Pulmonary Rehabilitation

• To give you a better understanding of your lung condition.
• To improve management of your breathlessness.
• To improve your exercise tolerance and support you to make lifestyle changes.
• Increase your confidence in managing your symptoms.
• Provide you with self-management techniques about your condition.
• Improve your mental well-being.
 

Over the next 6 to 8 weeks, you will be given information, practical advice and an
exercise programme aimed at improving your breathing and general health. This
booklet contains information on your lung disease and will support the education
sessions you will receive as part of your course. There will also be activities and
tasks for you to complete. During the programme we will signpost you to other
sources of information such as websites and leaflets which we feel will be of benefit
to you.
Sessions to expect as part of the programme:
• My lungs and what has changed?
• Keeping moving, pacing, and exercise.
• Breathing control and breathing techniques.
• Inhalers and respiratory medication.
• Exacerbation management and action plan.
• Ongoing self-management.
• Nutrition and Hydration.
Pulmonary Rehabilitation has a team of healthcare professionals who will guide you
through the programme. This includes Specialist Nurses and Qualified Technical
Instructors.

Your two lungs lie on either side of your heart and fill the inside of your chest. The
left lung is smaller than your right lung because it shares the same space as your
heart. Both lungs are made up of lobes, three on the right and two on the left.

Your normal breathing rate is between 12-20 breaths per minute. The amount of
air moving in and out of your lungs varies depending on if you are resting or
undertaking exerting activities. From just a few litres a minute, up to over 100 litres a minute!

Your windpipe, also referred to as your trachea, transports the air in and out of your
lungs when you breathe in and out. The trachea divides into the left and right
bronchi. The bronchi then divides into smaller and smaller bronchi, called
bronchioles. Right at the end of the bronchioles are air sacs called alveoli.

Inside the alveoli is where gas exchange takes place, oxygen moves across thin
walls called capillaries and into your blood stream. At the same time, a waste product
called carbon dioxide comes out of the capillaries, to be removed from our body
when we breathe out.

There are 300 million or so alveoli in the
lungs and if you were to spread them out,
they would cover the size of an entire tennis court.

The lungs are protected by the rib cage, between the ribs are muscles called
intercostal muscles, which are essential for breathing. Below the lungs sits a dome
shaped muscle called the diaphragm, which separates the chest from the abdomen,
and is the main muscle for inspiration.

The lungs also provide a defence system to try and prevent unwanted material, such
as germs, allergens and viruses from getting into the body.

There are three levels of defence:
• The nose.
• The cilia.
• The cough.

The nose is the first line of defence. It filters, warms, and moistens the air before it
enters our body. Nose breathing is more efficient than mouth breathing. When you are
breathless you are more likely to breathe through your mouth.
The cilia are the second line of defence. If particles escape filtration by the nose, they
can get trapped on a sticky mucus blanket called the mucociliary escalator, which is
constantly moving mucus upwards towards the throat.

The cilia can be damaged by:

• Smoking.
• Dehydration.
• Inflammation.
• Low levels of oxygen.

The third line of defence is the cough. Normally 100-300mls of mucus is swept to the
throat and swallowed every day. If the cilia are damaged, or there is too much mucus
for the cilia to cope with it may be difficult to be coughed up.

Respiratory conditions can affect how efficiently our lungs work. Depending on your
respiratory condition, your airways can become fixed, distorted, thickened or
variable. A person’s symptoms can also vary, dependent on their diagnosis.

Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease, or COPD, describes a group of lung
conditions that make it difficult to empty air out of the lungs because the airways
have become narrowed.
Chronic = it is a long-term condition and it does not go away
Obstructive = your airways are narrowed
Pulmonary = it affects your lungs
Disease = it is a medical condition

Two of these lung conditions are chronic bronchitis and emphysema.

Bronchitis: means airways are inflamed and narrowed. You can also produce more sputum.

Emphysema: affects the air sacs at the end of the airways in the lungs. These break down, creating larger spaces instead of many small ones. This eventually affects the way the lungs transfer oxygen and carbon dioxide.

These conditions makes it difficult for air to move in and out of your lungs as you breathe, therefore your lungs are less able to take in oxygen and get rid of carbon dioxide.

The airways are lined by muscle and elastic tissue. This tissue is usually springy and acts as packing and pulls the airways to keep them open. In a lung with COPD, the airways can become narrowed due to: 

• the lung tissues become damaged, so there is less pull to keep the airways
open.
• sputum obstructs parts of the airways.
• the airways become inflamed.

There is no current cure for COPD and the damage to the lungs is irreversible.
Therefore, it is important to self-manage your condition to slow down the progression
of the disease.

Bronchiectasis

Bronchiectasis is a long-term condition that affects the airways in your lungs. When
you breathe in and out, the air is transported through your airways (also known
as bronchi). The bronchi divides into thousands of smaller airways (these are
called bronchioles). Within the airways there are small glands that produce mucus.
Mucus is helpful for moistening the airways and trapping dust and germs.

If you have bronchiectasis, your airways can become widened and inflamed, with
thick mucus. It can be difficult for the airways to clear the mucus properly. A build-up
of mucus can lead to bacteria forming and causing an infection.

The changes in your airways cannot be reversed. Therefore, it is important
to recognise when you are getting a chest infection or a flare-up. If you do not seek treatment in a timely manner, your airways may become damaged further.

Pulmonary Fibrosis

Pulmonary fibrosis is a long-term condition which covers many different conditions,
where scar tissue builds up in your lungs. This scar tissue makes your lungs stiff,
which is called fibrosis.

Pulmonary fibrosis is a type of interstitial lung disease (ILD). Interstitial means the
disease affects the network of tissues supporting the alveoli in your lungs called
the interstitium. This condition can sometimes have an identifiable cause; however
this is not always the case and a cause cannot be identified.

The scarring can cause your lungs to become stiffer and less elastic, thereby
reducing the efficiency of your breathing. As the ability to take oxygen from the air
to your lungs becomes reduced you may feel increased symptoms such as
breathlessness.

When you have pulmonary fibrosis the air sacs are affected by the scarring. The
scarring of the air sacs and blood vessels (capillaries), limits the amount of oxygen getting into your bloodstream.

Other conditions

Individuals with other conditions who would benefit from attending Pulmonary
Rehabilitation:
• Pre and post lung surgery.
• Pre and post lung transplant surgery.
• Asthma.
• Long COVID.

Everyone should do some form of exercise regularly and people with chronic
breathlessness are no different. You may be more afraid or anxious to undertake
exercise because you believe that getting breathless is harmful. In fact, people who get
breathless on activity don’t like how that feels and find themselves doing less and less.

Inactivity can lead to:

• Muscle weakness
• Joint stiffness
• Depression

• Poor circulation
• Weight gain

During exercise your breathing and heart rate increase, and your lungs must be able
to respond to the body’s increasing demand for oxygen. As you start to exercise
the muscles send messages to the brain that they need more oxygen, in turn the
brain sends signals to the diaphragm and intercostal muscles, which causes you to
breathe more often. More oxygen will be absorbed from your lungs and carried to the
muscles you are using, mainly the arms and legs.

When you have a long-term lung condition you may often avoid doing activities
that make you feel breathless. By avoiding tasks frequently, you may start to notice
you are more breathless even though you have done very little. In this instance your
lungs are having to work harder. This can be related to deconditioning.

Deconditioning definition: This occurs after a period of reduced activity, where
you are unable to maintain your previous levels of activity. This causes weakened
muscles, resulting in reduced exercise tolerance.

Through exercise you can train your muscles to be more efficient in using oxygen.
People with lung conditions can benefit a lot from even small amounts of exercise and
it really is worth keeping as active as possible. Exercise cannot fix your lungs but can
make the rest of your body fitter. This will make it easier to deal with the demands of
everyday life and you should be able to do more without becoming so breathless.

The benefits of exercise:

• Increased ability to fight infections
• Improved ability to perform daily activities
• Strengthens the bones
• Strengthens the breathing muscles
• Improves energy levels
• improves confidence and wellbeing
• improves balance (reducing risks of falls)
• Reduces blood pressure
• Reduces risk of Diabetes
• Improves Cardiac Health

Home Exercise Programme

It is recommended you do 150 minutes of exercise / activity per week, that is around 30 minutes, 5 times a week.

• Start gradually (pace yourself).
• Wear comfortable clothing and shoes.
• Understand your normal level of exercise and aim to progress from this.
• Be in control – do not let your breathlessness control you!

A way to understand and measure the intensity of aerobic activity is by understanding
intensity and how physical activity affects your heart rate and breathing. The talk test
is a good tool to measure your intensity.

Remember: the talk test!

say to yourself "this activity is going to do me good"

• if you can say the sentence with 2 or 3 stops of breath - moderate intensity (you can talk but not sing during the activity)
• If you can say the whole sentence without stopping - increase intensity 
• if you can't speak - reduce intensity (you will not be able to say more than a few words without pausing for breath)

This is an aid to help you determine how breathless you are feeling

This is a scale that asks you to rate the difficulty of your breathing. It starts at number
0 where your breathing is causing you no difficulty at all and progresses through to
number 10 where your breathing difficulty is maximal.

0 No breathlessness at all
1 Very slight breathlessness
2 Slight breathlessness
3 Moderate breathlessness
4 Somewhat severe breathlessness
5 Severe breathlessness
6
7 Very severe breathlessness
8
9 Almost maximum breathlessness
10 Maximum breathlessness
 

What everyday activities can I be doing at home?

1. Sit Less

2 increase daily steps

3 Dancing

4 Gardening

5 Housework

Goal setting

Setting a goal gives you something to aim towards and achieving that goal is great for your well-being and confidence. Set yourself a long - term and short - term goal, doing so will give you something positive to work towards and you'll be able to see how far you have come. Set goals that are achievable and important to you. Make sure your goal is smart.

S = Specific your goal should be well defined, detailed and clear.

M = Measurable You should be able to tell when you reach your goal.

A= Achievable Can you reach the goal, taking into account your ability time and skills?

R = Realistic is your goal realistically achievable within the given time frame and with resources available?

T= Timely Set a start and finish date for your goal

Task 

Write down your own personal goal, display it somewhere obvious at home, tell your friends and family, get some support and encouragement, and reward yourself when you succeed! 

What is your Short-term goal? (this could be something you would like to achieve by the end of the programme). Ensure this goal is SMART. For example " I will go for a walk around the block for ten minutes this Saturday".

What is your Long-term goal? (This could be something you would like to achieve after the programme). Ensure this goal is SMART. For example " I will walk to my local shop rather than drive".

Breathing control means breathing gently, using the least effort, with your
shoulders supported and relaxed. Breathing control takes practice, so try and do
this at home, whilst you are relaxed. Using breathing control techniques may help
you when feeling short of breath, fearful, anxious, or panicked.

How do I do breathing control?

Make sure you are in a comfortable position. Breathe in gently through your nose
and breathe out through your nose if you can. If this is too difficult, breathe out
through your mouth instead.
• Try to let go of any tensions in your body with each breathe out.
• Gradually try to make each breath slower.
• Closing your eyes may help you to focus and relax.
• Do not force your breathing.
• Try to ensure your breath out is longer than your breath in. You can try counting or visualising.

Breathing techniques

Pursed lip breathing

This technique can be used whenever you need help to control your breathing.
You can use it whilst doing an activity that makes you short of breath.

How do I do pursed lip breathing?
• Breathe in gently through your nose.
• Purse your lips as though you were going
to blow out a candle or blow a whistle.
• Blow out with your lips in this pursed
position.
• Try to blow out for as long as is comfortable
without forcing your lungs to empty

Blow-as-you-go?

• Breathe in before making the effort.
• Then breathe out while making the effort. For example, when lifting a heavy box, breathe in before you complete the task and breathe out as you lift the box. 
• It can be useful to use pursed lips as you blow out

Paced breathing

This is a useful technique when you are on the go, for example climbing stairs or
even walking on the flat. You pace each step to your breathing. This can also
be used together with pursed lip breathing and blow-as-you- go.

Fan Therapy.

When breathless you instinctively go to open a door or window to “get some fresh
air”. A cool draft from a handheld fan can help reduce the feelings of breathlessness.
Use a handheld fan about 6 inches away from your face and direct it onto your nose,
mouth, and sides of cheeks.

Diaphragmatic breathing

The diaphragm is a large, dome-shaped muscle located at the base of the lungs.
The diaphragm is the most efficient muscle of breathing. Diaphragmatic
breathing is intended to help you use the diaphragm correctly while breathing to:
• Strengthen the diaphragm
• Decrease the work of breathing by slowing your breathing rate
• Decrease oxygen demand
• Use less effort and energy to breathe.

Rectangular Breathing 

Count in for 4 seconds as you breath in; count out for 7 seconds as you breathe out.
Visualising a rectangle can help. Trace your finger up the short side as you breathe
in, across the long side as you breathe out. You can also use rectangular shaped
objects in your household to help visualise, for example, a door, window or television.

How do I do diaphragmatic breathing?

1. Put one hand on your chest and the other on your abdomen.
2. Close your eyes to help you relax and focus on your breathing.
3. Slowly breathe in through your nose, with your mouth closed. If you’re relaxed,
the air will reach low in your lungs. Your abdomen will move out against your
hand. If your breathing is controlled, the hand on your chest will hardly move.
4. Breathe out through your nose. Your abdomen will fall gently. Imagine all the
tension in your body leaving as you let the air out.
5. Try to use as little effort as possible and make your breaths slow, relaxed, and
smooth. With every breath out, try to feel more relaxed and calmer. Gradually try to breathe more slowly.

Deep breathing.

Deep breathing exercises help to inflate all areas of the lungs, particularly the lower
parts. It uses all the muscles of inspiration and if you hold your breath at the end, for
up to 4 seconds, it can allow full inflation. To practice this type of breathing, position
yourself first in a comfortable supported way.

How do I do deep breathing?

1. Place one hand on your abdomen.
2. Breathe gently out till you feel your lungs your lungs are empty.
3. Slowly breathe in through your nose and fill your lungs from the bottom and
feel your ribs move outwards. You should feel a slight stretch and feel your
lungs are full.
4. If you can hold your breath for a few seconds do so but if you feel lightheaded stop and breathe normally for a few minutes.

The Active Cycle of Breathing Technique (ACBT) is a breathing technique to help clear
sputum from your chest. It is a set of breathing exercises that loosens and moves
sputum from your airways. The technique consists of breathing control, deep
breathing, and huffing. These are repeated in a cycle until your chest feels clear. You
can carry out ACBT when either sitting or lying down.

1. Relaxed diaphragmatic breathing

• Rest your hand on your rib cage / upper abdomen. Feel your upper
abdomen rising under your hand as you breathe in and falling as you
breathe out.
• Try to breathe through your nose then out through your nose or mouth.
• Breathe at a rate which feels comfortable; the rate will slow as you relax.

2. Deep breathing exercises

This helps loosen secretions.
• Take 3 to 5 long, slow, deep breaths in, through your nose.
• Pause at the end of each breath in for 2-3 seconds, then breathe out gently
through your month, like a sigh. Try to keep your shoulders and chest relaxed.
You should repeat steps 1 and 2 several times before moving on to step 3.

3. Huffing
A huff is a way of exhaling your breath forcefully out through your mouth, but without
coughing. This helps move secretions that are in your lower airways. Take a normal
sized breath in and then a long breath out until your lungs feel quiet empty, imagine
you are trying to steam up a mirror.

• Only perform 1-2 huffs, as repeatedly huffing can make your chest feel tight.
• Listen for ‘crackles’ when you huff. If you hear these, you may now need to
cough and clear secretions; try to spit them out into a tissue or pot. Try to
avoid excessive coughing as this may reduce how effective the technique is
and make it excessively tiring.

Repeat the whole cycle of about 10-15 minutes or until your chest feels clear.

You should repeat steps 1 and 2 several times before moving on to step 3

You should be doing ACBT once to twice a day when you are feeling well. If you are
unwell, particularly if you are producing more secretions and coughing more, it is
best to increase the length of time you are doing the technique / increasing the number of sessions.

The active Cycle of Breathing.

START 

Relaxed diaphragmatic breathing x6 

Deep Breathing x4

Relaxed diaphragmatic breathing x6

Deep breathing x4

Huff x12

Position of ease

The positions in this booklet will help control your breathing. Remember to take rests and use one of those positions before you get too short of breath. Choose a position
from the suggestions below which suits what you are doing and where you are. It is
important to relax when adopting these positions. Some positions will work better than others, the varies from each individual.

Forward

Sit leaning forward with your elbows resting on your knees. Making sure your wrists and hands are also relaxed.

Sitting leaning forward at a table

Sit leaning forward with your elbows resting on a table. You can also put a few pillows or cushions on the table to rest your head on.

Standing leaning forward

Lean forwards resting your elbows onto a wall, a windowsill, a railing, or a countertop. You could lean on a walking stick or a long umbrella if you use one. You can lean on a trolley while you are out shopping. A walking frame with wheels can be helpful.

Sitting upright

Sit upright against the back of a firm chair. Rest your arms on the chair arms or on your thighs 

High side lying

Lie on your side, with a few pillows under your head and shoulders. Some people like to use a foam wedge instead. A pillow between your waist and armpit can stop you sliding down the bed. Make sure the top pillow supports your head and neck. Your knees and hips should be slightly bent.

Standing leaning back

Lean back or sideways against a wall, with your feet slightly apart and about one foot (30cms) away from the wall. Let your hands hang loosely by your sides or rest them in your pockets.

Pacing

Pacing yourself is important when you are living with a long-term respiratory condition.
Pacing is all about managing the balance of all the tasks you need to do and some
you want to do without rushing, tiring yourself or making you feel worse. Pacing will
help you stay more in control of your physical symptoms and emotional well-being.
Pacing is about listening to your body, slowing down if necessary or taking short
breaks, if needed, to stay in control and manage your symptoms.

The Seven Ps of Pacing

1. Planning – think ahead.
2. Prioritising – what is important to you?
3. Positioning – what is the best way for you to manage tasks physically?
4. Problem solving – what can you do when you have a set back? E.g., look for
alternative ways to do something.
5. Practice – the more you are familiar with a task, the easier it becomes.
6. Perseverance – don’t be hard on yourself, it will need more than a few attempts

7. Patience - give yourself time to get pacing right.

Barriers to Pacing
• Ignoring your symptoms when your body is telling you to slow down.
• Continuing with old habits and routines.
• Being unable to say no to activities that will make you feel worse.
• Being fearful of symptoms. This can lead to avoidance of tasks.
• Feeling overwhelmed by symptoms which may affect your mood.

Energy Conservation

Energy conservation can help you manage fatigue and breathlessness to improve your
quality of life. Little adjustments can help you to use your energy more efficiently, which
in turn can help you do the things you want to do.
 

Here are some energy-conserving tips:

Self-Care

• Sit whilst washing, showering, putting make-up on.
• Use an electric toothbrush / shaver.
• Use equipment in the bath / shower e.g., shower stool, rails, and long-handed
sponge.
• Put on a towelling robe after having a bath / shower, instead of using a towel
to dry yourself.
• Keep the bath window / door open to reduce steam.
• Put the cold water in the bath first, then add the hot water, this reduces steam.
• Avoid using aerosol deodorant, talcum powder, hairspray, and strong perfumes.

Dressing

• Sit whilst dressing.
• Use dressing aids to limit bending down e.g., sock donner, long handed shoehorn.
• Wear clothes with front fastenings.
Household cleaning
• Spread tasks over the week.
• Sit whenever possible e.g., sit down whilst ironing.
• Avoid cleaning products that cause irritation (trigger feelings of breathlessness).
• Consider having cleaning products upstairs and downstairs.
• Use a trolley to take items from room to room.
• Use a long-handled dustpan and brush.
• Use fitted sheets and duvets.

Cooking

• Sit down whenever possible e.g., washing up, preparing vegetables.
• Use frozen / pre-prepared vegetables.
• Make larger portions and then freeze them for another time when you are
feeling unwell or fatigued.

Shopping

• Plan your food shopping list by aisles.
• Use a trolley rather than a basket, even for a few items.
• Accept help with packing bags.
• If you are feeling tired when you come home put the perishable food away
first, then rest before finishing the task.

Anxiety is a feeling of fear, worry, or unease that goes on for some time, and can get
in the way of your enjoying life. Anxiety can be particularly common when you have a
long-term condition, including a long-term lung condition. A lot of things can cause
anxiety, and it can affect everyone differently. Feelings of anxiety can often make your
lung symptoms worse.

The cycle of anxiety and breathlessness

Feeling breathless may make you feel more anxious, which in turn may make your
breathless worse, starting up a cycle that can be difficult to get out of.

You feel breathless

You have worrying thoughts

You feel anxious, panicky and overwhelmed

you experience physical symptoms like chest muscles tightening and breathing faster

How can I manage my stress, anxiety, and depression?

• Breathing techniques – see breathing control techniques within this resource
booklet.
• Keeping active – this can increase energy and boost hormones that make
you feel good.
• Relax – learn a relaxation technique that suits you. Take time out to practice,
the benefits will help your mind and body.
• Mindfulness – learn to be aware of the present moment.
• Eat healthily – this will boost the feel good hormones.
• Do activities you enjoy – this could be a hobby or spending time with others.

It is not always easy to discuss your emotions but putting on a brave face is not
always the answer. Try talking to your friends or family for some support. Do
consider getting help from healthcare professionals if you are finding your feelings
become overwhelming and are stopping you getting on with your everyday life.
There are lots of help and support available. If you feel your mental well-being is
deteriorating, seek advice from your GP surgery or speak to a member of the PR
team who can signpost you to the best service.

Relaxation

Relaxation is about resting your mind and body. It is an important part of taking care
of yourself. It is a useful method for managing anxiety, stress and the fight or flight
response. Below you can see how anxiety and stress can impact your body.

Brain

Problem solving may seem more difficult. You may also experience a dry mouth.

Neck and shoulders

Neck and shoulders can tense. This can also trigger aching and tightness in neck / shoulders and back.

Heart 

Your Heart rate increases

Bladder and bowels

Muscles in the bladder or bowels relax and can cause you to rush to the toilet.

Legs

Muscles tense making your legs shake or tremble

Lungs 

Your breathing can become faster. This can cause breathlessness, chest pains and palpitations, as your body prepares for fight or flight.

Stomach 

Digestion slows down causing nausea and indigestion

skin

Adrenaline causes blood vessels in your skin to open up, making you feel hot. Sweating is the body's natural way of cooling down.

Relaxation helps reduce anxiety and stress and alleviates the physical symptoms. You 
should practice your relaxation somewhere quiet, warm, and private, where you will
not likely be disrupted. It is good to practice every day, at times when you are not in a
hurry to do something else. It is helpful to build relaxation into your regular routine. Get
yourself into a comfortable position. You may want to sit down or lie down. Make sure
your body is comfortable and well supported, use extra cushions for support if needed.
Before you start relaxation, clear your chest, and think about doing the Active Cycle
of Breathing Technique. Once your chest feels more comfortable, you can start to
focus on other areas of your body where you carry tension in your muscles. Keep
practicing relaxation, it is a skill that requires practice.

Everyday relaxation

These are activities and hobbies you may find enjoyable:

• Listening to music
• Reading a book or magazine
• Spending time with family and friends
• Gardening, crafts, or baking.

Simple relaxation

This technique gets to you focus your thoughts to be aware of what your body is
feeling, where you are holding the tension in different muscles and learning how to let
go of that tension. Using apps on your phone or videos on the internet designed to
guide you through relaxation may be helpful.

Visual relaxation

This relaxation is used to create a picture in your mind. You can use this skill to create
a pleasant relaxing image. This helps to relax your body and distract you from worrying
thoughts. Everyone will have their own special picture to help them feel relaxed,
such as:
• A walk in the woods
• Lying on a sunny beach
• Sitting beside an open fire
• Looking out over your favourite view
• Baking in the kitchen, with the scent of bread or cake baking in the oven

Benefits of relaxation

• Lowers blood pressure
• Improves breathing control
• Improves move
• Increased blood flow to muscles
• Decreases muscle tension
• Decreases stress hormones, making you feel calmer
• Reduces fatigue
• Improves sleep

When you have a lung condition it is important to eat well to improve your lung function,
boost your immune system and maintain a healthy weight. Eating well also reduces
the risk of other diet-related problems such as, diabetes, cancer, and heart disease.
Being overweight can put strain on your heart and lungs, making breathing more
difficult. Losing weight reduces the strain and reduces the risk of associated
conditions.

Contact your GP if you experience sudden unexplained weight loss.

Use an eat well guide to help you get a balanced and healthier diet. It shows how
much of what you eat overall should come from each food group.

It is recommended to eat little and often when you have a lung condition, as opposed
to three large meals a day. This is because when you eat a big meal your stomach
can put pressure on your diaphragm (breathing muscle), which can make your
breathing harder.

Fruit and vegetables

These provide vitamins, minerals, and fibre for our diet. Vitamins and minerals help
support your immune system, which is vital when you are experiencing an infection.
Fibre is important to lower your cholesterol and helps us to feel full up. For your
convenience you can buy frozen, dried, or tinned fruit / vegetables, as they have the
same nutritional values. If you are trying to gain weight, try adding butter to your
vegetables or have ice cream with your fruit. If you are trying to lose weight, ensure
half your plate is full of vegetables at main meals.

Carbohydrates

Carbohydrates are our main source of energy. It is recommended to have starchy
carbohydrates with each meal such as, bread, potatoes, rice, and pasta. If you are
trying to gain weight then aim to have carbohydrates with the main meals and with
snacks e.g., crackers and breadsticks; you can add some cheese or dips with these.
If you are trying to lose weight ensure a quarter of your plate is carbohydrates, and
switch to wholemeal varieties such as brown pasta, bread, or rice.

Animal and plant-based proteins

Proteins help with your body’s maintenance and repair and help keep your muscles
strong. It is recommended to eat 2-3 portions a day. Proteins come in all sorts of
varieties e.g., meat, oily fish, white fish, baked beans and eggs. If you are trying to
gain weight focus on eating proteins first, if you are not managing full meals. If you are trying to lose weight, use lean versions of meat and remove any visible fat.

Dairy

Dairy is a good source of protein, vitamins, and minerals, including calcium and vitamin
D for healthy bones. Calcium is important if you take steroids, which increases the risk
of brittle bones or osteoporosis. If you are trying to gain weight, use full fat products. If
you are trying to lose weight, choose low fat or low sugar dairy products.

Oils and spreads

It is important to get most of your fat from unsaturated oils and spreads. These contain
a range of vitamins, which are important for fighting infections. If you are trying to gain
weight, use extra fats in cooking e.g., add extra butter to mashed potatoes. If
you are trying to lose weight opt for healthier fats such as olive oil or vegetable oil
rather than butter. Aim to reduce your intake of excess fat e.g., use a low-fat spray oil.

Fluids

Fluid intake is important because the cells in your body that repair and fight off
infections work best when they are well hydrated. Fluids are also good for lungs and
keeps your sputum thin, so it is easy to cough up. You should aim for 6-8 glasses a
day. If you are wanting to increase your fluid intake, make sure this is done slowly.

If you have heart problems or have been advised to restrict your fluid intake,
please follow the advice given to you by your health care professional.

The colour of your urine is a good indicator of how hydrated you are. If you are
adequately hydrated, your urine should be clear or yellow in colour. If you are
dehydrated your urine may appear to be darker in colour, which indicates you should
increase your fluid intake. If you have blood in your urine you should seek medical
advice.

Salt

Having too much salt in your diet can increase your risk of developing high blood
pressure. It can also increase the risk of water retention which can make your
breathing harder. To reduce your salt intake, use little or no salt when cooking. Try
using extra herbs and spices as an alternative. Cut down on salty processed foods Utilise the traffic light systems on most food labels.

There are several combinations of medication used to manage respiratory conditions.

Short-acting Bronchodilators

These work by relaxing muscles around the lungs when they are tight, allowing air to
come and go more easily. This in turn can help to ease the symptoms of
breathlessness. Short acting bronchodilators start to work within a few minutes of
taking them. These can be administered using different inhaler devices, that are best
suited to your abilities, so that you obtain the best effects. Try using breathing control
techniques prior to using this inhaler to increase the effectiveness. The effects of
these inhalers can last between 4-6 hours.

Long-acting Bronchodilators

This group of medication also affects the muscles around the lung tubes, allowing air
to move more freely. These drugs usually work for longer periods of between
12 to 24 hours. Following the instructions about when to take your inhaler is very
important. Try to take it at the same time, for example 8am and 8pm.

Inhaled steroids

Steroids help reduce inflammation of the airways, and therefore also allow air to
move more freely. Inhaled steroids are often given by combining several drugs in one
inhaler device to ensure maximum effect. After taking an inhaler that contains
steroids you should rinse your mouth and spit out. This can help to prevent side
effects such as oral thrush and a hoarse voice.

Oral steroids

You may be prescribed oral steroids to treat an exacerbation, with either or without
antibiotics e.g., prednisolone. They reduce inflammation of the airways and help
relieve multiple respiratory symptoms.

Antibiotics

Antibiotics are used for treating infections caused by bacteria. They will only work if
your infection is caused by bacteria, and not a virus like the common cold. It is
essential that a course of antibiotics is taken for the full number of days they have
been prescribed. Even if you feel better or show signs of improvement after a few
days, you must complete the course. By stopping antibiotics early you are at risk of
not fully clearing the infection, delaying your recovery, and causing bacteria to build a
resistance to that antibiotic, reducing its effectiveness in the future.

Mucolytics

Mucolytics are medicines that cause mucus to be less thick and sticky, making it easier to cough up e.g carbocisteine or erdosteine

Spacer Devices

Spacers are plastic tubes, that can be attached to some inhalers. These devices
help you get the best dose from your inhaler, if you are using a metred dose/aerosol
style device. If you are using a dry powered inhaler or breath-activated inhaler, you
won’t be able to use a spacer device

The benefits of using a spacer include:

• increasing the amount of medication that reaches the lungs, increasing its
effectiveness, and improving your symptoms.
• reduced possibility of experiencing side effects such as oral thrush, hoarse
voice, and dry mouth.
• it may be easier for you to administer your medication, as the medicine is held
within the chamber until inhaled.

Ensure you are washing your spacer at least once a week and leave it to air dry
(follow manufacturers guidelines). Do not towel dry your spacer as this creates static,
which makes the drug stick to the inside of the spacer rather than going into your
lungs. If you require you a new spacer device discuss this with your GP surgery or
pharmacy.

If you are struggling to use your inhaler device at any point, consider speaking to your
GP surgery, local pharmacist if you are no longer on the rehabilitation programme.

Nebulisers

A nebuliser is a medical device which aerosolizes liquid medicine into a fine mist. You
then breathe in the mist through a mouthpiece or mask. Nebulisers can be a better
way to deliver medication in an emergency to someone who is struggling to breathe.
Nebulisers are sometimes recommended by a specialist for use at home, when you
are unable to take inhalers effectively, or your condition requires this specific treatment
only given in this form.

Oxygen Therapy

Why is oxygen therapy used and how does it work?

If you’re living with a lung condition you may be offered oxygen therapy if your blood
oxygen levels are low. If they are, breathing in air with a higher concentration of oxygen
can correct this. If you have low blood oxygen levels, oxygen therapy can help make
it easier to do things you might otherwise find difficult. For example, it may enable you
to walk further. Oxygen can only be prescribed after a thorough assessment by a
Respiratory Specialist Practitioner.

Please be reassured that not everyone living with a lung condition will need oxygen therapy within their lifetime.

Remember

• Oxygen therapy will not stop shortness of breath
• it is important to stay physically active when you are on oxygen therapy.
• if you are planning to travel, speak to a healthcare professional who can help organise your oxygen needs.

An exacerbation is worsening of your usual respiratory symptoms. An exacerbation
can be caused by an infection that is bacteria, viral or fungal. It can also be caused
by air pollution or unknown origin. Anxiety may also contribute to exacerbations.

Remember:

• Each exacerbation you have can reduce your lung function if not treated, and therefore can worsen your activity levels. Inactivity can play a huge role in contributing to frequent exacerbations. 
• Poor inhaler techniques and compliance can also be a trigger for frequent exacerbations

Symptoms of an exacerbation may include:

• More breathless than usual
• Changes in colour, volume and consistency of sputum
• fever
• fatigue
• increased cough
• reliever inhaler isn't helping
• loss of appetite

What is your normal sputum like?

Changes in your colour of sputum (these are changes from what is normal to you) may indicate an infection.

What is your normal amount of daily sputum?

Amount of Sputum 

None

Some (up to a teaspoon)

A little (up to a tablespoon)

Moderate (up to 3 tablespoons)

a lot (a cupful or more)

What to do if you think you are having an exacerbation

• Commence your personalised self-management plan (if you have one)
• Use breathing control to help with breathlessness
• Perform chest clearance techniques
• Good oral fluid intake to prevent sputum from getting too thick
• Use your reliever inhaler more frequently, up to the maximum dose prescribed
• Use your rescue pack (if appropriate)
• Contact GP (the GP may ask you to provide a sputum sample)
• Access 111 or urgent treatment centres

The NHS 111 service is for medical problems that are urgent but not life-threatening,
and you’re not sure what to do when your GP surgery is closed. The service
operates 24 hours a day, seven days a week. They may suggest you got to
A&E, a walk-in centre, or attend an urgent same-day appointment at your GP
surgery or out-of-hours centre.

Remember:

Starting treatment early when you are feeling unwell is very important. As this will help reduce symptom duration, decrease the possibility of a hospital admission and for the infection to get worse for example pneumonia 

Seeking urgent medical help

Although breathlessness is a common symptom with having a lung condition,
it is important to recognise when to seek urgent medical advice. Call 999
if you’re struggling to breathe or have sudden shortness of breath and:

• your chest feels tight or heavy
• you have pain that spreads to your arms, back, neck and jaw
• you feel sick or are being sick

Other systems to be aware of that may require immediate help

• acting confused, slurred speech or not making sense
• blue, grey, pale, or blotchy skin, lips, or tongue
• a rash that does not fade when you roll a glass over it
• difficulty breathing, breathlessness or breathing very fast

• vomiting blood

Call 999 or present at A&E

Self-management plan

Your self-management plan is important, it is personal to you, and will help you make
key decisions in the management of your respiratory condition. When you have a longterm
condition, you might sometimes feel you don’t have control over your health,
your life, and what happens to you.

A self-management plan can help you to:

• Give you control over your condition
• understand your condition
• recognise an exacerbation
• know how to access and start treatment
• know when to seek further help
• reduce the risk or needing to go to hospital

Stopping smoking

Stopping smoking is one of the best things you will ever do for your health. Quitting is
much easier when you get the right support and there are lots of options to choose
from. Even if you’ve tried before, maybe more than once, you can still succeed. What
you’ve already learned will help you reach your goal of becoming an ex-smoker.

If you are wanting to stop smoking, speak to one of the team at Pulmonary
rehabilitation who can refer you to your local service. You can also contact your local
smoking cessation service independently for support and advice.

Local stop smoking services can help you stop smoking. Get up to 12-weeks
free support and medications (e.g., patches, gum, lozenges). Local community
Services are offering face to face appointments over several clinic sites. Telephone
support is available if you are unable to attend in person. Local services are free,
friendly, and flexible and you will always have access to our specialist stop smoking practitioners.

Tips for giving up smoking:

• Ask your GP / Pharmacist / Pulmonary rehabilitation team for support - you are significantly more likely to stop with professional support and treatments
• Come up with other ways to overcome the temptation.
• Keep your hands busy and mouth busy - putting a drink in the hand you usually smoke with, use a straw when drinking.
• A craving can last up to five minutes - come up with a strategy to distract yourself. 
• Make a list of reasons for quitting - this could be your motivation.
• Reward yourself when you are doing well.

Advance Care Planning

Advance care planning is a way to tell others what’s important to you and how you
would like to be cared for if you’re unable to tell them yourself. It can be used to share
your wishes and preferences, as well to make best interests decisions on your behalf
in the future if you are unable to say so yourself. Talk to one of the members of
Pulmonary Rehabilitation team for examples of documents you can use.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

Your doctor may discuss a DNACPR with you. DNACPR stands for do not
attempt cardiopulmonary resuscitation. It is a medical decision made when there is
a belief you would not survive, or your quality of life would be severely impacted if
resuscitation efforts were made. A DNACPR means if your heart stops beating,
your healthcare team will not try to restart it. This decision is usually recorded on a
special form, which is recognized by healthcare professionals.

A DNACPR will not affect your care or treatment. You will continue to have all the other appropriate care, treatment and support as needed.

Advanced decision to refuse treatment (ADRT)

This is a decision you can make when you have capacity to say treatments you do
not want under any circumstances in the future. For example, you may not want to
have a tube feeding if you have a stroke, even if you may die as a result, or you
may not want to be put on a breathing machine called a ventilator.

This document is legally binding and is only used if you can’t express your
wishes yourself and only for decisions about treatment that you describe in the document. You can discuss this further with your GP or practice nurse.

A lasting power of attorney (LPA)

This enables you to give another person the right to make decisions on your behalf.
This is only if you are unable to make the decision because you lack the capacity to
do so. This is generally assessed by a qualified healthcare or social care
practitioner. There are two types of LPA.

Health and welfare: It only comes to force if you lose the ability to tell those who are
important to you your preferences and wishes. Anything done under the authority of
the LPA must be in your best interests.

Property and financial affairs: With your permission, it can be used as soon as it is
registered.

You can discuss this further with your GP or practice nurse.

Travelling With a Long-Term Lung Condition

Before planning a trip, always speak to your doctor or healthcare professional to ask
whether you are fit enough to travel as there may be some additional tests they want
to carry out. You may need a hypoxic challenge test before flying.

We all have different and individual preferences when it comes to booking a holiday.
But you should think about things like:

• Climate: many people prefer warmer climates that have salty air.
Lower oxygen levels at higher altitudes, such as in mountains, can
make breathing difficulties worse.

• Temperature: extreme hot or cold weather can affect your
breathing.

• Terrain: check if your destination is hilly or rocky? This may affect
you getting around comfortably.

• Transport availability: check if there is appropriate transport for

Practical Issues

Travel insurance: you should arrange full travel insurance before going on holiday
abroad. Make sure your insurance policy covers all your medical conditions.

Medication: discuss your upcoming trip with your GP or practice nurse to make sure
you will have extra medication to cover potential delays or emergencies. You should
also check what is allowed as countries may have different rules about medications.
If you’re flying, you should carry your medications and any medical equipment
in your hand luggage so that it is accessible. Some medications may need to be
stored at different temperatures, this can be discussed with your GP or pharmacist.
It is also a good idea to travel with a copy of your prescription and a letter from the
GP confirming details of your medication.

Tips for travelling with a lung condition

Remember:
• Plan: Think about how far you can walk, how many stairs you can manage.
You may need a hypoxic challenge test before flying.
• Be realistic: pick a location which is suitable for you.
• Be prepared: plan ahead and make sure you have enough medication and
equipment.
• Shop around: look at different travel insurance companies and find the
best deal for you.
• Ask questions: speak to others who have travelled with a lung condition,
travel agents or healthcare professionals.

Hopefully you now have the confidence to self-manage your condition.

Key points to remember:
• Remain active.
• Pace your activities.
• Being breathless is OK.
• Use your Active Cycle of Breathing as often as necessary to clear
sputum.
• Practice breathing control (in particularly before administering your
reliever inhaler).
• Take your medications as prescribed.
• Know when you are becoming unwell and follow your action
plan/seeking medical advice when needed.
• Stop smoking.
• Eat well and stay hydrated.
• It is important to look after your mental well-being and don’t be
afraid to ask for help.
• Have you achieved your goal?