Chronic bronchitis is a condition of increased swelling and mucus (phlegm or sputum) production in the breathing tubes (airways). Airway obstruction occurs in chronic bronchitis because the swelling and extra mucus causes the inside of the breathing tubes to be smaller than normal. The diagnosis of chronic bronchitis is made based on symptoms of a cough that produces mucus or phlegm on most days, for three months, for two or more years (after other causes for the cough have been excluded).

Emphysema is a condition that involves damage to the walls of the air sacs (alveoli) of the lung. Normally there are more than 300 million alveoli in the lung. The alveoli are normally stretchy and springy, like little balloons. Like a balloon, it takes effort to blow up normal alveoli; however, it takes no energy to empty the alveoli because they spring back to their original size. In emphysema, the walls of some of the alveoli have been damaged.

When this happens, the alveoli lose their stretchiness and trap air. Since it is difficult to push all of the air out of the lungs, the lungs do not empty efficiently and therefore contain more air than normal. This is called air trapping and causes hyperinflation in the lungs. The combination of constantly having extra air in the lungs and the extra effort needed to breathe results in a person feeling short of breath. Airway obstruction occurs in emphysema because the alveoli that normally support the airways open cannot do so during inhalation or exhalation. Without their support, the breathing tubes collapse, causing obstruction to the flow of air.

COPD can be caused by many factors, although the most common cause is cigarette smoke. Environ­ mental factors and genetics may also cause COPD. For example, heavy exposure to certain dusts at work, chemicals, and indoor or outdoor air pollution can contribute to COPD. The reason why some smokers never develop COPD and why some never­smokers get COPD is not fully understood. Hereditary (genetic) factors probably play a role in who develops COPD.

Shortness of breath, cough, and/or mucus production, that does not go away, are common signs and symptoms of COPD and indicate the need for a visit to your health care provider and evaluation for the need of a breathing test called spirometry. Spirometry is a simple test that measures airway obstruction.

The first and most important treatment in smokers is to stop smoking. Medications are usually prescribed to widen the airways (bronchodilators), reduce swelling in the airways (anti­inflammatory drugs, such as steroids), and/or treat infection (antibiotics). COPD can also cause the oxygen level in the blood to below; if this occurs, supplemental oxygen will be prescribed. Breathlessness, however, will happen with COPD even if you have good oxygen levels.

Breathlessness is therefore not a good guide for oxygen use. To control symptoms of COPD, your breathing medications must be taken everyday, usually for life. Surgical procedures such as lung volume reduction surgery or lung transplantation may be helpful for some cases of COPD.

Pulmonary rehabilitation programs offer supervised exercise and education for those with breathing problems (See ATS Handout on Pulmonary Rehabilitation in a forthcoming issue). Support groups are also available for COPD patients for education and opportunities to share experience with other patients and families.

The term chronic in chronic obstructive pulmonary disease means that it lasts for a long time. While symptoms may vary from time to time, the lungs can still have disease, therefore, COPD is for life. While the symptoms of COPD sometimes improve after a person stops smoking and takes medication regularly, symptoms can further improve after attending pulmonary rehabilitation. Shortness of breath and fatigue may never go away entirely, however, patients can learn to manage their condition and continue to lead a fulfilling life.

Healthcare providers diagnose COPD based on both reports of symptoms and test results. The single most important test to determine if a person has COPD is spirometry.

The most common symptoms of asthma are shortness of breath, wheezing, chest tightness, and cough. You may have days when you have every symptom and other days you may have no symptoms. When you do have asthma symptoms, you may feel like you are breathing through a straw. You may also hear wheezing (a whistling or squeaking sound) as air tries to move through your narrowed airways. You may also cough, most often at night or early in the morning. Chest pain, chest pressure, or a feeling of tightness in your chest can be other symptoms of asthma.

An “asthma attack” describes very severe symptoms. During an asthma attack, you may breathe so fast that you may have a hard time talking. Coughing, wheezing, and chest tightness can cause you to feel anxious or scared. This may make you feel even more short of breath. Although rare, low oxygen levels in your blood may cause your fingertips and lips to turn blue or gray. If you think that you are having a severe asthma attack, you should immediately seek emergency care.

Asthma can be inherited or passed down to you from your parents through their genes, or you may have no history of asthma in your family. If you have asthma, your airways are more sensitive than normal. Your airways can get irritated and tighten very easily by a variety of things called “triggers.”

Examples of “triggers” are:

Allergies: If you have allergies, you may also be more likely to have asthma. This type of asthma often begins in children, but can happen in adults as well. Common allergens (things that cause allergies) are pollen from weeds, trees, and grass, mold, cockroach droppings, dander from cats or dogs and dust mites. These can cause sneezing, wheezing, itchy eyes and a runny nose. If the lungs are irritated enough, the allergens can cause an asthma attack.

Respiratory infections: Frequent lung or sinus infections can also cause asthma. Infections can trigger longer episodes of wheezing or shortness of breath than those from allergies. In fact, respiratory viruses are the most common cause of asthma attacks that are bad enough to keep you home from school or work.

Irritants that can also cause asthma are:

• Exhaust fumes from cars, buses, trucks etc.
• Chemicals like garden sprays.
• Molds and dust.
• Strong odors from paint, perfumes, colognes, hair spray, deodorants, and cleaning products.
• Tobacco smoke from cigarettes, pipes, or cigars.
• Temperature or weather changes.
• Stress or exercise.
• Medications, including aspirin and beta-blockers (heart or blood pressure medicine).
• Sulfites in foods such as dried fruits, wine and beer.

Asthma cannot be diagnosed without a breathing test. So, if you think you may have asthma, tell your health care provider (HCP) about all of your symptoms. If your HCP thinks your symptoms may be from asthma, they will ask you to have a breathing test called a pulmonary function test or spirometry test. Because there are many types of asthma and many different things that can cause asthma (or appear to be asthma), your HCP may want you to have additional tests. Blood tests for allergies or for detecting problems with your immune system may also be ordered.

If your asthma is not getting better after you start treatment, you might benefit from seeing an asthma specialist. Sometimes, other diseases can act like asthma. The asthma specialist may do more testing to find the specific cause of your asthma or things that may be making it worse. Testing may also be done to test if your symptoms are caused by another disease such as vocal cord dysfunction.

Once you are diagnosed with asthma, it is very important that you work closely with your HCP to control your asthma. You and your HCP will write an Action Plan that you will follow to treat your symptoms and improve your breathing. Your Action Plan will include when to take your medications, what you can do in your daily life to avoid triggers, and how to monitor your breathing.

Medications will be prescribed that keep your airways open and reduce swelling, so air can move in and out of your lungs more easily. You will be given an inhaler, but you may also be given a pill as well as an inhaler. The most important thing about controlling your asthma is that you must take the medicine exactly as instructed by your HCP. When you use the medication correctly, you should be able to prevent your asthma symptoms.

• Short-acting (relief or rescue) bronchodilators,such as albuterol or levalbuterol, relax the muscles around your airways.
• Long-acting medicines (controllers) include inhaled corticosteroids (e.g. beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone, mometasone) or inhaled corticosteroids in combination with long-acting bronchodilators (e.g. formoterol or salmeterol). These medications must be taken on a regular basis and are designed to keep your airways open over time. Inhaled corticosteroids decrease the swelling in your airways, so that they are less likely to be irritated by triggers. Long acting bronchodilators are never used alone as a controller in asthma; inhaled bronchodilators are to be taken at the same time as corticosteroids, often both are in the same inhaler. Pills, including leukotriene modifying drugs (montelukast, zafirlukast, zileuton) and theophylline, may also be prescribed. These drugs are not usually as effective as corticosteroids and long- acting bronchodilators.

Lifestyle management begins with learning what specific “triggers” may be causing your asthma symptoms. Keep a journal (or diary) to track your day-to-day activities along with any symptoms that you may be having during the day or at night. Once you know what may be causing your asthma, you can then try to stay away from those triggers.

Peak flow monitoring is often recommended. By blowing into a peak flow meter each day, you can see how well you are breathing. Sometimes your peak flow reading can make you aware that your asthma is worsening before you have symptoms. When your peak flow reading is high, you should generally be breathing well. When your lungs are tight, your peak flow reading will be lower. At these times, you may be asked to increase your medications, as outlined in your Action Plan. The goal of peak flow monitoring is to help guide you to prevent an asthma attack.

Medications: Take your asthma medication exactly as your HCP tells you. Work with your HCP to find a treatment plan that controls your asthma. Carry your relief/rescue inhaler with you at all times and follow the directions on your Action Plan for when to use it.

Regular visits to your HCP: Keep your regularly scheduled visits with your HCP so that your asthma can be monitored and treated before it gets out of control. Be sure to know how to contact your HCP and know what to do in case of an emergency. This information will be on your Action Plan.

Stay healthy: Eat nutritious foods and get regular exercise. Avoid people who smoke and those that may have an infection, especially a cold or the flu.

Prevent the flu and pneumonia: Get a yearly flu shot (vaccine) and a vaccine for pneumonia, as recommended by your HCP.

Cope with stress: Learn new ways to cope with stress. Coping with stress can help prevent and control your asthma.

By taking an active role in the management of your asthma by partnering with your HCP, you can breathe easier and live a healthier life.

Common reasons why a bronchoscopy is needed include:

• Infections—When a person is suspected of having a serious infection, bronchoscopy may be performed to get better samples from a particular area of the lung. These samples can be looked at in a lab to try to find out the exact cause of the infection. A person who has recurrent infection may have a bronchoscopy to try to figure out a cause. For example, tissue samples can be looked at for cilia function (brush lining of airways that move mucus). Airway fluid can be checked to see if there are any signs of aspiration due to swallowing problems that allow food or liquids to get into the airways.
• Lung spot—An abnormal finding (“spot”) in the lung viewed on an x-ray film or CT scan may be caused by an infection, cancer, or inflammation. Bronchoscopy is done in some cases to take samples from the area. These samples are then looked at in a lab to help find the specific cause of the lung spot.
• Airway blockage and Atelectasis—Atelectasis is caused when the airway to a lung or part of a lung is blocked and air cannot get through. The air sacs do not expand which can be seen on chest x-ray. This blockage is usually caused by something such as a peanut, a tumor, or thick mucus in the airway passage. Bronchoscopy allows the doctor to see the blockage and try to sample and/or remove the substance. This helps to open up the airway and lung, especially when lesser invasive treatments (like chest airway clearance) have failed.
• Bleeding—When a person has coughed up blood, bronchoscopy may help find the cause of the bleeding. For example, if a tumor is causing the bleeding, the doctor will locate the tumor and take samples of tissue (biopsies) through the bronchoscope. The samples are then looked at in the lab to identify the type of tumor.
• Noisy Breathing and Abnormal Airways—A person can have noisy or abnormal breathing sounds that may be caused by a problem with the throat or airways of the lung. There may be shortness of breath, noisy breathing, or labored breathing during sleep. Children may be born with abnormal airways such as a tracheal (windpipe) connection with the esophagus (feeding tube) called a TE fistula. Bronchoscopy allows the doctor to look directly at the throat, vocal cord area, windpipe, and major airways to identify any problems. Causes of this type of breathing may include vocal cord paralysis or weakness, floppiness in the airways (bronchomalacia) or voice box (laryngomalacia), or a blood vessel pressing on the outside of the airway (vascular compression).
• Lung Transplant—People who have had lung transplant will have bronchoscopy to check on how well the lungs are doing Samples will be taken of tissue and airway mucus to check for infection or signs of rejection in the new lungs.

Other tests and procedures, such as x-rays, CT scans and suctioning techniques can give the doctor some information about the lungs, but bronchoscopy allows the doctor to look at the inside of the lungs, obtain very specific samples and remove mucus if necessary. This is why your doctor may schedule a bronchoscopy even after you have had X-rays or other tests.

In a critically ill patient who has a breathing tube, feedings are stopped hours before the procedure to assure that the stomach is empty. The patient is given a small amount of medicine (a sedative) that causes sleepiness.

If you are having a bronchoscopy as an outpatient or as a non-critically ill inpatient, you will be told not to eat after midnight the night before (or about 8 hours before) the procedure. You will also receive instructions about taking your regular medicines, not smoking and removing any dentures before the procedure.

Right before the procedure, you may be given a medicine to numb your nose and throat area to make it more comfortable and help prevent coughing and gagging during the procedure. After that, you may be given a sedative by IV (in your vein). The sedative will help you to relax, and may make you sleepy. The sedative may also help you to forget any unpleasant sensations felt during the test.

Your doctor can explain what will happen during the bronchoscopy. If you are awake, he or she can talk you through it step-by-step. You will probably be lying down with the head of the bed tilted up slightly. The bronchoscope is placed through your nose, then advanced slowly down the back of the throat, through the vocal cords and into the airways. If a person has a breathing tube in place, the bronchoscope is passed through this tube.

Your doctor will be able to see the inside of the airways as the bronchoscope moves down. You may feel like you cannot “catch your breath,” but there is usually enough room around the tube to breathe and get enough oxygen. The doctor can also give you breaks during the procedure as needed.

The length of the bronchoscopy varies depending on what needs to be done and why you need it. The doctor can give you an estimate, but usually it can last from 15 minutes to an hour.

Bronchoscopy is a safe procedure. Serious risks from bronchoscopy, such as an air leak or serious bleeding, are uncommon (less than 5%). The risks associated with the procedure are as follows:

• Discomfort and Coughing—While the bronchoscope is passed through your nose and back of your throat into the lungs, it may cause some discomfort. It may also tickle your airways, causing a cough. You will be given medicine to help with this prior to the procedure.
• Reduced oxygen—Your oxygen level will be continuously monitored during the procedure using a pulse oximeter, with a sensor clip placed on your finger. The level of oxygen in the blood may fall during the procedure for several reasons. The bronchoscope may block the flow of air into the airway, or small amounts of liquid used during the test may be left behind, causing the oxygen level to drop. This drop is usually mild, and the level usually returns to normal without treatment. If the oxygen level remains low, the doctor will give extra oxygen or stop the test to allow for recovery.
• Lung Leak—Rarely, an airway may be injured by the bronchoscope, particularly if the lung is already very inflamed or diseased. The procedure could cause an air leak (pneumothorax) in which air comes out of the lung and gathers in the space around it, which can limit how well the lung expands. This complication is not common, and is more likely if a biopsy is taken during bronchoscopy. If there is a large or ongoing air leak, it may need to be drained with a chest tube. For more information see the ATS patient information piece “Chest Tube Thoracostomy” here.
• Bleeding—Bleeding can occur after the doctor performs a biopsy. Bleeding can also occur if the airway is already inflamed or damaged by disease. Usually bleeding is minor and stops without treatment. Sometimes a medication can be given through the bronchoscope to stop bleeding. Rarely, bleeding can lead to severe breathing problems or death.
• Infection—While equipment used is cleaned before and after use, there is a small risk that a germ could be introduced into the airways that could cause infection. If a new infection develops, it would be treated.

Patients vary in how long it takes to wake-up with sedation. If you are in the intensive care unit on a ventilator (respirator; breathing machine), you may already be sedated and will continue to receive medicines to keep you comfortable on the ventilator. If you are an outpatient or a non-critically ill inpatient, you will need to stay in a recovery area until the sedative has worn off. You will also need to wait until the numbing medicine wears off before drinking any liquids. If you are an outpatient, it is recommended that you bring someone along to drive you home.

It is unlikely that you will experience any problems after the test other than a mild sore throat, hoarseness, cough, or muscle aches. If you feel chest pain or increased shortness of breath or cough up more than a few tablespoons of blood once you leave the hospital, contact your doctor immediately.

Your doctor can tell you how your airways look right away. Lab results take more time, usually 1–4 days or more depending on the specific test that is being done.