Health Questions

advice on nursing

Questions Received:

  1. What is the effect of asthma and cancer on gas exchange in humans?

  2. For some four or five weeks I cough quite frequently and develop almost coughing fits. Doctor says it is an upper respiratory problem aggravated by my asthma or summer viral flu. Should get better. Saw him a week later with sore epiglottis but not unusually significant. Peak flow of 620 at 6pm and had steroid Prednisolone given over five days. Into 3rd day but no good coughing restricted breathing in spasm type. Just a short cough and something switched the pipe shut. Cleared after a few seconds. Wary of coughing at all now. This restriction has occurred at least six times in last two weeks. Is this really summer flu or a viral thing or could it be more serious? My two daughters aged 5 and 7 also have had an uncontrollable cough but seem to deal with it better than me.

  3. I have a problem that happens only when I get a cold. It usually happens when I am asleep in bed. I suddenly wake not able to breathe in or out. I am literally fighting to take a breath for about a minute. It feels as though my wind pipe is completely blocked. I eventually begin whooping and getting in some air and then resume breathing normally. I also get this when I go swimming and water is splashed in my nose/mouth region, again my airways become completely obstructed and I'm fighting for breath for a while. When I get colds I'm prone to bouts of severe coughing which again brings on this problem where I end up fighting to take a breath. I am becoming afraid of catching colds or going swimming because of this problem and don't understand why it happens. I have been this way ever since I can remember.

  4. My husband has been diagnosed with obstructed lung disease after steadily losing breath capacity since taking beta blockers. He has undergone tests for lung capacity after stopping the beta blockers for 3 weeks and his breathing improved considerably. After retaking the beta blockers his breathing under exercise has continued to decline. He says he would rather die of a heart attack than from the inability to exercise from poor breathing - are there any alternatives to beta blockers which will protect the heart but not damage or inhibit his lung capacity?

  5. I am a 24 year old female and hope that you might be able to help me. For the last 7 years I have started developing a breathing disorder. Symptoms: a feeling of suffocation, shortness of breath, adapted yawning to give a feeling of 'getting air', insomnia, dizziness, sore back and shoulders because of constant gulps for air, and headaches. I have consulted over a dozen doctors. I had a breathing test done which indicated that I have very good developed and healthy lungs. I have also been tested for anemia but everything seems to be in order. My doctor seems to think this might be panic attacks. I have followed recommendations like breathing into a paper bag etc. but none of these methods seems to calm the situation. This feeling of not getting sufficient air filtered into my lungs seems to be triggered by no specific event or situation.

  6. I hope you can help me understand a question that I need to answer for an assignment for Human Bioscience in Nursing. The question is, a client suffering from Hyperventilation. What effect does this have on the partial pressure of carbon dioxide in the arteries and explain the changes in pH that may occur and the mechanisms by which the body attempts to restore homeostasis. I look forward to your reply.

Responses:

What is the effect of asthma and cancer on gas exchange in humans?

8th April 2015

In asthma the airways become narrowed and there is increased resistance to airflow, both during inspiration and expiration. Impaired ventilation means that carbon dioxide, a waste product of the body’s metabolism, cannot be effectively cleared from the lungs and the amount of carbon dioxide in the blood rises (hypercapnia) and makes it more acidic (the pH drops: acidosis). At the same time the amount of oxygen in the blood falls (hypoxia) because the volume of inspired air is reduced.

Lung cancer can also impede gaseous exchange. A tumour may obstruct one of the bronchi. This will result in under ventilation, stagnation of air and collapse of the alveolar air sacs distal to the obstruction. However, because the lungs have a large surface area any impediment to gaseous exchange may not reveal itself until the disease is well advanced.

Asthma

Asthma (bronchospasm) is produced in response to a number of different stimuli. These include particles inhaled with the air (eg: house dust, pollen, feather protein, and animal dander) or ingested with the diet (eg: peanuts). Such substances may be regarded as "foreign" proteins which trigger an allergic response from the immune system. This can produce inflammation of the respiratory lining and spasm of the smooth muscle cells in the walls of the airways. When substances in the environment are responsible for provoking bronchospasm the term "extrinsic" asthma is often applied.

The obstruction to the airways which asthma produces disrupts both inspiration and expiration, particularly expiration. Constriction of the bronchi severely impedes the flow of air leaving the alveoli. Expiration is normally a passive process but during an asthmatic attack numerous muscles are employed in order to force air from the air sacs. Attacks of asthma are characterised by wheeziness, breathlessness and coughing. Fatigue can also occur unless treatment is instigated. An attack of asthma can be very frightening for the sufferer and anyone witnessing such an event.

Greater effort is also required during inspiration and the accessory muscles of respiration, particularly the scalene muscles in the neck and muscles linking the upper limb to the thorax, are employed to lift the rib cage and draw air into the lungs. Hence the fatigue which asthma can produce. As the volume of inspired air is reduced less oxygen enters the alveoli and a state of hypoxia occurs. If severely fatigued, the breaths taken by the person may be shallow and barely sufficient to overcome the physiological dead space. Under such circumstances treating the person by using Intermittent Positive Pressure Ventilation may be necessary.

Lung Cancer

Tumours of the lung are either primary tumours or secondary tumours (metastases). There are four main types of lung tumour:

Dyspnoea, experienced by about 60% of patients, may not become a problem until quite late in the disease, whereas the person may well complain of an irritating persistent cough, fatigue and/or weight loss early on. Infection may arise in a region of the lung obstructed by a tumour, producing chest pain and fever. In terms of metastatic spread, the effects will depend on how widespread this is. If it is extensive then gas transfer will be reduced and dyspnoea may be present; even at rest. Much depends though on the type and position of the tumour and how far advanced the disease is. Pulse oximetry will provide an indication as to how compromised a person's lung function has become. Pulmonary function tests and radiological investigations will provide more specific information.

For some four or five weeks I cough quite frequently and develop almost coughing fits. Doctor says it is an upper respiratory problem aggravated by my asthma or summer viral flu. Should get better. Saw him a week later with sore epiglottis but not unusually significant. Peak flow of 620 at 6pm and had steroid Prednisolone given over five days.

Into 3rd day but no good coughing restricted breathing in spasm type. Just a short cough and something switched the pipe shut. Cleared after a few seconds. Wary of coughing at all now. This restriction has occurred at least six times in last two weeks. Is this really summer flu or a viral thing or could it be more serious? My two daughters aged 5 and 7 also have had an uncontrollable cough but seem to deal with it better than me.

27th June 2015

Unfortunately we are not in a position to offer a diagnosis, so please consult your doctor if you continue to be troubled by the coughing. As you are probably aware, severe coughing - particularly at night - is often associated with worsening asthma, and should be acted upon. However, your peak flow was 620, so this is unlikely to be the case here. Try taking a measurement when the coughing is worse, to see if it is significantly decreased. There has indeed been a rather nasty strain of upper respiratory viral infection around over the last 2/3 months which has caused hoarseness, loss of voice and pain for some people over a long period of time. It may be that you contracted this virus, in which case your airways have become inflamed from the infectious process combined with all the coughing and clearing of your throat. The sudden transient occlusion of your airway may be linked with inflammation, but if you are still worried you should go back to your doctor. If the symptoms are not clear by now, he might ask an ENT consultant to examine your throat.

You mention that your daughters have also been affected by bouts of coughing. There is just a possibility that they have come into contact with the whooping cough bacterium (Bordetella pertussis) which causes paroxysmal coughing in children and which can on occasion be passed on to other family members. We tend to think of whooping cough as affecting only young children, but it can occasionally produce serious symptoms in adults too. We also assume that the widespread use of vaccination against pertussis has largely eliminated the problem, but the organism can still be prevalent even within an immunised population (He et al, 2014). Because of the possibility of transmission of pertussis within families, there has been a call for immunisation of adults as well as children (Halperin and Marrie, 1991). Another organism that can cause flu-like symptoms, coughing fits, and is transmitted within families is called Chlamydia pneumoniae (Hagiwara et al, 2015). The same organism has been linked with asthma that does not respond to steroids (Hahn et al, 2014). If a blood test shows the presence of antibodies to Chlamydia pneumoniae then appropriate antibiotic therapy may be helpful.

References

I have a problem that happens only when I get a cold. It usually happens when I am asleep in bed. I suddenly wake not able to breathe in or out. I am literally fighting to take a breath for about a minute. It feels as though my wind pipe is completely blocked. I eventually begin whooping and getting in some air and then resume breathing normally.

I also get this when I go swimming and water is splashed in my nose/mouth region, again my airways become completely obstructed and I'm fighting for breath for a while. When I get colds I'm prone to bouts of severe coughing which again brings on this problem where I end up fighting to take a breath. I am becoming afraid of catching colds or going swimming because of this problem and don't understand why it happens. I have been this way ever since I can remember.

9th December 2015

This is clearly a very distressing problem and if you have not already visited your doctor for a check-up and discussed what may be happening or what can be done it will be worth doing so soon. You point out that you have experienced sudden transient obstructions of your breathing for as long as you can recall, so it seems probable that you have already sought medical help on this, perhaps more than once. Assuming that no obvious anatomical or physiological reasons can be identified, then we have to look for another explanation.

Here is a suggestion - remember, it is not a diagnosis, but simply a suggestion about one possible way of interpreting what you have been experiencing, and it will be necessary to consult your doctor for a clear diagnosis. You are probably aware that the air we breathe and the food and drink we swallow share a common pathway provided by the pharynx (throat) for part of their course. At the lower end of the pharynx the pathway divides, with the air passing forwards into the larynx (voice box), trachea and succeeding parts of the airways to reach the lungs, while food and drink pass down through the oesophagus to the stomach.

The larynx has several functions, including the production of sounds which are used in talking and singing for example, and another important function is to prevent food and and liquids from accidentally entering the airways. Usually the system works very well, but you will know from personal experience that occasionally we accidentally "swallow food the wrong way" (for example when someone cracks a joke just as you begin to swallow something) and this is followed rapidly by a bout of coughing to expel the material from the airways. When we swallow normally, the larynx is lifted first to a more protected position behind and beneath the tongue, the epiglottis closes over the opening into the larynx, and the two vocal folds (also called vocal cords) close tightly together, sealing the entrance to the airway. We don’t have to think consciously about doing all these things when we swallow - they are co-ordinated by complex patterns of automatic control organised in the brainstem. Now, if fluid or a foreign object comes into contact with the sensitive lining of the larynx unexpectedly, the vocal folds close very quickly and firmly, again to protect the airway.

This laryngospasm is an example of a protective reflex, of which there are many examples in the body. It could be that in your case a reflex closure of your vocal folds is producing the alarming obstruction that you experience from time to time. So what might be triggering this reflex? You mention two main situations - when you have a cold, and when you go swimming. When you have a respiratory infection, the lining of the airways becomes inflamed and copious amounts of mucus are produced. Either of these might cause the nerve endings responsible for initiating the reflex to become more sensitive and more readily triggered. In the case of water splashing on your face, the reflex is triggered as a preparation to prevent water accidentally entering the airways. Quite a few people experience a similar response, particularly when the water is cold. So although it feels alarming, it seems probable that you are experiencing a protective reflex that in your case is particularly easily set in motion.

If this explanation has any veracity in your particular case, it may be helpful for you to explore in a safe environment your response to water splashing on your face, since here you have more control over the situation. The more familiar you become with the sensation of being obstructed the better able you will be to react calmly and wait for the few seconds to elapse before your vocal folds relax again. A feeling of panic can only aggravate the unpleasantness. It will of course be difficult for you to avoid exposure to common respiratory infections, but the above preparation might help in this situation too.

Reading

My husband has been diagnosed with obstructed lung disease after steadily losing breath capacity since taking beta blockers. He has undergone tests for lung capacity after stopping the beta blockers for 3 weeks and his breathing improved considerably.

After retaking the beta blockers his breathing under exercise has continued to decline. He says he would rather die of a heart attack than from the inability to exercise from poor breathing - are there any alternatives to beta blockers which will protect the heart but not damage or inhibit his lung capacity?

2nd April 2000

Beta blockers are used to treat people with cardiovascular problems. They are very effective in protecting against heart attacks, but it has been known for some 20 years or so that some members of the beta blocker family have an adverse effect on breathing in people with obstructive lung disease. In addition to reducing blood pressure, some beta blockers act on the smooth muscle cells in the walls of the airways and cause them to contract, thus causing the airways to narrow and impede the flow of air through them. Beta blockers are not alone in doing this - more than 100 cardiovascular drugs such as amiodarone and the angiotensin-converting enzyme (ACE) inhibitors have similar unwanted side-effects (Rosenow, 2010).

However, some beta blockers are cardioselective and have a much weaker effect on the airways. This is particularly the case with some of the newer beta blockers that mimic some of the effects of the sympathetic nervous system (known as intrinsic sympathomimetic activity - ISA). These agents decrease blood pressure and systemic vascular resistance, while the heart rate and cardiac output at rest are maintained. An example is celiprolol, which is effective against angina and hypertension without adversely affecting airway function and exercise performance (Fogari et al, 1990; Weber, 1991). Another option is to use combination therapy with alpha 1 blockers (which do not have deleterious effects on chronic obstructive lung disease), calcium channel blockers, and ACE inhibitors (Houston, 2014).

It will be worthwhile to ask your husband's doctor whether any of these alternatives may be helpful in the treatment of your husband.

References

I am a 24 year old female and hope that you might be able to help me. For the last 7 years I have started developing a breathing disorder. Symptoms: a feeling of suffocation, shortness of breath, adapted yawning to give a feeling of 'getting air', insomnia, dizziness, sore back and shoulders because of constant gulps for air, and headaches.

I have consulted over a dozen doctors. I had a breathing test done which indicated that I have very good developed and healthy lungs. I have also been tested for anemia but everything seems to be in order. My doctor seems to think this might be panic attacks. I have followed recommendations like breathing into a paper bag etc. but none of these methods seems to calm the situation. This feeling of not getting sufficient air filtered into my lungs seems to be triggered by no specific event or situation.

18th September 2004

A feeling of suffocation is very alarming - for anyone. You have been trying to cope with feelings of shortness of breath for 7 years now, and must be very distressed by them. Anyone who has experienced asthma will be able to empathise with you. Having consulted several doctors, it is reassuring to know that your lungs are healthy and that you are not anaemic. Presumably also your heart function, blood pressure, and blood gases have been carefully checked and found to be within normal limits. If so, there appears to be none of the common clinical problems such as lung disease, airway obstruction, or cardiovascular disease to explain your feelings of shortage of air.

However, the feelings of suffocation are there, and all the strategies the body then uses to try to overcome the apparent shortage of air. I say ‘apparent’, because it seems as if you are able to move air freely into and out of your lungs. Also, you mention dizziness, which can follow overbreathing and is a result of more carbon dioxide being removed from the blood than usual and the blood becoming more alkaline. (You can try this for yourself - if you choose to hyperventilate for a while at a time when you are not experiencing the unpleasant symptoms you have described, you will begin to feel tingly and dizzy.)

If there are no obvious clinical causes for your feelings of not being able to get enough air, then a doctor will begin think along the lines of panic attacks. These have all the signs and symptoms that you describe, and are usually triggered by moments of severe stress or high emotion when the affected person feels unable to control the situation. However, in your case you are not aware of any special circumstances that might be triggering your feelings of suffocation. And probably, you feel quite hurt by the implied suggestion that your very unpleasant symptoms are somehow “all in the mind”.

It may help you to carry out a little detective work so that you can make better progress with this problem. Firstly, is there anything in your day-to-day living that might be contributing? Do you smoke, or are you exposed to cigarette smoke? Are you exposed to a lot of traffic pollution, either as a driver or pedestrian? Are you cooking on a gas stove in a poorly ventilated room? Is it possible that you are exposed to exhaust gases from a gas central heating unit? Each of these is a source of carbon monoxide, a gas which combines very tenaciously with haemoglobin in the blood and reduces its ability to carry oxygen. Think about any holidays away from home you might have had recently - did your feelings of not being able to get enough air change at all in the new environment? If the feelings became less, then this might be a clue as to what could be acting as a trigger in every-day life.

What happens when you exercise, for example go for a walk or a swim, or climb some stairs? Does physical exertion make the problem worse? Clearly, you are experiencing the symptoms even when lying at rest, but it would be helpful to know the effect of exercise on your breathing patterns. Do you consider yourself to be fit and active, or is your lifestyle quite sedentary?

Do you carry out any activities that involve consciously controlling your breathing, for example: singing, playing a wind instrument, swimming under water, talking to groups of people? Sometimes, the discipline required for these specialised activities can be helpful when experiencing the feelings of being short of air. Our attention is taken away from the act of breathing itself as we focus more on doing the activity well, and with practice things improve.

Do you experience allergies? For example to pollen, the spores of moulds, or to animal dander? These can affect breathing.

Would you say that there are major sources of unresolved stress in your day-to-day life? Either at home or at work? If you can identify some of these, and then look for ways of reducing the stress, this might help to ease the breathing problems. Can you find ways of ‘unwinding’ after a stressful day? A good way is to have some form of exercise you enjoy doing, such as taking the dog for a walk, so that the tensions generated during the day can be dissipated before going to sleep.

I hope you can help me understand a question that I need to answer for an assignment for Human Bioscience in Nursing. The question is, a client suffering from Hyperventilation. What effect does this have on the partial pressure of carbon dioxide in the arteries and explain the changes in pH that may occur and the mechanisms by which the body attempts to restore homeostasis. I look forward to your reply.

21st July 2005

As this is an assignment, the best approach will be for me to suggest some of the things you should be considering as you prepare your answer, rather than writing the definitive answer for you!

Effect on partial pressure of CO2 in the arteries

Imagine that you are sitting quietly, feeling relaxed. Your breathing matches the needs of your body - since your muscles are mostly relaxed, and your general metabolic rate is quite low, the need for oxygen is correspondingly low and the amount of carbon dioxide to be excreted via the lungs is also low. Thus, your breathing is quite shallow and quite slow.

Now imagine that you decide to breathe much more deeply and much more quickly. You are generating the condition known as hyperventilation. (There are of course many possible causes of hyperventilation, including anxiety, fever, drug overdose, carbon monoxide poisoning, serious infections, pneumonia and other lung conditions, brain tumours, brain oedema, pregnancy, liver failure, high altitude, metabolic acidosis and so on...)

You may have tried hyperventilating while playing as a child, and noticed that after a while you became dizzy and tingly. The effects of overbreathing in a situation where it isn’t really warranted by the body’s needs are quite dramatic, and for your assignment you will need to work out why. You will need to look into the three ways that carbon dioxide (CO2) is carried by the blood as it travels back to the heart and then on to the lungs, and then understand how the CO2 is released from the blood into the air in the alveoli so that it can be exhaled. Overbreathing means that more carbon dioxide is being ‘blown off’ from the blood than required, and therefore the level of CO2 in the blood (its partial pressure or PCO2) begins to fall rapidly.

Explain Changes in pH

The excessive loss of carbon dioxide quickly affects the pH of the blood. The question is, how and why? There is a comprehensive review of respiratory alkalosis at the following web address that will help you understand:

http://www.emedicine.com/med/topic2009.htm

As the pH changes and other balances are upset, you get all the familiar signs and symptoms such as dizziness, tingling, and muscle pains/tremors/tetany.

Mechanisms to restore homeostasis

The body has three main strategies that it can call on to try and restore the pH to normal levels:

So, these are the main things to include in your assignment answer. See how it goes, and if there are any specific points that you are having difficulty with, contact us again and we can work through them.

 

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