2. Asthma is characterized by episodes or attacks of allergic asthmatic reactive inflammation and narrowing of small airways. Many elements can trigger asthma attacks such as allergens (e.g., pollen), infections, exercise, changes in the weather, and exposure to airway irritants (e.g., tobacco smoke). Asthma attacks can range from mild to a life threatening episode.
|Typical onset in middle life||Typical Onset in childhood|
|Symptoms slowly progressive||Episodic. Symptoms vary from day to day, early mornings & nights worse|
|Typically pre-onset smoking history||Typically no pre-onset smoking history|
|Dyspnea during exercise||Typically no Dyspnea outside the attack|
|Largely irreversible inflammation||Largely reversible inflammation|
|Hyper responsiveness often develops||Allergy, rhinitis, eczema more typical|
|Family history not typical||Family history of asthma more typical|
However, it is a fact of life that COPD can coexist with asthma. GOLD experts say that individuals with asthma who are exposed to noxious agents, particularly cigarette smoke, may also develop irreversible airflow limitation and a mixture of "asthma-like" and "COPD-like" inflammation. While asthma can usually be distinguished from COPD, in some individuals, it is difficult to differentiate the two diseases. Furthermore, longstanding asthma on its own can lead to irreversible airflow limitation.
In a longitudinal study, "Tucson Epidemiological Study of Airway Obstructive Disease" adults with asthma were found to have a twelve-fold higher risk of acquiring COPD over time than those without asthma. However, there is no conclusive evidence that chronic asthma in adults would lead to COPD.
Characteristic Symptoms of Asthma
Characteristic Symptoms of COPD
Note: Chronic cough and sputum production may precede the development of airflow limitation by many years.
GOLD Patient Education Guide advises that the following warrant prompt consultation with the doctor :
Lung experts recommend that a diagnosis of COPD should be made on the basis of the spirormetric assessment, symptoms such as the ones mentioned above, and the history such as of smoking and exposure to noxious gases.
Spirometer is as important for determining the diagnosis and severity of COPD as sphygmometer's blood pressure measurements are for the diagnosis and severity of hypertension. Spirometer measures how large a breath you can take and how fast you can blow it out. Thus, you can find out how effectively and quickly the lungs are emptied out. Spirometric results are expressed as % predicted using normal values for the person's sex, age, height and ethnicity.
Yoga/Self-care Tip: COPD advocates have a slogan, "Know your numbers!" If you suspect a breathing problem and/or have a history of smoking or a significant indoor, outdoor or work-related exposure to noxious environment, you should find out you're your spirometric results are. That should be part of your svādhyāya (self-study/self-assessment). Here are three spirometric readings you should know:
1. FVC (forced vital capacity): maximum volume of air you can forcibly inhale and exhale
2. FEV1 (forced expiratory volume in 1 second) the maximum amount of air you can exhale in the first second. This is a measure of how quickly the lungs can be emptied. "FEV1 80%" of the predicted value means that the amount of air you can forcibly exhale is 80% (and therefore 20 % less) of a person of your age, sex and height.
3. FEV1/FVC: FEV1 expressed as a percentage of the FVC provides a measure of airflow limitation.
FEV1/FVC is between 70% and 80% in normal adults (Example: FEV1 = 4.15 liter. FVC = 5.2 liter. Hence, 4.45/5.2 = 80%).
A value less than 70% indicates airflow limitation and the possibility of COPD.
(Example: FEV1 = 2.35 liter. FVC = 3.9 liter. Hence, 2.35/3.9 = 60
People with COPD typically show a decrease in both FEV1 and FEV1/FVC. The lower these numbers are, the greater the severity of COPD. More information can be found at the site of American Thoracic Society
Stages/Severity of COPD
(Source GOLD Pocket Guide 2006)
Stage I: Mild COPD - Mild airflow limitation
FEV1/FVC < 70%; FEV1 ≥ 80% predicted
Symptoms: Sometimes, but not always, chronic cough and sputum production.
At this stage, the individual may not be aware that his or her lung function is abnormal.
Stage II: Moderate COPD - Worsening airflow limitation FEV1/FVC < 70; 50% ≤ FEV1 < 80% predicted Symptoms: With shortness of breath typically developing on exertion. This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms (chronic cough, sputum, breathlessness) or an acute exacerbation of symptoms.
Stage III: Severe COPD - Further worsening of airflow limitation FEV1/FVC < 70; 30% ≤ FEV1 < 50% predicted Symptoms: Greater shortness of breath, reduced exercise capacity, and repeated exacerbations which have an impact on patients' quality of life.
Stage IV: Very Severe COPD - Severe airflow limitation FEV1/FVC < 70%; FEV1 < 30% predicted Symptoms: Chronic respiratory failure. Quality of life is very appreciably impaired and exacerbations of COPD symptoms may be life-threatening
Other "assessment devices and numbers you should know:
Oximeter: (also called "finger oximter") measures blood-oxygen saturation level, briefly referred to as, "O2 saturation." You simply insert your index finger in the oximeter and in a few seconds it gives you the reading. Small oximeters costs about a couple hundred dollars and some people with COPD like to own their personal oximeter in order to monitor their blood-oxygen saturation levels on an ongoing basis.
96-98 blood-oxygen saturation levels fall within the normal range.
95 and below blood-oxygen saturation levels are significantly below the acceptable range and indicative of hypoxemia (low oxygen).
A capnometer provides measurement of the carbon dioxide levels in the end exhalation phase, also called "end tidal CO2." End tidal CO2 is an indirect measurement of the arterial CO2, which is the really important value.
When we exhale the air coming out of the mouth towards the end of exhalation in a lung healthy person under normal circumstance contains the dioxide level between 4.5-5% of the exhaled air.
End-tidal CO2 below 4% begins to fall in the range of "hypocapnia" (hypo= low; capnia=carbon dioxide) and may set off a chain reaction reducing the oxygen supply to the body and the brain.
End-tidal CO2 above 5% begins to move in the range of "hypercapnia" (hyper= high) and create its own set of problems.
A higher end tidal CO2 (usually expressed as greater than arterial value of 45 mm hg) indicates the inability of the lungs to remove CO2, and therefore "respiratory failure." Pressure of CO2 is usually expressed as mm of Mercury (Hg). The normal range is 35 to 45 mm Hg.
Capnometer is very useful, and can avoid getting an arterial blood sample, but when in doubt, an arterial blood gas is essential, as capnometry in COPD can have technical measurement problems.
Both O2 levels and CO2 levels are important to track for people with breathing disorders. However, a capnometer costs at least a couple thousand dollars and therefore cost prohibitive for an individual to own one, yet!
You should of course know what these numbers mean and maintain a record of subsequent spirometric results to keep a track of the lung health, but you also need a simple and practical scale to determine what level of exercise and exertion is appropriate for you or your breathing difficulty student. Though the questionnaire provided below is intended for the assessment of breathlessness, but in addition to breathlessness it can also give some idea of the exercise tolerance level. Items in this questionnaire are in ascending order of the breathlessness and thus in descending order of exercise tolerance.
Modified Medical Research Council Questionnaire for Assessing the Severity of Breathlessness. (GOLD 2006 p.34 with minor modification by this author)
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Posted March 2007