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Pulmonary Rehabilitation Patient Education Manual

Part 2 Chapters 7-18

7. Airway Clearance 8. Nutrition and Lung Disease: One Bite at a Time 9. Supplemental 10. Understanding & Tobacco Use 11.Stress Management 12. Effective Techniques for Walking and Stair Climbing 13. Diagnostic Procedures 14. Energy Conservation 15. Falls Prevention 16. Emergency, Intensive Care and Supportive Care for Lung Disease 17. Advance Care Planning 18. Activity and Lung Attacks FN.100.P968.PHC (Jul-18) We would like to acknowledge the hard work and dedication of the many pulmonary rehabilitation professionals in Providence Health Care, Vancouver Coastal Health and Fraser Health who volunteered their time to develop this education manual. July, 2018 Table of Contents (Part 1) 1. Live with Lung Disease ...... 1.1 2. Understanding Lung Disease ...... 2.1 3. Preventing Lung Irritation and Chest Infections ...... 3.1 4. Medications & ...... 4.1 5. Breath Control ...... 5.1 6. Exercise ...... 6.1 (Part 2) 7. Airway Clearance ...... 7.1 8. Nutrition and Lung Disease: One Bite at a Time ...... 8.1 9. Supplemental Oxygen ...... 9.1 10. Understanding Smoking & Tobacco Use ...... 10.1 11. Stress Management ...... 11.1 12. Effective Techniques for Walking and Stair Climbing ...... 12.1 13. Diagnostic Procedures ...... 13.1 14. Energy Conservation ...... 14.1 15. Falls Prevention ...... 15.1 16. Emergency, Intensive Care and Supportive Care for Lung Disease ...... 16.1 17. Advance Care Planning ...... 17.1 18. Activity and Lung Attacks ...... 18.1

Important Notice - the information contained in this booklet is intended for educational purposes. This booklet does not replace instructions or advice given by your healthcare provider. If you have any questions, please ask any member of your care team.

The information in this document is intended solely for the person to whom it was given by the health care team.

Pulmonary Rehabilitation Patient Education Manual Chapter 7 • open the airways: ₋₋ use your bronchodilator as Airway clearance prescribed. It opens the airways by relaxing the Exposure to irritants can damage smooth muscles the natural cleaning system of your in the airways, lungs. Cilia are tiny hairs which line making it easier to the airways and rhythmically sway the mucous to leave back and forth. This action moves the your airways. mucous toward your main airways. Exposure to irritants can damage the • keep active: cilia so the mucous becomes trapped. ₋₋ do the exercises that have been This exposure can also irritate your prescribed to you airways, which causes them to make even more mucous than normal. This ₋₋ do twenty minutes of mucous can plug your airways and exercise daily makes an excellent breeding ground for infection. ₋₋ go for a walk What can you do to help clear If you have a chest infection or produce more than a your airways? quarter cup of mucous every day, you can remove your mucous with • drink lots of fluids to make your the methods below. You should do at mucous thinner and easier to cough least one of these procedures every up. The best to drink are: day to clear your airways. ₋₋ water 1. Active cycle of breathing ₋₋ juice This procedure is a very effective ₋₋ skim milk way of clearing your chest. It can be • avoid drinking anything with changed to meet your needs. It can be caffeine or alcohol, which can done in different positions. You might dehydrate you: need to follow the suggested cycle for 10 to 15 minutes to clear your chest. ₋₋ coffee A set of three different techniques to loosen and move mucous from small ₋₋ tea airways into larger upper airways ₋₋ alcohol includes breath control, deep breathing and huffing.

7.1 Pulmonary Rehabilitation Patient Education Manual Chapter 7 - Airway Clearance a. Breath control 2. Postural drainage Breathe in gently through your nose To use postural drainage, you position and out through pursed lips. Relax your body so gravity can help move your upper chest and shoulders while the mucous through your airways. You breathing with the diaphragm, or lower lie down or crouch in the positions chest. prescribed. Follow these steps for effective postural drainage: b. Deep breathing Take a long slow breath in until you 1. take your bronchodilator fifteen cannot take in any more air. Hold minutes before you start your breath while you count to three. 2. breathe in moist air by having a Breathe out slowly and gently through warm shower. You can also use a pursed lips. vaporizer or have a hot drink. c. Huffing 3. position yourself first on your right Take a medium breath in, then huff the side, with your hips supported on air out through a wide open mouth. two stacked pillows. After you have The huff should last about 2 seconds. done the controlled breathing and If it makes you wheeze, the huff is too controlled coughing on your right long. side, move to your left side and Follow these steps to use the active repeat the controlled breathing and cycle of breathing: controlled coughing. 1. begin with some gentle breath control until you are relaxed 2. take three or four deep breaths followed by more relaxed breathing 3. do one or two huffs 4. go back to relaxed breathing Note: Modify this position by lying on 5. continue this breathing sequence your side without the pillows under until you feel the mucous has your hips if: moved up your airways and is ready to be coughed out. Then it is • you have increased shortness of ready to be cleared. breath 6. often, a final deep breath followed • your heartbeat becomes fast or by a huff or cough will clear the irregular upper airway • you get a persistent headache • you have acid reflux disease 7.2 Pulmonary Rehabilitation Patient Education Manual Chapter 7 - Airway Clearance Do controlled breathing exercises to ₋₋ positive expiratory pressure expand and empty your lungs and devices – patients exhale into move the mucous along the airways: these using a mask • inhale through your nose • teaching your family members to use manual or mechanical • hold your breath for a count of techniques and/or devices three • exhale through slightly-opened lips 4. Controlled coughing • repeat for 15-20 minutes in each Coughing should be the last thing position you do to remove your mucous. Not all coughing is effective. Follow these Do controlled coughing: instructions to help remove your • after each position, sit up mucous as efficiently as possible. • perform two controlled coughs A cough is an explosive force to push mucous out of your chest. The No mucous might be present at this explosive force comes from exhaled air time, but the cough will loosen and and the tightening of your abdominal move the mucous along the airways. muscles against your diaphragm. You may cough spontaneously half an Controlled coughing should make hour to an hour later as the mucous a deep sound rather than a throaty reaches the main bronchus. sound. Excess mucous and breathing in 3. Additional airway clearance through your mouth can give you techniques and devices coughing spells. These can make you Some people need more help to move tired, more short of breath, and worry their mucous. you without moving any mucous. Often, a drink of water or hot lemon Your doctor can refer you for and honey helps to relieve the irritating secretion removal techniques from a ‘tickle’ and is useful to help loosen physiotherapist which may include: secretions. • manual techniques to help move the mucous • mechanical devices to get the mucous moving, such as: ₋₋ mechanical percussor or vibrators- hand-held devices which may be electrical and are held on the chest wall, or are mouthpieces

7.3 Pulmonary Rehabilitation Patient Education Manual Chapter 7 - Airway Clearance Steps for controlled coughing 1. sit, leaning slightly forward 2. take a slow, deep breath in through your nose and hold that breath for two seconds 3. with your mouth open, tighten your abdominal muscles and cough out forcefully 4. repeat a second time 5. the first cough will loosen the mucous and the second moves it along If the cough is clear mucous, do not force another cough or continue with coughing. This will tighten the airways. Spend a few minutes performing the mucous clearing exercises. Use deep breathing and huffing interspersed with breath control. This raises the mucous more easily, using less of your energy.

Control your cough- don’t let it control you!

7.4 Pulmonary Rehabilitation Patient Education Manual Chapter 7 - Airway Clearance Pulmonary Rehabilitation Patient Education Manual Chapter 8 Nutrition and lung disease: one bite at a time People with lung disease use a lot of energy just breathing. Good nutrition gives your body energy for breathing and other activities. Eating well can help you manage your lung disease.

The information in this chapter may help make eating and breathing easier.

Nutrition and lung disease Both eating and breathing are essential for life. What you eat can affect your overall health, as well as your breathing. Good nutrition helps to: • give your body energy for activities like breathing • provide you with enough fuel for your day-to-day activities • prevent infections • make you feel more energized • let you reach a healthy weight that makes it easier for you to breathe • maintain your muscles, including the ones you use to breathe

Eating a balanced diet that provides enough energy, protein, vitamins and minerals will give you the best chance to feel as good as possible and breathe as easily as possible.

The following suggestions are designed to help make eating enjoyable and easy for you. If you have any questions or concerns about your diet, call Healthlink BC at 8-1-1 and ask to speak with a dietitian. For more personalized recommendations, ask your doctor for a referral to see a dietitian.

8.1 Pulmonary Rehabilitation Patient Education Manual Chapter 8 - Nutrition and Lung Disease Milk, and milk alternatives (yogurt, cheese) Vegetables and fruit

Meat, and meat alternatives

Grain products A balanced diet

Variety is the key to a well balanced diet. Eat a variety of foods from each of the four food groups: • vegetables and fruit • milk and milk alternatives • grain products • meat and meat alternatives

Try to include at least three out of the four food groups at each meal. At snacks, try to include one or two of the food groups.

Have at least one vegetable or fruit at each meal or snack. If you do not eat many vegetables or fruits, try increasing the amount you eat a little at a time. Enjoy the different tastes, textures and colours.

Make at least half your grain products whole grain. Choose from options like whole wheat bread or pasta, oatmeal, brown rice, quinoa, and barley.

Choose lower fat milk & milk alternatives. Milk and yogurt should be skim, 1% or 2%. Cheese should be less than 20% milk fat (this is listed on containers as ‘M.F.’). If you do not drink milk, try alternatives like soy, rice, or almond milk.

Enjoy meat alternatives more often. This includes fish, beans, split peas, lentils, tofu, nut butters, nuts, and seeds.

Limit low-nutrition, high calorie foods such as chips, candy, chocolate bars, regular soft drinks, and baked goods.

8.2 Pulmonary Rehabilitation Patient Education Manual Chapter 8 - Nutrition and Lung Disease Tips to manage shortness of breath Tips to save time & energy when eating • rest before eating • eat five or six small • choose foods that are easy to make. meals or snacks See “Easy to Prepare Meal and throughout the day. If Snack Ideas” on the next page. your stomach is very full from a large meal • make extra meals and freeze them you may find it harder to breathe. • ask family or friends to help with cooking • take your time and relax at meal times • try a meal delivery program like Meals on Wheels or Better Meals • choose foods that are soft and easy to chew • eat your main meal at the time of day when you have the most energy • enjoy small bites of food • keep utensils and dishes where you • use oxygen while you eat, if you can get to them easily need to • keep non-perishable foods visible • eat while sitting up to take pressure and within your reach off your lungs • drink fluids after your meal to Tips to make eating avoid feeling too full more enjoyable • eat with • some foods can cause gas or friends bloating in some people. This can and make it harder to breathe. If this family is an issue for you, avoid these common gas-producing foods: • eat in a relaxed atmosphere. Try using more ₋₋ carbonated beverages colourful place settings or playing ₋₋ fried or greasy foods some background music. ₋₋ beans, broccoli, brussels sprouts, • include your favourite foods at cabbage, cauliflower, corn, meals cucumbers, leeks, lentils, onions, • include a variety of colours and peas and peppers textures with your meal • do not skip a meal if you are having • be creative. For example, you can a hard time breathing. Eat a snack eat breakfast foods at lunch or or try a nutrition drink like dinner. Boost or Ensure.

8.3 Pulmonary Rehabilitation Patient Education Manual Chapter 8 - Nutrition and Lung Disease Easy to prepare meal and snack ideas • macaroni and cheese dinner (add tuna & frozen peas) Choose simple meals that are quick to make. • pasta, tomato or meat sauce, salad, milk Breakfast • flatbread pizza – tomato sauce, • instant hot cereal or cold cereal, vegetables and mozzarella cheese milk, fruit baked on a pita, tortilla or naan • french toast, waffles or pancakes (frozen), fruit, yogurt Snack: • yogurt with granola, nuts or seeds, • poached, scrambled or boiled egg, fruit toast, milk • cottage cheese, fruit • whole wheat toast, peanut or almond butter, yogurt, fruit • rice cakes or crackers, tomato and cucumber slices, hummus • whole wheat english muffin, cheese, fruit • small bran muffin, fruit

Lunch • a handful of unsalted nuts with dried fruit • peanut butter and banana sandwich, milk Maintaining a healthy weight • beans on toast, tomato slices, milk A healthy body weight can help you • tuna melt: mix tuna, celery, breathe more easily. Keep track of your mayonnaise and shredded cheese, weight regularly and if you notice spread on buns and melt in oven unexplained weight gain or loss, talk to your doctor. Your doctor or your • canned low-sodium bean soup, pulmonary rehabilitation program can whole wheat roll, yogurt refer you to a dietitian if • salad with chopped egg, nuts or you are concerned grated cheese, bun, yogurt about your weight.

Dinner If you are overweight, breathing can be more • low sodium hearty soups (pea, difficult. Your heart lentil, chunky beef or chicken, and lungs may have chowders, chili), crackers with to work harder and cheese, apple the extra weight • cheese omelet, whole wheat toast, might mean you salad need more oxygen.

8.4 Pulmonary Rehabilitation Patient Education Manual Chapter 8 - Nutrition and Lung Disease Some tips to help you lose weight: • exercise regularly, as able and as advised by your doctor • limit high fat and high sugar foods; eat more fruits and vegetables • keep treats out of sight so you won’t be tempted • eat smaller meals

If you are underweight, you may feel weak and tired. Being underweight can also make you more likely to get an infection. It is especially important for someone with lung disease to eat enough calories and protein to prevent further weight and muscle loss. Some tips to help you gain weight:

• eat protein at each meal. Foods that have protein include: meat, poultry, fish, beans, lentils, eggs, nuts and seeds, nut butters, milk products, and soy products. • have high fat foods such as avocado, soft Meat margarine, vegetable oils, nuts and seeds, nut butters, whole milk, and yogurt Poultry • drink milk, smoothies or nutrition drinks like Boost or Ensure. Drink them after your meals so you’re not too full to eat. You can Fish also try drinking them when you take your medications. Nuts • see the tables on pages 8.7 and 8.8 for ideas for adding more protein and calories into your diet if you need to Eggs

Milk Milk

8.5 Pulmonary Rehabilitation Patient Education Manual Chapter 8 - Nutrition and Lung Disease Watch the salt! Long-term steroid use Eating too much salt can Some people with lung disease need make the body retain too to take steroids to help their breathing. much water, which can When taking a steroid like prednisone, make it harder to breathe. there may be some side effects. Follow Some tips to limit salt (or these tips to reduce the following side sodium) in your diet: effects.

Increased protein breakdown • do not add salt to foods when • have protein at each meal. Meat, cooking or eating poultry, fish, beans, lentils, eggs, nuts and seeds, nut butters, milk • use herbs or no-salt spices to flavour products, and soy products are your food examples of protein-rich foods. • limit your intake of processed and pickled foods. This includes deli Decreased calcium absorption meats, processed cheese, sausages, • include high calcium foods in olives, pickles and chips. your diet. Examples include milk • read labels. Avoid foods with more products, fortified milk alternatives, than 300mg of sodium per serving. canned sardines or salmon with bones, and some leafy green • choose foods that have less salt. vegetables. Make sure to also have a Fresh or frozen foods have the least Vitamin D supplement. Talk to your amount of salt. doctor or dietitian about the right dose. Fluids Sodium and fluid retention Fluids help keep mucous thin and easier to cough up. Drink six to eight • limit the salt in your diet. See tips cups of liquid with no caffeine each above. day. Fluids include anything that is liquid at room temperature such as Increased fat and sugar in your blood water, fruit juice, milk, soup, popsicles, • ask your doctor to check your blood ice , or sherbet. If your doctor cholesterol and blood sugar levels. has told you to limit your fluids due to If these are high, see a dietitian for other medical conditions, follow your specific dietary advice. doctor’s advice.

8.6 Pulmonary Rehabilitation Patient Education Manual Chapter 8 - Nutrition and Lung Disease Tips to add protein

Food Suggestions

Whole milk • drink instead of water, coffee, tea or juice (cow, goat, • use to make hot cereals, cream soups, smoothies, milkshakes, soy) puddings, and hot beverages like hot chocolate • add to milk, milkshakes, soups and cereals Powdered • use in mashed potatoes, baked goods, sauces, gravies, pudding, milk scrambled eggs, casseroles, and meatloaf

• enjoy yogurt as a snack or dessert Full-fat yogurt & • use in dips and salad dressings sour cream • use as a topping for perogies, potatoes, or fruit

Cheese (cow, • grate and add to sauces, salads, soup, sandwich fillings, casseroles, goat, soy) and mashed potatoes Ricotta • melt onto sandwiches, pizzas, potatoes, eggs, and vegetables • use in stuffed pastas Cottage cheese • eat with fruit or cracker

Nuts and • enjoy as a snack or in trail mix seeds • add to baked goods, ice cream, salad, and pasta sauce

• spread on toast, sandwiches, or crackers Nut and • blend into milkshakes seed butters • swirl into ice cream, yogurt, or hot cereal • use as a dip for vegetables, or fruit

• eat as a meal or snack Eggs (do not eat raw • use in sandwiches and salads eggs) • add extra to pancake or cookie batter

Meat, • add to soups, stews, salads, casseroles, sandwich fillings, cracker poultry, fish toppings, dips, stuffing and omelets

Beans, peas, • use in soups, stews, and casseroles lentils • have as hummus or bean dip

Tofu • add to soups, salads, stir-fries, casseroles, and sauces (regular or • can be used to substitute meat dessert) • blend into smoothie or milkshake • have dessert tofu as snack or add to fruit 8.7 Pulmonary Rehabilitation Patient Education Manual Chapter 8 - Nutrition and Lung Disease Tips to add calories

Food Suggestions

• add or melt on potatoes, hot cereal, grits, rice, noodles, and cooked vegetables Butter or margarine • stir into soups, casseroles, or sauces • spread freely on breads, sandwiches, toast, crackers, or rolls • mix with herbs and spread on meats, poultry, or fish

• use as dip for bread or rolls Vegetable oils (canola, olive, flax, sesame) • use in salads, pasta, and sauces • add to soups or vegetables • spread on sandwiches or crackers • use in meat, fish, pasta, or vegetable salads Mayonnaise • add to dips, salad dressings, or sauces • use to make devilled eggs

• spread on fruit slices, vegetables, bread, toast, or crackers • spread on slices of luncheon meat and roll as a snack Cream cheese • cook into scrambled eggs or pasta sauces • use flavoured cream cheeses to add variety

Half-and-half Cream (whipping or • use in place of milk or water in soups, sauces, batters, cocoa, whipped) custards, pudding, shakes, mashed potatoes, or cereals • use to make smoothies or milkshakes Evaporated milk • use whipped cream on top of fruit or dessert Creamo

Brown sugar, jams, • add to hot or cold cereals, fruit, ice cream, puddings, custards, jellies, , honey, and milkshakes sweetened condensed • use as a glaze on meats, fish, or vegetables milk • spread on toast, pancakes, muffins, waffles, and bagels

• add to yogurt, cereals, ice cream Granola, dried fruit • enjoy as a snack • add when baking muffins, scones, cookies, and loaves

• spread on toast or bagel • blend into smoothie or milkshake Avocado • add to salads and sandwiches • make guacamole and enjoy as a snack with tortilla chips ** Whole milk, full-fat yogurt, full-fat sour cream, cheese, nuts, seeds, and nut and seed butters are also good choices to add calories. See “Tips to add protein” for how to include them in your diet. 8.8 Pulmonary Rehabilitation Patient Education Manual Chapter 8 - Nutrition and Lung Disease Pulmonary Rehabilitation Patient Education Manual Chapter 9 pace. Your doctor may order these Supplemental Oxygen tests every year, or whenever there is a Oxygen is part of the air we breathe. change in your condition. Our bodies use it to convert our food Sometimes supplemental oxygen may into energy which is needed for all our be ordered even if the ABG or exercise body’s activities. tests do not show low oxygen levels. Sometimes, with lung diseases, This might happen if you have: it is difficult for the oxygen • activity that is limited by low we breathe to transfer into blood oxygen and improvement our blood. If your body no can be demonstrated with the longer receives enough use of supplemental oxygen oxygen, supplemental oxygen is required. Not everyone • oxygen levels that drop with lung disease needs during sleep (nocturnal supplemental oxygen. hypoxemia). However, sleep disorders must be ruled out. Supplemental oxygen is a • an enlarged and weakened medication and it must be prescribed right side of the heart by your doctor. The doctor will tell you (cor pulmonale). exactly how many litres of oxygen per minute you need. • increased pressure in the blood capillaries of the lungs (pulmonary The BC Ministry of Health suggests hypertension). that supplemental home oxygen be prescribed only for people with • a diagnosis of lung cancer documented low blood oxygen • a diagnosis of congestive heart (hypoxemia). Chronic low blood failure oxygen is most commonly seen in Chronic Obstructive Pulmonary There are many benefits of using Disease (COPD) and Interstitial Lung supplemental oxygen if your oxygen levels Disease (ILD). are low. You might: We use two tests to identify the need • be able to do more without getting for supplemental oxygen. An arterial tired blood gas (ABG) tests the blood taken • sleep better, or be less irritable from an artery in your wrist to measure • find your memory improves the amount of oxygen in your blood. An exercise oximetry test measures the • have more energy percentage of oxygen in your blood • be able to do more exercise while you are walking at a normal • live a longer, more productive life 9.1 Pulmonary Rehabilitation Patient Education Manual Chapter 9 - Supplemental Oxygen Paying for supplemental oxygen 1. Compressed oxygen cylinders Supplemental oxygen is set up by a Cylinders come in different home care company based on a written sizes. How long they last prescription from a doctor. There are depends on flow rates and two main options for covering the cost use. Large cylinders are heavy of supplemental oxygen. and must be securely stored in your home while small 1. Home oxygen subsidy program cylinders are reasonably portable and can be used This program is administered by for short trips. the Ministry of Health. It subsidizes patients on home oxygen. The plan is not based on income or the ability 2. Liquid oxygen to pay, but on a documented need for This equipment oxygen. Funding is not automatic. It consists of a large is necessary for your doctor to make insulated reservoir the application. The application must unit which stays at have complete documentation on the home, and a small need for supplemental home oxygen. portable unit which The subsidy only covers oxygen from you fill from the a government-approved supplier. large reservoir. The portable unit 2. Private health insurance provides oxygen outside the home. Home oxygen may be covered by This system is the most expensive. private medical insurance. Some insurance companies such as Blue Cross or the Department of Veteran 3. Oxygen concentrators Affairs will allow direct billing by the This device is about home oxygen supplier. Other medical the size of a bedside plans require the user to pay and table. It is electrically then submit a claim. Other support powered. It removes for home oxygen might come from from the air WorkSafe BC, and Non-Insured Health to deliver relatively Benefits (NIHB). pure oxygen. One type delivers 1-5 Supplemental oxygen equipment litres per minute There is a variety of equipment and the other associated with supplemental oxygen. type delivers 1-10 Your home oxygen supplier will litres per minute. provide you with more detailed Concentrators are safe and convenient. information about options and costs. 9.2 Pulmonary Rehabilitation Patient Education Manual Chapter 9 - Supplemental Oxygen 3. Portable oxygen concentrator Using oxygen appropriately (POC) Please notify your doctor if you notice This device is portable and has battery any of these symptoms when using and electric power supplemental oxygen: capabilities. These • confusion/disorientation concentrators deliver a pulsed flow of • drowsiness oxygen which is • difficulty waking from sleep triggered when you • headache breathe in. Most offer one setting of • increased shortness of breath continuous oxygen • significant decrease in activity flow, usually 2 litres tolerance, fluid retention (swollen per minute. Most ankles/feet) models are approved for travel. It is important to ensure the POC can Because supplemental oxygen is a deliver enough oxygen for your needs. medication, use it only as ordered. Shortness of breath is not always 4. Combination of concentrator/ caused by too little oxygen. Therefore, liquid oxygen/cylinders do not increase the flow rate when you This is the most convenient and are short of breath. Use breath control cost effective system if you need techniques outlined elsewhere in this continuous and manual. also need to be mobile. You use the concentrator in the home and the small Maintaining your equipment cylinder or liquid oxygen when away If you have any concerns about your from the main source. equipment, please contact your oxygen supply company. 5. Oxygen conserving device (OCD) • wash nasal prongs once a week, This device using 1/3 cup white vinegar and 2/3 delivers oxygen cup water. Rinse with warm, not only when you hot, water. breathe in. A • change your nasal prongs once a sensor triggers it month, when the plastic becomes to deliver a pre- hard, or after a cold or flare-up of measured amount of oxygen. With this your lung condition device, you can conserve the amount of oxygen you use.

9.3 Pulmonary Rehabilitation Patient Education Manual Chapter 9 - Supplemental Oxygen • have at least three sets of nasal • keep oxygen away from heat prongs: sources. ₋₋ one on the concentrator • never use oil or grease on the oxygen tank or regulator ₋₋ one on the portable oxygen system • do not use any aerosol sprays in the room where oxygen is being used or ₋₋ always keep one or two extra sets stored on hand • keep a fire extinguisher readily • never use more than a 50-foot available extension hose • have your oxygen company check • change the 50-foot extension hose your oxygen flows with a meter for every six months accuracy • have spare connectors on hand. You never know when you might need Travelling with supplemental one. oxygen • never use any alcohol or petroleum- General tips based products/creams near oxygen • when choosing a • if your nose or the inside of your destination, consider nostrils is dry or sore, use a non- conditions that may cause petroleum product, such as Secaris, problems, such as excessive Surgilube or KY Jelly pollution, altitude, epidemics, and • place oxygen tanks or concentrator allergens away from a high traffic area • once you have a destination in mind, talk to your doctor so that Supplemental oxygen safety they can advise you regarding • check your home and car insurance medical needs. Get copies of to find out if you need to change prescriptions and a letter from your your insurance coverage doctor in case medical attention is required or customs requests it. • notify your local fire department that you have oxygen in your home • consult with an oxygen supplier to help with your oxygen needs • post signs on your for travel. Many home oxygen windows and doors suppliers have branches across that say “OXYGEN Canada and contacts in the USA IN USE” and “NO and around the world. SMOKING”

9.4 Pulmonary Rehabilitation Patient Education Manual Chapter 9 - Supplemental Oxygen • be prepared to pay for oxygen • carry an “Emergency Phone List” equipment, refills and supplies with numbers for your doctor, during travels. Oxygen refills and airline, suppliers, etc. supplies can be subsidized when • REMEMBER, DON’T PANIC if travelling within Canada. something goes wrong — nothing • if you receive funding assistance is ever as bad as it seems. Assume a from the government or an comfortable resting position, remain insurance program please check calm and start doing controlled out reimbursement guidelines breathing. You will then be better before you go. Programs vary and able to deal with it. costs may not be reimbursed. Save all receipts to submit if you are Travelling by plane able to get reimbursed for oxygen expenses. • your doctor may refer you to take an altitude • keep all medications in their tolerance test. This original containers test will determine if you need • always sit in no smoking areas supplemental oxygen at high altitudes, for example, in-flight on • when you book your hotel, request an airplane. a non-smoking room/floor. Check that there is an elevator and guest • people with chronic lung disease services to help with your luggage. may have difficulty in adapting These will help conserve your to changes in altitude especially energy. altitudes of 5000 feet or above. Consult your doctor before you • practice good hygiene. Wash hands arrange air travel. Your doctor frequently to fight sickness. may advise against flying if you • keep medications and oxygen have severe shortness of breath, tubing in a carry bag so that it is pneumonia, a cardiac problem, or always available. Take along extra an ear/sinus infection. just in case. • airlines have a written policy • pace your activities and plan your regarding use of supplemental itinerary to suit your energy level. oxygen by passengers. Some Take frequent stops and rest to airlines rent cylinders and others avoid overtiring. require you to rent a portable • check medical insurance coverage oxygen concentrator from your for destinations outside Canada supplier. You must notify them well in advance. • arrange for any special requirements such as a wheelchair, special diet, etc. 9.5 Pulmonary Rehabilitation Patient Education Manual Chapter 9 - Supplemental Oxygen • you or your travel agent should • because of the dry air on planes contact the airlines to get a Medical drink plenty of fluids, such as water Information Sheet which must be and fruit juices. Avoid coffee, tea, completed by your physician. This and carbonated beverages. is used to gather information about • during the flight, be careful not your specific condition. It can be to eat too much and do not take sent by fax to speed up the process. alcoholic beverages or sedatives • if you need oxygen in the air • while you are seated or standing, terminal, you must make your own exercise your leg muscles. It’s a arrangements. Neither the airlines good idea to take slow short walks or the airport will arrange for it. in the aisle. • oxygen equipment and supplies

can be delivered to your destination address when arrangements are made in advance with your supplier Travelling by car or recreational vehicle • request a direct flight if available • pre-arrange with your travel agent • be sure to find or airline for assistance to the out in advance departure gate and luggage areas about oxygen on arrival suppliers in the cities where you will be travelling • arrange for oxygen if there is a layover, and for use at your final • securely fasten oxygen equipment destination in your vehicle • consider travelling with a • keep at least one window partially companion who knows your needs open to increase airflow and prevent an increase of oxygen • be sure your medicines are readily concentration. This can be available at all times dangerous. • pre-board the aircraft as soon • protect the oxygen unit from hot as possible and allow the flight sunlight and excessive temperatures attendant to assist you on boarding. On arrival you will usually be asked • do not store oxygen in the trunk to wait until the other passengers • store liquid oxygen in an upright have left the aircraft so that you can position move about more comfortably and receive assistance. • passengers should not smoke in the vehicle

9.6 Pulmonary Rehabilitation Patient Education Manual Chapter 9 - Supplemental Oxygen • an ‘inverter’ will convert Travelling by train automobile voltage (12 volts) to house voltage (120 volts) to run • you do not require electrical equipment such as an any medical oxygen concentrator. An inverter documentation to be is a special purchase and requires completed by your professional installation. physician but carrying a letter from your physician is recommended • if you are travelling in an RV, do not store oxygen near gas or an open • railway trains and stations do not flame provide or arrange for oxygen Check travel and information guides • you must notify the railway of before arriving at your destination to your oxygen requirements and the make sure power is available for the equipment being used at the time of concentrator. your reservation. Oxygen travellers are encouraged to occupy sleeping accommodations. • you can take your oxygen from Travelling by bus home for use while travelling • no medical • remember to take all oxygen documentation is supplies that you may need for the required but carrying a letter from trip your physician is recommended. • arrange for oxygen refills at When you buy your ticket, you stopovers and at your final must advise the bus line that you destination if necessary use oxygen. • if you are not travelling in a private • oxygen concentrators can be boxed coach, you may need to pay for an and placed with luggage. Contact extra seat for your oxygen your oxygen supplier for packing instructions. • porters are available to assist you with loading and unloading • an oxygen cylinder can be used equipment from the train on board but liquid oxygen is not allowed • a cylinder in a carry-on bag is recommended for storage under the seat while travelling. If you use a cylinder cart you may need to purchase a ticket for the seat next to yours.

9.7 Pulmonary Rehabilitation Patient Education Manual Chapter 9 - Supplemental Oxygen Travelling by ship

• contact the cruise line’s medical department in advance to find out about their policy for the use of supplemental oxygen and to discuss other medical needs • you will be required to have your physician complete a Medical Information Form for the cruise line to review and approve • the use of various types of oxygen equipment is allowed aboard • the cruise line will not arrange for oxygen or provide it • if you are not travelling with an organized group, contact your oxygen supplier for assistance with organizing for a supplier to provide oxygen for your cruise • generally cruise lines have no restrictions or additional charges for passengers using oxygen

9.8 Pulmonary Rehabilitation Patient Education Manual Chapter 9 - Supplemental Oxygen Pulmonary Rehabilitation Patient Education Manual Chapter 10 Understanding smoking & tobacco use

Cigarettes and second-hand smoke Carbon monoxide (CO) have many harmful chemicals. Studies • is a colourless, odourless and have shown that they tasteless gas. Carbon monoxide: contain 4,000 to 6,000 ₋₋ moves quickly into your chemicals. Forty to 60 of bloodstream after you inhale it these cause cancer. ₋₋ makes your body less able to Cigarettes also include absorb oxygen, which leads to several chemicals. serious tissue damage Nicotine ₋₋ makes your heart work harder to • is an addictive drug that: circulate oxygen because there is less oxygen available in your body ₋₋ tightens your blood vessels ₋₋ makes your blood pressure go up ₋₋ is poisonous. Carbon monoxide poisoning can lead to death. ₋₋ makes your heart rate go up Tar Smoking & lung damage • contains many chemicals that: Smoking and second-hand smoke causes lung damage, chronic bronchitis ₋₋ stick to your clothing and hair. and many other chronic diseases. The chemicals are bad for people, especially for children and babies. Long-term exposure to tobacco smoke shortens your life by an average of 10 ₋₋ make your liver work harder to get years and can also lead to COPD. For a rid of the poisons and also cause description of COPD and other chronic liver disease lung diseases, refer to the chapter on “Understanding Chronic Lung ₋₋ stain your hair and skin with an Disease”. orange color Despite all of this damage that tobacco ₋₋ give your clothes a musty smell causes, it is never too late to quit • changes to a gas in a lit cigarette. smoking. When you stop smoking, This gas: your cilia may grow back. When you stop smoking, you stop the damage to ₋₋ damages your lungs your lungs. Even if you have severe ₋₋ causes cancer and other diseases lung disease, quitting smoking will help you live longer, with fewer problems. Breathing will be easier, and you will have more energy. 10.1 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Healing happens when you are • you can taste and smell things better not smoking or breathing in than before second-hand smoke Within 3 days Did you know that every minute • breathing may get easier as your you are not smoking or breathing in airways relax second-hand smoke, your body is • the amount of air you can breathe in healing? Maybe you are not ready to and out starts to increase quit. Even during the times between each cigarette, your body is trying to Within 2 weeks to 3 months heal. Every minute you are smoke-free • your blood flow gets better makes a difference. • walking or exercising becomes Some damage to your body cannot be easier reversed, but there is also healing that Within 1 to 9 months happens. In as little as 20 minutes, your • you may notice less coughing and heart rate may go down to normal. sinus congestion When you’re not smoking… • you may have more energy and have less shortness of breath Within 20 minutes • cilia may start to regrow to help • your blood pressure and pulse rate clean your lungs drop so your heart doesn’t have to • you may have fewer colds work as hard Within 1 year Within 8 hours • your chance of dying from a heart • the amount of carbon monoxide attack goes down by half compared (poison gas) in your body goes to someone who smokes 1 pack a down day • your oxygen level goes up to normal Within 5 years or more • your chance of a stroke becomes the Within 24 hours same as a non-smoker • your lungs start to work better • your chance of dying from lung • you’ll feel less out of breath cancer goes down by half compared • your chance of a heart attack goes to someone who smokes 1 pack a down day Within 2 days Within 15 years • you may be coughing as your lungs • your chance of dying from a heart clean out some of the poisons from attack is the same as a non-smoker smoking 10.2 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Why is it hard to quit smoking? How will you feel when you stop smoking? Brain chemistry (addiction) Seconds after you breathe in cigarette Some smokers may feel very smoke, the nicotine goes to your brain. uncomfortable when they stop The nicotine makes your brain release smoking. Think about the times certain chemicals that make you feel between smoking cigarettes. When you good. These “good” chemicals in your get close to wanting the next cigarette, brain stop the nicotine withdrawal you begin to feel uncomfortable. Or symptoms and your desire to smoke. you will notice that the longer you wait The chemicals make you feel relaxed. to have the next cigarette, the more uncomfortable you feel. What you feel Within 1.5 to 2 hours, your body is nicotine withdrawal. This is because processes the nicotine, and the nicotine smoking is an addiction. level in your body goes down. The “good” chemicals also go down, and You may experience: you feel the need to have another • cravings cigarette. • irritability • anger Behavioural conditioning (habit) • anxiety For most people, tobacco is part of their everyday routine. Most people • difficulty concentrating experience situations or triggers • low mood associated with wanting a cigarette. • tiredness For example, if you have a cigarette • difficulty sleeping when you are stressed, the chemicals activated in your brain make you feel • constipation better. Your brain remembers that Some smokers may not feel many of smoking decreases stress. Soon you these nicotine withdrawal symptoms need a cigarette anytime you feel and do not have to use ‘stop smoking’ stress. Smoking when you feel stress products. Other smokers may need to has become a habit. Studies show that use these products to feel comfortable. some social activities, such as going Health Canada’s approved ‘stop to a pub with friends who smoke, are smoking’ products include nicotine strongly related to tobacco use. In these replacement therapy and ‘stop situations, it feels natural to smoke. smoking’ medications.

10.3 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use The cravings will not last forever. Over 2. Nicotine replacement time, the cravings will be less strong therapy and less frequent. You have a better chance of stopping smoking or tobacco Nicotine replacement therapy (NRT) use if you use ‘stop smoking’ products, comes in several different forms: get counselling and make behavioural • changes. • nicotine ‘Stop smoking’ products • nicotine gum • nicotine lozenge There are two groups of approved ‘stop • nicotine mouth spray smoking’ products: (Nicorette® QuickMistTM) 1. ‘Stop smoking’ medications ‘Stop smoking’ medications consist of the following: a. Bupropion (Zyban®) b. Varenicline (Champix®)

• ‘stop smoking’ medications do not contain nicotine. They work in your NRT contains a clean form of nicotine, brain to make stopping smoking without the 4,000 to 6,000 chemicals more comfortable. found in cigarettes. It helps you deal • these medications require a with your withdrawal symptoms prescription. Discuss your medical and allows you to focus on changing history with your physician before your behaviour. Once you become using these medications. used to life without smoking, you can gradually reduce your NRT dosage • some of the medication cost may be until you no longer need it. covered. Check with PharmaCare at 604-683-7151 or check with your NRT is recommended by Health private insurance. Outside the Canada for tobacco users who want Lower Mainland call Pharmacare at to quit. NRT is effective when used 1-800-663-7100. properly. It is important to adjust the NRT dosage to the right nicotine level that you need. You can do this by using a higher dosage of one type of NRT. You can also mix the different types of NRT. Studies show that using the 10.4 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use nicotine patch plus one other method, Nicotine patch such as nicotine inhaler, gum, lozenge or mouthspray, increases your chance • easiest to use of success. You have a higher chance compared to other types of NRT of quitting successfully if you also use behavioural counselling. • useful for smokers who need a continuous amount of nicotine BC residents can get free NRT for 12 • the nicotine is absorbed through the weeks each calendar year from the skin BC Smoking Cessation Program. You can choose one of the four options: • the patch should be placed on the nicotine patch, inhaler, gum or lozenge. upper part of the body (where there is less hair and sweat) so it will stick Visit your local pharmacy for more information and to register. • the dose you need depends on how much you smoked previously WARNING: NRT is an over-the-counter • the patch should be placed on your medication. You do not need a doctor’s skin. Leave it on 24 hours a day. prescription. Please speak with your pharmacist or physician before you • when you put on a new patch on start any NRT if the following apply to the next day, do not put it on the you: same place again. Stick it on a different area each day. • are pregnant or breastfeeding • are being treated for any serious Dosage heart condition Your starting dose is based on the • had a heart attack or stroke within number of cigarettes you smoke. last 2 years Heavier smokers might need a higher dosage. Start at one dose and wait • require kidney dialysis 2-3 hours. If you still feel the urge • use any prescribed medications to smoke, you might need to go to a regularly are less than 15 years of higher dosage for the patch or add age another type of NRT such as the nicotine gum, inhaler, lozenge or mouth spray.

Dosage chart for the patch

Number of cigarettes smoked per day Starting dosage for patch

More than ten 21 mg - Step 1

10 or fewer 14 mg - Step 2

10.5 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Side effects • mimics the use of a cigarette • may cause local skin reactions or • to help you absorb the nicotine rash, headaches, sleep problems well, rinse your mouth with water and abnormal dreams, cold and flu- or drink some water before you use like symptoms and dizziness the nicotine inhaler • if you have trouble sleeping with Side effects: the nicotine patch on your skin, take • many people experience mild off the patch before sleeping. Then irritation of their mouth when you put on a new nicotine patch the they first use the inhaler. This side next day in the morning and wear it effect lessens as you keep using the until you go to bed. inhaler. WARNING: If you have chest pain, WARNING: If you have chest pain, irregular heartbeat, palpitations, irregular heartbeat, palpitations, leg leg pain or stomach pain that does pain or stomach pain that doesn’t not go away, stop using the patch go away, stop using the inhaler immediately. Call 8-1-1 to talk to a immediately. Call 8-1-1 to talk to a nurse or see your doctor. nurse or see your doctor. NOTE: If you still have cravings while NOTE: Avoid coffee, tea, soft drinks or you are wearing the patch, you can citrus juices 15 minutes before or after mix and match the NRT. For example, using the inhaler, gum or lozenge. you can use nicotine gum, lozenge or These drinks reduce the how much inhaler together with the patch, to feel nicotine you absorb. more comfortable. Tip: If you are using NRT but are still

TM experiencing cravings, you may need to Nicotine inhaler (Nicorette® Inhaler ) increase the dosage.

Nicotine gum

• the inhaler is a plastic cigarette- • good for occasional smokers who shaped cartridge containing just want to manage occasional nicotine cravings or stress • when you breathe in from the • nicotine gum is not like normal inhaler, the nicotine is gum. Do not chew it like regular absorbed through the lining of the gum. You must use it the right way mouth for it to work and to avoid side effects. 10.6 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use • bite twice and then park the gum Nicotine lozenge against your cheek for one minute. Repeat the biting twice and park for 30 minutes. • the nicotine is slowly released and • may be a good choice for those who absorbed through the lining of the do not want a steady dosage of mouth. The nicotine reaches the nicotine but would like support to brain faster than with the nicotine deal with cravings patch. It takes 15-30 minutes for the • useful if you have dentures or are gum to start working. missing teeth • the dose you need depends on how • it is like a hard candy which much you used to smoke. Two mg releases nicotine as it dissolves in gum is for people who smoke 25 or the mouth. The nicotine is absorbed fewer cigarettes per day. Four mg through the lining of the mouth. gum is for people who smoke more than 25 cigarettes per day. • can be used to reduce-to-quit, replacing cigarettes with a lozenge • to help you absorb the nicotine well, rinse your mouth with water • don’t bite, swallow or chew or drink some water before you use • do not use more than 15 lozenges the gum. per day Possible side effects: • do not eat or drink 15 minutes before using or while lozenge is in • mouth, throat or gum irritation your mouth • nausea and stomach upset • to help you absorb the nicotine • jaw ache well, rinse your mouth with water • hiccups or drink some water before you use • headache the lozenge • lozenges contain phenylalanine. WARNING: If you have chest pain, Advise your healthcare provider if irregular heartbeat, palpitations, leg you have phenylketonuria. pain or stomach pain that does not go away, stop using the nicotine gum Possible side effects: immediately. Call 8-1-1 to talk to a • mouth, throat or tongue irritation nurse or go see your family doctor. • nausea • stomach upset • hiccups • headache • taste change

10.7 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use WARNING: If you have chest pain, Possible side effects: irregular heartbeat, palpitations, • hiccups leg pain or stomach pain that does • headaches not go away, stop using the lozenge immediately. Call 8-1-1 to talk to a • nausea nurse or see your doctor. • mouth, throat or gum irritation Tip: Keep gum, lozenges or inhalers • upset stomach tucked away in several locations so that WARNING: If you have chest pain, you always have some close at hand if irregular heartbeat, palpitations, leg you have a craving. pain or stomach pain that does not go away, stop using the nicotine mouth Nicotine mouth spray (Nicorette® spray immediately. Call 8-1-1 to talk to QuickMistTM) a nurse or go see your family doctor.

Nicotine replacement therapy

Is NRT addictive? Smoking is more addictive than NRT. When you smoke, the nicotine reaches the brain in 7 to 10 seconds. The faster the nicotine reaches the brain, the more addictive it is. Nicotine from NRT takes • useful if you have dentures or are longer to reach the brain. missing teeth • the nicotine is absorbed through the Can I smoke when I am using NRT? lining of the mouth Yes. If you still want to smoke when • to help you absorb the nicotine well, you are using NRT, you may not be rinse your mouth with water or getting enough nicotine from the NRT. drink some water before you spray Increase your dose of the NRT or mix different types of NRT. Using the 100% • one spray is equal to approximately NRT would be a better choice because one cigarette NRT does not have the 4000-6000 • may not be suitable for those with chemicals found in cigarettes. an alcohol addiction because it contains small amounts of alcohol Can I use NRT longer than 3 months? You can use NRT for as long as you need to.

10.8 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Is it safe to use more than one type of NRT? Is it safe to use electronic cigarettes to stop Yes. It is recommended that you use smoking/tobacco use? the nicotine patch plus another type Electronic cigarettes are not approved of NRT (e.g. nicotine inhaler, gum, by Health Canada for stopping lozenge or mouth spray).You may smoking/tobacco use. They are not need to use more than one type of NRT regulated. The label may not have depending on your nicotine needs and accurate information about what is in lifestyle. Combining the different types them. Electronic cigarettes are known is safe and better for you than smoking. to contain metal particles, cancer- causing chemicals and a chemical also Is it safe to use NRT if I have heart disease? found in antifreeze. Some have been NRT is safer than smoking. NRT gives known to catch on fire or explode. you the nicotine your body craves without the harmful chemicals.

Cost comparison: cigarettes and NRT

Using NRT can double your chances of quitting. It may be cheaper than buying tobacco. How can you afford the cost of NRT? The following cost comparison may surprise you!

I spend $ per day on tobacco. Nicotine Replacement Therapy multiplied by 7 equals Sample cost: $ per week. one box of nicotine patches costs approximately MINUS $ 30 NRT per week. $ 30 per week EQUALS $ savings per week.

Tip: The BC Smoking Cessation Program provides 12 weeks of FREE nicotine replacement therapy each calendar year. You can choose one of the four options: nicotine patch, inhaler, gum or lozenge. Visit your local pharmacy for more information and to register. 2 Adapted from: BC Lung Association. QuitNow SMART STEPS…towards a tobacco-free life. 10.9 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Being smoke-free 3

Getting ready to be an ex-smoker Congratulations on deciding to quit! Quitting tobacco may not be easy, but good resources, tips and a support network can help you take the smart steps to success.

Why do you smoke? Complete the table below. Think about why you want to keep smoking. Think about why you want to stop smoking.

The benefits and costs of using tobacco 1. What are the good things about using tobacco? (eg. Helps me relax) ______

______

2. What are the not so good things about using tobacco? (eg. Going outside in the cold to smoke) ______

3. What would be the not-so-good things about quitting? (eg. Avoiding my friends who smoke) ______

4. What would be the good things about not using tobacco? (eg. Saving lots of money) ______

3 Some sections have been adapted from: BC Lung Association. QuitNow SMART STEPS…towards a tobacco-free life.

10.10 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use On the first day you are to go smoke-free, what would be the first positive thing you would notice? ______

On a scale of 1 – 10, how confident do you feel that you could go smoke-free? (Please circle one number.) 1 = LEAST confident 10 = MOST confident

1 2 3 4 5 6 7 8 9 10

What is one change you can make to make this number higher? (If you chose 5, what is one thing you can do to make it a “6”?) ______When would you be ready to quit? Choose a quit date.

My Quit Date: ______Promise yourself not to smoke

Understanding your smoking behaviour: about the cigarette tally sheet

Understanding your smoking behaviour can be helpful when you are quitting smoking. Writing down your tobacco use every day is a great way to do this. By recording when, where, why and who you smoke with, you will notice patterns in your smoking behaviour. Once you understand them, you can take steps to change these patterns, one at a time. Copy the tally sheet on the next page and carry it with you. Attach it to your pack of cigarettes if possible. Every time you have a cigarette, write down the information.

10.11 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use At the end of the day, look at your tally sheet. Take three different colour highlighters or pens such as yellow, orange and pink. Colour code each of the following time frames with a different colour. • less than ½ hour between cigarettes (colour these times all one colour, like pink) • ½ to 1 hour between cigarettes (colour these times a second colour, like orange) • over 1 hour between cigarettes (colour these times a third color, like yellow) What did you learn? When do you smoke the most? When do you smoke the least? What can you do to change these patterns? If you like, share these discoveries with your support network, including family and friends.

Date:

How much did Activity I crave a How was I feeling before Cig cigarette? (What you are doing?) Time having the cigarette? # (Who you are with?) 1=low (e.g. angry, bored, unhappy) 2=med 3=strong

10.12 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Control your cravings: use the 4 Ds As you start to smoke less, here are four simple things to remember when you feel the cravings. 1. Delay – Don’t smoke when you feel the craving. Wait five minutes. The craving will pass. 2. Deep breathing – Breathe in through your nose. Count to 5 while you hold your breath. Count to 7 as you slowly breathe out through your mouth. 3. Drink water – Drink a glass of water slowly. Hold each sip in your mouth for a few seconds before swallowing it. 4. Distract – Keep your hands and mind busy. Do something which makes it difficult to smoke. For example, have a shower or do some exercise. Do something you enjoy to help you think of something else. Tip: If you would like more help with cravings, talk with your pharmacist, physician, nurse, or other healthcare provider, or go to www.quitnow.ca.

Dealing with cravings: knowing your triggers There are behaviours, feelings and situations that will make you want to smoke. These are called triggers. If you know what makes you want to smoke, you will be more successful in stopping smoking. Think about what makes you want to smoke Write in the chart below about what makes you want to smoke. Then write down a plan of what you can do differently the next time the situation occurs. Tip: Having cigarettes, ashtrays and lighters near you may make you want to smoke. You should get rid of these triggers.

Triggers: behaviours, actions, Plan for avoiding thoughts or emotions or substituting Example: After I eat a meal Example: I’ll go for a walk after eating

10.13 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use What could you buy with the money you spend on tobacco? What would you rather be doing with the money you spend on tobacco? Use the chart below to figure out what you could buy if you did not buy tobacco for the next 10 years. In the second column, start by entering the amount you spend on tobacco per day and then calculate how much that adds up to as time goes by. You can use the calculator on www.quitnow.ca to help you with this. For example, if you smoke one pack a day and each pack is $7, in one day you would save $7, in one week you would save $49 ($7 X 7) and in one month (4 weeks) you would save $196 ($49 X 4 weeks).

Time Amount spent on tobacco What could you buy? 1 day

1 week

2 weeks

1 month

6 months

1 year

2 years

5 years

10 years

10.14 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Where do I go for help? QuitNow (BC Lung Association) Free phone, online, live chat and text Talk with your doctor services to help you quit Let your doctor know when you want • phone: 1-877-455-2233 to quit smoking. He or she may need to • online: www.quitnow.ca check your medications. • text: Text the word “QUITNOW” to 654321 (standard text message/ BC Smoking Cessation Program data rates) to sign up for a 14-week • BC residents can get either FREE motivational QuitNow by TXT nicotine patches, inhaler, gum or program. You can also register at lozenge for 12 weeks each calendar www.quitnow.ca. year • visit your local pharmacy for more Ask for help and support from information or to register family, friends and ex-smokers • depending on your Pharmacare If smokers or tobacco users have a good coverage, you may be covered support network, they will have an for prescription ‘stop smoking’ easier time coping with quitting. So, medications. Contact Pharmacare tell your family and friends that you for more information are quitting and ask for their help and support. Tell them your reason(s) for Vancouver General Hospital quitting. Smoking Cessation Clinic Set a quit date and tell your family, • see a doctor or nurse who has friends and co-workers so that they can special education in tobacco use support you. • get FREE counselling and support Ask them to be patient, encouraging • learn about stop smoking products, and to help you celebrate successes. including stop smoking medications Even small successes are worth Gordon and Leslie Diamond Health celebrating! Care Centre, 6th Floor – 2775 Laurel Street, Vancouver, BC Talk with other ex-smokers to learn 604-875-4800 (press “2”) about how not to give up on quitting.

Stop smoking groups Check for stop smoking groups in your area.

10.15 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use MY PLAN

I will stop smoking/tobacco use on: ______(choose a date) My reason(s) to stop are: 1. ______2. ______

To stop smoking/tobacco use, I will:

£ visit my local pharmacy to register free nicotine replacement therapy through the BC Smoking Cessation Program

£ use nicotine replacement therapy products or stop smoking medications £ call the VGH Smoking Cessation Clinic 604-875-4800 (press “2”) £ get help from QuitNow: www.quitnow.ca or 1-877-455-2233 £ get help and support from my family, friends and ex-smokers £ check for stop smoking groups in my area

Most important: £ I will never give up trying!

10.16 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Notes

10.17 Pulmonary Rehabilitation Patient Education Manual Chapter 10 - Understanding Smoking & Tobacco Use Pulmonary Rehabilitation Patient Education Manual Chapter 11 Stress management

Stress is our human response to situations or conditions that challenge or excite, confuse, frighten, or irritate us. Stress is a natural part of everyday life. How individuals respond to stress differs from person to person, depending on the person and the type of stress. It is important to recognize the types of stress to manage or cope with them.

Some types of stress are important and desirable, and lead to positive changes in us. Some of our noblest achievements as human beings were in response to stress. However, stress might affect us negatively. Instead of being helpful, it might damage us.

Stress is often described as ‘good stress’ or ‘bad stress’.

Good stress Good stress can motivate us, protect us, and help us perform better. Examples include: writing an exam, starting a new job, buying a home, or the birth of These events can bring challenging, a child. negative changes in our lifestyle such as an uncertain future, disability, financial difficulties, or change in personal roles Bad stress and responsibilities. Bad stress is a change that we fail to recognize or manage successfully. If stress is not recognized and We can feel overwhelmed, develop a managed, your overall health will weakened immune system, or suffer suffer. Fortunately, you can use various from depression. strategies to help you control your response to stress and adapt to changes Examples include chronic illness, death such as those listed above. First, of a loved one, or loss of a job. however, you must recognize: • what triggers stress in you, and • how your body and mind respond to stress. 11.1 Pulmonary Rehabilitation Patient Education Manual Chapter 11 - Stress Management What can trigger stress? In your mind: The following list has examples of what • frustration might cause stress for you: • grief and loss In the environment • worry • weather conditions • guilt • smoky or stuffy rooms • anger • crowds • fear • family demands • concentration problems • workload • memory problems • traffic • feeling irritable

In your body: Remember: We are all individuals. Stress for one • chronic medical conditions person is not necessarily stress for • shortness of breath another. We must each be responsible for recognizing our own triggers of • pain stress. • indigestion How do we respond to stress? • fatigue When we experience stress, our bodies • weakness try to deal with the physical and mental • persistent disturbances occurring within us. cough Our immediate response to short term stress is usually physical. It is sometimes called the ‘fight or flight’ response.

When we perceive something as stress, adrenalin is produced, setting off an alarm system in our bodies. Sugar is poured into our blood stream for fuel. Our body can now respond to a ‘threat’.

11.2 Pulmonary Rehabilitation Patient Education Manual Chapter 11 - Stress Management A series of reactions takes place within The response to excessive or prolonged your body and you may experience stress is usually mental. This is some of the following: different for each person and you may experience some of the following: Physical response: • heart beats faster Mental / behavioural response: • increased blood pressure • racing thoughts • increased respiratory rate • inability to concentrate • muscles become tense and sore • inability to make simple decisions • shakiness in legs • loss of confidence • desire to go to the bathroom • social withdrawal • increased perspiration • irritability or anger • dry mouth • blaming • tightening or butterflies in the • increased cravings for things like stomach alcohol, cigarettes, food, drugs • clenching jaw • increased worry and anxiety • grinding teeth • fear and panic • clenching fists • depression • tightening throat muscles (lump in • inability to sleep throat) • impulsive behaviour • inability to sit still • teary eyes How can we cope with stress? • blotchy skin Coping is the process in which individuals learn to manage • breathlessness their physical and mental • rapid breathing responses caused by stress. Try to use good, healthy • shallow coping strategies, and limit breathing or avoid bad, unhealthy strategies.

11.3 Pulmonary Rehabilitation Patient Education Manual Chapter 11 - Stress Management If you want to cope effectively with Take action stress: • talk it out. Clear your mind. • acknowledge reality and confront it • don’t wait until you have lost control • use a problem-solving, decision- making process • replace tension with action • look for positive aspects in each Build in change situation • do something different • seek help from appropriate • change your pace resources • accept support • engage in regular physical activity • choose healthy coping strategies • practice relaxation techniques Get rid of your anger More strategies to help you cope • bottling up anger does more harm than good Do not allow circumstances you did not create to overwhelm you. • try not to punish those around you • do something to change your • don’t distance yourself: stay social situation • do something for someone else • no one can cope for you – it’s your life • remove the focus from yourself Look at the situation rationally Smile • change what you can • smiles use fewer muscles than frowns • accept what can’t be changed! Be realistic • smiles are less tiring than frowns • don’t expect too much from yourself Healthy strategies Unhealthy strategies • you can’t always be in control • you can’t always be right • proper nutrition • smoking • you are only human • exercise • alcohol Be flexible • relaxation • overeating • try alternatives • recreation • drugs • learn from your mistakes. Make them a good • assertiveness • social withdrawal experience. • time-outs • self-pity • take one step at a time; don’t overwhelm yourself • humour • blaming

11.4 Pulmonary Rehabilitation Patient Education Manual Chapter 11 - Stress Management Relaxation Techniques

Begin to regularly check your whole body for feelings of tension. Especially notice any tension or stress in the muscles of your shoulders, face, back or hands. Check if your mind is racing or your heart is beating fast. Once aware of these feelings, use these techniques before the tension becomes intense. You will be gaining more control over your body.

Incorporate the following quick and simple-to-use techniques in your daily routine. They can be practiced anytime, anywhere. They will provide short, frequent periods of relaxation. These techniques will reverse feelings or sensations of tension. They will prevent the build-up of stress.

Do this Because

1. Move and stretch all parts of Movement improves blood flow and helps to the body. remove tension.

2. Realign body into correct During stress, we often hold our head and posture. Take special note of the lower jaw forward and raise the waist and back, shoulder and lower jaw. the shoulders up toward our ears.

3. Start slow, deep breathing Stress often makes us breathe shallowly. and think about letting your Deep breathing seems to have a relaxing muscles go when breathing out. effect.

4. Imagine a pleasant scene Focusing on one pleasant thought or Healthy strategies Unhealthy strategies where you are comfortable and scene will help calm your mind and stop relaxed. Continue slow, regular the continual flow of rapid, demanding • proper nutrition • smoking breathing. thoughts. • exercise • alcohol • relaxation • overeating • recreation • drugs • assertiveness • social withdrawal • time-outs • self-pity • humour • blaming

11.5 Pulmonary Rehabilitation Patient Education Manual Chapter 11 - Stress Management Pulmonary Rehabilitation Patient Education Manual Chapter 12 Walking on the level To control your breathing while Effective techniques walking, count the number of steps you take while inhaling and then exhale for walking and stair for twice as many steps. For example, climbing if you inhale for two steps, then exhale through pursed lips for four steps. This pattern will become a habit after you Walking and stairs find your comfortable breathing rate. Important things to remember when walking: Distance walked Twice the distance while inhaling of inhale l. breathe in through your nose. This Inhale Exhale warms, moisturizes and filters the air you breathe.

2. pause very slightly after you inhale. Walk at a pace that challenges you but This pause gives your lungs a does not cause uncomfortable shortness chance to trade the oxygen you of breath. Start with a short walk to see inhale, for carbon dioxide that you how far you can go before you become can breathe out. too breathless. Stop and rest whenever you feel uncomfortably short of breath. 3. breathe out through pursed lips with a soft blowing action Walk as far as you can comfortably. Try to allow you to exhale to walk further gradually by setting fully specific goals to go a little further every day. Keep your goals reasonable. 4. try to breathe Remember that you must be able out approximately to return to your starting point twice as long as you without uncomfortable breathe in breathlessness. Never do too much. Always stop 5. exercise and and rest for two or three shortness of breath will not minutes when you feel harm your lungs. If you slow your uncomfortably short rate of breathing and concentrate of breath. Never let on exhaling, you will have better yourself be hurried control of your breathing and be beyond your able to manage more activity. capabilities. 6. if you are short of breath, stop and rest 12.1 Pulmonary Rehabilitation Patient Education Manual Chapter 12 - Effective Techniques For Walking And Stair Climbing Walking upstairs Walking downstairs 1. at the bottom of the stairs hold the 1. breathe in at the top of the stairs handrail. Breathe in before you and breathe out while you go begin to climb. down as many steps as you are comfortable 2. place your whole foot flat on each step 2. place your whole foot flat on each step for 3. go slowly. Breathe better support and out while you climb for more efficient energy as many steps as you expenditure feel comfortable. 3. breathe as 4. stop and breathe in described for when you need to walking on level 5. breathe out as ground, but go a little you step up slower. Rest between steps if you feel breathless.

12.2 Pulmonary Rehabilitation Patient Education Manual Chapter 12 - Effective Techniques For Walking And Stair Climbing Pulmonary Rehabilitation Patient Education Manual Chapter 13 Medical history Your health care professional will Diagnostic procedures ask about your medical history. Your medical history includes the details Assessment and testing for lung about your lung condition, including disease things that may have caused your lung condition, the symptoms you When you visit your doctor or other have, the medications you take, or health care professional, there are a other health conditions you may number of questions they will ask you, have. The following table lists some and there are several tests. of the questions related to your medical history that your health care professional might ask.

• what age did you start smoking? Smoking • what age did you quit smoking? • how much did you smoke in a typical day?

• were you exposed to any lung irritants at home or at work? Environmental • were you exposed to secondhand smoke?

• do you cough? • how often? Cough • does your cough bring up phlegm or mucus? • what colour is it?

Wheezing (Wheezing is a • do you wheeze? high, whistling • if yes, when do you wheeze? sound when you • what makes it go away? breathe.)

• have you ever had pneumonia or chest infections? Serious chest • how often do you get these kinds of chest illnesses? illnesses • when you do, how long does it last?

• when you feel breathless, how long does it last? Breathlessness • do you feel breathless when you are not moving around? • do you feel breathless when you are active?

Table continued on next page

13.1 Pulmonary Rehabilitation Patient Education Manual Chapter 13 - Diagnostic Procedures • how far can you walk or run? • how long can you spend moving around before you need to Activity level rest? • how often do you walk, run, or exercise?

• is there lung disease in your immediate family – your parents, Family history brothers and sisters, or children?

Physical examination Diagnostic tests After asking questions about your Pulse oximetry medical history, the health care A pulse oximeter measures the level professional might do a physical of oxygen in your blood. It shines examination. This means observing beams of light through your finger your breathing, listening to your to calculate how breathing with a stethoscope, or much oxygen is touching your body to learn more in your blood. about your lung condition. Knowing how much oxygen is Things the health care professional may in your blood observe: helps us find out Airflow problems, identified by: how well your lungs are working.

• wheezing Pulmonary function tests • taking a long time to exhale 1. Spirometry 2. Lung volume testing • shortness of breath whether or not you are exerting yourself 3. Diffusing capacity • lungs larger than normal, often These breathing tests measure how with elevated shoulders well your lungs work. This helps us diagnose lung disease and measure • quieter than normal heart and how your lung function changes over breath sounds time. You breathe into a machine • use of accessory muscles to breathe for all the pulmonary function tests. while you are not moving around. They take 30-60 minutes to complete. ‘Accessory’ refers to some muscles You must not use any fast-acting that are not used for normal rescue medication (bronchodilators) breathing unless you have a lung within 6 hours before these tests. disorder. We need to measure how your lungs work without any medication affecting them. 13.2 Pulmonary Rehabilitation Patient Education Manual Chapter 13 - Diagnostic Procedures 1. Spirometry Exercise oximetry For spirometry testing you breathe When you are moving, your body into a mouthpiece of a device called uses more oxygen. This test measures a ‘spirometer’. This device measures how well your lungs keep up with the speed and the amount of air your body’s demand for oxygen you breathe into the mouthpiece. during that activity. It measures the Sometimes amount of oxygen in your blood as we test you you exercise. before and For exercise oximetry testing, after you we place a probe on receive your finger while four puffs you go for a walk of the fast- in the hall. If acting rescue your oxygen medication, salbutamol. This helps level decreases us assess how well your airways while walking, respond to the medication. This we will give you test also is used to diagnose lung oxygen. Then you walk conditions. again. If you can walk further using oxygen, you might 2. Lung volume testing benefit from home oxygen. Lung volume testing measures the Six minute walk test amount of air in your lungs. This includes the how much air that you This test measures how far you breathe in, how much you breathe can walk in six minutes. You walk out, and how much is trapped and at your own held in your lungs. We use this test pace. You rest to measure the severity of your lung as needed disease. while you walk back and 3. Diffusing capacity forth along a marked This tests your lungs’ ability to walkway. move oxygen and carbon dioxide between your lungs and your We use the six- bloodstream. minute walk test to find out how much exercise you can do. We often do this test before you start an exercise program, and then again afterwards. This tells us if your fitness level has changed.

13.3 Pulmonary Rehabilitation Patient Education Manual Chapter 13 - Diagnostic Procedures Cardiopulmonary exercise test V/Q lung scans (Ventilation-perfusion We use the cardiopulmonary exercise scan) test to measure how your heart and V/Q lung scans evaluate where air is lungs respond to going in the lungs (ventilation scan) exercise. For this and how well blood is circulating test, you ride a in the lungs stationary bicycle or (perfusion walk on a treadmill. scan). For We measure your these tests breathing, heart you inhale a rate and oxygen radiographic throughout the test. gas and we We will encourage inject radiographic dye into your you to exercise as arm. The scanner can detect the gas long as you can. and the dye and this allows us to look at the air and blood circulation We do this test to find out if your in your lungs. This kind of scan is shortness of breath is caused by particularly useful to find blood clots. problems with your lungs, your heart, or both. The test also helps us Bronchoscopy develop an exercise program for you. Bronchoscopy lets us Chest X-ray examine the inside of your lungs and airways A chest x-ray is a picture of your for anything unusual. We chest showing your heart, lungs, can also collect samples airways and blood vessels. X-rays during the procedure. help us diagnose and treat lung This procedure uses a infections, pneumonia, tuberculosis flexible fiber optic scope that we and cancer. put into your lungs. We give you CT scan (Computed Tomography Scan) medication to help you relax during this test. CT scans are similar to Arterial blood gases chest x-rays. Arterial blood gas tests measure how However, well your lungs move oxygen into they offer your blood, and carbon dioxide out pictures of your blood. which are We take a much clearer blood sample than regular x-rays. CT scans help from your us diagnose many different types of wrist and then chronic and acute lung conditions. test it. 13.4 Pulmonary Rehabilitation Patient Education Manual Chapter 13 - Diagnostic Procedures Pulmonary Rehabilitation Patient Education Manual Chapter 14 When you have a chronic lung condition, your lungs are less efficient Energy conservation at providing oxygen. Sometimes simple tasks can make you feel tired. Even though we encourage you to Saving your energy for those things exercise to increase your overall energy that you enjoy doing levels, it is important to know how to pace yourself so you don’t overdo it. Energy conservation is: By employing energy saving steps, • avoiding fatigue by you make the most of the energy finding the easiest you have so you can do your daily way of doing your activities better and more easily. activities • balancing rest, play How do you save energy? and work • set priorities Exercise and energy • plan your time Exercise helps to increase your energy • pace yourself level, but the process takes time. It is • perform the activity more important that you don’t exercise so efficiently, by using proper hard that you use up all of your energy body positioning and you don’t have enough to do your other activities. • simplify tasks

If you don’t exercise enough, you Priorities will find that your energy level will decrease over time. Look at the activities you do and eliminate those which are not crucial. It is important to exercise and also Be sure to include leisure activities important to make sure you use your such as hobbies, social events and energy carefully throughout the day. favorite pastimes, as these activities are ‘energizing’. Why conserve energy? Remember: you are the only one who Each of us has a limited supply of can decide which activities are most energy and after completing any important. These will be different for necessary activities, we want to have everybody. enough energy to enjoy ourselves.

14.1 Pulmonary Rehabilitation Patient Education Manual Chapter 14 - Energy Conservation Planning Change your environment Planning your day or week ahead of When working, ensure that things are time can save you unnecessary steps within easy reach, especially the things and frustrations. It will ensure you get you use most frequently. things done and still have energy left to have fun. Pace yourself

First, decide when you feel most Work at a moderate pace — not too fast energetic and plan high energy or too slow. You will get tasks done in activities for these times. Also, plan a reasonable period of time with fewer to do these activities about fifteen mistakes. Never let yourself be hurried. minutes after using your fast acting Hurrying is stressful and stress is bronchodilator, when it is the most energy wasted. effective. Plan rest periods throughout your day and remember to alternate If you rush and get short of breath, you high with lower energy activities. will spend longer trying to catch your breath. If you pace yourself, you will go Simplify further before you need a rest. By breaking large tasks down into their There is often more than one way of different steps, you can analyze them doing a job. Most of us do things a and find creative ways to reduce the certain way because we’ve always done amount of energy used. Maybe you can it that way. But now, it’s time to look at delegate all or part of the task. Make your old habits more closely and decide use of community services such as how you can change them in order to grocery delivery. save yourself some steps. • walking: try to get into a pattern Use proper body mechanics of breathing that matches your Perhaps energy saving equipment walking pace would be useful, for example, a • stairs or hill: slow down when dishwasher or wheeled shopping cart. going up these and maintain control Make sure all equipment is in good of your breathing. Do not hold your repair. breath or try to rush up with stairs or hill as this will make you more If you are already tired, consider if you short of breath and make gaining can do the activity by sitting instead of control difficult. standing. • bending: try to breathe out as you bend over

14.2 Pulmonary Rehabilitation Patient Education Manual Chapter 14 - Energy Conservation Different things are important to • use long handled equipment (for different people, so only you will example, long handled reachers, be able to decide where and when long handled pruning shears, a you will make these changes. By broom, a dressing stick, a sock aid setting priorities, planning your time, or a bathing brush) simplifying tasks and by pacing • bring your feet to you (for example, yourself you can start teaching yourself rest your foot on your knee to towel some new habits and save some energy dry, put on socks or tie up your for doing those things you like to do. laces) Ideas for energy conservation • avoid heavy lifting:

Control and coordinate your breathing ₋₋use a wheeled cart; push rather than pull; slide rather than lift with daily activities ₋₋let your bigger muscles do the • standing up: breathe in before you work – squat with your legs, avoid move. Breathe out as you rise up bending your back from your seat. ₋₋ask for help • lifting an object above your head: breathe in before you lift. Breathe ₋₋divide the load; for example, fewer out as you lift your arms above you. groceries, half fill the kettle

• putting on shoes: breathe in before Sit when possible to perform you move. Breathe out as you bend activities down to put on your shoe. • standing uses more energy than Reduce strenuous movements sitting. When possible, consider sitting while ironing, washing • carry objects close to your body dishes, showering, chopping • organize equipment or food to be vegetables, gardening, making a within easy reach phone call, or working in the shed. • keep most activities between waist • keep a high stool or chair for you to and shoulder level use in your kitchen or at your work bench • store commonly used items on middle shelves between your waist Take frequent rest breaks and shoulders • continuing to work until you are • work at benches that are at waist out of breath might then take you height longer to recover. So take regular breaks to rest and recover while working. Don’t wait until you need a break. 14.3 Pulmonary Rehabilitation Patient Education Manual Chapter 14 - Energy Conservation Plan and prepare before you perform Pace yourself tasks • use slow, rhythmic movements • high expectations can lead to • alternate light and heavy activities frustration, so be patient with yourself and set achievable goals. • spread heavier tasks throughout the Challenge old habits. Ask yourself day, week, and month ‘Is it essential that this task be • learn to ask for help, or get someone performed in the usual way?’ else to do the task, such as family • plan for rest breaks and members, community services, interruptions neighbours, volunteers or friends. Asking for help does not mean • break jobs into smaller steps. For you are dependent, it means you example, rather than cut the entire are using your energy to its best lawn in one go, do it in two or three advantage. goes. • prepare and prioritize Avoid extremes of temperature • hot or cold environments place • use a diary or calendar to plan greater demand on the body daily, weekly, and monthly tasks which may increase feelings of • put items where they can be found breathlessness, fatigue, discomfort easily and quickly and anxiety. • keep most frequently used items • avoid strenuous tasks, particularly between waist and shoulder level in hot weather • use equipment that makes the job • where possible, control the easier, e.g. light weight crockery, temperature in your environment long-handled reachers, long- • use fans, air conditioners, heaters handled garden equipment, stools, trolleys, Velcro shoes, buttonless • avoid extremes in temperature shirts and clothes that don’t need ironing. • reduce steam – open doors, windows • avoid strenuous activity after meals

14.4 Pulmonary Rehabilitation Patient Education Manual Chapter 14 - Energy Conservation Relax • When you feel worried, anxious or uptight your body uses a greater amount of energy. • This can add to feelings of being tired or breathless. • Relaxation can help restore energy. • Concentrate on relaxing your muscles and slowing down your breathing.

‘Ideas For Energy Conservation’ was adapted from the Pulmonary Rehabilitation Toolkit of the Australian Lung Foundation.

Alison J et al, The Pulmonary Rehabilitation Toolkit on behalf of The Australian Lung Foundation (2009). *

* Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide is a joint project of the Statewide COPD Respiratory Network, Clinical Practice Improvement Centre, Queensland Health and The Australian Lung Foundation, COPD National Program. This work is copyright and copyright ownership is shared between the State of Queensland (Queensland Health) and The Australian Lung Foundation 2012. It may be reproduced in whole or in part for study, education orclinical purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial use or sale. Reproduction for purposes other than those indicated above requires written permission from both Queensland Health and The Australian Lung Foundation.

© The State of Queensland (Queensland Health) and The Australian Lung Foundation 2012. For further information contact Statewide Respiratory Clinical Network, Patient Safety and Quality Improvement

Service, e-mail: [email protected] or phone: (07) 36369505 and The Australian Lung Foundation, e-mail: [email protected] or phone: 1800 654 301. For permissions beyond the scope of this license contact: Intellectual Property Officer, Queensland Health, email: [email protected] or phone (07) 3234 1479.

To order resources or to provide feedback, please email: [email protected] com.au or phone 1800 654 301.

Queensland Health Statewide Respiratory Clinical Network and The Australian Lung Foundation, COPD National Program – Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide, 2012.

14.5 Pulmonary Rehabilitation Patient Education Manual Chapter 14 - Energy Conservation

Pulmonary Rehabilitation Patient Education Manual Chapter 15 Prevent falls - stay on your feet

Preventing falls Preventing falls is important to help maintain a healthy and independent lifestyle. Falls are a major reason for admission to hospital and residential care homes. Although a fall can happen to anyone, anywhere, the result of a fall is usually more serious as we age.

The first step to avoiding a fall is to understand what causes us to fall. Some people The second step is to take action to believe that prevent the fall. falls are a normal part of aging, that no matter what they do falls can’t be This chapter suggests simple, practical prevented, or that it won’t happen to things you can do to remain active and them. independent. The truth is: Causes of falls Falls are NOT a normal part of aging There is no single reason why people and there are many things you can do fall. A fall usually occurs when several to prevent falls. events happen at the same time. The causes of falls are often called risk This chapter identifies some of the factors. The more risk factors, the major risk factors that can cause falls greater your chances of falling. For and suggests ways you can decrease example, if you walk down the hallway your chances of falling. If you want in your home, during the day, in no more detailed information on any of particular rush, there is little chance the causes of falls or what you can do you will have a fall. If, however, it is the to prevent them, see your health care middle of the night, there are no lights on, shoes are sitting in the hall, and provider. you are rushing to get to the bathroom, your chances of falling are much greater.

15.1 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet Vision • increase the amount of light in your Good vision is important for safely house getting around your house and • use night lights, especially in the community. As we get older there are path from the bedroom to the some normal changes in our vision bathroom that can affect how well we can see. These include things like being more sensitive to shiny surfaces, having Taking risks trouble seeing at night, and needing Taking risks and putting yourself more time for our eyes to adjust in unsafe situations can increase when we go from a bright room to a the chances of a fall. Look at daily dark room. There are also some eye activities to see if there are safer ways diseases that are more common as we to accomplish everyday tasks. If you get older. These include glaucoma, answer yes to any of the following cataracts, macular degeneration and questions you may be taking chances diabetic retinopathy. and putting yourself in harms way.

Do you: Do you: • notice you are more sensitive to • climb onto furniture when reaching glare? for something? • have dirty or scratched eye glasses? • see hazards in your home but don’t • have difficulty reading, or avoid get them fixed? reading? • move heavy objects by yourself? What you can do: • wear slippers with an open heel or • have regular eye exams every two socks around the house? years by an eye doctor to identify • rush to get things done or be on age-related eye diseases such as time? cataracts and glaucoma • do things on your own rather than • use different or brighter colours ask for help? to mark objects in your home that you need to reach for such as light • get overtired by trying to do too switches, grab bars or handrails much? • add different coloured strips to the • go up and down stairs carrying edge of steps to show how deep things in both hands? each step is • clean eye glasses often so you can see clearly

15.2 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet What you can do: Sedatives, anti-depressants, and anti- • use a sturdy step stool with a psychotic drugs can reduce mental handrail to reach high places alertness, worsen balance and gait, and cause drops in blood pressure • fix unsafe areas of your home (see while standing. Alcohol can also Home and Community Hazards, react with many common medicines page 15.6) to affect your balance and increase your fall risk. • store items on lower shelves • keep regularly used items at arms Do you: reach • take medication to help you sleep? • wear lace-up sturdy shoes with • neglect to take your medications as nonskid soles prescribed or recommended? • look where you are going, and try • drink more alcohol than the not to be distracted or to rush recommended low-risk drinking guidelines (9 standard drinks per • ask for help to carry or move heavy week)? and bulky objects • minimize sudden movement and What you can do: avoid changing positions quickly • know why you are taking each medication • use a walker or cane, if one has been recommended for you • use only your own medications • keep one hand free to hold the • go to the same drug store for handrail even when carrying items all your prescription and non- prescription needs Medication use • visit your doctor and pharmacist It is important to learn about your to review all your medications medications and take them as periodically prescribed. Dizziness, drowsiness • use alcohol in moderation and tell or loss of balance are some of the your doctor and pharmacist how negative effects of medications that much alcohol you drink can cause falls. Older adults who take four or more medications a • keep a list of all your medications day, including over the counter and take it with you when you visit medications and herbal supplements, your doctor or pharmacist have a significantly greater risk of falls. Medications that help you sleep • tell your doctor and pharmacist if can also increase your chances of your medications are making you falling. drowsy or dizzy 15.3 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet • know the common side effects of all What you can do: medications taken • learn about your illness or condition • return all medications you no • join a support group if you have a longer use or are out of date to your chronic condition that affects your pharmacist lifestyle

Illness • learn how to manage your illness to remain as active as possible A chronic illness is a condition that lasts a long time and for which • increase your activity level there is usually no medical cure gradually to your usual level, after (such as arthritis, stroke, cancer an acute illness or heart disease). An acute illness • use meal delivery, housecleaning, is one that lasts a short time and and grocery services until your begins suddenly (such as the flu or normal abilities return throat infection). Both chronic and acute illness increase your chances • eat a healthy diet and drink plenty of having a fall. The more chronic of fluids illnesses you have, the greater your risk of falls. You are also more likely • find activities that you can do to fall when you are ill, tired, or without fatigue or discomfort. upset. If you are ill, for every day you Monitor your activity level and stay spend in bed, it takes at least three within your comfort zone. days of activity to gain back your • visit your doctor to monitor your normal strength. Keeping as active as illnesses/conditions possible is very important to staying strong. • maintain regular participation in activities to maintain strength and Do you: balance • have an ongoing illness or illnesses • talk to your doctor about the correct that affects your lifestyle? pain medications to take. Inactivity • fatigue easily? Experience pain due and pain can cause you more harm a chronic illness or condition? than many medications. • restrict your participation in activities due to your health?

15.4 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet Fear of falling • continue to exercise, socialize and Fear of falling is a serious concern participate in normal activities after for many people and can restrict a fall both social and physical activities. • use a cane or walker to maintain Perhaps you know someone who has your independence and be sure been injured or disabled by a fall. Or they are fitted and used correctly maybe you have taken a minor spill yourself and are afraid the next one may be worse. What to do if you fall Although a fall may damage more Take the time to develop a plan of what than your dignity, you do not need to you might do after a fall. Some things let the fear of falling rule your life. In to consider: fact, the fear of falling itself increases • wear a personal alarm around your your chances of having a fall if you neck allow yourself to become inactive. • keep a mobile or cordless telephone Do you: with you at all times • stay indoors and avoid going for a • set up quick dial numbers on your walk for fear of having a fall? home phone • avoid social activities that require • carry a whistle travel outside the house? • have a friend or family member call • choose not to use a cane or walker you daily and leave them a spare because you think it makes you look key, so they can get to you quickly more dependent or “old”? • think frequently about the dangers of a fall? What you can do: • exercise to improve your strength and balance • include activities such as dancing, gardening, and stretching to improve flexibility and balance • stay as active as possible after a fall and return to regular routines as soon as possible

15.5 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet Getting up after a fall Home hazards Stay quiet for a moment — don’t panic. Home is the most common place for If you are injured, stay where you are. older adults to fall. Half of all injuries Call for help using one of the methods from falls happen at home. Look mentioned previously. If you are not around your house to find areas that injured, use your judgment and try to may present problems. You can often get up. make some simple and inexpensive changes to make your home safer and 1. Look around reduce the risk of falls. for a sturdy piece of Check to see if the: furniture, such • front steps, walkways and as a chair. driveways need repair? 2. Roll onto your side. • walkways have cracks, holes, leaves and debris? 3. Crawl or drag yourself over to the chair. If • stairs need handrails installed or you can, replaced inside and out? pull your • stairs have clutter and items stored walking aid on them? along with you. • stairs seem dark or difficult to see?

4. From a kneeling position, put your • carpets and rugs slip and curl up? arms up onto • walking areas have telephone and the seat of the electrical cords and clutter? chair. What can you do? 5. Place your strongest foot • repair and remove debris from flat on the floor. outdoor sidewalks and steps • install and repair handrails on both 6. Push up with your arms and legs, sides of stairs move your bottom around. • clear clutter from walkways and stairs 7. Sit down. Rest before trying to move. • increase the wattage of light bulbs in your whole house, especially at the top and bottom of stairs

15.6 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet • remove loose carpets or rugs that What can you do? you may trip over • report unsafe conditions, poor • use only non-slip rugs on the lighting, and unkempt bushes to kitchen and bathroom floor, and property owners or managers, or to non-skid mats, decals or abrasive city hall strips in the bathtub and shower • report broken, uneven, or cracked • install nightlights in the bedroom, sidewalks to the municipality or city bathroom and hallways hall • find walking and bus routes with Community hazards benches and resting spots Community hazards include unsafe • contact Handi-Dart, social or church sidewalks, parks, businesses or shops. groups to assist with transportation Look around your community to see if it is safe. Strength and balance Check to see if there are: Exercise is the best way to reduce • places to sit and rest while going for your risk of falling. Any activity you do can make a difference, but the best a walk or waiting for a bus? activities to reduce falls include those • hand-rails in public buildings that that improve muscle strength in the are too wide to hold on to? legs and improve balance, posture and stamina. We have all heard: “I have • floors in supermarkets or public worked hard and been active all my buildings that are slippery? life. I have always been able to look • stairways or public areas that are after myself and I’m not sick. How can my legs be weak, and how can there poorly lit? be anything wrong with my balance? • sidewalks that are unsafe because of I have never had any problems before tree roots or cracks? and have never had a fall”. The fact is that muscles tend to get weaker • public places you avoid because of a and balance becomes harder if we fear of falling? don’t continue to remain active. The only way to maintain or improve • transportation difficulties due to both strength and balance is through access and/or cost? exercise. It is never too late to improve your strength and maintain balance to reduce your chances of falling.

15.7 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet To check your leg strength and balance, centre, or church to find out what try the following tests. activity programs are offered

You may like to have a friend or family • do a few exercises when you make member stand by while you try these. yourself a cup of tea or get a glass of water Check your leg strength: See the following Strength & Balance • can you stand up from a chair safely Exercises. Make your activities fun. without using your hands? • can you do it three times in a row? Exercises

Check your balance: These simple exercises can help improve your strength and balance. For safety, try this test while standing Only do the exercises you feel safe and near the kitchen counter. comfortable doing. It may be safer and • can you safely stand on one leg for easier to do just a couple of exercises 5-12 seconds without holding on to at a time. If you have increased pain anything or anyone? or a significant increase in shortness of breath stop exercising immediately. What you can do: Stand up straight. Hold onto the edge • get up from a chair three times in of the kitchen counter if you need to for a row, without using your hands, safety. As this gets easier, try to hold on whenever you can less. • go up and down stairs to keep your legs strong. Make sure you use the Small Squats hand rail. 1. Stand with feet apart • walk as much as you can. If you 2. Bend knees as if to sit become tired quickly or feel unsteady, a four-wheeled walker 3. Keep your heels on the with a seat and a basket is a great floor idea. Have a professional help you buy the right one. 4. Hold for 5 seconds • bend and straighten your legs when The Bird you are watching TV. Add small 1. Face counter and hold weights to your ankles. on with one hand • mark out a walking path in your house if the weather is bad 2. Stand with feet apart • call your community centre, seniors 3. Shift your weight to one side 15.8 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet 4. Reach sideways as far as you can Side Leg Raise with free hand 1. Stand with feet apart

5. Switch hands and 2. Lift one leg to the side reach to the other side 3. Keep your toes pointing forward 6. Hold for 5-10 seconds 4. Hold position for 5 seconds, then slowly Marching on the Spot lower 1. Stand straight 5. Repeat with other leg 2. Lift one leg and raise the knee toward your Walk the Line chest 1. Place one foot directly in front of the other 3. Hold the position, then slowly lower 2. Hold position for 10-30 seconds 4. Repeat with other leg 3. Repeat with other On Your Toes foot 1. Stand on tiptoes 4. Progression: walk 2. Hold for 5 seconds heel to toe along length of the counter 3. Slowly lower and rock back onto the heels, lifting up the toes Remember: Strength and balance can reduce your risk of falling by 4. Hold the position for 5 50%. seconds Speak with your doctor or health care provider about any medical condition which may affect your ability to do these exercises.

Adapted from Prevent Falls - Stay on Your Feet, © Vancouver Coastal Health, March 2012

15.9 Pulmonary Rehabilitation Patient Education Manual Chapter 15 - Prevent falls-stay on your feet Pulmonary Rehabilitation Patient Education Manual Chapter 16 Intensive care When your lungs do not work well Emergency, enough to meet your body’s needs, it is called respiratory failure. What kind intensive care and of care is given to someone who is supportive care experiencing respiratory failure? You will be admitted to hospital. You may for lung disease talk to the medical staff about the type of care that you would like to receive Emergency care based on what you decided when you So, what happens if your breathing worked through your Advance Care does not get better despite following Plan. Do not hesitate to ask questions your Respiratory Action Plan? Contact about your treatment. Here are some your physician and make certain they treatments that may be offered if know that you are a respiratory patient medically appropriate. and you are in distress. Your physician may want to see you or may direct you Medications to go to the Emergency Room. If you • bronchodilators help open the can’t contact your physician, go to the airways. We may give them by Emergency Room. If you are extremely inhaler, orally or by a . A breathless, anxious, fearful, drowsy or nebulizer delivers the medication have chest pain, call 911. You need an as a fine spray you inhale through a ambulance. mask. What kind of care do we give to people • steroids reduce swelling in the with respiratory problems when they lungs. We may give this medication arrive in the Emergency Department? orally, by inhaler or through an IV. First, a registered nurse will assess you. We may give you oxygen by face • an antimicrobial such as an mask or nasal prongs. We may give antibiotic may be given if the you inhaled respiratory medications. physician determines that you have Diagnostic tests may include a chest an infection. x-ray and blood tests. Initial care • medication for pain or anxiety will will probably include inserting an be given as needed. IV (intravenous catheter) to give you antibiotics, fluids or other medications. Airway Clearance Most often people improve soon after medication is started and you may not A physiotherapist may work with you even need to stay in the hospital. to help clear mucus from your lungs.

16.1 Pulmonary Rehabilitation Patient Education Manual Chapter 16 - Emergency, intensive care and supportive care for lung disease Supplemental Oxygen As you recover, we slowly turn down We may give you oxygen with a mask the ventilator machine so you breathe or nasal prongs. This can temporarily more on your own. When you are help deliver life-sustaining oxygen strong enough to perform all of the to your body. You may still feel short work of breathing, we turn off the of breath. This is because the illness ventilator and remove the breathing causing your troubles might not go tube. This process is like an exercise away with oxygen treatment alone. program for your lungs. There is always a risk that you may not be able BiPAP to come off the ventilator if your lung This is a tight fitting mask attached strength does not return. The worse to a type of breathing machine that your lung illness is, the greater the can temporarily help to reduce the risk. work of breathing. It can be used with Cardiopulmonary resuscitation (CPR) added oxygen. It can help reduce high levels of carbon dioxide in the If you are so sick that your heart stops blood. It might be used for a short beating, medical personnel may start time if your shortness of breath can be cardiopulmonary resuscitation or reversed. CPR. This procedure continues blood flow to the organs when a person’s Mechanical ventilation heart stops beating. It involves If you can’t breathe enough to pushing on the chest and forcing support your own life, and medicine, air into the lungs. This is basic CPR. oxygen or other treatments fail, we Often medicines and electric shock may place you on a life support are needed to restart the heart, and machine called a ventilator. This the person may need more treatment is only done if there is risk to your in the Intensive Care Unit (ICU). This life. A specialized medical team is advanced CPR. CPR does not work puts in the ventilator. We give you in all situations. Even in the hospital, medication to relax your muscles fewer than one in five people survive and “make you sleep” (sedation). We a cardiac arrest. insert a breathing tube through your It is important to decide whether mouth into your windpipe. We attach or not you want us to attempt CPR. a ventilator to the tube. The ventilator Some people with severe lung disease blows air into the lungs and you do not want to be resuscitated. If you breathe out naturally. The ventilator do not want to be resuscitated, speak does the work of breathing for you, to your family doctor. You need to fill allowing you to rest while you heal. out a special form to say that you do not want CPR.

16.2 Pulmonary Rehabilitation Patient Education Manual Chapter 16 - Emergency, intensive care and supportive care for lung disease After you receive this form, you can • it is not meant to hasten or postpone order a MedicAlert bracelet from death your pharmacy indicating that you • it provides a support system so do not want CPR. If you are getting that patients can live as actively as a bracelet, have your lung disease possible. It supports the patient and engraved on it as well. You can also their family as they cope with the tell us that you do not want CPR patient’s illness. when you are admitted to hospital. • it is meant to enhance the quality of We will always try to ask you about life and may positively influence the your choices for care. We have found course of the illness that it is also helpful if we know in advance what your choices would be. • it can be provided in a hospital That way, if you become too sick to setting or sometimes in the home make decisions, we know what you would have wanted. You can change It is very difficult for physicians to your mind at any time, and we will estimate life expectancy in patients continue to discuss options with you who have lung disease. These patients as your condition changes. often recover from severe illnesses even though their lungs are quite damaged. Supportive care When you receive supportive care, you Supportive care can also be called can expect the following treatments if hospice or palliative care. The medical they are medically appropriate for you. team may determine that a patient is not likely to recover from their • medications: you will receive all illness even with the most advanced your usual medications and any procedures and equipment available. other medications needed to treat Sometimes patients may choose not to infection or worsening of your have certain procedures such as CPR or illness mechanical ventilation. Supportive or • if you need airway clearance palliative care is specialized care that treatment, supplemental oxygen helps to improve the quality of life of and BiPAP, these will be provided patients and families who are facing a life-threatening illness. Supportive care • CPR and mechanical ventilation provides relief from pain and other will not be provided distressing symptoms such as shortness of breath. Supportive care affirms life and treats dying as a normal process.

16.3 Pulmonary Rehabilitation Patient Education Manual Chapter 16 - Emergency, intensive care and supportive care for lung disease Pulmonary Rehabilitation Patient Education Manual Chapter 17 What is the process of advance care planning? Advance care planning Advance Care Planning for future Advance care planning is a process of health care choices is a process of personal reflection and communication thinking and talking about complex about your values, beliefs and wishes and sensitive issues, and then acting on about the health care you may want your decisions. Here’s what the process in the future. Planning in advance for looks like: future health care choices is a wise 1. you consider what makes life thing for all capable adults to do. It meaningful to you. This reflection involves thinking about the kind of helps you identify your values and health care you would want now as beliefs around living well and dying well as in the future, especially if you well that are important to you. ever became too sick to communicate your wishes. Talking with those closest 2. you learn about possible medical to you and your doctor is important. treatments you may face in the By talking to your doctor, together you future and their implications. can make sure your health care choices 3. you think about when you might are medically sound and individually want your future health care to suited to you. focus on comfort care rather than life-sustaining measures. Unfortunately the reality of having a chronic disease is that you may be 4. you may choose what medical care faced with some complex and sensitive you want, and don’t want, so that decisions about what kind of treatment the care you receive honours your options you want. values, beliefs, and faith tradition. 5. you discuss your choices and wishes with those closest to you so they know what you would want in a variety of situations. 6. you think about whom would honour your wishes and speak for you if the time comes when you cannot make your own medical decisions. 7. lastly, if you wish, you put your Advance Care Plan in writing.

17.1 Pulmonary Rehabilitation Patient Education Manual Chapter 17 - Advance care planning Completing this process will provide great comfort to you and strength to those who may have to make important medical and end-of-life decisions for you at a difficult time.

Doctors, nurses, and other members of your health care team want to respect your choices for future medical care. They can’t do that unless you plan in advance and let them know about your choices.

For more information and booklets to assist you in this process, go to: www.gov.bc.ca/advancecare Or contact Health Link BC at 811

17.2 Pulmonary Rehabilitation Patient Education Manual Chapter 17 - Advance care planning Pulmonary Rehabilitation Patient Education Manual Chapter 18 Your action plan (see Chapter 3, Lung irritants and chest infections for Activity and lung information on action plans) An action plan will help you recognize attacks the signs of a lung attack early and know what to do. You might need What is a ‘lung attack’? to increase your rescue inhaler With lung disease, if you are not medication, see your family doctor, managing your disease and breathing take antibiotics or prednisone, or go to easily, you are having a ‘lung attack’. the Emergency Department. A lung attack is also called an ‘exacerbation’ or a ‘lung flare up.’ Why should I stay active during and after a lung attack? Signs of a lung attack: Sometimes when we are sick we just • you are more short of breath than want to rest and be quiet. This is ok usual for a short time, but research tells us • you produce more mucus than that the more you get up and move normal around the faster you recover. Being up and about is much better for your • you are coughing up mucus that is body and your lungs. Staying in bed all yellow, green, or red-brown day or being very inactive makes your muscles weaker. Being inactive also A lung attack can occur in any of the decreases how much exercise you can following situations: do. It is better to stay active during and • after you have a cold especially after a lung attack. • when you are very tired • when you are exposed to air pollution or very hot or cold weather

18.1 Pulmonary Rehabilitation Patient Education Manual Chapter 18 - Activity and lung attacks How should activity make me feel? What equipment do I need? What is ‘safe activity’? A good pair of walking shoes is really Exercise during a lung attack will make all you need to start. Walking for short you feel even more breathless. You intervals is good exercise. Walk 5 to might feel slightly sweaty and your 10 minutes at your own pace 3 times a heart will beat faster than when you are day to keep your muscles active. Once resting. This is normal. you have fully recovered from your lung attack, you can add some other One good way of knowing how hard exercises and go for longer walks. You to work is by how difficult it is to talk. might want to add some strengthening While you are exercising, try to say the exercises with simple equipment such following sentence. as hand weights or tubing. “This exercise program is going to do me good!” • if you can say the whole sentence without stopping, you are not working hard enough • if you can’t speak at all, or can only say one word at a time, you are working too hard • if you are able to say the sentence slowly with a few stops, the pace of your exercise is just right Everyone needs to go at their own pace. When you are still recovering from your lung attack you might need to What are some easy exercises I can start slowly and pay attention to how do while recovering? you feel. The important thing is to keep Besides walking, you can do the moving! Your body will tell you if you following simple exercises at home are working too hard. You might feel or in your hospital room to keep your dizzy, light-headed, nauseous, very muscles strong. sweaty, or your heart might race. If you feel any of these symptoms, sit down • repeat each exercise 6 to 8 times and rest. If your symptoms don’t go • do this 3 times a day to start away, get medical attention.

18.2 Pulmonary Rehabilitation Patient Education Manual Chapter 18 - Activity and lung attacks Exercise 1: Exercise 3: Wall push-up Arm curls Stand a few feet from a wall and place Sit in a comfortable chair with a your hands on the wall. The palms of weight in each hand. You can also use your hands should be flat on the wall. household items like a can of soup. Let Slowly bend your elbows and lean your your arm hang down straight beside body into the wall. Your knees and hips your chair and bend your elbow to lift should be straight. Then slowly push the weight up toward your shoulder. out again so you are standing straight. All the movement should happen at the elbow. Don’t raise your arm at the shoulder. Slowly lower the weight back down. You can lift both weights at once, or lift one weight at a time.

Exercise 2: Wall squats Stand with your back against a wall. Have a chair nearby in case if you need Exercise 4: to rest. Slowly bend your knees and Thigh extension slide your back down the wall a few Stand at your kitchen counter. Hold inches. Hold the position for a count of on to the counter to help you balance. 5, then slide slowly back up. You might Bend your knee behind you, hold and be only able to go down a few inches. count to 10. Slowly lower your leg and Don’t slide down too far. You might repeat on the other side. If this exercise find it hard to slide back up if your is easy, you can make it more difficult legs are weak. Have a chair or counter by putting on ankle weights. nearby to hold onto if you feel your legs are too weak.

18.3 Pulmonary Rehabilitation Patient Education Manual Chapter 18 - Activity and lung attacks