Save Your Breath, America!

Prevent COPD Now!Information for Patients Who May Be Developing COPD

(Chronic Bronchitis or Emphysema)

Dennis E. Doherty, M.D.Thomas L. Petty, M.D.

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National Lung Health Education Programwww.NLHEP.org

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What is your FEV6?

Forced Expiratory Volume in six seconds

What is your FEV1?

FEV1Forced Expiratory Volume in one second

What is your Ratio?(FEV1/FEV6)

FEV6

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The National Lung Health Education Program (NLHEP) healthcare initiative is designedto identify and to treat patients in the early stages of emphysema and related chronicbronchitis. Together, emphysema and chronic bronchitis are known as ChronicObstructive Pulmonary Disease (COPD). Approximately 125,000 Americans die of COPDeach year! In 2000, more women than men died of COPD, and it is now the fourth mostcommon cause of death in the U.S.A. It is the only disease among the top five killers inAmerica that continues to rise in the number of annual sick days and deaths.

By contrast, great progress has been made in reducing the number of people whobecome sick or who die from other major diseases, such as heart attack, stroke, andmany cancers, largely because of early identification and treatment programs.

The NLHEP initiative is directed to primary care physicians, other healthcare clinicians,government officials, healthcare policy makers, healthcare agencies, and especially topatients. Many societies within the United States sponsor and/or endorse the NLHEP'sinitiatives. Several governmental agencies act as liaisons to the NLHEP. Financial supportfor the NLHEP comes from a wide range of sources including unrestricted grants fromnon-profit organizations, patient advocacy groups, private donors, as well as thepharmaceutical and medical support industries. The NLHEP enjoys a partnership with theAmerican Association for Respiratory Care (AARC), a professional organizationrepresenting over 130,000 respiratory care professionals.

Together, the NLHEP and other like-minded organizations are attacking COPD, acommon disease which results in suffering and premature death. Please learn how youcan work with your doctor and other healthcare clinicians to help prevent, recognize, andtreat COPD! We aim to reduce both the social and the economic impact of thisimportant problem. We believe that through education to the public by professional andgovernmental agencies, the problem of COPD can finally be prevented and solved.Please visit our web site (www.nlhep.org) for more information about our organization.

Dennis E. Doherty, M.D.Chairman, National Lung Health Education Program (NLHEP)Thomas L. Petty, M.D., Emeritus Chairman

Introduction

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This booklet is dedicated to people who liveand breathe and to those who either have ormay develop chronic obstructive pulmonarydisease (COPD) — a name for two diseases,chronic bronchitis and emphysema. COPDaffects an estimated 24 million Americans, buthas only been “diagnosed” in about half ofthose who actually have COPD, largely due toa lack of awareness. In 2000, for the first time,more women than men died of COPD.

“Save Your Breath, America!” a patient booklet,is a companion to a booklet for physicians,“Prevent COPD Now.” The patient booklet iswritten in easy-to-understand language, and itprovides the most current information on thecauses and treatment of COPD. Based upon 30years of study on COPD, the information in thisbooklet is offered as advice for persons who:

• Smoke now or who have smoked in the past

• Have a long-term cough, excess mucus,shortness of breath, or wheeze

• Have family members with COPD

Remember that the symptoms of COPD,including emphysema, may not show up or beacknowledged for 30 or more years after startingsmoking, and the risk of developing COPDcontinues, to a smaller degree, even if you havestopped smoking. You should ask your doctor toorder or to perform a breathing test (Spirometry)to determine if a breathing problem is present orwill likely be present in the future. Everyone losessmall amounts of lung function every year afterreaching adulthood, but if you do not acceleratethis yearly loss ( i.e. by smoking), the lungs’reserve is more than adequate to support yourusual daily activities, and you will not notice this

small slow loss. If you stop smoking, the lost lungfunction is not regained, but the annual lossusually returns to the rate near that of a non-smoker. Thus, it is never too late to stop smoking.

You may need treatment to potentially slow theprogression of COPD before it gets serious enoughto cause symptoms that affect your lifestyle. If younotice a change in your ability to breathe as youperform ordinary daily routines or activities requiringexertion that you could easily do in the past, don’tdelay. See your doctor! A major part of this booklet isdevoted to the steps you can take to save yourbreath and prevent COPD.

Breathing is essential for life. Your body needs theoxygen in the air you breathe to create theenergy that keeps you alive. Your respiratorysystem carries the oxygen to your lungs, where itenters your bloodstream to travel throughoutyour body. The bloodstream also carries the“used” air, which is mostly carbon dioxide, backto your lungs so that you can breathe it out.

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Save Your Breath, America!

Trachea

Bronchus

BronchioleBronchioles

BloodVessels

Alveoli

When fresh air is breathed in through thenose and mouth, it is pulled through thewindpipe or trachea and into the lungs.There it moves through two largepassageways, called the bronchi.

Then a complex system of much smallertubes or bronchioles branch out 30 times ormore to carry oxygen to the “working parts”of the lungs (300 million plus air sacs) calledalveoli. These small sacs (like tiny foldedballoons) have very thin walls that are full ofblood vessels. The walls are so thin that theoxygen in the air can pass through them toenter your bloodstream and travel to cells inall parts of your body. Oxygen is required to“burn” food for the energy required by everyorgan of your body. The waste product ofthat energy is carbon dioxide, and it movesfrom the bloodstream into the air sacs, andthen is exhaled from your lungs.

What does the term COPD mean? It standsfor Chronic Obstructive Pulmonary Diseaseand refers to a problem with breathing airout of your lungs. If you have difficultybreathing “used” air out of your lungs, notenough space is left for oxygen-rich air toenter your lungs. This is sometimes called‘hyperinflation’ or ‘air trapping.’

Until recently, most people who had COPDwere grouped together and considered tohave one disease. We now know thatseveral different diseases are responsible forthis difficulty in providing oxygen to thebody and releasing used air (carbon dioxide)from the lungs. Chronic bronchitis and

emphysema are two of the major diseasesthat are grouped together as COPD.

Chronic BronchitisChronic bronchitis occurs when the largebreathing tubes of the lungs, or bronchi, areinflamed and swollen. Imagine what happensto your skin when you have an insect bite andit becomes swollen, red, and painful. This sameidea can be applied to the swelling that occurswith bronchitis. The lining of the air tubesbecomes swollen and produces large amountsof mucus. Because mucus clogs the airways, itcomplicates the problem, much like pus infectsand irritates a wound and delays healing.When chronic bronchitis leads to persistentairflow obstruction, this is called chronicobstructive bronchitis, indicative of COPD.

The muscles that surround the airways maytighten when they should not, causing spasmsof the bronchi, or bronchospasm. Thesenarrowed airways prevent a portion of the“used” air from leaving the lungs.Bronchospasm, inflammation, and swelling allmake the space inside the airways smaller. Thisreduces the amount of air that can flow in andout of the lungs. It is like breathing through astraw.

The first symptom of chronic bronchitis is apersistent cough that brings up mucus. This isoften followed by wheezing, shortness of breath,chest tightness and frequent chest infections.Shortness of breath is caused by increased work tomove air out of the obstructed lungs. Thesymptoms of bronchitis can usually be relieved orimproved with treatment.

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What is COPD?

EmphysemaEmphysema develops when many of thesmall air sacs in the lungs are destroyed.This reduces their ability to deflate (a lossof their elastic recoil) and to pass oxygeninto the blood and remove carbon dioxidefrom the blood.

Shortness of breath (dyspnea) is the majorsymptom of emphysema. At first, thisdifficulty in breathing may occur only withmoderate to heavy exercise. Later, ithappens with light exercise and, still later,even when walking or engaging in othereveryday activities, or at rest in its mostsevere stage. Do you notice that you nolonger can keep up with friends your ownage without getting out of breath? Do youget more tired with less exercise than youdid a year ago? Can you now only shop twostores in the mall (instead of the five youeasily shopped in the past) before you haveto sit down and rest on a bench in themiddle of the mall? If so, tell your doctorabout these gradual changes, and ask yourdoctor to check your lungs with aninstrument called a spirometer. Many peoplewho have emphysema also have chronicbronchitis. The excess mucus produced bythese inflamed airways makes breathingeven more difficult.

In most cases, the lungs can take a lot ofabuse. It may be 30 or more years beforesomeone who has emphysema notices oracknowledges a change in his or her

health. Those with COPD often slowlymodify their lifestyle, over months toyears, to avoid taking part in activities thatcause shortness of breath. Accordinglythey become less physically and sociallyactive which can bring on anxiety anddepression. However, when COPD isdiagnosed early, more can be done to treatit and perhaps slow its progression. Bystopping smoking and using appropriatetreatments or medications, persons withCOPD (chronic bronchitis with or withoutemphysema) can generally lead morecomfortable lives.

What Causes COPD?Chronic bronchitis and emphysema mostoften develop as a result of one or more ofthese factors: cigarette smoking, familysusceptibility, and/or inhaling large amountsof dust or fumes at work or at home.

Other conditions that can make COPDworse are frequent colds or infections inthe nose, sinus, throat, or chest. It is alsoknown that emphysema can be hereditary.In some families this might be due to a lackof normal lung “defenses” that fightdamage within the lung (alpha-1antitrypsin deficiency). It may also bebecause certain habits are passed along toother family members. For example, ifparents smoke, there is a good chance thattheir children will smoke. Since more than85% of COPD is caused by smoking,persons with family members who smokeare at greater risk of getting these diseases.

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Early discovery of a breathing problem and appropriate treatment can often prevent the disease from progressing to the point that itseriously affects the way you live and work.

Anyone who has an ongoing cough orshortness of breath, even if it seems minor,should see the doctor. Morning cough, forexample, is not normal. It is usually a result ofsmoking and indicates that there is irritationand swelling within the lung. Shortness ofbreath while exercising, climbing stairs, orwalking can also be a sign of a breathingproblem. Many people simply feel that they are“out of shape”, slowing down, or getting olderwhen, in fact, they are working harder tobreathe — perhaps due to early COPD.

Breathing TestsA spirometer test can indicate whether yourbreathing is normal. It takes only a couple ofminutes to blow into this machine, which candetect a change in your breathing ability evenbefore you do. Fortunately, many physicianshave a spirometer in their offices. The nexttime you see your doctor, ask for a spirometrytest (lung function test), if you think youmight have COPD.

Remember, when you take a spirometry test,no needles are involved. You don’t have totake off your clothes. This test is not painfuland will not cause you any discomfort. All youhave to do is fill your lungs completely, pause,and then blow out all the air you can as fast asyou can for six seconds. This test will give two

numbers for you and your doctor tounderstand together. The first number is theforced expiratory volume in one second(FEV1). This is the total amount of air youblow out in the first second. The total amountof air you blow out in six seconds is called theFEV6. Most people can blow all or most of theair out of their lungs in six seconds.

“Test Your Lungs–Know Your Numbers”is the motto of the NLHEP. Most peopleknow their blood pressure and cholesterolnumbers and can tell if these numbers gethigher or lower. You also should record andremember your spirometry test results forfuture comparisons. Spirometry will help youdetermine if you do have or don’t have anyamount of airflow problems. If you have anyabnormal airflow, this could mean that you’reon the pathway to developing emphysema orrelated chronic bronchitis. Prevent COPD now,and you will not have to face it later.Breathing tests should be done on anyonewho may be at risk for developing COPD,such as those who currently smoke, thosewho have smoked in the past, those who havefamily members with one of these diseases, orhave one or more of the earlysigns/symptoms of COPD. Even if yourairflow is normal on the test, and youcurrently smoke, you still need to stopsmoking right away. Your lung function mayfall below normal in the near future, andyou are currently at a significantly increasedrisk of developing lung cancer or having aheart attack or stroke if you continue tosmoke.

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Early Detection

After taking the test, you can ask yourdoctor these questions:

• Are my breathing measurements normalor abnormal?

• If abnormal, how abnormal are they?• Is the problem one that can be treated

with medications and/or by stoppingsmoking?

• If I have had a previous abnormalspirometry test, is the abnormalityworsening?

• What exactly should I do for myproblem?

If the answer to any of the questions belowis ”Yes,“ you should see your doctor for aspirometry (breathing) test.

• Do you now or have you ever smokedcigarettes, cigars, or a pipe?

• Do you have a cough, wheezing, chesttightness or shortness of breath?

• If you cough, do you bring up mucuswith your cough?

• Have you ever been exposed to fumesthat may have affected your lungs?

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The NLHEP has created posters that are intended to highlight these questions related to thecommon signs/symptoms of COPD. There are nine posters available, representing all ages,genders and ethnicities, and you can view these on our web site. Above are two examples ofthe posters.To find out more about this project, go to http://www.nlhep.org/posters/info.cfm.

What can you do if you have an early stageof COPD (chronic bronchitis or emphysema)?Certainly you should change any behaviorthat can make it worse. The single mostimportant thing you can do for yourself is tostop smoking. In fact, if you don’t stopsmoking, none of your other efforts will be aseffective as they could be, and your COPDwill get worse.

Smoking CessationStopping smoking is a complex matter. If youdecide that you want to quit, no matter what,you will succeed. People even with an earlystage of COPD are often very addicted to thenicotine in tobacco. Nicotine replacementproducts are available to help deal with theuncomfortable symptoms of nicotinewithdrawal that many patients experiencewhen they try to quit smoking. Nicotine gum,nicotine patches, and nicotine lozenges areavailable at drug stores without a prescription.Nicotine nasal spray and nicotine vaporinhalers are available by prescription. Anantidepressant drug called bupropion (Zyban®)can help you stop smoking. Additionalsmoking cessation agents have been approvedor are on their way to approval by the FDA.

You must decide to quit and pick a specific quitdate. No one can decide this for you. Quitcompletely all at once (“cold turkey”). Startnicotine replacement on your quit date. If yourdoctor prescribes bupropion (Zyban®), it shouldbe started two weeks before your quit dateand continued after your quit date. Ifprescribed, bupropion (Zyban®) can and shouldbe used along with nicotine replacement.

If you fail, wait a week or so and set anotherquit date. Don’t get discouraged. Try again.Many heavily addicted smokers succeed afterseveral attempts to quit smoking. Quitting isthe most important thing you can do foryour health and for the prevention of COPDand its more severe manifestation ofemphysema. In addition, you will decreaseyour risk for having a heart attack, a stroke,or developing lung cancer. It slows thepremature wrinkling of skin or preventsimpotence that is often associated withsmoking!

Breathing Clean AirAs a COPD patient, you especially need tobreath in clean air. Therefore, you shouldalso avoid being around smokers (second-hand or side-stream smoke) and fume-ladenair. During days of fog or smog, try to stayindoors with windows closed. If possible,fumeless appliances should be used forheating.

Polluted air can possibly irritate yourbreathing passages. Try not to go outwhen the air quality is rated poor. But ifyou cannot avoid excessive air pollution,protecting your mouth and nose with amask may prevent acute worsening of yourbreathing.

See Your DoctorYou should see your doctor on a regularbasis to have your lungs checked withspirometry, to have a physical, and toevaluate your medicines — especially if youhave a chest cold or any time you cough up

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Treatment

excess mucus. It is also important to guardagainst catching the flu by getting aninfluenza vaccine each fall, well beforewinter starts. A pneumonia vaccine shouldalso be given to anyone over age 50, and toall persons of any age with COPD.

There are many different types oftreatments that can help you cope with achronic lung disease and live your life to thefullest.

Clearing Your LungsCoughing has an important “cleaningaction” and is something you should doevery morning and evening. You must

learn to cough in such a way that you canclear your lungs of excess mucus with twoor three coughs. There are many ways todo this. Your doctor will teach you the wayto cough that is best for your particularproblem or he/she may refer you to arespiratory therapist or another healthcareclinician who can help you.

As an aid to this cleaning, your doctormight recommend breathing moist orhumid air, and drinking plenty of fluidsevery day. This may help some with COPDto thin out the mucus so that they cancough it up more easily.

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Notes:

Many different medications are used astreatments for COPD (chronic bronchitis oremphysema). Your doctor will decide whichmedicine is best for you based on your medicalhistory, breathing tests, laboratory tests, andseverity of COPD.

To help you breathe easier, your doctor mayprescribe bronchodilator medications for you.Bronchodilators relax the muscles that surroundthe breathing tubes and widen them, letting airtravel in and out more easily (reducing airflowobstruction) and not become trapped in yourlungs (causing hyperinflation).

Your doctor may prescribe drugs to liquefy theexcess mucus in your lungs. He may also prescribedrugs called inhaled corticosteroids, which mayreduce swelling in the breathing tubes in moresevere COPD. If you have an infection in yourrespiratory system, your medications may includeantibiotics and/or a very short course ofcorticosteroids taken by mouth.

These medications may be available in manydifferent forms. In addition to pills or syrups, thesemedications come as metered-dose inhalers (MDI)and dry powder inhalers (DPI). In order to get themost benefit from your medications, you mustlearn to use them correctly.

A device called a spacer or extender can alsobe used to make it easier to take yourmedication if it is delivered by an MDI. Thisdevice catches the mist produced by the MDIand holds it so that you can breathe it in at aslower rate. If you are taking a corticosteroidby MDI, it is very important to use a spacer orextender device.

Newer inhalers use DPIs to deliverbronchodilators and corticosteroids. It is notnecessary to use a spacer when takingmedication using a DPI device.

Inhaler Devices

While the most common way to takemedication is in pill form, most medications forCOPD come in an inhaled form. There aremany types of devices that deliver inhaledmedication and there are differences in how touse each of them. It is important that youknow exactly what type of inhaler you areusing and exactly how to use it so that you getthe most benefit from your lung medications.On the following pages are step-by-stepinstructions on each major type of device alongwith general information and a list of the mostcommon errors in taking medication using eachdevice. These devices, which delivermedication to your lungs, require aprescription. Carefully read the package insertthat comes with the inhaler you are using. Ifyou have questions, please consult your doctor,pharmacist, or respiratory therapist.

The following instructions DO NOT take theplace of the instructions you may receive fromyour doctor, respiratory therapist, and/or yourpharmacist on how to use the medicines youare prescribed for your COPD. These aresummaries and suggestions only. Alwaysfollow your doctor’s and/or health careproviders' instructions first and ask them if youhave questions about the followingsuggestions.

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Medications

Metered-dose inhalers (MDIs)

This type of inhaler releases a mist ofmedication in the form of an aerosol"cloud." Most of these devices require aprescription from your doctor. Themedication in a metered-dose inhaler thatcan be bought without a prescription (overthe counter), such as Primatene® Mist, is anon-specific adrenaline-like, short-actingdrug which may be dangerous for personswith heart disease. It is not adequate totreat COPD.

In order to get the maximum benefit fromany medication, it is important that thedelivery device is used properly. Here aresome helpful tips for using a metered-doseinhaler (MDI):

MDI ”Open-Mouth“ Technique

1. Remove cap. Shake the canister.2. Sit straight or stand up straight.3. Hold the MDI canister “two fingers”width away from your mouth. Then breatheout all the way.4. As you slowly breathe in, press once onthe MDI, breathing in to fill your lungscompletely.5. Try to hold your breath for 10 seconds —or as long as you can, then blow out slowly.6. If your doctor wants you to take morethan one puff, wait one minute. Thenrepeat steps 2-5.7. Rinse your mouth out after you finish.Spit the water out; do not swallow it.Rinsing is always important if the MDI is acorticosteroid.

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MDI ”Closed-Mouth“ Technique

1. Remove cap. Shake the canister.2. Sit or stand up straight. Breathe out allthe way.3. Put the MDI in your mouth, between yourteeth, tongue below the mouthpiece, with lipssealed.4. As you breathe in slowly, press once onthe MDI, breathing in to fill your lungs.5. Try to hold your breath for 10 seconds —or as long as you can, then blow out slowly.6. If your doctor wants you to take more thanone puff, wait one minute. Then repeat steps2-5.7. Rinse your mouth out after you finish. Spitthe water out; do not swallow it. Rinsing isalways important if the MDI is a corticosteroid.

Here are some other things you should know:

• Always PRIME your MDI before using it forthe first time or if you have not used it insome time. This means to shake it well andthen puff it 1 to 4 times away from your facebefore using it. (This rarely needs to be done,and can waste medication if done frequently.)This assures that the medication is mixed welland that the puffs you take will have the rightamount of medication in them.

• Always CLEAN the plastic mouthpiece areaonce a week by rinsing it under water,shaking off the water and then letting it airdry.

• We suggest that you use a SPACER withyour MDI. If using a spacer, insert the end ofthe MDI canister holder (the plastic device) into

the holder on the spacer. Then put one puff intothe spacer. Inhale slowly and deeply and then holdyour breath if you can. If your doctor wants you totake more than one puff, repeat these instructions.When you are finished, remove the canister holderfrom the spacer, put the cap on your canisterholder, and also cap the spacer.

• To clean your spacer, wash it in warm, soapywater, rinse it well, and allow it to air dry. Youonly need to do this every few weeks.

• Many steroid inhalers have a built-in spacer.However, if yours does not have a built-in spacer,be sure to get one from the pharmacist. Using aspacer will help to keep the medication fromcausing a mouth infection or sore tongue.

• Always STORE your MDI at room temperature.If it gets cold, only use your hands to warm it up.

• Always DISCARD the medication canister afteryou have used the number of doses that it holds.If you are in doubt about how many doses itholds, ask the pharmacist when you pick up yourprescription. Write the start date and the numberof doses on the side of the canister and whenyou have used up that number of doses, throwaway the canister. It may feel like there ismedication left in the canister, but only use it forthe number of doses that it has in it. Do not floatthe canister in water to see if it still hasmedication in it.

Some common errors include:1. Not coordinating the puff from the canisterwith breathing in2. Breathing in too fast and not holding yourbreath at the end

3. Not pumping the inhaler until after youhave taken in your deepest breath4. Pumping the inhaler too many timesbefore taking in a deep breath (doublepumping)5. Breathing out instead of in after releasinga puff of medication

Dry Powder Inhalers (DPIs)

These inhalers release a dry powder, and thisdry powder begins to work when it hits themoist airways of your lungs. There are manydevices that deliver dry powder, so it isimportant for you to know the specific nameof the inhaler device you are using. There aredo’s and don’t when you use these types ofinhalers.

Do hold the device level so that the powder does not fall out.Do store in a cool, dry place so that thepowder stays dry and does not cake up.Don’t open the powder packet until youare ready to use it.Don’t shake the DPI before using.Don’t breathe into your DPI, as that willblow the medication away or make it cakeup.Don’t use a spacer.

Each manufacturer includes directions for usewith every medication. Please read thesedirections closely and be sure to talk to thepharmacist if you have any questions. Anyinstructions in this booklet for commonlyused devices are not intended to be areplacement for instructions included withyour medication when you pick it up fromthe pharmacy!

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Aerolizer DPI (Foradil)®

Don’t open the package until you are readyto use the medication. Don’t wash thisdevice, as you will get a new one everytime you refill your prescription.1. Remove cover and twist open inhaler.2. Take capsule out of the blister pack andput it in the inhaler chamber.3. Twist to close the inhaler.4. Press blue buttons on both sides ofinhaler to pierce capsule.5. Breathe out fully with your mouth awayfrom the device.6. With your head slightly tilted back, putthe mouthpiece in your mouth and inhalerapidly to fill your lungs.7. Remove the device from your mouth andhold your breath for a few seconds.8. Exhale slowly.9. Twist open inhaler to remove and throwaway the empty capsule.10. Store device in a cool, dry place.

Autohaler DPI (Maxair)TM

1. Hold autohaler device upright and raisethe lever, snapping it into place.2. Gently shake the device, continuing tohold it upright, and making sure not toblock the vents on the bottom.3. After breathing out (don’t strain), put yourlips around the mouthpiece and take in adeep breath. You will hear a “click.” Keepbreathing in to fill your lungs completely.4. Take the device out of your mouth and tryto hold your breath for about 10 seconds —or as long as you can. Then breath out slowly.5. If your doctor wants you to take morethan one puff, repeat steps 3 and 4.

Diskus DPI (Serevent, Advair*)®

This device has a dose indicator on the top.The numbers on the dose indicator turn redwhen there are only 5 doses left. If you areleft handed, it is OK to turn the deviceupside down as it will work the same way.1. Remove mouthpiece cover.2. Slide the lever, making sure to keep thedevice level.3. Exhale fully away from the device so youdon’t blow away the powder.4. Then inhale quickly and fully.5. Remove the device from your mouth andhold your breath for a few seconds.6. Then exhale slowly.7. Store device in a cool, dry place.* Only 250/50 dose of Advair is approvedfor COPD by the FDA

Handihaler DPI (Spiriva)®

Each card contains two strips with threecapsules in each strip. Use all three capsules ineach strip before starting to use another strip. 1. Remove mouthpiece cover.2. Take capsule from package and put it inthe inhaler. Close the inhaler.3. Press button so that needle pierces bothsides of the capsule.4. Keep the device level. Put the device inyour mouth and inhale slowly to fill yourlungs completely.5. Hold your breath and remove the devicefrom your mouth. Let your breath outslowly.6. To get full dose, repeat steps 4 & 5.7. Open the mouthpiece and remove thecapsule. Brush off any powder that remainsin the device.8. Store device in a cool, dry place.

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6. Wipe the mouthpiece dry.7. Check to make sure the arrow is in linewith the dose counter. Put the cap on firmlyand rotate it clockwise as you press down.You will hear a “click” that will tell you thecap is fully closed.* off label use in COPD

Nebulizer treatmentsWe are not reviewing how to use anebulizer (powered by an air compressor)due to variations in equipment anddisposable supplies. Consult your doctor ordurable medical equipment (DME) providerfor information pertinent to the equipmentand disposable supplies you are using.

A word about hydrofluoroalkanes (HFAs)Studies by environmental scientists on oneof the propellants used to “power” inhalers(CFC or chloroflurocarbon) show that CFCscan damage the ozone layer in the Earth’satmosphere. While CFCs are safe for patientuse, the United States and other countriessigned an agreement to discontinue usingCFCs (the Montreal Protocol of 1997). Thismeans that aerosol drug manufacturershave had to change the way inhalermedication is delivered. So when you hearthe term “HFA” or see it in print, beassured that the medication you are takinghas not changed — only the way it is“powered.” You may notice a change in:• Feel. The medication does not come outas fast.• Taste. Some patients say their medicationtastes different using an HFA.

Turbuhaler DPI (Pulmicort)®

When the red dot appears at the top of thewindow, you have 20 doses left. When thered dot is at the bottom of the window, thedevice is empty.1. Twist and remove cover.2. Hold device so that the mouthpiece is up.3. Turn grip to the left and then back to theright until you hear a click.4. Breathe out all the way, keeping yourmouth away from the device.5. Put the mouthpiece in your mouth andinhale fast until your lungs are full.6. Hold your breath and remove the devicefrom your mouth.7. Let your breath out slowly, keeping yourmouth away from the device.8. Replace cover and twist to close.9. Rinse your mouth with water, but do notswallow the water. Spit it out.10. Store device in a cool, dry place.

Twisthaler DPI (Asmanex)®*1. Remove the Twisthaler from its foil pouchand write the date on the cap.2. Hold the inhaler straight up with thepink portion on the bottom. Remove thecap while the inhaler is in this position.3. Holding the pink base, twist the capcounterclockwise. When you do this, thedose counter will go down one number, andthe device is loaded and ready to use.4. Exhale fully. Then put the device in yourmouth, holding it horizontally. Take in a fastdeep breath.5. Remove the inhaler from your mouth andhold your breath for a few seconds. Youmay not be able to taste or feel themedication because it is a very fine powder.

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Progress is continually being made in thetreatment of COPD (chronic bronchitis andemphysema).Two major classes ofbronchodilator medications are nowavailable in metered-dose and/or dry-powder inhalation devices (anticholinergicsand beta-agonists). For COPD patients whorequire more than one bronchodilator, thesemedications can be used together and canlead to effective bronchodilation greaterthan that obtained from either medicationalone. These medications should be usedtogether only if your doctor prescribes themthat way. Two of the short-actingbronchodilators sold in separate metered-dose inhalers also come in an inhaler thathas both of these medications mixedtogether in a single inhaler for convenience.Other inhalers have a long-acting betaagonist mixed with a corticosteroid. Sincethese medications work on the respiratorysystem in different ways, they can be usedtogether to treat COPD.

A new replacement therapy that may beeffective in a rare hereditary form ofemphysema (an inherited deficiency ofalpha-one antitrypsin) is commerciallyavailable. Although it restores a protectivematerial in the lungs, its effectiveness inpreventing the progression of emphysemaremains to be proven.

Surgery that removes areas of major lungdamage is called lung volume reductionsurgery (LVRS) and may make breathingeasier for people with emphysema. In somepatients, this operation can improve

shortness of breath and quality of life. Themechanisms behind the improvement arecomplex, but it is thought that removingthe over-inflated and diseased part of thelungs (the apices) will help the diaphragmwork better.

The upper lungs (the apices) take up a lotof space for expansion in comparison to therest of the relatively normal lung, and theydon’t play a very important part inbreathing – but they are often the mostdamaged area of the lungs. An extensiveevaluation of the lungs must be done,including lung scans and tests of heartfunction, to determine who is a goodcandidate for LVRS. The NationalEmphysema Therapy Trial (NETT) comparedthe results of this lung surgery pluspulmonary rehabilitation to pulmonaryrehabilitation alone. The results of the NETTtrial and other studies have taught us thatwhile some may benefit, this surgery is notfor everyone – and it can actually lead to aworse quality of life or premature death.

Qualified surgeons are now offering thisoperation to selected patients after athorough evaluation-based on the findings ofthe NETT. Patients should be evaluated bypulmonologists (lung specialists) andsurgeons working together before goingahead with this treatment. Ask you doctor iflung volume reduction surgery may be atreatment option to be considered.

14www.nlhep.org

New Developments

Today, doctors and scientists have a betterunderstanding than ever before of thenature of COPD (chronic bronchitis andemphysema). These diseases are viewed ascausing damage to the lungs resulting fromat least two factors. The first factor is thatoutside conditions such as smoking, air andenvironmental pollution, and in some cases,frequent infections can damage the lungs.The second factor is the hereditary loss ofcertain lung defenses, which leaves thelungs easier to damage. The future promisesmore advances in understanding whypatients get COPD and how to betterprevent and treat this disease process.

Diagnosing any breathing problem byspirometry at an early stage is mostimportant. The treatments and medicationsdiscussed in this document can often help toslow the progression of COPD, in addition tomaking your life as comfortable as possible.The earlier the diagnosis is made andtreatment started, the better your health willbe. Diagnosing COPD (chronic bronchitisand emphysema) early can Save Your Breath,America!

The Future

Carter R, Nicotra B, Tucker JV: Courage andInformation for Life With ChronicObstructive Pulmonary Disease. NewTechnology Publishing, Inc. Onset, MA,1999, 264 p.

Good JT Jr, Petty TL: Frontline Advice forCOPD Patients. Snowdrift PulmonaryConference, 2006, 99 p. XLibris PublishingCo. (orders @XLibris.com)

Hodder R: Every Breath I Take. A Guide toLiving with COPD. Stoddart PublishingCompany, Limited. Park Centre, Toronto,Canada, 2001, 244 p.

Petty TL, Nett LM: Enjoying Life With COPD.Laennec Publishing, Cedar Grove, NJ, 3rd

Edition, 1995, 199 p.

American Association for Respiratory Care:www.aarc.orgYourLungHealth.com

American Cancer Society:www.cancer.gov/cancertopics/factsheet/Tobacco/cessation

American College of Chest Physicians (ACCP):Inhalation Devices Handoutswww.chestnet.org/patients/guides/inhaledDevices

American Thoracic Society (ATS)www.thoracic.org

Global Initiative for Obstructive Lung Disease(GOLD)www.goldcopd.com

National Institute for Health (NIH):www.smokefree.gov

National Lung Health Education Program:www.nlhep.org

U.S. COPD Coalitionwww.uscopd.com

For Additional Reading:

Web Sites:If you type “COPD” into your computer to do aninternet search, you will find more than 600,000references. Please be aware that not all these referencescontain accurate information — information that hasbeen written by or edited by health care professionals. Tobe more confident of the information you receive, lookfor addresses that end with “org” or “gov,” as thisdesignation means that the information comes from anon-profit organization such as NLHEP or a governmentalagency such as the National Institutes of Health (NIH).

15www.nlhep.org

Doctor’s Name Doctor’s Phone Number

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Put’m Out!

Keep’m Out!

The New Era

The prevention of lung disease and the promotion of lung health is the goal of theNational Lung Health Education Program(NLHEP), conducted in collaboration with government, medical and other health professional organizations. Chronic ObstructivePulmonary Disease (COPD) is the fourthleading cause of death in the United States.Because of this, the NLHEP was implementedto develop and promote a nationwideeducation program designed to identify COPDin its early stages. One objective is to promotea program of intervention to slow theprogression of COPD before development ofclinical symptoms of chronic cough, excessmucus and shortness of breath, which are earlysigns of risk leading to disabling forms of thischronic lung disease. The spirometer can beused to identify early stages of COPD and canalso identify people at risk of death from lungcancer, heart attack, and stroke. Indeed,preservation of lung health is the key to goodhealth in general.

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National Lung Health Education Program (NLHEP)9425 N. MacArthur Blvd, Suite 100

Irving, TX 75063Phone: 972-910-8555

Fax: 972-484-2720Web Site: nlhep.org

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