Nasal CPAP

Definition
CPAP stands for "continuous positive airway pressure." CPAP is a treatment that delivers slightly pressurized air during the breathing cycle. This keeps the windpipe open during sleep and prevents episodes of blocked breathing in persons with obstructive sleep apnea and other breathing problems. It is sometimes called nasal continuous positive airflow pressure (nCPAP).

Alternative Names
Continuous positive airway pressure; CPAP; Bilevel positive airway pressure; BiPAP; Autotitrating positive airway pressure; APAP; nCPAP

Information
WHO SHOULD USE CPAP Continuous positive airflow pressure (CPAP) is the best treatment for most people with obstructive sleep apnea. It is safe and effective in patients of all ages, including children. If you only have mild sleep apnea and do not feel very sleepy during the day, you may not need to use it. After using CPAP regularly, many patients report the following: Better concentration and memory Feeling more alert and less sleepy during the day Improved sleep for the person's bed partner Improvements in work productivity Less anxiety and depression and a better mood Normal sleep patterns Improvement in heart and blood vessel problems, such as high blood pressure A similar machine, called BiPAP (bilevel positive airway pressure) is used as an alternative to CPAP. With this machine, the pressure changes while a person breathes in and out. These devices are useful for children and adults with collapsible airways, small lung volumes, or muscle weakness that makes it difficult to breathe, such asmuscular dystrophy. CPAP or BiPAP may also be used by people who have: Acute respiratory failure Central sleep apnea

COPD Heart failure HOW CPAP WORKS CPAP works in the following way:

The device is a machine weighing about 5 pounds that fits on a bedside table. A mask fits over the nose. A tube connects the mask to the CPAP device. The machine delivers a steady stream of air under slight pressure through this tube into the mask. CPAP will be started while you are in the sleep center for the night. Sometimes, it can be started on the same night you have your sleep study. The doctor, nurse, or therapist will help choose the mask that fits you best. They will also help adjust the settings on the machine while you are asleep. The settings on the CPAP machine depend on the severity of your sleep apnea. If you are using the CPAP machine but your sleep apnea symptoms do not improve, the settings on the machine may need to be changed. Some patients can be taught to adjust the CPAP at home. Otherwise, you will need to make trips to the sleep center. CPAP works by steadily increasing pressure in your airway. Newer devices, called autotitrating positive airway pressure (APAP), can respond to changes in pressure in your airway as they occur. This may be more comfortable, and it also can help you avoid overnight stays and other trips to the hospital. GETTING USED TO THE DEVICE It can take time to become used to a CPAP device. The first few nights of CPAP therapy are often the hardest. Some patients may sleep less or not sleep well at the start of treatment. Patients who are having problems may tend not to use CPAP for the whole night, or even stop using the device. However, it is important to use the machine for the entire night or for as long as possible. Common complaints include:

A feeling of being closed in (claustrophobia) Chest muscle discomfort, which usually goes away after awhile Eye irritation Irritation and sores over the bridge of the nose Nasal congestion and sore or dry mouth Noise that interferes with sleep (although most machines are quiet) Nosebleeds Upper respiratory infections

Many of these problems can be helped or prevented by the following methods: Ask your doctor or therapist about using a mask that is lightweight and cushioned. Some masks are used only around or inside the nostrils. Make sure the mask fits correctly. It should not be too tight or too loose, and it should not leak any air. Try nasal salt water sprays for a stuffed nose. Use a humidifier to help with dry skin or nasal passages. Keep your CPAP equipment clean. Place your CPAP machine underneath your bed. Your doctor or therapist can lower the pressure on the CPAP machine and then increase it again at a slow pace. Some new machines can automatically adjust to the pressure that is needed.

References
McArdle N, Singh B, Murphy M. Continuous positive airway pressure titration for obstructive sleep apnoea: automatic versus manual titration. Thorax. 2010;65:606-611. Tomfohr LM, Ancoli-Israel S, Loredo JS, Dimsdale JE. Effects of continuous positive airway pressure on fatigue and sleepiness in patients with obstructive sleep apnea: data from a randomized controlled trial. Sleep. 2011;34:121-126. Basner RC. Continuous positive airway pressure for obstructive sleep apnea. N Engl J Med. 2007;356:1751-1758. Epstein LJ, Kristo D, Strollo PJ Jr., et al.; Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management, and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5:263-276.

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Chronic obstructive pulmonary disease

Definition
Chronic obstructive pulmonary disease (COPD) is one of the most common lung diseases. It makes it difficult to breathe. There are two main forms of COPD: Chronic bronchitis, which involves a long-term cough with mucus Emphysema, which involves destruction of the lungs over time Most people with COPD have a combination of both conditions.

Alternative Names
COPD; Chronic obstructive airways disease; Chronic obstructive lung disease; Chronic bronchitis; Emphysema; Bronchitis - chronic

Causes
Smoking is the leading cause of COPD. The more a person smokes, the more likely that person will develop COPD. However, some people smoke for years and never get COPD. In rare cases, nonsmokers who lack a protein called alpha-1 antitrypsin can develop emphysema. Other risk factors for COPD are: Exposure to certain gases or fumes in the workplace Exposure to heavy amounts of secondhand smoke and pollution Frequent use of cooking fire without proper ventilation

Symptoms
Fatigue

Cough, with or without mucus

Many respiratory infections Shortness of breath (dyspnea) that gets worse with mild activity Trouble catching one's breath Wheezing Because the symptoms of COPD develop slowly, some people may not know that they are sick.

Exams and Tests

The best test for COPD is a lung function test called spirometry. This involves blowing out as hard as possible into a small machine that tests lung capacity. The results can be checked right away, and the test does not involve exercising, drawing blood, or exposure to radiation. Using a stethoscope to listen to the lungs can also be helpful. However, sometimes the lungs sound normal even when COPD is present. Pictures of the lungs (such as x-rays and CT scans) can be helpful, but sometimes look normal even when a person has COPD (especially chest x-ray). Sometimes patients need to have a blood test (called arterial blood gas) to measure the amounts of oxygen and carbon dioxide in the blood.

Treatment

There is no cure for COPD. However, there are many things you can do to relieve symptoms and keep the disease from getting worse. Persons with COPD MUST stop smoking. This is the best way to slow down the lung damage. Medications used to treat COPD include: Inhalers (bronchodilators) to open the airways, such as ipratropium (Atrovent), tiotropium (Spiriva), salmeterol (Serevent), formoterol (Foradil), or albuterol Inhaled steroids to reduce lung inflammation Anti-inflammatory medications such as montelukast (Singulair) and roflimulast are sometimes used In severe cases or during flare-ups, you may need to receive: Steroids by mouth or through a vein (intravenously) Bronchodilators through a nebulizer Oxygen therapy Assistance during breathing from a machine (through a mask, BiPAP, or endotracheal tube) Antibiotics are prescribed during symptom flare-ups, because infections can make COPD worse. You may need oxygen therapy at home if you have a low level of oxygen in your blood. Pulmonary rehabilitation does not cure the lung disease, but it can teach you to breathe in a different way so you can stay active. Exercise can help maintain muscle strength in the legs. Walk to build up strength. Ask the doctor or therapist how far to walk. Slowly increase how far you walk. Try not to talk when you walk if you get short of breath.

Use pursed lip breathing when breathing out (to empty your lungs before the next breath) Things you can do to make it easier for yourself around the home include:

Avoiding very cold air Making sure no one smokes in your home Reducing air pollution by getting rid of fireplace smoke and other irritants Eat a healthy diet with fish, poultry, or lean meat, as well as fruits and vegetables. If it is hard to keep your weight up, talk to a doctor or dietitian about eating foods with more calories. Surgery may be used, but only a few patients benefit from these surgical treatments:

Surgery to remove parts of the diseased lung can help other areas (not as diseased) work better in some patients with emphysema Lung transplant for severe cases

Support Groups

People often can help ease the stress of illness by joining a support group in which members share common experiences and problems. See also: Lung disease - support group

Outlook (Prognosis)

COPD is a long-term (chronic) illness. The disease will get worse more quickly if you do not stop smoking. Patients with severe COPD will be short of breath with most activities and will be admitted to the hospital more often. These patients should talk with their doctor about breathing machines and end-of-life care.

Possible Complications
Irregular heartbeat (arrhythmia) Need for breathing machine and oxygen therapy Right-sided heart failure or cor pulmonale (heart swelling and heart failure due to chronic lung disease) Pneumonia Pneumothorax Severe weight loss and malnutrition Thinning of the bones (osteoporosis)

When to Contact a Medical Professional

Go to the emergency room or call the local emergency number (such as 911) if you have a rapid increase in shortness of breath.

Prevention

Not smoking prevents most COPD. Ask your doctor or health care provider about quit-smoking programs. Medicines are also available to help kick the smoking habit. The medicines are most effective if you are motivated to quit.

References
Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mlken MP. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax. 2010;65(8):711718. Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Inhaled corticosteroids vs placebo for preventing COPD exacerbations: a systematic review and metaregression of randomized controlled trials. Chest. 2010; 137(2):318-325. Shapiro SD, Reilly JJ Jr., Rennard SI. Chronic bronchitis and emphysema. In: Mason RJ, Broaddus VC, Martin TR, et al. Murray & Nadel's Textbook of Respiratory Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 39.

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