WORLD COPD Day (20th November) aims to raise awareness of Chronic Obstructive Pulmonary Disease by improving care throughout the world.
COPD is a chronic inflammatory lung disease which causes obstructed airflow from the lungs. It is a collective name for a variety of lung diseases, such as emphysema, chronic bronchitis and chronic obstructive airways disease.
Pulmonary rehab in COPD
Three million people have COPD, a disease characterised by airflow obstruction, causing breathlessness. Another two million go undiagnosed. It is not curable but people can manage their symptoms to improve quality of life. Pulmonary rehabilitation (PR), an evidence-based intervention, offers education and supervised exercise for people with COPD. However, uptake of pulmonary rehab is poor, sometimes due to fear of breathlessness.
Shortness of breath and difficult, laboured breathing (dyspnoea) is a common feature of COPD. Patients diagnosed with COPD will have weak inspiratory muscles.
“This feasibility study of IMT in those who declined PR met its aims and was successful in showing that IMT could be easily implemented and IMT proved acceptable to participants.”
World COPD Day
Every year, GOLD chooses a theme to help raise awareness of COPD across the world. GOLD is the Global Initiative for Chronic Obstructive Lung Disease. This year the theme for World COPD Day is “All Together to End COPD”. It’s likely that over 50 countries will carry out activities on this day. This makes it the most important COPD awareness event in the world.
A recent report claims that switching to ‘green’ inhalers could reduce carbon emissions and cut costs. The study, led by researchers at the University of Cambridge, finds that metered-does inhalers contribute approximately 3.9% of the carbon footprint of the NHS. This is due to the hydrofluoroalkane (HFA) propellants found in these asthma inhalers. HFAs, like CFCs before them, are potent greenhouse gases. As a result, there is a call to switch to alternatives that have a lower carbon footprint.
The report suggests alternatives to metered-dose inhalers include dry powder inhalers and aqueous mist inhalers. However, these have a higher “up-front” price.
“It’s important to stress that patients shouldn’t stop using their usual treatments to reduce their carbon footprint. Instead we recommend patients review their condition and treatment at least annually with their healthcare professional and at this point discuss whether a more environmentally-friendly inhaler is available and appropriate in their situation.”
In other research, Inspiratory Muscle Training (IMT) reduces the number of puffs on asthma inhalers, from 3.9 to 1.6 per day.
Reduction in use of asthma inhalers
Three separate studies into the use of inspiratory muscle training in patients with asthma observe an average 51% reduction in β2-agonist consumption1,2,3. A further study2 finds a decrease in corticosteroid use by asthma patients ~80%. Beta agonists relax muscles of the airways while corticosteroids reduce airway inflammation.
Breathing not only presents a limitation to athletes but also impacts people with respiratory illness, such as asthma. It is this recognition that began research into Inspiratory Muscle Training.
POWERbreathe Medic for asthma
One such IMT device, the POWERbreathe Medic, is available for prescription in the UK by the NHS. It is an evidence-based, drug-free treatment for patients with difficult or laboured breathing, especially those with asthma, COPD and heart failure.
POWERbreathe International Ltd. Managing Director Harry Brar says:
“Because POWERbreathe IMT is drug-free it can be used in combination with traditional asthma medication.
“By using POWERbreathe IMT to strengthen their breathing muscles, asthma patients will find that their breathing technique improves too, enabling them to inhale their medication past the back of the throat to reach the areas where it can be of most benefit.”
Developed by scientists at leading UK universities, POWERbreathe IMT is being used in clinical trials for use in clinical medicine and home healthcare.
POWERbreathe Inspiratory Muscle Training is a recent topic of interest at the European Respiratory Society’s International Congress, Madrid. Furthermore, the pre-conference workshop at Transform uses the POWERbreathe device to demonstrate IMT. Transform is the physiotherapy conference in Adelaide, led by Rik Gosselink, Professor of Rehabilitation Sciences KU Leuven, PT Respiratory Rehabilitation, University Hospital Leuven.
If you have a disease that results in sputum production, your physiotherapist will prescribe respiratory physiotherapy for you. Initially, this will involve the physio assessing you to identify the problem. As a result, management techniques and a treatment plan will be put in place. This will include airway clearance techniques, such as oscillating PEP. Different types of mucus clearance device use oscillating PEP, including the Shaker by POWERbreathe. Such devices combine the techniques of positive expiratory pressure (PEP) with oscillations. Your physio will refer to these as ‘oscillatory positive expiratory pressure’, or OPEP devices.
Shaker mucus clearance devices
The Shaker device will help to shift your bronchial secretions by combining PEP and oscillations. This combination will help you to expectorate the increasing amount of mucus you’re producing. By coughing out more mucus, you’re helping to prevent infections of your respiratory tract. It is also helpful if you have hay fever, which can make symptoms of asthma, such as coughing and wheezing, feel worse. Devices like the Shaker are easy-to-use without medical supervision, so you may decide to use it as an alternative, or additional, treatment to your prescribed medical respiratory physiotherapy.
Although it works similarly to the older Acapella mucus clearance device, research reveals the Shaker to have better linearity at higher airflows. The same research also finds the pressure amplitude produced by the Shaker and Flutter mucus clearance device to be greater at low and high pressures. Finally, the same study shows a higher frequency of oscillation for the Shaker and Flutter at an intermediate pressure. This is all beneficial in helping you get the most from your therapy.
The Shaker Classic, Shaker Deluxe and Shaker Medic Plus by POWERbreathe all mobilise mucus using oscillatory positive expiratory pressure (OPEP). An important point to note is that the Shaker devices are all gravity-dependent, as opposed to gravity-independent. This is worth bearing in mind as a 2018 study finds,
By contrast, this same study finds that the two gravity-independent OPEP devices, the Acapella Choice and Aerobika, “probably require higher expiratory pressure to reach theoretical therapeutic effectiveness.”
Therapeutic effects of the Shaker
If you have a condition such as chronic bronchitis, cystic fibrosis, bronchiectasis or asthma, then you’ll be only too aware of the excessive amount of mucus you produce. You may also notice a change in the type of mucus you’re producing. Because of this, it’s no surprise that you’ll be having difficulty clearing the mucus, even after coughing. But this is where using the Shaker by POWERbreathe for respiratory physiotherapy can help you.
The Shaker uses a stainless-steel ball, weighing 30g, to help clear bronchial secretions. It does this by ‘shaking’ and causing a vibration, or percussion, in your chest. This happens as you exhale through the mouthpiece. As you breathe out through the device, the 30g steel ball provides a resistance. This causes the ball to move and shake and makes it more difficult for you to breathe out. All this shaking and vibration loosens the mucus. After breathing out through it a few times, you’ll find you’ll need to huff, or cough, to expel the mucus. You can see this being demonstrated in the video above. After a few uses, you’ll begin to work out for yourself how long and how frequently you’ll need to use your Shaker device, as everyone is different.
To further enhance the therapeutic effect of your Shaker airway clearance device, its mouthpiece is designed to allow you to use it in a sitting or lying position.
Respiratory physiotherapy techniques
In respiratory physiotherapy, no one technique fits all. A therapist must take into consideration the strength of their patient, the thickness of their mucus and where it is located. However, as a patient, the price may be a criterion for selecting the most suitable device. In this 2013 study, assessment of the Flutter, Acapella and Shaker shows all three mechanical behaviours to be reliable. However, the Shaker is likely to be the most cost-effective.
This type of respiratory physiotherapy aims to help you clear excessive phlegm, sputum, mucus and catarrh. Consequently, breathing effort reduces and exercise tolerance improves, helping you return to a better quality of life.
Young children benefit from respiratory physiotherapy too, but they will require something with a lighter resistance to exhale against. If you have children, you’ll know that you’ll also need to make their therapy more fun. Blowing games using the Flowball by POWERbreathe can help them to clear secretions.
You should always consult a doctor before starting any treatment if you’re concerned about any medical issue.
Tour de France 2019 is a gruelling event. The 21 stage race begins on the flat. But this isn’t for long. The race winds its way through flat, hilly and finally mountainous terrain. This year, we now know, is one of the most demanding Tour de France races. It includes 7 mountain stages with 5 mountain-top finishes. Because the seven mountain stages climb above 2,000 metres, it is one of the highest Tours for many years. This adds another challenge for the riders, that of breathing at high altitude. This is particularly challenging for riders of the 2019 Tour, as the highest point in the race, the Col de l’Iseran mountain pass has an altitude of 2,770m.
Breathing at high altitude
As a cyclist climbs to high altitude breathing increases. This happens automatically. The reason for this is because the body is responding to less oxygen in each breath. As a result, ventilation increases as they try to increase oxygen uptake. However, in spite of an increase in breathing, less oxygen will reach the working muscles, such as the legs. This is because signals are sent to the nervous system telling it to redirect oxygen from the legs to the diaphragm in order to keep up with breathing at altitude. Consequently, the cyclist’s leg muscles begin to suffer from fatigue. Inevitably, this affects performance.
Effects of high altitude breathing
Breathing harder and quicker is an automatic response to the fall in air pressure. In addition to this, the heart works harder too. It does this to try and increase the flow of oxygen-carrying red blood cells to the lungs. It’s a desperate bid to ensure the lungs don’t ‘steal’ the oxygen-carrying red blood cells from straining muscles.
“You just can’t do the same powers that you do at sea level… It is just like a thinner sort of air, really, up there. You can just tell, like, when you’re breathing, you’re just not getting quite as much oxygen in the lungs as you normally would.”
Another consequence of the challenges that breathing at high altitude inflicts on the body, is that of greater quantities of lactic acid. Cycling at altitude requires intense power and energy to climb the hills. But the body’s response to trying to produce energy with less oxygen is to produce larger amounts of lactic acid. It’s the build-up of lactic acid in the muscles that causes that feeling of ‘muscle burn’. It’s also responsible for slowing a cyclist down as it reduces the muscles ability to function.
Active.com explain that lactic acid is the end product of anaerobic metabolism. It says that a build-up of lactic acid occurs when there is insufficient oxygen to produce the energy required by the exercise. Furthermore, they say that when a very high level of work is reached, as in the Tour, lactic acid production becomes constant. As a result, the cyclist will experience acute muscle fatigue.
Preparing for the challenges of breathing at altitude
Will increase the aerobic capacity of the breathing muscles, making them more efficient lactate consumers during and after exercise.
Research shows that breathing against a small inspiratory load immediately after exercise reduces lactate by 16%. It also reduces lactate as soon as exercise finishes, unlike traditional active recovery which may take 5-minutes to clear lactate. Another bonus for Tour de France and Giro d’Italia riders is that subsequent research demonstrates a post-exercise inspiratory resistive loading (after a Wingate test) reduces post-exercise effort perception and improves peak power on subsequent all-out maximal-intensity exercise. This is obviously beneficial when riders need to perform at their best, day-after-day.
This new study investigates the effects of inspiratory muscle training (IMT) on smokers and non-smokers. Researchers from Ondokuz Mayıs University and Gaziantep University in Turkey look into how IMT may affect pulmonary function and respiratory muscle strength in both these groups.
Respiratory muscle strength is an indication of how much pressure the breathing muscles generate when a person breathes in or out. Assessment of respiratory muscle strength involves measuring MIP or MEP. MIP or maximal inspiratory pressure reflects the strength of the inspiratory muscles, such as the diaphragm. Meanwhile MEP or maximal expiratory pressure reflects the strength of the expiratory muscles.
The IMT program
For the IMT program, subjects use the POWERbreathe Classic IMT device. The procedure consists of 30 x 2 dynamic inspiratory efforts with a 1-minute interval. They perform this for four weeks, seven days a week. The reason researchers chose this procedure is that it has been previously applied in healthy individuals.
Smokers group, non-smokers & placebo groups
Forty-two healthy males enrol in this randomised, double-blind, placebo-controlled experimental design study. There are 16 subjects in the IMT smokers group (IMTS), 16 in the IMT non-smokers group (IMTN) with the final 10 subjects in the placebo group. This final group receive a sham ‘placebo’ treatment that will have no real effect.
By using a double-blind, placebo-controlled experimental design study, researchers can test out a therapy. The placebo treatment will feel just like the actual treatment, in this case, IMT. The reason for this is so that both the subject and the researcher’s expectations will not affect the outcome. Furthermore, a double-blind controlled study means that neither the researchers nor the subjects taking part know who will be receiving which treatment. This is vital in helping to avoid bias when measuring outcomes.
For the study, the experimental groups (IMTS and IMTN) perform POWERbreathe IMT at 50% of maximal inspiratory pressure. Researchers increase this each week. Meanwhile, in the placebo group, subjects perform POWERbreathe IMT at only 15% of MIP.
Improvements occur in smokers after IMT
Results of the study show significant improvements in respiratory muscle strength and pulmonary functions after the 4-week POWERbreathe IMT program. Even more promising is the fact that improvements in smokers are greater. Potentially, this is a result of a:
“greater influence of exercise on smokers’ lung microbiome in reversing the negative effects of smoking.”
For smokers, this means that their stronger inspiratory muscles will improve their ability to breathe in more air, for longer and with less fatigue. This will have a positive impact on daily life by helping them improve their ability to perform daily activities that may have been prohibitive before.
POWERbreathe receives ISO accreditation certificate of approval for ‘Design & manufacture of medical devices for improvement of respiratory function’
The Quality Management System of POWERbreathe International Ltd has been approved by Lloyd’s Register to the following Quality Management System Standards set out under United Kingdom Accreditation Service (UKAS) accreditation:
POWERbreathe International Limited commits to the overall aim of maximising customer satisfaction. We will provide impartial advice on what is appropriate for the customer and comply with such requirements that are necessary to supply high quality medical devices for improvement of respiratory function.
This new study (2019) looks into whether chronic IMT improves hypoxic endurance exercise performance.
Endurance exercise performance
The study, in the International Journal of Sports Physiology and Performance, is using a cycling time trial to measure endurance exercise performance. Endurance exercise is typically performed at submaximal intensity. The purpose of this is to estimate VO2max, or ‘aerobic fitness’. The measurement VO2max is the maximum amount of oxygen a person will consume during intense exercise. In fact, cycling time trials offer the ideal exercise to increase both heart rate and breathing. Similarly, so do running and swimming.
What is IMT?
IMT is a form of resistance training for the breathing muscles. The term IMT stands for inspiratory muscle training. The inspiratory muscles, the breathing muscles, are the ones that draw air into the lungs. The main inspiratory muscle is the diaphragm. Like any other group of muscles, the inspiratory muscles benefit from training too. Inspiratory muscle training, such as with POWERbreathe, provides the stimulus for that training. Following IMT, the breathing muscles adapt and become stronger after only a few weeks. This results in exercise feeling easier and an improvement therefore in performance.
Although breathing comes naturally, some of the time it can feel like an effort. This may be due to the demand endurance exercise places on breathing. It may be due to a respiratory issue. Either way, it’s not uncommon for the respiratory muscles to fatigue, just like any other muscle.
If the respiratory muscles are weak from disease or exercise is overloading them, breathing demand will not be met. As a result, breathing will start to feel shallow and rapid. Sustaining this type of breathing is impossible. Furthermore, the more rapid the breathing, the more oxygen they require and the more carbon dioxide they produce. Consequently, oxygen is re-directed from the skeletal muscles, such as arms or legs, to the breathing muscles, where it is most needed. This results in fatigue of the skeletal muscles.
Inspiratory muscle training helps the body meet the needs of both the respiratory muscles and the skeletal muscles by improving their strength and stamina. The way IMT achieves this is by providing a resistance to breathe in against. POWERbreathe IMT is just like a ‘dumbbell for your diaphragm’.
Data from this recent study suggest that,
“performing 6 weeks of inspiratory muscle training may benefit hypoxic endurance exercise performance lasting 30-40 minutes.”
Hay fever may make symptoms of asthma, such as coughing and wheezing, feel worse. In fact, people with respiratory symptoms may experience continuous coughing as a result of their hay fever. This is likely to be due to the type of allergens affecting them. However, if a cough becomes unusually persistent, it is always best to report it to a doctor. But for those with asthma already taking medication, finding a natural remedy for hay fever induced coughing is of interest.
Natural Remedy for Hay Fever Induced Coughing
Coughing is the body’s natural way of trying to clear the lungs of fluid or mucus. Mucus production increases as a result of respiratory infections, such as a cold or the flu. However, mucus also increases when a person has an allergic reaction. In the case of hay fever, this will be to a type of pollen. It’s this allergic reaction that can cause persistent coughing, as the body tries to shift mucus, or phlegm, from the lungs.
Phlegm is produced by the respiratory system. When there is a large amount of phlegm, it can clog the airways. When phlegm is present in large amounts, the body naturally coughs to expel it. This resulting cough from clogging of the airways is particularly distressing in people with asthma.
Antihistamines and decongestants are traditionally taken to help relieve symptoms of allergies and hay fever. However, neither will get rid of phlegm on the chest. Furthermore, both are drugs. Additionally, an expectorant will help to make mucus thinner so it is easier to cough up, but that too is made from a type of drug.
People with asthma know how important it is to ensure that any additional medication they take is safe to use with their prescribed asthma treatment. It is helpful, therefore, to find a drug-free cough treatment that will help with mucus clearance. A drug-free cough treatment, by its nature, will have no drug interactions.
How to Clear Mucus
A natural remedy for hay fever cough is to use a mucus clearance device. The Shaker offers chesty cough relief by shaking loose the phlegm on the chest.
The weighted ball inside the Shaker rises as the user breathes out through the device. It then falls under its own weight. However, it does this so quickly that it feels like a vibration. It’s this vibrating action that mobilises lung secretions, breaking them down and making them thinner and less sticky. This makes it easier for the user to then expel the phlegm. A productive cough will result after using the Shaker; sometimes immediately and sometimes it may be an hour later. But the productive cough that the Shaker induces will help the user to eliminate the mucus. Ultimately, this brings much relief from chest congestion.
Shaker devices are ideal for ‘shaking’ loose mucus and catarrh that is associated with:
Shaker devices are also suitable for children to use, under parental guidance, as they are easy-to-use and effective. Please always speak to a medical professional first about medical issues or concerns and also read the precautions before using.
How to Keep Your Lungs Healthy
If you are finding breathing difficult because you have a lung condition, the European Lung Foundation believes exercise is helpful. In fact, you can discover how exercise helps to keep your lungs healthy in one of our previous blogs, How To Keep Your Lungs Healthy With Exercise. Additionally, by eating a healthy diet you can also help to keep your lungs healthy. If you find this topic to be of interest, then you may like to read another one of our blogs, Foods for Keeping your Lungs Healthy.
There is a new Review Article in Frontiers in Physiology (January 2019) that looks into using respiratory/inspiratory muscle training for acclimatisation to altitude.
Respiratory muscle training
Respiratory muscle training, or RMT, is a programme of exercises that aim to improve the function of the respiratory muscles. Otherwise known as the ‘breathing pump’ muscles, the expiratory muscles and the inspiratory muscles make up the respiratory muscles. It’s the inspiratory muscles that we use when we breathe in. The main inspiratory muscle is the diaphragm, but to a lesser extent, the intercostal muscles also help with inhalation. To help improve the strength and stamina of these inspiratory muscles, respiratory muscle training will include Inspiratory Muscle Training (IMT).
Inspiratory Muscle Training
Inspiratory muscle training, such as with POWERbreathe, uses resistance to provide the training effect. When breathing in against the resistance, the breathing muscles have to work harder. As a result, they get stronger. Consequently, breathing stamina improves resulting in a reduction in breathing fatigue. There is numerous research validating this form of breathing training and, as a result, it is the most commonly used.
For the review, researchers perform a comprehensive search, analysing seven appropriate studies. Three of these studies refer to using respiratory muscle endurance training (RME with isocapnic hyperpnea). However, the remaining four studies use respiratory muscle strength training (RMS with POWERbreathe IMT).
Acclimatisation to altitude
Studies suggest that respiratory muscle training with IMT is a useful preparatory method for enhancing respiratory muscle efficiency 4-6 weeks before being exposed to hypoxia/altitude.
It is evident that breathing during exercise in hypoxia is associated with increased energy costs (20–30%) when compared to normoxia. Therefore, it is more likely to cause respiratory muscle fatigue. However, inspiratory muscle training will help to combat this. This is because IMT trains the inspiratory muscles to become stronger, increasing stamina. Consequently, breathing muscle fatigue reduces.
It, therefore, seems apparent that breathing muscle training has the potential to minimise at least some of the limiting respiratory factors that occur during training and competition in hypoxia/at altitude.
Benefits of acclimatisation to altitude using IMT
The Review suggests that both elite athletes and non-elite individuals may benefit from RMT, including:
A delay in the onset of premature fatigue.
A delay in respiratory muscle metaboreflex onset/activation.
An improvement in clearance and tolerance to anaerobic metabolite products.
A decrease in the perception of dyspnea (‘air hunger’).
An increase in oxygen saturation values.
A more favourable blood redistribution to the locomotor muscles.
Finally, evidence from this review finds that respiratory muscle training is an effective stimulus for improving the strength and endurance of the respiratory muscles. In fact, it’s these adaptive responses that contribute to the improvement of ventilatory function and efficiency. In translation, this means that respiratory muscle training is very likely to improve exercise performance in normoxia and particularly in hypoxia/altitude.