Respiratory Services Video Scripts

• Week 1 - Chronic Lung Disease

  Hi I’m Jenna, one of the respiratory nurses and I’m going to be talking about your chronic lung disease. We’re going to cover various conditions: COPD, Interstitial Lung Disease, Asthma and Bronchiectasis.

  Firstly what we’re going to cover today is what your condition is and what’s in the body. We’re going to look at the signs and symptoms you may experience. We’re going to look at how it’s actually caused. We’re also going to look at how healthcare professionals come to the conclusion that you’ve got these underlying conditions, so what sort of tests they’re doing. This is a really important one, we’re going to look particularly at how you’re going to manage your condition.

  The first question we have is whether you think lung diseases are common? Just looking at these statistics now, these lung conditions are common and there’s a lot of people suffering these conditions in the UK today.

  Firstly in order to understand how our lung conditions work we need to understand how the body systems normally work, particularly our lungs. So this is our body system – what we need to think about is what happens when we breathe and why are we breathing? We’re breathing to take in oxygen, which is that energy supply that allows us to do every activity we do every day, so it’s really vital. We breathe in oxygen and then get rid of the waste product carbon dioxide. In order to transport these gasses we need some sort of transport system. If you look at the body we have the nasal cavity where we take in oxygen. If we follow that pathway down it takes us into the lungs. You’ll notice it has these branches that come off, almost like an upside-down tree. We’ve got our trunk here and then it separates into these smaller branches. At the end of these branches we have these little air sacs where all the magic happens. We take in the oxygen, it travels into our lungs – this is breathing. It travels down those branches and then there’s an exchange of gasses. The oxygen hops off into our blood stream to be delivered to our muscles so they can move. Then as those muscles have used up that oxygen they’re going to get rid of this by-product, the carbon dioxide. The waste carbon dioxide has travel from that muscle back to the air sacs to be breathed out of the body. That’s our basic lung movement, we breathe in, take that oxygen to our air sacs, it gets taken around the body and we breathe out carbon dioxide.

  We’ve talked about oxygen and how important it is, so we want to make sure we’re getting in as much oxygen as possible and we’re getting rid of carbon dioxide. We don’t want that to stay in the body, we want to make sure that this is a constant moving cycle. So we need to look at the mechanisms around the lungs that allow us to take the air in and breathe the air out. First of all if we look at what happens when we breathe in, we need to expand the chest to allow us to create more oxygen space. The other really important aspect of breathing in is the diaphragm – this is the muscle that sits just below the lungs and as we take the breath in the diaphragm gets lower and it allows us to take more air in. It’s creating more space to allow us to take in more oxygen. Then we breathe out, so the rib cage comes in to force the air out. The other thing that happens is that our diaphragm relaxes; moves back up into the chest, and help us to breathe out the waste product, which isn’t something we want to keep in the body, we breathe it out by pushing the diaphragm higher and pushing against the lungs.

  The first topic is COPD. This is a term that a lot of people use but we don’t really talk about what it means. The “C” stands for chronic, which just means it’s long term. There’s nothing we can do about the scarring that’s happened, but what we look to do with the help of inhalers and lifestyle changes is to manage the condition. “Obstructive” – if you think about the motorway when there’s been an accident, there’s a sign that says there’s been an obstruction, so there’s something blocking the normal pathway. So your airways are restricted and it blocks off the normal passage of oxygen. “Pulmonary” is a fancy word for the lungs. Finally “disease”, we know it’s a medical condition that affects your body functioning.

  The other thing we say about COPD, it’s an “umbrella term”. It covers a number of conditions. We’ve got chronic bronchitis, chronic asthma, emphysema and ACOS. The reason we call it an umbrella term is because every one of these is chronic, it’s an obstruction, it’s in the lungs and it’s a disease. It’s a way of grouping these conditions together because they have some similarities, but they also have many differences and are treated differently as a result. When people use the term COPD and chronic asthma, they’re talking interchangeably about the same thing, but there are slight variations between each condition.

  Condition 1 is chronic bronchitis. This is a long term condition. Every time you see the word “itis” at the end of a word that just refers to inflammation. When we think about the branches of the lungs, these branches are called “bronchials” or other words that begin with “bronch”. When we talk about “bronchitis” this is an inflammation of the branches in the lungs. The inflammation and narrowing of the airways. What happens is that oxygen we take in is being obstructed. If we look a little closer, these are our normal airways, there’s muscles around it and the circle is nice and open for the oxygen and carbon dioxide to travel through. In people with chronic bronchitis airways, there’s the inflammation and swelling in the area which the oxygen can travel through so it gets a lot narrower. There’s a lot of inflammation there and sometimes we get thick mucus – the body is trying to send things there to try and deal with the inflammation, but unfortunately the mucus gets trapped. We’ve got a narrow airway, we’ve got a sticky mucus inside, so it’s going to be more difficult to get that transportation of the oxygen and carbon dioxide to happen.

  The next thing under COPD is chronic asthma. When you think of asthma you think about the asthmatics that have very short, sharp attacks, but this is looking at something happens long term. This may be someone that’s had asthma for many years and it isn’t very well controlled. In asthma there are some very similar elements to bronchitis. Here are our airways, and what happens here is that the muscle wall thickens and starts to squeeze the airway very tightly. It will be very narrow for the oxygen to get through. Again there’s increased inflammatory cells, so the inflammation is building up. You may also have scars – if you look at scars on your skin you’ll notice that area of your skin is thicker, and it’s the same here. If we have thicker skin on those areas then we’ll notice again that it’s narrowing. So it creates a more narrow airway for the oxygen to move through. The other thing you’ll notice is that we’ve got the mucus here, which is what we talked about before. The mucus will make the oxygen and carbon dioxide exchange a lot more difficult.

  ACOS is “asthma COPD overlap syndrome” – what I mean is that there are elements of both conditions. We talk about asthma in a chronic way in COPD but I mentioned there’s the other type of asthma where they have the flare ups, the part of their condition where they struggle with their breathing. Somebody with this overlap syndrome has both elements, they have the chronic problems and the acute problems as well. What we’ll notice again is the inflammatory cells that build up, which causes inflammation. Because it’s long term we’ve still got that COPD element, the scarring, and we’ve got the muscle cell wall thickness so we’re making the airways narrower. But we’ve also got the mucus – because there is that inflammation going on there is a thick sticky mucus in the airways which is making that transportation process difficult. We have the extra inflammatory cells, so we know that the acute process can happen where you feel very short of breath, similar to how young asthmatics might have their symptoms.

  The final thing we’re going to talk about is emphysema. In the previous conditions that come under the branches of COPD we talked about these airways and how those airways are affected. Emphysema is quite unique in the fact that doesn’t actually affect the airways as much and it focuses more on what’s at the end, these tiny air sacs that we talked about, those things like a bunch of grapes. If we revert back to what the normal process is when we breathe in, we take in the oxygen and it travels through the branches, it goes to the end where the air sacs are and that’s where the oxygen hops off to be delivered around the body to give us energy, we use it up and then we have the by-product of carbon dioxide that we need to travel back to our alveoli (air sacs) to be breathed out. That’s the exchange process. The air sacs are somewhat like train stations, they’re the main area where we’re going to transport things around the body. Each one of these air sacs is a different station, and the oxygen is hopping on to be taken around the body to be delivered to the muscles. Carbon dioxide is then hopping on to be taken out. In emphysema these train stations become damaged, they become large, or loose, or don’t help the transfer of oxygen and carbon dioxide. Going back to our analogy about train stations, it’s like the train station being broken down. So the oxygen has arrived there but it can’t be transported around the body. The reverse of that is that carbon dioxide is trying to leave but we don’t have an effective way for it to go. The train station is broken down and we have the gasses left behind. One of the things I also say is that it loses elastin, which is important because if we imagine the air sacs have got to help us push out the carbon dioxide, there’s a certain level of movement that it allows. It helps push out that carbon dioxide so we can breathe. When the elastin is damaged it goes from a balloon consistency to something more like a carrier bag and it becomes quite floppy and doesn’t aid the process. I always imagine something like on a warm day when you’ve got two doors open, if you have a gust of air that travels through the doors they slam shut. It’s the same thing that happens in this situation. We’ve got this elastic, not very loose and damaged air sac, and what happens is when the air rushes through it slams shut. What’s left behind is the air, so there’s carbon dioxide left behind. We call that air trapping, when carbon dioxide is left behind, the train stations have broken down, and this is a waste product that we want to get rid of.

  Bronchiectasis doesn’t come under COPD umbrella because it works differently. Here we have our normal airways; these are the passageways our normal air moves through. Then there are the widened airways, and this is what happens in bronchiectasis. Areas in the lungs will have abnormally wide airways. You may think “if we’ve got wide airways surely that’s helpful because we’ve got more room?” But what happens is that wide airway allows mucus to build up, because like all of the other conditions we’ve still got the scarring and inflammation, so there’s still the mucus. What happens in some pockets of the lungs and where there is the abnormal widening, this mucus is building up. Inside your airways you have these little hairs called cilia, they work like a broom that sweeps up dust and dirt. In this case when you breathe in, you’re breathing in particles and bacteria and our cilia isn’t working effectively, because although we’ve got wide airways they’re very short so can’t work as effectively, like the broom’s been cut off a bit so we’re not able to sweep up the dirt and particles effectively. All of the mucus is able to build up because we’ve got an enlarged airway and suddenly it’s becoming overwhelming for the body to be able to clear this out. That causes a problem because we breathe in particles and bacteria and this is the perfect breeding ground for bacteria, it’s a warm and moist environment that allows bacteria to multiply. If we allow bacteria to multiply it’s going to cause chest infections and they result in more scarring. So the cycle continues.

  Now on to Interstitial Lung Disease. Like we said with COPD this is an umbrella term, Interstitial Lung Disease also is. In COPD we have four details that we went into, with Interstitial Lung Disease there are over two hundred different variations of the condition. The main principles are the same – it’s either scarring or inflammation that happens in the lungs that affects the transportation of carbon dioxide. Normally our airways are soft and squishy, that helps because it’s a rubbery material that allows the easy passage of movement. We go from this soft tissue to something almost similar to cardboard, so it becomes very rigid. With Interstitial Lung Disease it’s not necessarily an obstruction, it’s not an obstruction in the road, it’s more of a restriction, so our airways are restricted. That movement of our lungs that we use to help us breathe in the oxygen isn’t as effective. Some people describe it like a balloon inside a glass tube, if you try and inflate the balloon it can’t get any further than the glass because it’s stuck. Our airways and lungs cannot expand to draw the oxygen in and allow us to use it effectively. As a result of this scarring and scar tissue, it affects the alveoli to help with the transportation of oxygen and carbon dioxide. So not only are we struggling to draw the air in, but we’re also struggling to enable us to get it to those tissues and transport it around the body.

  We’ve looked at the lung conditions and now we need to talk about the signs and symptoms. I want you to think about the symptoms that you have that might be related to your lung condition. We’ve got a few of them here, we’ve got cough, wheeze, breathlessness, recurrent chest infections and increased sputum. If we go back through all of the previous slides and everything we talked about it makes sense why these will be the signs and symptoms of your condition. If we talk about all the inflammation that happened in those airways and the mucus that builds up, that’s the increased sputum, or phlegm, it’s the sticky green stuff that you might bring up when you cough, not very glamorous but that’s what we’re talking about. As we said, when we breathe in lots of bacteria stick to that mucus which can result in getting a chest infection. Then we go on to breathlessness – as we’ve talked about, that oxygen and carbon dioxide transportation allows us to do activities day to day. If our airways become narrowed or if our alveoli become damaged, if our lungs are scarred, that transportation isn’t going to happen as well. So when we try and do those day to day activities we’re going to feel breathless.

  We’ve talked about the different forms of testing, but there was so much variation with the different lung conditions we’ve discussed, and as a result there’s so much variation with the amount of testing needed. Some people might need the full works; for some conditions we’ll need to get a really specific picture to understand that type of lung disease. But for others it may just be a case of getting your symptoms and your full history and some lung function testing to diagnose you.

  We’ll look at scanning in slightly more detail. When we talk about a chest x-ray, this is what the doctor’s going to be seeing. On the left side we’ll look at the normal landmarks, this is what a normal lung and chest x-ray is going to look at. This block in the middle is your heart, these are our lungs, and this large bit here is our diaphragm. If we went back to when we talked about the mechanisms for breathing the diaphragm played a really important role in flattening to allow us to expand our airways, taking in more oxygen, and then it was getting larger and pushing the carbon dioxide out. It was the thing that helped us move our airways and create more space in our lungs to allow us to breathe in and out effectively. If you look at the one on the side, this is someone with a lung condition, and if you notice the main difference here is that diaphragm has flattened down. What happens in lung diseases, we’ve been trying to get the air in and struggling, so our diaphragm tries to overcompensate. It’s trying to create more space to give us more oxygen. Obviously we know that’s going to be a problem when it comes to breathing out, because we use the diaphragm to push up against the lungs so that we can expel the carbon dioxide. When we look at it from the perspective of a chest x-ray, that’s a clear indicator of lung disease.

  This is a C.T. scan. At the side you can see the image of the airways. If you notice, it looks very different from the image in the chest x-ray and that’s because it’s look at the body as if it was lying down and it’s taking slices of the images. What you’re seeing right now is us looking inside the airways. The main difference here is you can see inside the tubes, here they’re nice and thin, there’s no large airways or scarred areas. But if we look on the right side, you can see the enlarged airways and there’s the thickening where the clear white edges are, that’s thickening and scarring. This indicates somebody with a combination of conditions, bronchiectasis and COPD. We talked about the scarring and the enlargement of the airways that you can see there. On the bottom one there’s lots of that white detail here, and as we talked about, that’s a really good indication of scarring. Going back to our previous guide when we talked about conditions, this is a very good indicator of Interstitial Lung Disease which is a condition that causes a lot of scarring that affects our ability to breathe.

  When we talk about lung conditions we can’t talk about them as one thing. There are a lot of associated conditions which are either made worse or caused by having a lung condition. Firstly there’s anxiety. If you think of the idea of breathlessness and not being able to breathe that in itself is going to cause a lot of anxiety, and over a long period of time it can result in these problems getting worse and worse. Next we look at depression; if you think about being breathless, having a cough or chest infection, it’s going to hugely affect how you live your life. You’re not going to be able to do things as effectively as you could do before. As a result, people feel a certain amount of loss which can result in things like depression. Sleep deprivation – if you’re trying to get asleep with a cough or a cold, as soon as you lie down it feels so much worse, so imagine trying to sleep when you’ve got a lung condition, it can be very difficult. Finally malnourishment – if you’re feeling breathless, you’ve got a cough, just that normal process of eating a meal is going to be significantly more difficult, and because your lungs and body are working a lot harder to overcompensate with that exchange we talked about, you’re going to be burning more calories than average.

  We’ve covered what these lung conditions are, we’ve looked at the signs and symptoms, we’ve looked at how they’re diagnosed. We’ve also looked at associated conditions that lie parallel with those lung conditions. The reason we’ve gone through so much detail and it’s got a little bit science-y is because we want you to understand the processes that are happening in your body so you understand how best to treat it. Throughout the rest of the programme we’ll do various different topics that are going to cover these other different conditions and look at how you best self-manage. If you have the understanding behind how these conditions occur you will better appreciate how we can teach you to be able to manage your own condition effectively. The aim of that is to reduce the amount of chest infections you have, reduce the symptoms that you have, allow you lead a more independent and better quality life, and avoid those hospital admissions. 

  [end]

• Week 1 - Breathlessness and Exercise

  Hello, my name’s Helen, I’m a Specialist Respiratory Physiotherapist, and I’d like to welcome you today to this pulmonary rehabilitation education session on breathlessness and exercise. I’m going to go through the slides with you today but you can pause the presentation at any time if you would like to go back over something again, or write something down. So the purpose of this education session, and the pulmonary rehab course that you’ve started is to really help you manage your lung condition, and we’re thinking today about how your lung condition impacts your ability to exercise or be as active as you’d like to be. Taking all that into account, we’re really trying to think today about how to maximise your potential. We put this talk right at the beginning of your program, because if you can get this right then it’s going to open the door to you being able to ghet the maximum benefit to the course that you’re just starting.

  The first question I want to ask you to think about is why do we breathe at all? You’ll be thinking “we breathe to survive and stay alive”, and this is just a reminder that the only way to get oxygen into our body is by breathing through our lungs. Of course we need oxygen for everything, for our heart, to keep our brain healthy, to keep our muscles moving, for our digestion to get the nutrients from our food, if you’re going to climb the stairs or go for a walk, or play with your grandchildren, or go for a dance or swim, or a game of golf, any activity that you can think of requires oxygen to fuel it. So how much oxygen is there in the air that we breathe? Well maybe you’ll have a conservative guess, but I wonder if you’d be surprised to know that there’s only 21 per cent oxygen in the air, not very much, so it’s not surprising that we do get breathless.

  IS it normal to be breathless? Perhaps you think “no it isn’t” and maybe you identify with the lady in the photograph who looks quite uncomfortable or distressed by her breathlessness. But what about this photo? I think it’s safe to say this lady has just finished a run. Or Mo Farah or Usain Bolt, two highly fit trained athletes, and yet both are looking exhausted and out of breath in these photos. And what about these children running around who look happy and healthy, and yet we’ve all seen children playing and getting very out of breath. So we know that lung disease makes you more breathless than other people, and that breathlessness can be upsetting, but it’s important to remember that being out of breath is a normal healthy part of everyday life for all of us.

  What do we know about breathlessness in relation to your lung condition? If you’ve had a chance to listen to Jenna’s talk on chronic lung disease, she went through how breathlessness is caused when you have a lung condition, that the inside structure of the lungs is changed, making the breathing more difficult. The tubes become narrower, so getting the air in and out can be challenging. The alveoli, the little air sacs at the end of the airways, can become damaged so they’re not doing such a good job at getting the oxygen and carbon dioxide exchange that we need. The diaphragm can become affected and is flattened, making it work less effectively and meaning that we have to work harder, using a lot more muscles around the upper chest and shoulders in order to support our breathing and get more air flow. But all of that causes us to be more tired and more breathless because we’re using up a lot more oxygen.

  We learned at the beginning of this presentation that breathing is fundamental to our survival, so it’s not surprising that when our breathing becomes challenging that we can become anxious and frightened, and panic trying to find a solution to the problem. We also know that breathlessness is brought on by activity, we’ve seen on the photographs of Usain Bolt and Mo Farah, very fit people but very out of breath because they’ve just finished their races.

  If breathlessness is brought on by activity, and having chronic lung disease can mean that we’re more prone to anxiety and panic when we’re out of breath, and we can’t catch our breath, you’d think that perhaps anxiety being brought on as a result of breathlessness that we would be advised to avoid exercise, if it’s going to bring on unpleasant symptoms? But if we avoid activity to try and prevent the fear or anxiety that comes with being out of breath, what are the consequences? What happens is that we end up in a vicious cycle of inactivity, we feel very breathless as a result of our condition and we can become fearful of the activity that is going to bring on excessive breathlessness. So as human beings we’re great problem-solvers, if faced with a predicament we’ll find a way round it, so if we know that certain activities are going to make us breathless, and that maybe we’ll get a little uncomfortable or even fearful and panicky when that breathlessness comes on, we’ll avoid the activity. So we avoid the activities that make us breathless, but by doing less activity our muscles become weaker. Here’s the interesting thing – weak muscles use oxygen less efficiently than strong muscles. In other words, weak muscles demand more oxygen and the only way to supply that oxygen is to breathe heavily, so we’re breathless. So now the simple tasks or activities that we were able to manage now make us even more breathless than they did before, so we’re more inclined to not do that. We get into this vicious cycle: we’re breathless, so we want to do less activity, the less activity we do the weaker we become, the weaker we become the worse our breathlessness gets, not as a result of our lung condition but as a result of the deconditioning of our body.

  So what can we do about it? It’s really important that we break the cycle. This is what pulmonary rehab is all about, and this is why you’ve been referred to this programme. We want to break that cycle of inactivity. We want to gradually increase your muscle strength and fitness which will make activity easier. If activity is easier then you’re more inclined to do more of it. Doing more activity gets you stronger and fitter. Stronger and fitter muscles need less oxygen than weaker ones, so now the activities that you’re doing take less out of you, make you less breathless, and minimise your chances of becoming distressed and panicky, and ultimately they’re easier to accomplish, so you feel more inclined to do them. The other thing that we’re going to help you with over the course of the programme is gaining control of your breathlessness so that you feel that you have the tools and power to be able to manage your breathing in a comfortable way, so you’re not feeling frightened or distressed, and therefore not avoiding activities than bring on unpleasant sensations.

  How can we do that? It might seem a bit daunting. You might think: “I haven’t got the breath, I can’t exercise, I can’t get fitter.” But it’s really important to remember that no matter how daunting it feels for you right now, even the very longest journeys start with a single step. We have to start somewhere. All we’re going to ask of you with this rehab course is that you start small. Start with what you can do. Nobody can ask any more of you than that. But what I will ask is that tomorrow you do a little bit more than you managed today, just a small amount, not a big leap, a small change, but be determined and stubborn, do not allow yourself to do less than you did today. By doing a little bit more each day, you won’t really notice it at first, but over time that can turn into a huge improvement in your strength and fitness, and a reduction in you breathlessness as a result of being stronger and fitter in your body. What I’m asking you to aim for is to feel that you’re puffed, but you’re still able to talk. We’re asking your body to make a change, we’re trying to get you physically stronger and fitter, and therefore if you’re going to make a change in your body, it needs to feel that you’re making a difference. In other words, if you only do what you can easily manage your body is not being challenged to get stronger, it’s just coping with what it easily can undertake. So you need to feel that you’re out of breath, but in a manageable way. I don’t want you to push yourself so hard that you can barely utter a syllable or you’re really distressed. Because the likelihood is you’ll stop exercising because you don’t want to feel like that, nobody does. But you do need to challenge your body to get fitter, so make sure you’re puffed but able to talk. That’s sufficient to get your body fitter, but it isn’t sufficient to cause distress. So that’s what we’re aiming for.

  What you’re doing there is setting up a new cycle. You start with doing a little bit of activity, just as much as you can manage, and this is going to help your breathing by developing fitness and strength in your body. As your muscles become stronger, they use oxygen more efficiently. By using oxygen more efficiently they don’t need you to breathe as hard, and so therefore you’re not as breathless doing simple tasks or activities. Because you’re no longer as breathless you feel better, and doing those activities and tasks feels more enjoyable because it isn’t as distressing as it was. So because you now feel better about the tasks, you’re able to do more of them, and by doing more of them you get fitter. By getting fitter you actually are less breathless. We’re not targeting your lung disease as such, we’re targeting the impact that your body is placing on your lungs. The way I want you to think about it is like a see-saw. We want to keep both sides balanced. If your lungs are in really good shape then they can deliver oxygen quite easily without any problem, and whatever state your body is in, your lungs will catch up and cope fine.

  But if your lungs are not coping as well as you would like them to, and they’re struggling to provide oxygen, thinking about that see-saw maybe the lungs are low on the see-saw, then actually what we want to do is balance the see-saw out by making sure that the body is as fit and as healthy as it can be. Because if the body is healthier it puts lets strain on the lungs that are already struggling, and we start to balance the see-saw out a bit. If we can’t tackle the lung disease, or get rid of it altogether, we can help you to manage it. This makes it more important that your body is as fit as it can be, so that the demand it places on the lungs for oxygen is as low as possible. That’s really what we’re trying to do, set up the new cycle of activity.

  What sort of exercises should you try? Walking is a great one. We can all do it, it’s free, you don’t need high-tech equipment, and we can do it anywhere. Exercise that is going to improve stamina and fitness will help with your breathing overall. It will help you to get from a to be as well. An important exercise group to think about are the muscle-strengthening exercises of your arms and legs, and regularly tuning into the exercise videos that Ian and Jenna have done with you will really help to gradually progress the strength in the muscles in your arms and legs. You may not feel that the muscles in your arms and legs are weak, but even so they will benefit from getting stronger. The stronger those muscles are, the less demanding they are of oxygen. If they’re less demanding of oxygen, you don’t have to breathe as heavily, you’re not as breathless, and therefore you’re able to persist and do more activity. So strengthening your arms and legs is a really important way of managing your lung condition. We also want you to maintain flexibility though. It’s important your lungs are surrounded by your rib cage and as the name suggests, that’s a solid cage protecting the lungs from harm. But if the joints in your rib cage, spine, between your ribs, in your shoulders, if those joints re allowed to get stiff then they will impede the smooth inflation of the lungs, making it more difficult for you to breath. So we want to make sure that you maintain as much flexibility as you can. Again Ian has put some exercises into his videos that will help with your flexibility.

  We want you to feel motivated and supported to embark on your pulmonary rehab programme, and if you do and follow this course through, what can we promise you? We think we can promise a new you. Yes you have a lung condition that makes life difficult, we understand that all too well, but if you follow these steps and videos, and the education that goes with them, you can help to manage that condition and maximise your potential. So over the course of pulmonary rehab we’re going to look at breathing control. This really is just a fancy way of saying gentle, relaxed breathing.  This is your recovery phase, this is the way you’re going to manage your breathlessness, whether you’re exercising or becoming anxious, this will help you to manage those bouts of breathlessness, and we’ll go through that in one of the next talks that you have, which is managing your chest. We’ll also look at the way that you can recover when you are out of breath, and this is important in a way to manage the anxiety that can be associated with not being able to catch your breath. We know it’s frightening, your brain is programmed to know that if you can’t breathe that’s bad news and you need to do something about it, so we want to teach  you techniques to help you manage that breathlessness when it comes on without fear of anxiety and panic.

  Once you’ve got those techniques under your belt, as you’re learning them over the next few sessions, it’s going to help you to be more able to exercise. Remember we said at the beginning when breathlessness brings on anxiety and unpleasant feelings we avoid the activities that bring on those nasty side effects. So now we’re saying: “we have the tool to deal with the breathlessness so we don’t have to avoid it.” That way we become less frightened or desensitised to being out of breath, reminding ourselves back to the early slides, that being out of breath is normal and healthy, we shouldn’t try to avoid it, we just need to have the tools and the techniques to be able to manage it when it comes on. Once we’ve got these tools and we’re no longer frightened of being out of breath it enables us to exercise even more and build up a gradual training effect. So a little bit more each week or session, means that our muscles are getting stronger and our physical fitness is developing. By strengthening our muscles and developing our physical fitness it enables us to exercise even more. Over time that can turn into a vast change in ability. A little bit more each week, month or year, and over time we can achieve a lot more than we were able to do before. Yes we have a long term condition, and we’re not getting any younger, but we can make significant progress on our symptoms over the next months and years of continuing to be active. What we would want to see is that you’re finding improvements in your daily life, so how easy it is to do chores and activities around the home, and that you have the breath, energy and motivation left over to do some hobbies, to get out and about. Maybe you can do things that you haven’t done for a little while, hobbies that you thought you’d never get back to, but you feel empowered, energised and capable of taking them up again. One thing we have learned over the experience of pulmonary rehab is that the more passionate you are about your exercise, the more you love the hobby and activity that you’re doing, the more likely it is that 2 or 3 years down the line you’re still doing it and still motivated to get that regular exercise.

  The real take-home message from today is that we really wish you well in this course and we hope that you hope you work really hard and feel motivated to achieve great things. But this is just the beginning and the important thing is that over the months and years that come you can continue to exercise and continue to be active. Just following this course for a few weeks is unfortunately not enough, these need to be life-changing habits moving forward from here.

  This is what we think you can achieve from following this pulmonary rehab programme, and we will do anything we can to provide you with the motivation and support to achieve the very best out of yourself. Good luck with your education sessions and really good luck with your exercise videos! Follow them regularly and work as hard as you can.

  If you have any worries or queries and you want to get in touch with one of the team, then please do. There’s numbers on the letters that we sent you, so please do get in touch with the team and we’d gladly hear from you and help you with any questions you have.

  I look forward to seeing you again for another session very soon.

  [end]

• Week 2 - Medical Management of Lung Disease

  Hello, my name is Hayley and I am one of the Community Respiratory Nurses working in Luton. Today as part of your Pulmonary Rehab, we are going to talk about medication and management of your condition, whether that be medical or non-medical.

  So first looking at the non-medical side we are looking at some of things you can do to help manage your condition. Now all of these things are going to be mentioned in one of the talks as part of your course.

  So I am not going to go into detail now. But have a think about some of the things you can do to help manage your condition at your home.

  So they are things like pacing, nutrition, hydration, weight management, good chest clearance, attending education, learning more about your condition, exercise, stopping smoking, attending support groups, relaxation and sleep, taking your medication correctly, which we will cover more today. Managing your flare ups and breathing control and good positioning.

  So now we have looked at what you can do, we are now going concentrate on what medication can do for you. So what you are prescribed. So these can really reduce your symptoms. That’s basically what we want your medication to do.

  We want to reduce your symptoms, including we want it to reduce wheeze, flare ups and help to reduce coughs and shortness of breaths.

  So what do we want your inhalers to do and how do we want them to work in the body?

  We want your inhalers to help open up your airways and to allow you to breath more easily.

  Inhalers deliver your medication like bronchodilators and anti-inflammatories directly where they need to be.

  There is a large variety of inhalers that work in different ways and this is what will help to manage your symptoms.

  So we often use this word bronchodilators and lets break the word up

  So firstly, ‘broncho’ and then ‘Dilate’. So what do these two words mean?

  Well ‘Broncho’ really is your airway

  ‘Dilate’ just means to ‘open’. So when we use this fancy term ‘bronchodilation’ we are just saying we are opening these airways.

  So what we need to understand is what happens in your airways and to do that let us look at this diagram of your airways and look at the areas it works on.

  If you are looking at this diagram you can see this smooth muscle here and all around here and this is the opening of the airway or ‘lumen’ as it would be called.

  So air travels through the airway, all the way through to the alveoli, so that the oxygen can be used in the body.

  If this smooth muscle contracts and contracts here, it means this airway becomes smaller and less able to have oxygen going comfortably through it and that’s when you may experience tightness or wheeze.

  We want the inhaler to stop the smooth muscle from contracting and encouraging it to relax and this works on different receptors.

  I am not going to go deep into these receptors but it is just so that you understand that it encourages this smooth muscle to relax. It stops this contraction of the smooth muscle.

  We also have another type of inhaler which can be used in combination with this and that is an ‘Inhaled Corticosteroid’

  This works on reducing this inflammation that some people have in their airways.

  Now not everybody has this inflammation and it is decided by your healthcare professional based on your symptoms, how many exacerbational flare ups you are having and your recent blood tests.

   So just to recap, we want it to do three things.

  One - We want to encourage the smooth muscle to relax and that’s here;

  Two – We want to stop contracting of this muscle, to try and reduce contraction which again is going to make that airway tight of the smooth muscle.

  Thirdly we are going to try and reduce the inflammation

  All with the same purpose  of opening up your airways

  So lastly now we have relaxed the muscle around the airway and opened and dilated them breathing should hopefully be better.

  So we are now going to group the Bronchodilators into ‘short-acting’ and ‘long-acting’.

  So ‘short acting’ are often prescribed for quick relief of your symptoms. An example of this would be maybe your blue inhaler, Salbutamol.

  This helps open up your airways after 5 to 15 minutes of taking and lasts for around 4 hours.

  The ‘Long Acting’ bronchodilators, there are couple of examples there, work better at managing your ongoing symptoms and are taken regularly whether you have symptoms or not.

  Now we have looked at what the inhalers can do for you and how they work on the body, we now look at this huge array. This is a tiny proportion of actually the type of inhalers that are out there for you and the reason these companies do this is because it is not one shop fits all. It is really what works for you. It can be something as simple as your dexterity and how you are able to twist and turn something to the convenience of having it in your pocket.

  So we have got all these different types of inhalers but they can really be based into three groups.

  So now I have brought in Jenna, so I am able to show you how to use your metred dose or aerosol inhaler

  Now for the purpose of this it’s white just because it’s a placebo device but yours maybe pink, grey or blue or any other colour. We are not talking about the drug just device.

  So first thing is always to remember when you are looking at your inhaler is to make sure it is in date.

  And also making sure that if your dust cap is off and in a handbag or a pocket, that you do check and make sure that you are not breathing in any nasties and that it is nice and clean.

  So first of all, remove this cap from the device and shake well.

  Breath all the way out, not into the device, just breathe out.

  Then place the mouth piece between your teeth and seal your lips tightly around it.

  As you start breathe in slowly, press down on the canister one time. Keep breathing in slowly and deeply as you can. Should take 5 seconds to breathe completely in.

  Now hold your breath for ten seconds or as much as you can tolerate to allow the medication to reach the airways of the lung.

  You then repeat the steps for each puff ordered by your doctor and wait one minute if you can between puffs, making sure that you shake the device before you take it again.

  When you have completely finished replace the cap on the device so it is stored safely.

  So we are now going look at the second device which is your dry powder inhaler, some of you maybe on or not and they do come in different forms, whether they be pre-loaded or you need to put the capsule in yourself.

  So first of all you are going to open up the device, open up the mouthpiece, check that is clear and that there is not a capsule in there already and then you are going to put one of your capsules in. The right capsule for the right device.

  Close it up and you should hear a click. Take a nice deep breath out. Not into the device because that can cause moisture clumping. Press the button down to the device and put it between your teeth, lips round and a nice hard, fast breath in.

  You need to do that and count to ten as you would do before. You need to do the work for this device because its dry powder so you need to take really nice hard and fast breathe in.

  Once you have finished, you open it up and have a look at the capsule and ensure you have taken all of the dry powder from that capsule. If you have not then you can repeat the procedure.

  This is a comparison of one that has got all the powder in it so that you can see that you know you have taken it well.

  Then that can be then shut back up. Lid back on, mouthpiece back on, locked and the capsule can be thrown away into your normal household rubbish ensuring that you put the caps back on your medication part 2.

  If you have a pre-loaded device like this one, again it will be in lots of different colours, it is just the placebos, you open up the cap, the lid so that it takes it off and then pull back on the button until it clicks.

  Now Jenna is not going to take this one because it is an older device. Nice breathe out as you would before. Between the teeth. Lips around it and a nice hard fast breathe in and again counted for that ten seconds or as long as you can tolerate before you take your breathe out.

  So the third device we are going to look at is your soft mist device and we will show you how to use that.

  So hold the inhaler upright with the cap closed. Turn the base in the direction of the arrow until it clicks, it’s usually half a click and you can hear that quite loud click.

  Breath out gently away from the inhaler. Put the mouthpiece close to the lips and make a good seal, again Jenna is not going to do this one.

  So as you start breath in slowly and deeply through the mouth, at the same time press down on the dose counter. Continue to breathe in slowly and deeply for about 5 seconds or as long as comfortable.

  While you are holding your breath, remove the inhaler and breathe out gently when you are ready.

  For two inhalations, you need to put the cap back on and repeat the instructions from the one.

  So just as a recap, we are going to look at the different type of inhaler techniques quickly.

  So we are looking at the aerosol, the dry powder and the soft mist.

  So with the aerosol or your metred dose inhaler, you need to remember that’s coming out super fast. So you need to make sure that that breathe that you are taking in is really slow and steady.

  Try to remember that it is really important that you don’t double press and you will not be getting on that second dose the right amount of drug that you have been prescribed. So take each dose that you take as a separate.

  Also they are better used with a aero chain bottle spacer device and we will cover that a little bit later.

  Looking at the powder, this powder as we know is in the capsule and you have got to do the work this time. This has got to get down into those lungs. So you need to make sure you take a breath, really hard and fast

  If you are going to use a capsule ensure that you only press the button once and keep the device upright.

  With a soft mist inhaler, we try to remember TOP and that is TURN, OPEN and then PRESS. Making sure that the breath you take in is nice, slow and steady.

  So now we are going to look at using your metred dose inhaler with a space chamber or aero chamber. For the purpose of this one is going to be with the aero chamber. Take the dust cap off your inhaler and put into your spacer device.

  Keep it upright. Give it a good shake. Take a nice deep breath out. Pop the inhaler between the teeth, make a good seal, press the canister down once and breath in and out, normal breathes for 3 to 4 breathes.

  If you hear a squeaking noise, it is your inhaler telling you that your breathing too hard and you need to slow that breath right down.

  Remove the spacer from the mouth, breathe out gently and repeat the steps again if another dose is required

  We do find that taking the inhalers themselves can be difficult whether it be pushing down on the metred dose inhaler or sometimes with the turbo inhaler having the dexterity to actually twist it and there are things available that can help this along.

  So one of the devices we use is called a haler aid and a haler aid really just sits and fits over your metred dose inhaler. Taking the dust cap off first it just slips over the top.

  And instead of having to push down on the inhaler instead it can be used like so. Very easy to use if you are finding it difficult.

  These can be purchased from the chemist or ask one of your health professionals who can best advise you for that. They are not expensive. They are not available unfortunately on prescription.

  Another device you can use if you are finding it difficult to twist the turbo inhaler is a device that just sits over the top and makes it easier to be able to do that with the palm of your hand rather than your fingers.

  These things are just designed to make assisting devices easier to use

  So now we have had a chance to look at our inhaler therapy, we are going to look at medication, tablet form, things that you can take to help manage your condition and they are not for everybody but we have to give you an overview of everything that is out there.

  So the first drug we ae going to look at is Carbocisteine also called Mucodyne and there are other medications that do the same thing.

  What these drugs do is they thin the mucus in the lungs making easier for us to cough it up.

  So if you have got thick and sticky mucus in your lungs, you are more prone to infection and its also very unpleasant.

  So this just thins it down and allows you to actually get rid of it.

  So you are usually given this as capsules, one to two tablet, three times a day but this could be interchangeable depending on your infection and we trial it for four weeks and if it not successful it is stopped. If you find it helpful it is something you will stay on.

  The second drug we are going to look at is Theophylline which is a bronchodilator as we talked before airway opener and it is usually taken twice a day.

  Sometimes known as Slo-Phyllin or Uniphyillin. It can possible give you side effects which are nausea, feeling a bit a sick and a fast heart rate. When this drug is taken you do have to be monitored and you do have to have blood tests just make sure it is in working range and this working range can be greatly affected by smoking and anti-biotics. So again it needs to be monitored.

  So now we have looked at inhaled steroids, we are now going to look at in tablet form and this often given as a short course when we have a flare up as there is more inflammation in the lungs and you need something extra. So it is given as a short course.

  It can have side effects and it cause muscle weakness and thinning of the skin and just to be aware if you are a diabetic, it can affect your blood sugars and they do need to be monitored.

  Antibiotics are used to treat infections in the lung.

  Signs of infections we will go into more detail throughout the course but it could be the change of colour production or thickness of your phlegm. You may feel feverish and tired and genuinely unwell. If this is the case you are prescribed a short course of anti-biotics you should always remember to take exactly as prescribed and make sure you finish the course.

  There are some people that need to have preventative antibiotics. These are people that have frequent infections and this is done where they are taken weekly under the direction of the consultant.

  There next group of medications we are going to look at are medications that help with anxiety and unfortunately we know that breathlessness and anxiety are very closely linked, its vey hard to be breathless and not have anxiety about that.

  So looking at breathlessness one of the medications that is sometimes used is Morphine.

  Now I know that sounds a bit scary but in a really really small dose, morphine is very effective at taken off the edge of breathlessness and is prescribed by your GP or consultant.

  The next medication is Anxiolytics which is a very posh name for anti-anxiety medication. These are sometimes used and are really effective at helping improve breathlessness by helping reduce down that anxiety and they can be things like Diazepam or Lorezepam.

  The next thing we are going to touch on is Oxygen Therapy and this is not for everybody. Just because you are breathless does not mean you need oxygen.

  Oxygen Therapy is for patients that have a low oxygen saturation and this is a test that is done. We often take your oxygen saturation on your finger or on your ear and it’s your low saturations at rest.

  Now a test is done by the hospital and this is usually done when you are well and not when you have a flare up and will be able to give an indication of when this needed.

  Some people do need oxygen therapy long term and this is for 16+ a day. Other people need oxygen therapy just when they are moving around. Ambulant test is another test done at the hospital to see if that is the case.

  So just as a recap, it’s been a long talk and you have done really well but it was just to let you know how some the inhaled medications on what they do for your lungs, how they work and how to use them, also looking at some of the oral tablets that are available to you and oxygen therapy.

  So I hope this has been informative. If you have any questions, we would really like to answer them, 1 to 1 you can get in touch. Thank you for your time.

   

• Week 3 - Managing Your Energy

  Hi my name is Claire, I’m an occupational therapist for pulmonary rehab and I’m going to be talking to you about managing your energy. The aim of this session is to help you make the most of your energy, to help avoid the boom-bust cycle, to help you save energy doing everyday tasks, to give you the energy to do things that you enjoy, to give you a number of techniques to have a go at, and to give you some tips on how you might restore and balance your energy.

   

  So with regard to energy, we’re talking about the energy that you have for everyday tasks and not the energy in your house. What could be affecting your energy levels? There are many things that can, for example you might be out of condition, you might have poor sleep quality, either not enough or too much. You might find that your breathing is hard, you might be using your shoulder muscles, and that’s really tiring. It could be that your mood is affecting your energy levels also, and I talk about mood and energy in another presentation. You might have an infection, like a chest infection or exacerbation; one of the first symptoms could be a reduction in energy levels. For some people they have an advanced lung disease – this can mean that their energy levels are very low.

  Thinking about your energy, it can be useful to use a visualisation as to how we think about our energy within us. For some people thinking about our energy levels as a battery is a really useful image. You can think about things that use up your energy, so your battery is coming down, things like stress and anxiety, activities of daily living. Then we’ve got things that recharge your energy levels such as good quality sleep, getting a decent amount of fluid, making sure that you drink enough during the day – often when you’re dehydrated you can feel more tired. Adequate rest as well, relaxation also.

  Another way to think of your energy levels is to think of your energy as spoons! Imagine you’ve got twelve spoons in a day, and each spoon contains some energy. When you’re thinking about what you do on a regular basis, think about how many spoons of energy that activity might take up. Let’s go right to the beginning of the day and think about getting up, washed, and dressed. I’ll take some spoons off. For me this morning, actually getting washed and dressed and ready for the day I still felt energised, so actually I’ve still got all twelve spoons left, however for other people with a long term lung condition particularly it can be really difficult, can make you really out of breath, and leave you having very little energy for the rest of the day. Going back, maybe if we take six spoons away, now you can see that these are the spoons of energy that you’ve got left available for the rest of the tasks of the day. That might be getting down the stairs or getting your shopping later. What we’re going to look at is ways that you can restore some of those spoons, or use them more wisely, make tasks easier for yourself.

  With regards to managing your energy, there are three main principles of conserving energy. These are: prioritising, planning, and pacing. There are also ways to boost and manage your energy alongside, such as breathing techniques that we talk about a few times through the course. You’ve got positions, and positioning. There’s work simplification, making things easier. Assistive devices and sleep hygiene.

  Starting off with prioritising: what we want you to do is think about your daily lives, weekly lives. Each of you will have different responsibilities and roles, different things that you have to do. You’ll have some similar things like getting washed and dressed, cooking and eating, so there are some basic things that everybody does. What we want you to do is prioritise – write a list, see what you do on a weekly and daily basis, and ask yourself: What do I need to do today or this week? What do I want to do today?

  Don’t just do all the mundane stuff. Could any of it be put off to another day? Is there something else that you would rather do today and the other tasks could be done another day? What about someone else doing the task for you? Could you get a family member to mow the lawn or do the shopping? Is there anyone else that can help me? For some people it might be carers coming so that they can do the things that they enjoy and the carer will come and help them get washed and dressed in the morning.

  Examples of prioritising: do you need to shower every day? Could you use dry shampoo? Could you shop online and buy ready meals? Right at the bottom of this slide we mention exercise. With pulmonary rehab the major component is exercise, so we really want you to prioritise exercise because overall it will either help maintain what you’ve got or improve your fitness levels. So that’s really important and we won’t let you forget it. Please do come back to this slide, there’s quite a lot of information on here. Looking at some everyday tasks like cooking, laundry, washing and dressing, making the bed and shopping, you can ask yourself some of these questions. Can someone else cook or could you buy ready meals? What about laundry – do you have to iron everything? For me, ironing I’ve prioritised out of my life unless I absolutely have to. For other people that could be something that you love to do, so you want to prioritise that task in. Washing and dressing – do you need to shower every day? Could you strip wash? Could you have carers to support you if you’re really struggling? Making the bed – could someone else make it for you? Shopping – could you do it online, or could someone else go? Could you do it on a different day? Those are examples of prioritising.

  Now moving on to the planning stage. Look at what you do on a daily and weekly basis – what could you do to make tasks more efficient? That’s the main idea of planning. Look at spreading your weekly tasks, by which I mean some of the bigger tasks like laundry, shopping or gardening, over several days, rather than doing them all in one day. You can risk totally exhausting yourself, which I shall talk about later. Could you do the bigger and heavier jobs when you’ve got the most energy in the day. You might be a morning person, or an evening person, you might find that getting washed and dressed is exhausting so you need a nap for more energy after lunch. It might be that you need to do them at the beginning of the day so you’ve got more energy, and then you can pace yourself for the rest of the time. Think about when you have the most energy, try and avoid two really busy days together because that can really build up. If you’re very tired one day and then try and go straight into another day that can be really draining. Try spreading heavier and lighter tasks throughout the day. Maybe getting the washing on and then light dusting or paperwork, or even having a cup of tea or doing some gardening, followed by sitting down and doing some potting up. Mix up the tasks that you’ve got to do. Then try and keep everything that you use regularly in one place. Rather than rushing around and going backwards and forwards picking things up, try and keep everything that you’re going to use for cooking or washing close together. Then make sure that when you start a task that you’ve gathered everything you need before you start, instead of going backwards and forwards. Try eliminating unnecessary elements – buy pre-prepared vegetables for a meal. Scrub your carrots rather than peeling and slicing them – little things like that.

  A few examples of planning: going back to the same list as before, looking at cooking could you batch cook and freeze extra portions so you’ve planned the week ahead? With laundry, wear clothes that wash, dry and iron easily to make it easier for yourself. Plan ahead with washing and dressing. Have everything together in one place. Making the bed – have your bed positioned so you can walk round it all the way. Have a shopping list so it’s nice and efficient when you go shopping, rather than going backwards and forwards.

  The third principle is pacing. This is a really key approach to help you have enough energy to complete an activity and avoid the boom-bust later (which I’ll talk about shortly). With pacing, it’s really important to try and slow down. The technique that you can also use within the exercise sessions that you do with Ian and Jenna is to slow it down so that you’re getting quality rather than quantity. You should be allowing yourself plenty of rests. With tasks, if you’re finding that you’re getting tired doing things allow yourself that extra time to do it, instead of rushing around the shops, give yourself extra time so you can take some breaks. You might be doing this naturally. Make sure you take some rests in between each task. It might be that with hoovering that you hoover one room, take a rest, do another room, take a rest, or you hoover one room and then sit down and do something that’s easier and not so demanding. Then go back to it later. Again, do the most tiring tasks when you’ve got the most energy. Spread things throughout the day – don’t try and blitz through everything all in one go, and then spread your heavier tasks throughout the week as I’ve said, through planning and prioritising. Try and sit down as well, because it uses less energy. Things where you’re on your feet, try sitting down for your ironing, cooking, or washing. It could also be, with regards to sitting down, if you really do struggle with breathlessness and fatigue, that family members take you out in a wheelchair and you just get out of the wheelchair or off your mobility scooter to walk around the shop if that’s the important part for you. That makes it easier for yourself by getting up close to the door, this is where your car disability badge is helpful. There are lots of little tips and techniques for pacing. We’ll just give you some examples there going back to the same list, these are ideas to look through your own time to pace those activities.

  Now moving on to the two different approaches, I’ve mentioned boom-bust and the pacing approach. Boom-bust is something I’ve mentioned regularly and it’s something that we want to avoid. The boom-bust approach is where you rush everything, you go really quickly whatever the task is or throughout your day because you know you’re going to be shattered so you give it your all and then you’re absolute flaked out at the end of it. Using this approach takes an awful lot longer, to recover than if you pace yourself and slow it down. Taking stairs as an example, which is something we talk about in different presentations, using the pacing approach when you’re going up the stairs – breathe in for one to two steps, out for one to two steps and repeat. What you’ll find is that you need to rest less at the top and you’ll feel less tired the next day. You could do this when you’re walking, pace your breathing – breathe in for what is comfortable and breathe out for what is comfortable. The idea here is that you keep doing the stairs, you won’t be exhausted and out of breathe at the top, you’ll maintain your fitness levels, and that’s really key. If we’re looking at pros and cons, the con is that you may actually have to go slower than you’re used to. You may have to take more time than you’re used to and for some people this can be really frustrating. Taking the boom-bust approach is taking the stairs at once, you might hold your breath the whole way, you’ll have to rest for ten minutes at the top and be panting to catch your breath, feel achy and tired the next day. You may have got that short-lived sense of achievement, yes, but when you’re faced with the stairs again you feel wiped out and gasping for breath before and start getting anxious. You might think “I can’t really do the stairs anymore.” You might end up in the downward spiral where you think you might need a stair lift or move to a bungalow.

  Now we’re looking at using your breathing more effectively. Using diaphragmatic breathing and all breathing control, calming your breath down, and using your breath to make your stomach rise and fall, rather than using your shoulders, is a really useful tool for restoring some energy and for getting your breath back when you are really breathless and tired .This is a technique that we can talk to you about separately and that we mention in other presentations. Also using breathing to pace yourself is a very useful way of helping make that task easier. We’ve talked about the pacing approach, breathing in and out to walk up the stairs or go for a walk, try inhaling on the easiest part of the task and exhaling when you’re carrying out the most strenuous part of the task. Inhale when you bend down and exhale when you lift the box. The same can be said for when you’re doing the sit-to-stands or some of your exercises that you’ll be doing with Jenna and Ian. Use your positions of ease or recovery positions as well. If you do find you’re getting breathless, try and get your breath back a little bit sooner before you’re completely exhausted. You want to get to a four on the Borg Scale that we use here and no further.

  I will show you some pictures just to remind you on the next three slides, and then remember that keeping your chest clear if you are full of phlegm will help you manage your breathing and your energy levels. If you need more information do ask us. This is the Active Cycle of Breathing Technique (ACBT) that you may have heard of.

  Also remember to use your inhalers. Make sure that if you do have an inhaler that you’re using them at the right times of the day. In Managing Your Chest we talk about inhalers and inhaler techniques and when to use them. Just to remind you of the recovery positions, one is leaning forwards that you can use over a shopping trolley, window sill or back of a chair to catch your breath. You’re stopping your shoulders going up and down and coming back to regular breathing, using your diaphragm effectively and giving it more space. High side lying is a handy one if you’re particularly tired or if you’re feeling that you’re having a flare up, this will help keep you nice and upright. You can see in the photo there’s a lot of pillows there so you want to be nice and high. We call the next one the lazy boy position, leaning forwards onto your knees.

  Simplifying what you’re doing is also a really good way of using less energy, making it easier for yourself. These are some ideas that you can try and you can come back to this slide, pause and have a look at some of the techniques again. As I mentioned sitting instead of standing for long periods, try pushing or sliding rather than pulling or lifting because these use less energy. Use good body mechanics, so when you’re carrying objects carry them close to your body, keep your posture nice and upright and not slouching. Use a rucksack as well because that’s closet your body and will make your body work more efficiently. Try using wheels instead of carrying, like shopping trollies or using a four-wheeled walker. If you’ve got garden pots to move, for example, use something with wheels to move them. Minimise on movements like bending because this can drain energy, if you don’t need to. Have things at worktop height, such as your cutlery, pots and pans. Avoid reaching up high and bending down low if you don’t need to. Use good posture – bend from the knees rather than the waist. Work on the squats, the chair sit-to-stands to strengthen your legs. Try and bend your knees to lift things off the floor like shopping bags, rather than bending over.

  Assistive devices as well are another useful tool for keeping your energy maintained. They can help you keep your independence as well if there are things you’re already struggling with. There is equipment out there that some of you may have already seen or use already. If you’ve got a particularly low chair then chair raisers can make life a lot easier. An extra stair rail is often a useful thing, so you can use both hands on the stairs to help you up, rather than just pulling on one. Long-handled aides such as shoehorns, sponges or sock aids, all help you avoid bending down. There are the grabbers as well you can use to pick things off the floor rather than bending over, as that can often take the breath away. Perching stools are great for giving you a little bit of height if you need to reach the worktop or do some ironing, so you’re not completely sitting but you’re not standing. They’re also really useful for having a strip wash in the bathroom. If you want any more information speak to your occupational therapist, and me as well. You’ve got grab rails as well that are quite handy to be installed around the bath to help you get in and out. A kitchen trolley is a fantastic tool for sliding, using wheels to transport meals around instead of having to lit and carry them. A wheeled walker is a great tool, particularly the four-wheeled walker, is great for giving you that place that you can have a sitting rest, or you can lean over to catch your breath, then you can out oxygen or shopping in there. That’s handy but not for everybody of course. If you do have prescribed oxygen, particularly ambulatory oxygen, make sure that when you’re active and about exercising like walking or going up the stairs, that you use it.

  Looking at balancing your energy, coming back to thinking about your energy as a battery. You’ve got things that are demanding your energy, not just your activities of daily living and things you’re doi8ng on a daily basis. Other things such as stressed, any conflict or being ill, feeling anxious, they can all demand your energy. Mental activities as well –if you’re rarely having to concentrate on something and work hard on that, that can drain energy for some people. For some, socialising can be very tiring. It might be that you really love to socialise but its tiring because your breathing and get breathless, you have to think harder, and that can really demand energy. If you’re not getting enough sleep that is also demanding of your energy. Some medications can demand energy as well. If you’re finding that your energy levels are suddenly affected and you’ve had a change of energy, it might be worth talking to your GP.

  On the other hand, there are things that can restore energy levels. Relaxation – we can give you a really good relaxation CD that you can try. Learning to relax and use mindfulness is a really great way of topping up your energy levels. Having fun lifts your mood and makes you feel great overall. Do what’s good fun! Make sure that you eat the right types of food, that you’re well-nourished. Take some rest. Fluid is also really important. Make sure that you’ve had enough to drink through the day. Keep your chest clear. Use your medication and inhalers effectively. Get some nice restful sleep.

  Other ways of giving you some energy back, topping up the spoons of energy, and giving you more energy to work during the day, would be fluid. If you’re not drinking enough, have low fluid intake, what it can physically do is lower your blood volume, and when you’ve got a lower blood volume you’ve got a lower blood pressure and it can increase your fatigue levels. Having a good fluid level is really important. The benefit is that if your mucus is really thick and sticky, it will make that a whole lot better and easier to clear out. Good nutrition we mention – we talk to you also about nutrition and nutrition for your lungs. Relaxation, learning how to control your breathing particularly when you’re anxious or over-exerted, is something we mention in another presentation. It really helps restore your energy and bring it back. It can make you nod off, if you’re doing it well, but also in the end it’s going to restore your energy. Good sleep, exercise also, may make you tired to start with, but over time you’ll find that you can manage a lot more and it should boost your energy levels overall. Taking some rest, putting your feet up, watching a bit of telly, doing a crossword, having a chat with friends, having a cuppa, are all good ways to rest. Breathing control as well, which we’ve already mentioned. Recovery positions too, will restore your energy in the moment. Having some fun, and setting some goals as well. Have some purpose and something to work towards. Some extra little spoons you can add!

  We’ll briefly mention sleep, as it’s a huge topic. Sometimes people find that they sleep too much. IF you find that you have sleep apnoea make sure that you use your sleep C-Pap machine. It might be that it’s undiagnosed. If your sleep is restless and you don’t sleep very well, wake up with a headache, find it difficult to get going in the mornings and feel groggy, get checked out for sleep apnoea, because lots of people with COPD can also have this alongside, and that can mean that you feel really tired. If you are sleeping too much and you’re napping in the day, and overall you feel very tired all the time, try and reduce napping in the day so that you can sleep better at night. Make sure that you get some daylight as well, because getting daylight will trigger the right hormones and give you better quality of sleep at night. Try and increase your activity levels as well, because you can get into a vicious cycle of poor sleep at night, so you nap a lot, don’t do very much because you have no energy, and that makes your night’s sleep worse. So really give it a go. Also if you’re on a lot of medications, if you’ve had any changes in medication, get these checked with your GP just to make sure. Never stop medications without getting it checked out first, but have a chat with your GP about the side effects. Your mood can really affect how much you sleep. It can affect the quality of your sleep. Are you feeling low or anxious? There are ways that we can support you to look at your mood also.

  If you’re not getting enough sleep it’s worth having a look at some of these issues. Think about where you’re sleeping if you’re not in a quiet, calm, darkened room. Your environment can impact your sleep. Set yourself a good sleep routine as well, this is really good. If you have a good bedtime and wind-down routine this can trigger you to go to sleep and get a better quality of sleep. Try and go to sleep at around the same time every night as well. Wind down, regular bed time, regular get-up time. Avoid caffeine in the afternoon or evening. While you might get to sleep quickly with alcohol it can disrupt your sleep in the early hours as it’s coming out of your system. Limit technology before bed as well. Put down the iPad or game or computer or TV. Not smoking before bed time too, because nicotine is a stimulant like caffeine. Try and keep active in the day, try not to nap, and keep your chest clear. Go through your routine before bed. Make sure that your inhalers are being taken at the right time of day. Make sure you’re taking your medication at the right time of day and that you can check there aren’t any side-effects that can disrupt your sleep. Relaxation techniques can really help if you’re feeling anxious before bed, or if you wake up. Some of the breathing techniques we can give you on the other presentations can help settle your mind before bed and help your quality of sleep.

  Just to wrap up, if you have an advanced lung condition or have heart failure alongside, what you can do is use these tips to make the most of the energy that you have available. Plan, prioritise and pace your activities, use some adaptations to what you’re doing, like sliding rather than lifting or sitting where possible. Make sure you have those recover positions to use if you’re getting very breathless. Look at breathing control and using your breathing more effectively. Learn to avoid using your shoulders and the effortful breathing to calm it down. Use exercise to maintain your fitness and keep what you’ve got. This is really important! You should not stop exercising, but it might be that you need to modify it. If you are recovering from an exacerbation or chest infection or ended up in hospital, you might be deconditioned. Your mood might be low – also use these tips and prioritise, plan and pace while you’re recovering. Here try to build up activity levels, set yourself goals so you’re building activity levels up and exercising gradually, so that you’re improving what you’ve got and your condition. Make sure that you’re getting the right amount of sleep also.

  [end]

• Week 3 - Managing Your Mood

  Hello, I'm Claire. I'm an occupational therapist and I'm going to talk to you about managing your mood. So the aim of this session today is to introduce you to the most common mood disorders to demonstrate the link between breathlessness and your mood and to give you some strategies to try at home, but also to know where to access further help and support should you need it. So with regards to feelings and lung conditions, living with a lung condition can affect you in different ways. It can affect you by giving you physical symptoms, which is probably what sent you to the doctor in the first place such as breathlessness, phlegm, cough and feeling tired. But it may also affect your mood and consequently your mood can also affect your lung condition. In fact, people with long term lung conditions are more likely to suffer from a mental health disorder also. So we're going to look today briefly at depression, anxiety, panic and stress.

   

  So let's look at Derek. Derek has recently been diagnosed with COPD. He finds his coughing and breathlessness, is embarrassing, and he's had to stop going out as much as he used to. He started avoiding physical activity such as walking and gardening. He feels he just can't do them. He gets too breathless. He isn't sleeping as well as he used to, and he's lost interest in things he used to enjoy. He's declining invitations to go out with his friends and spends quite a lot of his time sleeping. His feelings: he's feeling angry, irritable, disheartened and hopeless about all of this. Now sometimes these are quite normal and common feelings that are associated with learning to adjust to a major life change because Derek has only just been diagnosed with COPD.

  However, if these symptoms persist and he avoids doing things more and more, they’re also symptoms of depression. Now, depression can affect both how you feel and affect how you behave. With regards to your feelings, you might be feeling down, upset, sad, tearful, restless, or irritable, guilty or worthless. Isolated, unable to relate to people, no joy in things, no pleasure in things that you used to enjoy and lack of self-confidence or self-esteem. You may feel hopeless or despairing or even suicidal. Now, this can also affect how you behave. You start avoiding events that you used to enjoy. You might find it difficult to concentrate. You might be sleeping too much or not enough. You may find you have a lot less energy before you're seeing people - thinking of Derek. You may lose your appetite, or you may actually find you eat too much. You may struggle to speak clearly. Or think clearly. You may find that you're moving more slowly than normal or you could be more restless. And some people do find that they have some self-harming behaviors or suicidal behaviors.

  So what causes depression? Sometimes there may not be an obvious cause. Sometimes it just happens. However, it can actually be set off by a number of different things. Sometimes with long term conditions such as living with a chronic lung condition can trigger depression because of the change in circumstances that you experience. It might be that you're not able to do as much as you used to. It might be a major life event, such as moving house or bereavement, or family problems, or losing your job. Sometimes other mental health problems such as anxiety can turn into depression as well because you start avoiding things and start beating yourself up about things and that then affects your mood and you can become low. Sometimes the medication that you might be taking can have a side effect of depression, and so if for some reason you feel depressed and there are no other causes that you can identify, it might be worth having a look at those side effects and checking with your GP.

   

  Alcohol is a well-known depressant. Depression affects your thoughts, your feelings, your body, and your behavior and these are interlinked. As you can see in this diagram you can start anywhere really on that cycle. You might be thinking: “I'm useless; I can't do anything without getting breathless.” Think about Derek. He's breathless. He feels he can't get out and about as he used to, he starts feeling down. He feels like he's got no energy all the time and it affects him by making him feel a bit more breathless. He then goes back to bed because he's tired and this vicious cycle can cause more breathlessness.

  So there are ways that you can help yourself manage depression if you're just starting to feel a little bit low in mood. Something like setting some small goals in the day. You might start really small and just write yourself a little list such as walking the dog, washing up, and having a nice warm bath, and then take it from there. Keeping active and exercising regularly is also really important if you even if you don't feel like it because exercise is a great mood boost that you release endorphins, the happy hormones, by exercising regularly. Pulmonary rehab as well has been proven to improve mood. Most of our patients find that they their mood improves from the beginning of the course to the end of the course. By getting outdoors, you're getting some daylight, which is a great mood booster and getting some exercise is also fantastic. Try and keep connected with people. Also, it might be that you can talk to family and friends and let off some steam. It might be that you would prefer to join a group in Lou’s talk about help and support she mentioned some support groups that you could access. Eating well is also really important, and trying to avoid junk food. Avoiding alcohol because alcohol is a depressant, although it might feel great to drown your sorrows, it will actually make you feel more depressed in the long term. Getting a good night's sleep is really important too, so trying some routine and mindfulness to help you sleep well is really going to help, and I'll talk to you about sleep in another presentation.

  Learn to relax as well, because sometimes we do keep that tension within and so learning to relax can kind of help your mood overall. Treat yourself, that is within reason to something small, so it might be a new book. It might be a little bit of alone time and taking a long bath. Try keeping a mood diary: note down the times of day that you might be feeling low. Whether anything has triggered it? And also, what might you might do to try and make it? Then there are some great self-help resources out there. For example the NHS Choices Questionnaire on their website. There's a lot of information out there on helping yourself with depression

  Then challenge your thinking. If you find that you are slipping into negative thoughts, I can't do this, I'm useless, I'm no good. Say: “Stop that. I am good. This is what I can do and try and stop it and see whether that makes a difference.”

  However, for some people these feelings might persist and there is further treatment available. Chat with your GP as to whether starting some medication might help. Sometimes medication is amazing and it really kicks start recovery. However, it is best taken with talking therapies and also some self-help along the way.

  Now moving on to Andrea, Andrea was out shopping with her daughter when she became very breathless. Andrea was very scared and could not catch her breath or stop coughing. She also felt a bit embarrassed as a crowd of people had gathered to see what the commotion was. She felt guilty because she had to cut the day short, and this upset her. Since then, Andrea has felt very anxious about going out and has begun to only shop at her local shop instead.

  She's also cancelled going back into the Town Centre with her daughter twice and is getting more and more worried about going out again.

  So what Andrea is experiencing here is anxiety triggered by not being able to catch her breath. And not being able to stop coughing.

  And now we're going to talk about Paula. So Paula was recently discharged from hospital following a nasty chest infection where she had a really high temperature, fatigue, lots of green phlegm, really, severe shortness of breath. She had been blue lighted in by ambulance. That night she struggled up the stairs to bed and was left absolutely exhausted and absolutely fighting for breath. When she came home again, she was feeling a lot better. Her phlegm was clear, the coffered gone, her temperature was normal. However, the next time she went up the stairs, she started feeling really breathless. Her heart rate increased, she became sweaty and felt like she was going to die and became even more breathless. She started to think “I can't do this anymore, I'm going to die.” Her husband was so alarmed he called an ambulance. They came along and took her to hospital again. However, she was discharged straight away. She was told her chest was absolutely fine. Now every time she goes up the stairs, she feels like this. She started avoiding going up the stairs and began sleeping on the sofa instead. So this is what we call a panic attack. This is what Paula was experiencing which was triggered by a traumatic experience.

  Panic and anxiety are similar. They come from the body triggering cortisol and adrenaline. So anxiety itself is a word to describe fear and worry. It's actually a really normal response to threat or danger. Anxiety itself normally goes away when the danger or threat has passed, and it can actually be really helpful. It can improve our performance in that job interview, or make us work harder to prepare for an exam because it kind of spurs you on. You've got something to do.

  However sometimes feelings of anxiety can persist or develop into chronic anxiety, or they can be so strong they become completely overwhelming. In Paula's case, they become experiences, panic attacks. This is when anxiety and panic become a problem because they're impacting your health and well-being and you start avoiding doing things and changing your behaviour. Sometimes our minds perceive something is a threat that actually and actually there is no danger at all. It's just a thought.

  So what are panic attacks specifically? So in everyday life, a sudden shock such as a near miss on the roads can trigger a fight or flight response. This fight or flight response can be triggered by something that's not an actual immediate threat, such as a memory of a traumatic event. So with a near miss on the road, there's a sudden burst of adrenaline in the body and that fight or flight response kicks in. However, sometimes the body creates this response when it's remembering something that happened that was traumatic. Thinking back to Paula and the stairs - her traumatic event was going up the stairs and being so breathless, she thought she was going to die and needed to go to hospital with this terrible chest infection. So this is where cortisol and adrenaline are released for Paula.

  So panic attacks themselves affect both your body and your feelings, and as do anxiety. So this diagram is showing you in green that these can be the feelings that you might be experiencing. And in orange you've got the different sensations that your body might be feeling. So you might be feeling: “I can't sit still, I'm going to die, every time I do this this happens, my lungs aren't working,” and your body might be experiencing increased sweating, pins and needles, feeling faint or dizzy, churning in the stomach. Breathing rates go up. People might experience palpitations, raised blood pressure, muscles tense, get headaches.

  If you see in bold, some of these are similar to actual chest infections you or getting unwell. You might start feeling faint or dizzy when you're getting poorly, your breathing rate might increase. You might be feeling chest pains or palpitations, breathlessness as well.

  And with anxiety as well there is that vicious cycle again, and your thoughts and your feelings and your behaviour are all interlinked. So something can trigger the anxiety; you might be getting breathless or have a worrying thought, you'll feel breathless. You might think “I'm going to die” or “what will people think of me in town. My breathing is terrible. They’re staring at me.”  You might start to feel overwhelmed, anxious, or panicky. Physically, your body will change. Your breathing gets faster, you might get more breathless, you feel hot, sick, your muscles get tense. Your behaviour might change. You might avoid start avoiding that situation, and because of that cycle and you feel breathless again, because you're avoiding activity, you've got that downward vicious cycle.

  So moving on to how we might manage it. There are different tips and techniques that you can try at home to try and help manage those feelings of anxiety. So we have some breathing techniques which you can learn that really, really help with managing anxiety when anxiety or panic start to kick in. But the key here is to practice these when you're feeling relaxed so that you can use them confidently when you're anxious.

  You might try talking about it. You might talk about how you're feeling to friends and family. You might find you need a therapist to talk to. Keeping active and taking regular exercise also really helps with people who are anxious doing pulmonary rehab as well as well of course has been shown to improve anxiety symptoms.

  Knowing your anxiety, symptoms and triggers is really important. Pay attention to when you're starting to feel anxious or when a panic attack appears. What's happening? And why? What are the triggers? What do you do to resolve the situation? Are these helpful? Try keeping a diary to to note them down and also allow yourself some worry time. Sometimes, particularly anxiety hits us at bedtime and thoughts whir and whir, but if you allow yourself a little bit of time beforehand to note them down, you can put those to bed and that can really help settle you at night.

  Also, by knowing your normal chest symptoms, so Louisa talks to you about managing your chest, that's really key to know what's normal for you so that you can pick out what is anxiety and panic and what is actually an exacerbation, and where you might need some help medically. That's a really, really important part of this course.

  Learning to relax is also really important. We all hold a lot of anxiety and stress and tension, and by learning to relax it'll help those feelings. Overall, you might like to try some relaxation DVDs or apps, listening to music, joining a class. Again, eating a healthy diet is really important for you too, and for all of us. Avoid alcohol. Alcohol  can help in the short term, but overall it's a real depressant. Then caffeine. We can often drink far too much coffee or Coca Cola and these can trigger anxiety in themselves. Keep social, have some fun and keep connected with people these. This really does help with anxiety.

  We've got some distraction techniques, relaxation techniques and mindfulness that can really help. You will have access to a relaxation DVD as part of this course with some different techniques to try, but I'm also going to mention in the next few slides a couple of techniques that that might really, really help.

  And then if these feelings persist, there is other treatment available. Medication can really help, particularly when it's taken alongside talking therapies and with some self-help techniques.

  Now, just to mention stress. So stress is all around us and stress is also very similar to anxiety as cortisol and adrenaline are released. So situations and events around us. Although that sometimes put pressure on us so the stress of it is our reaction to being put under pressure when we can't cope and then our physical health problems can actually make stress worse. Because you've got a lot more worrying. Stress is a really important thing to try and help manage. Now, there are ways that you can help manage stress. You may already have some techniques that you help that you use to manage your own stress in your daily lives. Some other tips are to exercise regularly to, try and prioritize - if you're feeling overloaded and stressed with a lot of things that are on your plate, it might be worth noting down all those tasks all those demands and think: What do you need to do? What could somebody else do do? Does it really need doing? You can have a good look through and see if you can weed stuff out. It might be that you've got some unhelpful thoughts going through your head that are causing some stress. Challenge those thoughts say: “Hey stop. How can I think differently about this?”

  And then breathe. Remember, if you're feeling really stressed at the time, remember to breathe. Take a breath in and let those worries go. Also, I'm going to talk to you about a couple of breathing techniques that you can use alongside all of all of this. Distraction is also great to help relieve stress. It might be that you use one of the distraction techniques or mindfulness techniques that are available, or it might be that you choose to do something like go and have a coffee with a friend or go and do something else if you're feeling particularly stressed by a particular activity that you're doing.

  For example, change what you're doing until the stress has gone down. Distance yourself from the source of stress as well, so it might be if you're in a particularly stressful situation at work, it might be you need to say: “Right OK, I'm feeling really stressed right now, I'm just going to go and have a have a break.” Then use some relaxation techniques in your daily life, they are really helpful with dealing with stress overall. And then you can try dealing with one problem at a time. If you've got a lot of different problems on your plate, make a list and have a look at and say: “right OK I've got these problems that need dealing with. They're causing me a lot of stress right now, but I can only deal with one thing at a time.” Then pick one and then work through that and then come back to the other things.

  So as I said, I was going to mention some different breathing techniques that might be helpful dealing with all of these issues, whether it's stress, anxiety, depression, panic. It's really key to try these at home when you're actually feeling really nice and calm.

  Diaphragmatic breathing is also known as breathing control. It can take some time to master. This is something that we can give you if you are interested in learning about diaphragmatic breathing or breathing control. Do ask any one of us and we can send you a sheet and then we can go through it with you calmly at home. You can then practice this on your own so that you really get familiar.

  The basic premise is that you are trying to get your breath into your stomach, and so you're relaxing your shoulders, because very often our shoulders can go up and down when we're stressed and a lot of tension is kept in there. You're going to be focusing on your breath, you're going to fill your lungs down and out so that your belly rises and falls.

  Another technique is called rectangle breathing, so you should only move on to rectangle breathing if you can slow your breathing down, and if you've mastered breathing control. Regular breathing when we're doing it naturally, you breathe in for a shorter period of time than  you breathe out, so generally you should breathe in two to maybe account of two and you would breathe out to account of four, so it's slower and more controlled than the in breath. This is our subconscious breathing. For people with COPD and with hyperinflated lungs, sometimes breathing can be very much in and out. And quite rushed. So it's a one to one ratio and what it should be is a one to two ratio. By breathing in and out in this way you can really calm your breathing down, and it's a great technique to help with managing panic and anxiety. However, if you want to learn more about it, we can go through this with you separately.

  Another great technique that you can literally use anywhere is a little distraction technique. Again you should try and practice when you're calm so that you know and it doesn't cause you stress to think or what comes next. What you should do is, when you're nice and quiet and calm, hold your hand out and curl in one finger and think of five things that you can see around you or look at five things that you can see around you and then you can either say them out loud or you can say them to yourself. And then four things that you can touch or feel. So it might be something like your chair underneath you or it might be some fabric, or it might be that the little itch on the end of your nose, so it could be internal sensations, or it could be external sensations. So again, either say them to yourself inside, or you can say them out loud. Then curl in your middle finger and three things that you can hear. So pay attention to what's around you see what you can hear. Can it be the fridge humming, the birds tweeting, the cars going past. So that's three things that you can hear. Then two things that you can smell, so it might be that you can't really smell anything around you. So then maybe imagine something that you can smell something that you like. It could be coffee roses, the beach, anything that you want. And then the last thing is one thing that you can taste. So it might be that you can still taste the toothpaste where you brush your teeth this morning, or it might be something that you have to imagine. Like you know, nice pizza or a cup of coffee. And when you've gotten through all of those, notice how you're feeling. Do you feel any different? Has it brought you all your feelings down and calmed you down. So that’s the idea of that little distraction technique.

  Now one of the ways that particularly talking therapies and other self-help therapies can help with feelings of anxiety, depression and stress is a technique called cognitive behavioral therapy. Cognitive behavioural therapy or CBT looks at the cognitive side, so that's your thoughts and thinking patterns, behaviours as well. So what you do and the therapy is changing those. So this is one of the most effective treatments for things like anxiety and depression, and it's the one that's recommended by NICE guidelines. And it's generally done over a process of a number of weeks with homework to do, and a therapist can guide you, but also you have the NHS Choices which can give you CBT self-help strategies to do as well.

   

  So how does it work? So now you remember, this should look familiar to you now. This is a bit of that vicious cycle. However, now I've got a blue box for you to look at. So as you know and I've talked you through already, that your body, the way you feel your behaviour, your feelings, and your thoughts all are very much interlinked and can affect each other. And when you're stuck in that vicious cycle of anxiety or depression or panic, one of the ways that we can help stop that cycle and start a positive cycle is by changing one of those elements. So here I've got your thoughts in blue. So this is where we're going to change the way you're thinking. So instead of saying: “I'm going to die, I'm so breathless. I can't do this,” and that negative cycle then makes you feel low and fed up and you're tense and anxious and breathless, and you're avoiding the stairs and you're feeling even more breathless. What we're going to do is say no, actually, I can do this! So if you remember positions of ease or recovery positions, if you're feeling breathless, say: “I'm going to try one of these to see if my breathing settles down.” Or maybe you pace your breathing. In another presentation we talk about pacing, and that's a really good strategy. So you've got some strategies. You know what's normal for you and you say: “Actually, I'm breathless, this is what I'm going to do.” So your thoughts have changed. And that means that you start feeling much more calm, much more confident, and notice that your breathing will slow, your muscles relax. Hey, you can't climb the stairs, you're going to carry on climbing the stairs. Even though you might feel a little bit breathless, you might feel less breathless. So then you think: “Hey. I'm doing this. I can do this.”

  And you continue to feel calm and confident. And physically, you don't feel as terrible the next time that you do it, so you're going to carry on doing it. That means instead of ending up with a style lift that you can actually carry on doing the stairs because it's you know really good for you. So that is how CBT works.

  So now if you find that you do actually need further help, this is now where I'm going to tell you a little bit about how to access that pulmonary rehab. We are a great resource, all of us, come and talk to us about different strategies. If you're struggling with anything on how to do any of these techniques, whether you want to learn more about the breathing control, whether you want to talk about your own situation. It might be that your mood is really really low, or you're very very anxious. If you have completed any of the questionnaires at the beginning of the course and found that you’re moderate or severe on the PHQ 9 or the GAD7, it might be that you want to talk to your GP about starting some medication because that can really, really help support you if anxiety and depression and your mood are really getting you down.

  Talking therapies are also really, really useful, and the talking therapies that we recommend from here are Bedfordshire Well-Being and Luton’s Total Wellbeing service, so they're there for people in our area. For Luton residents we guide you towards Total Wellbeing Luton. You may very well have heard about these guys because they do a whole range of different things from smoking cessation, active lifestyles as well, they also provide talking therapies, so please do feel free to pause this slide to take down the telephone number or if you want to look at the website there is a lifestyles questionnaire that you can access and you fill in your details and they will get back to you. Or if you prefer to speak to somebody on the phone, the telephone number is there at the bottom.

  If you're in Central Bedfordshire, so that's Dunstable, Houghton Regis, Toddington, Leighton Buzzard, we guide you towards  Bedfordshire Well-being service. They also have a website and you can fill in their quick and secure form and they will get back to you. If you prefer to talk to them over the phone the contact details are there as well, so again you can pause this slide and get in touch.

  Alternatively we've got MIND who work across Bedfordshire, Luton, and Milton Keynes, and it might be that you prefer to speak to these guys. They also have an online support and they have a huge amount of information and self-help ideas and videos and worksheets on their website. So if you are interested in MIND, it's a really excellent resource.

  You may feel really, low really needing some urgent help. If you don't want to talk to a family member or a friend about things that are difficult for you at this precise moment. If you're really struggling, please do again, pause this slide, have a look and these are really useful numbers for either yourself or loved ones if they're going through difficulty because it's not just for people with lung conditions. These are for everybody, so we've got the Samaritans, we've got SHOUT, Saneline and No Panic.

  Then what to do if you're really having a crisis? If you've harmed yourself, if a loved one is harmed themselves. If you're worried that you might harm yourself if you can get yourself to one of the local hospitals or if you really need help straight away, then you can dial 999.

  [end]

• Week 4 - Active Lifestyles

  Hello and welcome. My name's Ian, I'm the therapy instructor for the pulmonary rehab team. And today I'll be going through with you all about active lifestyles. So we'll be looking at why exercise is important and crucial for our overall health and well-being and why just keeping active is essential as well.
  
  So as you can see at the moment, there's various ways to keep active and keep healthy and strong as well, and I’ll just go through with you just some of the benefits of exercise and being active.
  

  So what is exercise? So exercise is an activity that results in an increased heart rate.  , so you could be doing a bit of walking, you could be on your bike, anything that's just going to get the blood pumping?

  Your respiratory rate goes up as well. So you start to breathe a little bit quicker, but that's fine. That's something that needs to happen to help refuel your oxygen stores. So then you're able to continue with that exercise.

  Perspiration occurs as well. Now, for some people, you may feel that perspiration is a bad thing, but it's not. It's a sign that your body is doing what it's supposed to do, which is to cool you down so you can then continue on exercising. If you weren’t to sweat, then you may overheat, which then may lead to other issues too. So it's a good sign.

  It's designed to increase your levels of fitness and improve your health as well, so through regular exercise, you may be able to walk a little bit further, lift a little bit more. So overall, fitness is going to gradually go up through consistent exercise and also your health as well is going to improve. So maybe you sleep better as well. Maybe you're not having to take certain medications as much. Or if you're diabetic, maybe your blood sugar is a bit more under control through regular exercise.

  So there's lots and lots of benefits to exercise, which we’ll cover throughout this presentation, and exercise is enjoyable. We all love doing a little bit of exercise, especially when you get family and friends involved. I mean, sometimes doing it on your own can be a bit of a chore, and you feel like you need to get that motivation to actually do the exercise. But when you involve friends, family members or you’re in a group based setting, then that whole scene is part of what exercise is your there encouraging each other, you're pushing each other a long, you know, plus you get to conversate with each other as well. But then also by seeing that you are making progress throughout your exercise journey, that's going to be enjoyable part as well. You think to yourself, you know, I can walk a little bit further. I can do a little bit much. And you get enjoyment out of that. So then you continue junior exercises. So it's not just the exercising on its own, it's everything that comes along with exercise.

  So we're going to break down those first three headings. So what happens when we exercised? So your heart rate increases, so your heart is like any other muscle, so you do need to exercise to keep it healthy and strong.

  Now you can't specifically target your heart muscle unlike your arms and like your legs. But by getting your blood flowing and getting your heart rate pumping as well, you're then able to increase the efficiency of the heart muscle.

  And again, it's just all about trying to be as consistent as you can while hitting the right targets and hitting your goals as well.

  Your respiratory rate increases. So as we say, your breathing goes up, and that's because you’re drain and all of your oxygen stores, which are said, it's not a bad thing. So when you're doing some exercises, you will then be increasing your breathing rate to replenish your lost oxygen stores, which again is going to help you recover in the long term.

  And circulation as well plays a massive part when we're exercising. So you may be someone who tends to get cold fingers and toes, and it can be a nice hot summer's day outside, and that can be down to poor circulation. So through regular exercising you can help blood flow to side areas of the body.

  Now, if circulation is something that you have trouble with, then maybe doing like a long walk or lifting some heavy weight or something might not be ideal, but something like a little stress ball that you can use can squeeze to help the blood flow to the fingers. And to add something to mobilize your ankles as well can help blood flow to those areas.  . So again, it's just all about just being consistent. To help to get all of these regular benefits of exercise.

  So there are two types of exercises that we generally do in pulmonary rehab. But it's not just in pulmonary rehab or every exercise that you do tends to fall into two categories. So you've got your aerobic training. So when we move our muscles or move our body they then require oxygen again. Over time, the body gets used to that action of you depleting your oxygen stores and then having to replenish it through increasing your respiratory rate. So the more we do our aerobic activities, like our walking, like our cycling,  , your body is going to get used, to get accustomed to that. And then then we'll come back stronger, fitter and healthier so that you won't need as much oxygen. So again, it's about improving the efficiency of the way the body works, but then the way the heart works as well, so it's going to be improving your resting heart rate. It's going to be a little bit slower, which is a good thing because each pump is pumping more blood and more oxygen to where it's needed.

  And then you put your strength based exercises as well. So again, this could be if you've got a set of dumbbells at home and you're using those to lift or if you're using your milk cartons or your packs of sugar, anything that you've got at home, which has got a little bit of weight to it, you can use to build a bit of strength, build a bit of muscle, improve posture, but then also improve things that you do on a day to day, which I will get into as well.

  So over time, muscles get stronger and it becomes easier to lift that weight, and that is through just regular strength training. I'll get into in a bit more detail later on in the presentation.

  So these are just some of the benefits of exercise. So through regular exercise, as I said, you may feel fitter. You may feel stronger, may stamina is improved. You're able to walk that little bit further without getting as out of breath. But what's actually going on in the body when it comes to exercise and the benefits it gives us?

  As you can see, this decrease in the risk of coronary heart disease and stroke by 35%, so your increasing the efficiency and overall health of your heart muscle. Type two diabetes, as well is decreased by 50%. So again, we're using up your blood sugars throughout the body through regular exercising, and you can do your aerobic activities like you're walking and cycling in your gardening. But it's mainly through your strength based activities as well. So are you working on those legs, working on those arms specifically to help burn up a lot of excess glucose, which you may have in the body, which then will help decrease the risk of getting type two diabetes, but not only decreasing the risk of getting type two diabetes, but then also managing type two diabetes as well.

  So again, another really good benefit of regular exercise that helps lower the risk of breast cancer and colon cancer as well, again through lowering those levels of oestrogen within the body, depression that feel good feeling, you know, as I mentioned before, doing a bit of exercise in a group based setting or a friend or family member or someone who lives in your home, you know, to get everyone involved, get everyone involved in it, and it just picks you up. It really does. You know, you're working off each other, you benefit from the exercising as well again. And that can help just lift your mood, you know, be releasing those endorphins, but then also noticing those changes to your body or hitting your targets, hitting your goals. You're feeling good. That's going to help lift your mood as well, which then helps lower the risk of a depression,

  But then dementia as well. So all the chemicals that are released to the brain through regular exercise, you know, helps lower the risk of getting dementia. Helps manage dementia as well, and just having that goal in mind, you know, always having something to focus on which is improving your health can help lower the risk of getting dementia.

  It also helps to prevent osteoarthritis, falls and hip fractures. So falls: something that, well, anything that we do that when we're on our feet, we're going to be using our core stability, so those muscles right here in the tummy and the lower back as well. So through regular exercises which utilize your core stability muscles, you're going to help improve, improve posture. It may help improve balance, which is then going to help prevent falls. Osteoarthritis as well. So again, keeping those joints loose and lubricated and flexible, it's going to help to prevent osteoarthritis, but then also then also help manage osteoarthritis as well, especially during the winter months. You know, when it gets a little bit colder and muscles and joints tend to stiffen up a little bit. Just by doing some regular flexibility, so not go not for a long walk or having to lift some heavy weights, but just some flexibility training, you know, like flicking the wrists around, flicking your ankles around, moving the hips a little bit. You know, it's going to help manage osteoarthritis, but also help prevent it as well. And then hip fractures it helps to prevent. So not only do strength enough muscles, but we also strengthen our bones as well through regular exercise, and that comes along with having plenty of sleep or getting enough sleep, I should say, but then also having a good diet and nutrition, which we'll touch on on another presentation.  , and many others, you know, improve sleep, improve mood, healthier diet, breathing lots and lots of different benefits to exercise.

  And a good thing is it can be done anywhere. You know, it can be done in your back garden, it can be done in your front room, it can be done in your kitchen while you're co ing dinner. You know it can be done at any point throughout the day, and you still get a lot of these great, great benefits.

  So what happens when we stop exercising? Right? So, yeah, we don't want to lo  like this man here. But again, there's nothing wrong with that. But what happens when we stop exercising - so it’s kind of the case of use it or lose it?

  So that can be for any amount of reasons why you having to stop exercising that you've become unwell, you’re having to go to the hospital, you got a nice, lovely holiday. You've been sitting on the beach for two weeks enjoying yourself when you haven't really been moving around as much.

  But then you come back home and things come become a little bit more challenging. hat's because your body then adapts to that more sedentary lifestyle where you haven't done as much, you haven't worked in your heart, you haven't been getting it breathing up as much as you were when you were exercising.

  So again, as I said, the body does then adapt to that and it doesn't take very long. Talking to Claire, who you would have seen on a previous talk, if you asked if anyone one of us was to be in hospital for about a week, whether you are then told to sit in in your bed for however long, you may be in hospital for a week, doing that is the same as ten years of deconditioning.  ? So again, it just shows how quickly the body does  decondition and gets used to the fact that you are maybe just laying in bed or just sitting down watching TV.

  But then there is a bright side. Deconditioning is reversible once active again because your body has got a very good muscle memory.  , so it does remember what you have done previously. So say, for example, you used to do lots and lots of swimming and then you to  a break for however long. Let's just say a month or so,  ? It may only take you 15 days so half the month to get back to where you were previously compared to someone who's never swam before in their life.  . Because again, the body has got that good memory and you can get back into a nice regular routine.

  so how much is enough? How much do we think we need to do to get those regular benefits of exercise? So what we suggest is that you aim for 150 minutes of moderate intensity exercise per week. So moderate intensity exercise is highlighted. So what do we mean by that? So you might have seen in our pre one of the previous talks or if you have ever been to the groups before, that motor intensive exercise just means that you want to feel a little bit puffed the heart rate and breathing up. You may start to sweat a little bit, but you're still able to hold a conversation. Now, getting beyond that point wouldn't do you any good, really, because you just can become over fatigued and you may do yourself more harm than good.

  So you want to aim for a level three, level four on the Borg scale, so feeling a bit puffed but able to talk  ? That can be br en down into 30 minutes of exercise, five days a week so you can get the weekend off as well, if you'd like. But five days a week for some may be a bit much of specific exercise. So if you wanted to break it down to fit your routine but you have at home, you may like to do a Monday. Then you have a rest on Tuesday until Wednesday. Rest on Thursday or Friday. Perfect, perfect. Perfect routine to follow. If you are lo ing at doing specific exercises,  ? You can break it down any way you want as long as you are doing at least ten minutes of continuous exercise. So for that first ten minutes, you're just getting the body warmed up, just getting the blood flowing, getting the heart rate up. Breathing might come up a little bit, but that's not the idea behind the warmup.

  So you want to warm up the body first. Firstly, to prevent injury, I would say, and as I said, to just get the body prepared for the exercise that you're about to partake in.  . So always do for a minimum of ten minutes if you are looking at doing some specific exercises, and it can be broken down any way which suits you. Again, that's the good thing about exercise as well. It's a very tailor-able, you know, you can tailor it to your lifestyle or what you're doing at home, or whether you are, whether you need to go out and about, do your regular shopping and anything like that, you can always fit exercise around that.

  So is exercise the same as being active? Well, this is a more like a yes and no. Some people may say no. Some people say, Yeah, it's the same. So let's break it down a little bit. Is exercise the same as being active? So if we look at the definition of exercise, it’s any activity where you're physically active for a minimum of ten minutes and it's specific, so you’re specifically target in your leg muscles you’re specifically targeting your upper body muscles. You're specifically targeting your posture. So that's something that you want to work on - correcting posture. You know, if you're sitting forward or you're hunched forward and you want to work on that, then through exercise, you can typically target your upper back muscles to correct your posture. So if I'm sitting up right now, so you want to your specifically target your upper back muscles?  So exercise it.

  Being active is just unspecific, So you may do a bit of gardening and you may do a bit of housework. You may go out shopping for the day.  . Again, all lovely things. But if you finding that through these regular activities, you're not getting a bit puffed, you're not getting about of breath, you're not starting to sweat a little bit, then no, I wouldn't call that exercise  . The idea of calling it exercise is to get your heart rate up, get your free trout rates up and may cause you to sweat as well and again, achieve a level four on the Borg scale.  , and making it at least ten minutes.

  So if you think about some of the chores and activities that you do around the house, a lot of the time they do last more than ten minutes. So if you're doing your hoovering, for example, you're having to go up and down constantly working your arms, working the legs, working those core stability muscles as well or if you're having to do a bit of gardening. You're getting down, you’re digging, you know, you're pulling up flowers or putting flowers back in. You know, you may be cutting the grass, working your upper body, working the arms.

  There's a lot of these activities which you find they do last more than ten minutes. You may do them for an hour. And after you've finished, you have to have a sit down, take a breather. And that's because you've worked your muscles, you've got your heart rate up, you've got your breathing up as well.

  So absolutely. Exercise as I said. It's a yes or no answer. So yes in the sense that if you are getting a breathing up, getting your heart rate up and you may start to sweat, then absolutely. Why wouldn't it be exercise? You can include that as part of your half an hour of exercise per day. But if you're not hitting those targets, then I wouldn't say it's exercise.

  What does count as exercise? So we can say? I will always say the best form for me, the best form of exercise is walking. It's low impact. So if you do have any issues with lower back, with knees, ankles, any of those things right there, it reduces all of that impacts.  , so walking can be done anywhere.  , if you're walking up a hill, you find it just going up a hill. You get a bit puffed and out of breath. Yeah, absolutely. That's exercise. Going downhill, a little bit easier. Yes, but you're still having to work different muscles throughout the body. Walking on uneven surfaces where you're having to utilize your core stability muscles. I always bring it back to core, because core is the connector between your legs and your upper body. And if you can have your core muscles nice and strong, then, as I said, improve posture and balance, but then also help with a lot of other activities that you do at home as well. So walking is brilliant, perfect exercise that you can do anywhere at any time as well.

  So gardening, we mentioned gardening: digging, or pushing a lawn mower. Lots and lots of different ways. You can stay active, get your heart rate up. Get your breathing up through gardening as well. Going up and down stairs? Yeah, absolutely. Yeah. Working all the muscles in your lower body, in those legs, and legs are such a crucial muscle that we all need to have nice and strong. Those are our ambulatory muscles. You know, they help us get from point A to point B.

  So being able to keep those nice and strong is key. Yeah. So going up and down stairs? Absolutely. Really, really good exercise. Exercise classes as well. Know in the current circumstances, exercise classes are out of the equation. But you don't have to go out somewhere to do an exercise class. You can have the exercise class at home with whoever you live with, you know, family members, your friends. Doing a class at home or doing some of the exercise videos that you would have watched through this pulmonary Rehab course is part of that moderate intensity exercise that you can keep up with as well. Any type of aerobic activity as well. So just general walking, general housework, you know, gardening or doing the best cycling, perfect aerobic activity, which is going to work the whole body all at once and hit all those targets that you need to help to get those regular benefits of exercise.

  And set yourself targets as well. That's the main thing.  ? So set yourself those goals, which I'll touch on another slide, but it's very important because it gives you something to work towards. It doesn't have to be a big, big target,  ? It can be something as small as saying, right, today I want to do 20 minutes of gardening today, so I'm going to do half an hour of housework, you know, and you've done that and you feel good for doing it as well.  , so set yourself these small, achievable targets, which will then build up to those long term targets and goals.

  So when it does come to writing down goals or choosing the right goal for you, you want to make it smart.  , so we're going to break down the SMART goals and what it actually means. So we've got someone let's say we've got John, so John's goal for coming to or partaking in our pulmonary rehab course is to increase his walking distance by 200 meters without stopping by the end of the course.

  It's a very specific goal right there. You may have a goal to improve stamina, there is nothing wrong with that, but improving  Stamina can mean a lot of different things. So we just want you to be just a little bit more specific about it.

  So increase walking distance by 200 meters. That's improving your stamina right there. So try and look at your goals and your targets for your exercising and yeah, a bit more meaning a bit more feel into it, and that way you're more and more likely to then work towards it.

  Is it measurable? Is your goal measurable? So how can you see your progress to get towards your specific goal? So John is trying to increase his walking distance by 20 metres each time, so you can measure each session he's going to do twenty metres extra, then come the end, he's going to hit his 200 meters by the end of the course, so you need to find ways to measure your SMART goal.

  Is it achievable? Absolutely. Yes, he can. If you attend each session and then aim to progress each session as well, so do that a little bit more. So then you can feel the difference, absolutely it is achievable just by doing a little bit more.

  Is it realistic as well, given the time and the resources available to John? So if John is going through all the videos that you're watching, he's doing the videos twice a week in his own time, so that's the resources that he's always got support from us and others and hopefully his family members as well, who are supporting him as well.  So would you say that's realistic? I would absolutely. With the right support and help. Yeah, he can. We would say it's realistic.

  So you've set a time. We're going to go for a seven week pulmonary rehab course.  . So for about that? So by the end of the seven weeks, he would have achieved his target of walking an extra 200 meters without stopping.

  So that's what we mean aim for the bull's eye. So, yeah, small achievable goals to then aim for your big, big goal at the end.

  So what happens after the course?  , so yeah, you will have these videos, which you can continue on with. Absolutely nothing wrong with that. But if you would like a home exercise booklet, we can send you out one as well. Very similar to the exercises, but something where you can record your goal, record the exercises that you do doing as well, how you felt after each exercise session that you've done. And it's just the way to just morning monitor and measure your progression throughout the course. . Again, exercising at home and just keeping that active lifestyles. So yeah, you're doing your exercises, your specific exercises for at least ten minutes, 15 minutes, 20 minutes, however long you choose to do.

  But then you are just keeping active as well. So going out for walks, doing your regular shop, your housework, you know, seeing friends and family members, you know, as well that's going to incorporate into your exercise. So you do get all those benefits that you have built up throughout.

  So just some of the pros and cons of exercising at home. So, yeah, very convenient. Less time required in the comfort your own home, you know, you can do at any point throughout the day. You can say ten minutes in the morning. So after you've woken up, you can do some, you know, your mobility exercises again, it all counts, but you're doing your mobility type exercises just to loosen up the body from the night before weight in the morning. You might may tend to feel a little bit stiff. You do need some mobility exercises ten minutes around lunchtime, so you have a lovely lunch. You feel good, you feel energetic. So then you decide to go out for a little walk. And then later on in the evening, you start to do some more mobility type exercises to help widen the body down for bed.

  So you can fit here at any point throughout the day,

  But then cons. So again, if you do find it, that motivation is something you have trouble with and you do need someone like myself or one of the team to give you a call or come to see you and give you the extra little bit of a push, you know, it can be quite difficult. But as I said before, you know, we are here to support you throughout this journey to help you improve your overall health and your fitness as well. We are always here on hand to help. If you haven't got any equipment at home as well. So you haven't got any ankle weights or some dumbbells or anything like that, then you may feel like you can't do the exercises that we're asking or showing you to do. And that's fine, because then you can use, as said, you can use anything at home with a bit of weight to it. So if you've got your four pints of milk, once you finish with that filled out with water and then you've got two perfectly good dumbbells right there. If you've got a sock or anything like that at home, you can fill it with something wrapping around your ankles and you've got perfectly good ankle weights right there as well. And anything else, anything that you feel that you can use with just a bit of weight, so it doesn't have to be heavy, but anything that you can use to just get your muscles working a little bit. If improved posture and strength is one of your targets, then yeah, you can use that to progress your exercises. No questions about that.

  So going to a gym or leisure centre, I would say, because then it's not all about the gym itself. There are leisure centres which have gyms, so leisure centres, they tend to have swimming pools. They tend to have lots of different classes and lots and lots of different activities for anyone to partake in. It's not just the gym, and we're just trying to remove that stigma that, yeah, it's just for the younger fit and the healthy. And if that was the case, then what's the point in them? Because if they're already young, fit and healthy, then they won't need to go to the gym. The gym is for everyone. Anyone that you see walking down the high street, you may see in a leisure centre.

  And a lot of GP's these days are doing what they call an exercise referral scheme or GP referral scheme as well, where now you can literally go to the GP and say you may be struggling with weight, with wood, with your diet and nutrition, and they may refer you want to a leisure centre where you will have you'll get a bespoke program you'd be working with someone maybe work in a group based setting as well. As I said at the moment, those things aren't running, but when they are, you could have gone to one of these exercise groups.

  And again, it's just another tool which you can, which you can use to help achieve your goals and your targets. So leisure centres are for everyone, regardless of age, regardless of nationality. You know, it's they are for everyone. So if you are a Luton based resident, the they have a service called the Total Wellbeing Team  , and they've got various sites in and around Luton.  So you've got Inspire, the big swimming pool up in Stopsley. You've got Lewsey Sports Park, very close to the hospital. You've got the Lea Manor Recreation Centre in Moss Farm, you’ve got the Stockwell Park Athletic Centre and golf, and you've got High Town community sports centre.

  So very various different centres and they all offer different activities and services. So they do specific classes and groups for people who have completed the pulmonary rehab course. They do a gardening project as well. So during the summer months, when the weather is lovely, they do community gardening projects as well. So just getting out and about, meeting new people, making new friends again, you've got a similar goal in mind, which is to improve your health and mood. And yeah, maybe make new friends as well. They generally say, go into an exercise group or leisure centre or anything like that. It's one of the best places to meet new people and making friends. They have got lots and lots of different services on offer.

  So all you have to do is complete the pulmonary rehab, we’ll then send a referral over to the total wellbeing team. They'll get in contact with you, invite you down and get the whole process started of getting you joined up and getting your program written out and go from there. As I said, it's just another tool which you may use to achieve your goals.

  Leisure centres, not for everyone. I know I 100% understand that it's not for everyone. And it's absolutely fine. For me and the floor for the rest of the team, I should say, all we would like to know, is that you are keeping active and you are doing the right things to keep yourself healthy and well.

  And then for the Bedfordshire side of the things as well. So you've got your Dunstable Leisure Centre, Houghton Regis leisure centre Flitwick, and Tiddenfoot leisure centre as well. And there are various others as well. In and around the Bedfordshire area, but very, very similar scheme as the total wellbeing. So again, we would refer you onto their course at a reduced rate, if you went to sign up, we’ll refer you onto their course, they will get in contact with you and then you can get signed up and work towards your goals as well. So if anyone does have any questions about the total wellbeing team or the Bedfordshire Exercise Referral Scheme as well, please, please get in contact with us and we can go through it with you in a bit more detail.

  So just some of the benefits of exercise in a gym or a leisure centre or a group. So as I said, special groups for those who have completed the pulmonary rehab course, you will be in it with a team of professional qualified instructors. So they will know about your condition and what you have, and then'll be able to work with you to help improve symptoms as well.  And again, it's all about just helping to build that active lifestyle as well.

  Again, some of the pros and cons. So yeah, very motivating, social and supportive. Just like with us as well. And if you did want to try get back into the swimming and do some bowls, do some Nordic walking, you know, or just general health walks as well, a lot of these centres, they do health walks, you can join in to those as well.

  But then some of the cons. So if they get in there, if one of the centres is a bit out of the way for you, then that can be a con. The costs. So what the total wellbeing do, they do twelve sessions for £24, so for the first twelve, two pound per session and then after that is £3 per session. And I'll give you a little voucher and each time you come in, there they will stamp your voucher, and that can allow you to use any of their services. So whether you are using the leisure centre or whether you are using a swimming pool or tring and one of the classes like Yoga or Taichi, really, really good for breathing and many others. You can use to offer a little voucher for any of those services.

  But then there are those set times of day. So with the various different centres around Luton and the Bedfordshire ones, they may only have like the Taichi on a Friday, which you may not be able to attend to as well. Or they may only have that certain group on a Wednesday, which you may not be able to attend, but hopefully there is something there which you can join up to, which then will help you help your progression, so there are those set times a day which you may have to look into.

  But as again, as I said, if you did want any more information about those two services, please get in contact with us and we can get through with you. So just some of the reasons to go to at least give it a try because with both services, the first session is free just to see if you enjoy it, whether you liked it, if not absolutely fine. If he did, then yeah, you can then progress on. So as I said, it just helps you set at the targets. Maybe help you set out the goals. Socialize again. Meet new people, make new friends,   and improve your overall health, as we said right at the start to exercise. Keep an active, have an active lifestyle. Is going to improve your overall health and your fitness as well. So reduce exacerbations and hospital visits, which we all want.

  You have lots of different equipment and machines that you can use throughout all of these different leisure centres. And again, it's just about having fun and enjoying it again as you're doing it as well. It's just like you would do at home or just as you would do if you were to come to our pulmonary rehab groups. Again, we're not sure when we're going to be getting those groups up and running again, but hopefully through this and through maybe some online live course, we can still have fun and we can still enjoy it as well. So yeah, just some of the reasons to at least give it a try for that first session.

  If not, there's many other ways we can keep you active and keep you exercising.

  So in short, just to round everything up. We know that exercise is key is crucial for your overall health and well-being as well, regardless of your age or if you've got a condition so exercise can help with wide range when you when you're doing cardiac rehab. You've got pulmonary rehab. You've got weight management groups or stroke groups. You know, MS groups, lots and lots of different types of rehab groups. And all you're doing is exercising. And that's because of everything that can help with.

  I remember reading an article one day and it said that if exercise are put into a medication, it'll be like the miracle cure for a lot of different conditions. That's because of everything that can help with. It's just as I said sad, setting yourself those targets and setting yourself those goals to help achieve those long term goals. Your long term goal maybe, as I said, to go on holiday somewhere, but you haven't been able to because of your health and your condition. So by setting yourself, as with John, setting yourself to do an extra 200 metres come the end of pulmonary rehab.

  What's the next step, John?  John now wants to walk an extra 500 meters, you know, in the next seven weeks. Brilliant. What's the next step? What about today? What can I do today to help? Oh, I'm going to do some gardening.

  You know, I'm going to go shopping. Yeah, just thinking of it like that way, you know, just setting yourself a small, manageable tasks for now to help you then aim for that big long term goal, which again, hopefully, hopefully we’ve all got

  And through this talk hopefully, it's just getting you thinking of what you do want to achieve from going through this pulmonary rehab course.  

  Thank you very much, everyone. If you do have any questions, I would love to hear them. So please do get in contact with us at any point.

  We are always here and we're here to help. We're here to support you, as I said, to help achieve your goals. Myself and the rest of the team, we are here. So any point, any questions at all about the presentation that we've just gone through or any of the previous presentations.

  Please do get in contact with us and we'll be more than happy to support and help. Thank you very much.

• Week 4 - Smoking

  My name is Peter. I am a healthy lifestyle specialist focusing in stop smoking, from total well-being Luton and this talk today is about how smoking or passive smoking impacts you and your exact respiratory condition. Now we don't focus on specific respiratory conditions, rather taking a broader view encompassing emphysema, COPD and many others.

  So firstly, like I said, I'm employed by total well-being Luton. For those of you that never come across us, we’re are an amalgamation of Turning Point and Active Luton, their aims are to look after and support the physical and emotional needs of Luton.

  This includes a variety of classes available for free of charge or very, very low charge. Turning Point are a mental health charity and Active Luton are a physical health provider. Focusing on gyms particularly.

  What Total Wellbeing do is they do a selection of these, and again, free or very, very low charge, including health checks, long term conditions, effects among different exercise classes which are available to you. Exercise on referrals of a GP referral at the extra exercisem social prescription is about getting you to know what's exactly out there in your community, this wonderful thing that you probably have never heard of. Weight management changes your perception of weight, so it's a to if you think you're too large. But it's also the side where you're too skinny and you have a really poor relationship with food basically. Stop Smoking that kind of does what it says on the tin. And emotional health includes a number of talking therapies, but alongside that, many workshops are based on stress anxiety, especially in the current coronavirus crisis that has come very much to the forefront required.

  So this talk is, like I said, to understand cigarettes and passive smoke and how it impacts you. So obviously we do know cigarette smoke is obviously bad. So I'm not going to go for that. Perhaps he likes discussed tobacco in a different light and we'd like I said, we focus on your quality of life around smoking and a few facts along the way which could help you win that all-important pub quiz.

  So things we’ll recover quickly will be backgrounds, tobacco, some of the important chemicals, how it's going to impact you, noticeably in the current climate, how tobacco and COVID 19 are related. I'm going to touch on why smoking isn't illegal.

  Any major questions we have about e-cigarettes that come up in the past and how and who do we help?

  So tobacco came around in the mid 1500s. Francis Drake brought over to the UK. Spain adopted, becoming the capital of tobacco as not surprisingly, it became very popular and as with everything to become very popular it's very quickly taxed by the royal family in England and across most of Europe.

  Cigarettes have been a mainstay in society, probably since the early times right through to probably the early 2000s. Many of you can probably relate to when doctors may have suggested even going to have a cigarette or a cigarette improves many, many symptoms. Obviously, that is wrong, but that's how perceptions have changed over time and probably since 2000s, when the laws have rapidly changed. We'll go for some of those laws as well and how they've impacted general life for many as well.

  So first question would be  when was smoking first linked to lung cancer? I've listed up there four answers now.

  If you just take a guess what you think? And the correct answer was C the 1950s, it was first linked to lung cancer and a doctor's health study in 1954, so Tobacco was around for four hundred and 50 years prior to being linked to lung cancer.

  And obviously since then, there's been many, many, many findings which have gone on to show how detrimental tobacco smoke is to your health. The doctor's health study was a longitudinal study, and their findings are still ground-breaking even today. So at a time, they were so important.

  So we said the first known lung cancer was linked in 1954. It wasn't until the late sixties and seventies the first laws really came into around tobacco. Mainly they were about taxation, and they've accelerated in recent years. Like I said earlier on the 2000s of probably a changing point with the worldwide ban on advertising in tobacco. And then in the UK 2007 indoor smoking ban. And more recently, the doors have revolved around the shutters on tobacco in supermarkets and convenience stores to changing packaging and wording on packaging, the colour of packaging, the pictures on packaging and obviously the big one is taxation.

  So there’s currently four main categories you can get taxed on in the UK, we’ll only actually touch on two because they’re easier to break down, but these other two include cigars and pipe tobacco.

  On every packet of 20 cigarettes, there's £4.75 plus 16.5% of retail value. Now if you did the work of ten pound a pack, you're looking at paying over about 55 to 60% of that just on taxation and even on a 50 gram tobacco pouch, you can get these in 30 or 50 grams. You're looking at paying two thirds or most of that is tax. However, the U.K. government does only generate about approximately £7 billion annually. Yet, tobacco costs society approximately £14 billion each year.

  A little fact along the way that, on average 230 children or adolescents will pick up a cigarette and become a lifelong smoker each day, and that number has been dwindling down over the last 40 years. If you are to think back for 40 years, 30 to 40 years, smoking was approximately 35% of the population did it. Now you're looking at between 14 and 16% as a general population figure. So it's coming down as a trend.

  So in terms of how many chemicals are in each and every cigarette or roll up, there’s four answers on the board here you just take a shot in the dark what you reckon.

  And the answer is actually D, it's 4000 chemicals. More importantly, we still don't understand some of these chemicals, and many of these chemicals actually have alternative uses. So I've listed for you that two of which you've probably heard of arsenic of formaldehyde.

  Obviously, a rat poison and an embalming fluid. But Polonium 230 is actually radiation. And again, how many of these 4000 are known to cause cancer? And if you don't know, it's 69, it's B, and this is what is currently known as some chemicals and not fully understood. So that could well be more something that we don't actually know about yet.

  And this is where it starts to impact you as primarily most of you will be non-smokers. So of these 4000 chemicals, how many do you think are available in second-hand smoke?

  To which the answer is 250. What is apparent, even for a non-smoker, these chemicals will impact on your health substantially. Roy Castle is a good example, notably as a non-smoker, he only ever received passive smoke, he died of lung cancer along the way.

  So we will go on to 3 chemicals, particularly available in cigarettes. And when we start talking about how it impacts you, I've got a pint glass, this will be one of the alveola one of the air sacs in your lungs.

  So every time you're exposed to second-hand smoke, the glass will fill up a little bit, your little lungs will fill up and then you will then cough a little bit traditionally the smoker's cough and get rid of a little bit. I’m accelerating this a little bit, but every time you can kind of see up and down, up and down, up and down, you get to a certain point where your quality of life has impacted. That's normally around half way.

  At that point you may be exposed second-hand smoke more and it keeps filling up and up and up and up and up, and it gets to the point where it becomes incredibly difficult to breathe. And that's probably what some of you are experiencing.

  And oxygen helps along the way, but it's because the air sacs are unfortunately full of chemicals from second-hand smoke. So from now on, if you can minimize your exposure to second-hand smoke, you'll improve the quality of life as this won't get any fuller, which would be which would only improve.

  So one of the chemicals we touch on is carbon monoxide. Unfortunately, Luton does have one poorest air qualities outside of London in the entirety of the South, with many reasons for this. Luton, for instance, is in a valley, it’s in a bowl, as the airport overhead as well, and there's a lot of traffic as well with idling cars. Carbon monoxide is actually a poison on the heart and this may increase your risk of heart attacks and other coronary heart diseases. It is very apparent in second-hand smoke. And what it does is it attaches itself to red blood cells 200 times faster than oxygen. Now, red blood cells are like little taxis around the body, and they basically take the carbon monoxide over oxygen every single time to the extremities of the body, right the way our to your fingers and toes, but notice the impacts of heart the most.

  Tar is the chemical responsible mainly for turning your lungs black and your ceilings yellow. It is a very thick yellow-black chemical, which is incredibly hard to break down, is mainly responsible for the smoker's cough and often when people will quit smoking, they’ll end up coughing up a yellow black phlegm, and that is the tar trying to come away from the lungs. It leads to many known health problems involving the lungs but also other organs as well.

  Smoker's lungs can look two different ways generally and I’ve put these in inverted commas for healthy and unhealthy lung. So if you have a healthy smoker's lung, you have a normal lung that's black. If unfortunately, you develop an unhealthy lung that statistically 50% of people will, you will have a lung that has lumps on it, and it's likely to be rough and abrasive, which can indicate COPD, emphysema or lung cancer.

  So a 20-a-day smoker will on average generate about 400 grounds of tar build up in their lungs every year. Now, tar, like you said, it's incredibly hard to clear away from the lungs. So this is a pint glass, for reference, so 400 grams is about that much in your lungs every year, over two thirds of a pint glass.

  And the last one last chemical is obviously nicotine. So these are a bit of a revolving points of why do people relapse? It's because it's addictive and that's why people relapse along the way. So nicotine by itself is an incredibly addictive chemical. It's actually more data than cocaine or heroin. Now, the nicotine pathways form from the moment you're exposed to nicotine, that could be if your mother carried you and she smoked, which my mum did.

  You could develop a hairline fracture to nicotine, making you more susceptible to smoking at a younger age and unfortunately, becoming a lifelong smoker. So in my brain, I have a hairline fracture to nicotine. My brothers and sisters also have one because smoked through all four us, and at that point, the moment we picked up a cigarette and tried one, it was much easier for us to become addicted. However, even those that want that weren’t carried while their mother was smoking. Even if they pick up one cigarette, they'll still have the chance of becoming addicted and that nicotine pathway is still there in your brain, regardless of however long you've quit smoking for, so many of you would have quit smoking and not smoked for many, many years, but you might get the odd craving. And I'm sure you all know people who have relapsed after five or ten years without a cigarette, because once the chemical is there, once the nicotine pathway is there, all it needs a little bit of the chemical to come alive.

  And that's why the Stop Smoking team is about stopping smoking, but it is more important about reducing your dependence on nicotine to support long term relapse prevention. So that is arguably why people relapse along the way.

  So how does this impact you? It's one of the most important part. Some of you may still smoke, some of you want to and some will never have. Second-hand smoke will impact your breathing, making things make it even the little things harder. So it's all about your quality of life, as I said earlier on with pint glass analogy. Every time it fills up, you cough, it goes down, fill up, cough, down, and it gets to a point where it is impacting on your quality of life.

  Every time someone around you smokes and you breathe in the smoke, these 250 chemicals will go into your body. Now some of these chemicals, we know what they do on the primary smoke and on the secondary smoker. What is generally apparent again is your breathing becomes more and more difficult each and every time.

  As it's obviously a hot topic right now. COVID 19 is smoking. Currently, there substantial evidence that anyone with a lung condition is more susceptible, obviously, particularly if you smoke. Smoking obviously damages the respiratory system, and COVID 19 is a respiratory disease, so there's that element as well to be considerate of. One of the big questions we mainly get asked “Why isn't smoking illegal if it does all of these harmful effects to the body?” Lots of people have their own theories, but there's no official answer by the government. So here's my take on it. Cigarettes generate some income for the government to fund health care for people who smoke. Now, obviously, that's half what it does cost society. Within the cigarettes are also highly regulated, so we at least know what is in each and every cigarette.

  Now, for those of you who have ever bought cigarettes from outside Europe. So Turkey, for instance, or Pakistan, India, to name a few other countries, even Far East Asia, where cigarettes cost a fraction of the part of the price. They're really, really bad, and they obviously taste a lot worse than cigarettes generally. That it's because they don't necessarily know what's in them, at least if you're smoking in the UK or in Europe, you at least know what's in each and every cigarette, albeit how bad it is for you.

  Additionally to that, if smoking was illegal, they’d become a higher percentage of black market and there would be little regulation around this so if 14-16% of the population smoked, 14-16% of the population would need to get tobacco. And suddenly that becomes an illicit trade of this.

  E-cigarettes are obviously quite a bit of a buzzword at the moment. E-cigarettes or vaping, depends what you want to call them. Generally, the same is a useful tool to help the individuals quit smoking.

  Many have similar views to what's the point of just not smoking? We don't know enough about them, and that is a very good point. And it's kind of do one or the other. What is known about e-cigarettes, more importantly, is they are 95% safer than smoking conventional tobacco.

  There is a 5% risk there has not been around for a long time, been around ten to 15 years. And like we said, right at all, smoking was around for 450 years before it was linked to lung cancer. An incredibly long time. So there is ongoing research all the time into e-cigarettes. The UK is really fortunate that we don't actually have a youth culture involving these. Lots of governments believe that if you’ve got a youth culture of this, it leads many into actually adopting cigarettes. But it's only about 0.3% of under 16 year olds who vape. For many of those who have tried other forms of quitting smoking, this can help them to finally quit, and lots of people do fall into this, and it is estimated about 2.5 million people are regular vapers. Within a vape there's about six chemicals, four of which are food based products so often rankings roles, one of which is like flavorings. They probably all smell some wonderful flavours, including like strawberry cheesecake, bubble gum, for instance, to name two of the craziest flavours, but those of the more mainstream flavours such as menthol and tobacco.

  And then the last one is obviously nicotine. They can get varying strengths on nicotine. E-cigarettes are ridiculously highly regulated in the UK, down to the strength of nicotine and the size of juice you are allowed to buy at any one time and also on age more importantly.

  So the last part is what we do to stop smoking service. Currently, we deliver remotely, but we'll move to a hybrid model of remote delivery, as well as face to face appointments. We support anyone who is addicted to nicotine and needs support. So again, we do help people come off of e-cigarettes in the long term. They might have used an e-cigarettes to quit smoking, but then they have decided, You know what? I don't want to be nicotine anymore. I want to come off of that.

  And for a lot of people can even be the last one they're stuck with. A lot people tend to hold onto the last two or three cigarettes. They're really good at getting rid of all the others, but they're going to get stuck there so we help a lot of people with that.

  Every member of our team are trained and we do ongoing development that includes any of the vape shops we work with as well as pharmacists. All our support is free where possible, more importantly is impartial and most important is always confidential and finally is a no judgment service. So we do kind of see a lot of people relapsing and coming back to us, but that's what we're here for.

  Any questions or queries relating any information, you can contact myself on that email or that's my direct line. Or if you're more interested in stopping smoking and accessing any of the other services, you can contact Total Wellbeing Luton either email info@totalwellbeing.org or their phone numbere 0300 555 4152.

  Hi, my name is Natalie and I work for the Total Wellbeing Service. The Total Wellbeing Service has been integrated into Luton to help support the emotional and physical wellbeing of Luton residents. Our service offers various programs, and these programs vary anything from talking therapies to smoking cessation health checks, anything like adult weight management.

  We've got long term health conditions as well, and that's where I come in. So our long term conditions, we cover various conditions anything from cancer rehab, stroke rehab, any respiratory, any bone joint problems. We cover quite a few, and going to talk to you about our respiratory program.

  So with the majority of our programs, we offer a twelve week program system. On that twelve week program, you pay £3 each time that you count for each activity that you choose, and these activities can vary anything of what you would like to access so it can be from the gym to swimming to any type other classes. These classes can vary anything from tai chi to our football. Also, we've got bowls, we've got such a range to cover all sorts.

  And also with our twelve week program, if you'd like to use the gym, we offer a one to one system where we help tailor programs specifically designed to help you achieve your goals and your needs. Also, if once you've completed one of our programs, if you're eligible, we can also help transition into one of the other programs to help support you as well. So if you have multiple conditions, we can help support you with things like that.

  Now, all of our activities are mainly based out of four sites. These sites are our Inspire Centre up in Stopsley. We have our Lewsey Sports Park. We have our Lea Manor, which is up in Marsh Farm and we have our High Town based in the town.

  And again, depending which activity centre that you choose, the activities will vary from centre to centre as well. We also have a friend or buddy system. So what this means is that if you would like a friend or family member to come along with you, they might want to exercise themselves. Or you might feel that you know you might well have more motivation with someone else being there, and they can access everything that you have access to so they can access the classes, the gyms where we can help again set them up on a program.

  And again, they'll pay the same £3 each time that you come as well do anything that don't get that you get yourself. If you come to our programs, we do start you off with a voucher or voucher is twelve sessions of £2 pound per session and again, you can use on any activities of your choice.

  So if you'd like further information, please have a look at our website through active Luton, type in “total wellbeing” and all the information to come up there.

• Week 5 - Nutrition

  Hello and welcome. My name's Ian, the therapy instructor for the pulmonary rehab team. And today we're going to be lo ing at nutrition. So what we're going to lo  at today is to understand what BMI is and why it is important to maintain a healthy weight.

  We're going to have an understanding of what a healthy diet is, whether you are lo ing to maintain your weight, gain weight, or lose weight as well. How to tackle excessive malnourishment. And then we're just going to go through some practical tips to help manage nutrition with a lung condition.

  BMI is your body mass index. And it is a good quick tool, which most health care professionals use to give them an idea of whether someone is the right weight for their height so that we use the formula weight divided by high squared. It'll give you a number, put you on the scale and determine whether you are underweight,  , overweight or obese or clinically obese. Obviously we do want you to be within “ ay” range because there are many complications which come along with being severely underweight or being severely overweight, which we’ll come into. Why is our weight important and what are the consequences of being overweight and underweight? Many consequences on both sides of the spectrum, which we lo  at.

  So if you lo  at overweight first, you've got pressure on your bones and joints. We carry a lot of our weight around our midsection. So then that means that your hips, your knees and your ankles are having to work over time to help carry that excess weight around the midsection. And because of that, because you're having to work a little bit harder to get around, you have decreased mobility, your heart muscle and overall circulation is having to work over time because there is a lot more of you to feed a lot of blood. But the blood has to get around to a bigger area. So your heart, because of that, is having to work a little bit harder. And again, more difficulty in breathing as well.

  But if you lo  at underweight loss of muscle mass, skeletal, cardiac, and pulmonary. So that can be through, not getting enough nutrition and not getting enough food. Your body has to feed itself somehow, so it then feeds from itself. So it starts taking nutrients from your bones and your muscles. And that's why when you are severely underweight and the way you tend to feel a lot weaker because your body's using a lot more energy to keep itself going. Bones are a lot weaker because again, you're not getting the nutrition to help keep your bones nice and strong. But then also, as I said, your body is feeding on its own nutritional supply. So that's going to weaken your muscles further. Because you haven't got the energy through the food, if you were to get an infection, then it could be very hard to get over that.

   , so on the screen now, is just eight tips for just general, just healthier choices. So you want to base your meals off of starchy carbohydrate foods. So these are things like your rice breads, your pastas, you couscous and quinoas, you know, things that are more nutrient dense, which are going to give you more energy and make you go for longer, unlike things like your crisps and your sugary drinks, you know, your sweets, your chocolates, those things are less nutrient dense, which will give you a quick energy spike, but then, say, half an hour later, you even feel hungry again or you get that sugar crash, which then you will need something to give you that pick me up again.

  So you've got your complex carbohydrates, which are your breads, your rices, pastas, and then you've got the simple again, because there's no real nutrient intensity to them. So go aim for those complex carbohydrates.

  Eat lots of fruits and veg. So you want to go for every colour of the rainbow.  , so you reds, yellows, blues, your greens, each colour generally gives you a different nutrient, vitamin, mineral fibre. These are all going to help the body with all these different functions.

  You know, if you’re nutrient deficient in one area, then maybe we'll need to have more of the same food type of food group to help boost those nutrients.  , so eat as much fruits and veggies as you can or you want to aim for your, you know, five of your fruits and veggies per day.

  Have at least two servings of fish a week, fish is very good, a protein source. And include one oily fish as well. So your oily fish, they're going to include things like, you know, your mackerel, things like that.

  What is the benefit of having oily fish? Well, that gives us the omega three. So your essential fatty acids, omega three is something that the body doesn't produce on its own. So you will need to get it from outside sources, whether that be through our oily fish or if you’re not eating fish, then maybe having your cod liver oil tablets or fish oil tablets, or you can get omega three tablets. Even things like chia seeds are really good for omega 3s. Certain nuts as well like almonds and walnuts. Really good, healthy fatty oils, which again is good for a lot of different benefits for the body.

  Try to eat less salt. Salt is still required in our diet.  , so just trying to limit the amount of salt, I mean, if you make everything yourself, then you know exactly what's going into your foods. But a lot of foods do have many sort of hidden salt and sugars. So sometimes all it takes is just to have a lo  to the back of the packet, or packaging and see how much salt is actually in it. But it is still required in our diet. So anything between sort of six to seven milligrams of salt is still good for us.

  Drink plenty of water and other fluids to help with circulation to help you with that transfer of nutrients. So water, tea, coffee, certain fruit juices. It all counts. And it's a fluid to help with, as I said, to help with that transfer of nutrients. With things like fruit juices and squashes, they have the added benefit of being from a fruit or veg and will still give you some benefit, as in the vitamins that you get from it.  , so fluid, plenty of fluids and water as well.

  Get active and trying to be the healthy weight. So if you are a little bit on the above on the BMI scale, that getting a bit more active is going to help use up that muscle or use up their excess blood glucose throughout the body and help build you up as well. So you would have had my active lifestyle talk where again, we're lo ing at builds up the muscle, building up our strength, our fitness.

  So from having that good balanced diet with enough protein, fats and carbohydrates, plus getting plenty of sleep as well to help your body rest and recover, because that's just as important as the exercise in itself. With a healthy diet, you can help speed up that process.

   , don't skip breakfast. So again, breakfast is to help kick start the body's energy systems. So, again, you may be a person who doesn't want to have breakfast early on in the morning. That's fine for you, just like with exercise. It's about fitting it around your day. If you find that you wake up, let's say, 7 or 8 o'clock and your first meal is not till maybe 11 or 11.30, that's  ay. As long as you're not maybe going out and doing too much, that way you won’t deplete your energy stores too much.

  So maybe just having something, just something small, just that kicks all the energy levels to give you that push to maybe do your exercises or go about your day to day tasks.

  And then cut down on saturated fats and sugars. So we mentioned about the simple sugars or simple carbohydrates. So things like your chocolate, biscuits, your crisps, your fizzy drinks, which have no real nutritional value to them, and then you cut down on saturated fats. So things like your red meats. So as you can see there, it says cut down, not cut out,  ? It's about having a balanced diet. Not getting rid of any one thing, it’s just having a good range, a good range of everything.

  So this is the Eatwell Plate. And it just gives you a good idea of the portion sizes of each food group that we should be having. But rather than having too much of one thing, this just gives you the idea of how much should of each we should be going for. So in the green, we've got our fruits and veggies. So aim for at least five portions of fruits and veg every day. And as you can see there, there's a wide variety. So you've got your frozen peas, frozen is just as good, your chopped tomatoes as well, again, your 10 things. And then you've got your dried fruit as well. Again, just as good.

  Some of them have a bit more of a high sugar content with your dried fruit. But it's still a good benefit, maybe just to give it that bit of a energy push. And having something like dried fruit is going to be more beneficial to you than having that chocolate bar.

  But as you can see, again, lots and lots of different colours when it comes to your fruits and veg.

  Then you've got in the yellow is your carbohydrates. So a lot of these foods are generally like that pale beige colour, like your carbohydrates. And again, you want to go for the foods that are more nutrient dense. So things like your porridge, your potatoes, sweet potatoes, your yams, pastas, rices. Going for your wholemeal option, again, it's going to have more nutritional value to them than the general ones can. But again, wide variety is key and crucial.

  Then you've got in the pink bit is your proteins that your chicken, your lamb, your beef, you know, your turkeys, your fish. And then you've got your plant based proteins as well. So your chickpeas, your lentils, you know, broccoli, cauliflower, really good plant based options, fish as well. As we mentioned.

  In the blue, you've got your dairy foods. So your yogurts, your cheeses, your milks, you know, your butters as well. Dairy foods still play a really, really good part in our diet. Lots of protein, healthy fats as well, and good energy boosters.

  And in the last little purple section is fats so high fatty foods. So again, it's not cutting any food group. It's just having the right ratios of those food groups. So your oils and spreads, your butters, your olive oils, things like that. They're going to give you things like your omega three. So your nuts as well, almonds and your walnuts, your macadamia and Brazil nuts. Those are going to be sort of in that type of section, which, again, lots and lots of good benefits to them, including heart health. Really good for heart health, brain function and circulation's as well. So really, really good benefits from the fat. But as you can see, is the smaller part of the plate.

  Top left hand corner. We've got the food labels, so this just gives you an idea of the fats, the saturated fat, the sugars, assaults and the energy that you get him from those. So you can make better decisions on your foods based on that traffic light system. So you know that if it's green, it's going to be low in those nutrients. If it's in the amber by the middle and red is going to be high in those bad nutrients. So again, you can choose healthier options based on that traffic light system.

  Top right you've got your water, all your fluids. So six to eight glasses per day or the two litre bottles per day as well. But again, you can incorporate your teas and coffees, your fruit juices into that two litres of fluids per day.

  Bottom left hand corner, you've got your high sugary foods. So as it said, we're not cutting out completely because you deserve a treat at the end of the day, if you like lemon drizzle cake, or a carrot cake or a glass of wine with your meal, there's absolutely nothing wrong with that. It's just having that right balance, you know, not overindulge. And if you are going to open up a pack of biscuits, not having the whole packet, it's just about having that right balance with those types of foods. And again, as I said, we all deserve a treat at the end of the day.

  So this is the food plate. And what I'll do is I'll break this and each segment down. So the first segment we've got is our carbohydrates. So there's yellowy-based foods. And there's the old misconception that these foods are fattening and they're not. It's just that they take longer for the body to process them, to use them as energy. But that's a good thing, because it gives you longer lasting energy.

  That's why we generally recommend that you have something nutrient dense, like porridge, like Weetabix, like your wholemeal toast or something in the morning to keep you going for longer. So you have the energy to then go do your exercises, go out shopping, do your gardening and do the things that you like to do. These types of food will give you more energy to get those things done.

  Choose wholegrain where possible. So wholegrain just means more fibre, fibre helps with digestion, helps with that break down process so choose  fibre where possible. And then you've just got some portion sizes, say two slices of bread or toast, that Weatabix, you got medium sized potato and one medium, or large bit of bread.

  So really, really good options. And again, is choosing the right foods to suit your lifestyle. You know what you like and what you don't like.

  So fruits and vegetables.  So aim for five portions of fruits and veggies per day so you do get each vitamin and mineral. Choosing a certain colour is going to give you a certain type of vitamin mineral. But then also, you do get a lot of  fibre with your fruits and veggies as well. So you want to try to keep them whole where possible, because a lot of the benefit comes from the fruit or vegetable in its whole form, rather than maybe adding it to like a smoothie where you're breaking down a lot of the nutrients with them and you do lose a lot of it. So try and keep them whole where possible. You can have them any way, fresh is pretty good, frozen as well. As we mentioned, if you do like to have frozen peas or frozen sweet corn or frozen blueberries, you know, if you're having a porridge in the morning oven, some frozen fruit to that can will be part of your five a day. If you’re making a casserole or a spag-bol, adding some frozen peas or sweet corn, too, that is going to incorporate as well. So you can have it frozen. And then same with tinned.

  Fruit juices, any as one portion, as I said, because you do lose a lot of the nutrients through that blending or that breakdown process. So it only does count as one portion of your five a day. And if you are trying to gain weight, you can you can use them in puddings and cream. If you're trying to weigh on, as I said, you can add your fruits and veggies to any meal throughout the day for that quick nutrient boost.

  And then you've got your portion sizes there. So two handfuls of vegetables, salad and a fist sized full fruit. So if you've got bigger hands, then you're all good. Yeah, you can have a little bit more.

  Protein foods are your ones that again are going to help build up your muscle and give you a good amount of energy. So, again, through their exercises that you're doing with us, you want to have maybe trying to increase your protein content, but you're having. So chicken, fish, eggs, again, beans, pulses, lentils, chickpeas, lots and lots of different variety, whether you're a little or no meat or a meat eater. Lots and lots of different benefits and lots of lots of different ways that you can get your protein into your daily diet.

  Again, you want to maybe go for leaner cuts rather than your higher fatty foods. But as I said, maybe cut down, not cut out, because, again, they still have their part to play as well. Again, fish. We already mentioned fish, really good protein source. Plus, you get your omega three if you go for your oily fish. And then you've got some portion sizes there.

  So that statement where says add gravy to soften meats that’s just looking at maybe some of the medications that you're taking. If you’re on inhaled based steroids, which have the side effect of causing dry mouth, sore throats, you know, thrush, it can be hard to incorporate these protein foods into your diet. Now, add a gravy to soften meats may sound quite basic as something that you do anyway, especially if you’re having something like a casserole or pie. It's going to be in gravy anyway. But it's just to give you an idea and just to remind you, you know, that rather than avoiding food altogether, maybe having something like a chicken soup, you know, you're getting a chicken, you can have some veg into that. Very easy to consume. So you're not missing out on this food group.

  And at the bottom there, you've just got a food example, so scrambled eggs, really, really good protein source, maybe adding a bit of cheese in there as well. So lots and lots of different options. But again, meat eater, non-meat eater doesn't matter as long as you getting your protein in to help build your muscle up, build your strength, build your fitness up as well. It's going to help.

  You've got your dairy based foods as well. So, again, really, really important if you are on long term steroids as well. So really good for bones and joints through your dairy based foods. And again, lots and lots of different options out there these days. So we have got a non-dairy based milks and butters and cheeses which you can go for as well if you're not able to have the dairy. Lots of different options out there. And that's the same with every food group, really. Lots and lots of different options to suit your needs and requirements. Full fat if you are trying to put on weight low fat for trying to lose weight, doesn't matter. Again, it's about getting that food group into your daily diet and nutrition.

  Again, some portion sizes there. So, you know, yoghurt, or a third of a pint of milk is the portion size, one ounce of cheese around or two finger sizes. So that's all we're allowed to have, I'm afraid. I know, I'm sorry. But those of you that do like your cheese have only allowed two finger sizes. But, you know, try and grate it to make it last a little bit longer. But again, it's down to the fat content because cheese does have a high fat content in them. So you do sometimes have to limit the amount of cheese that you have, I'm afraid. And then we can fortify to add protein, which I'll get into fortified foods shortly.

  And then you've got your fats and sugars as well. So not particularly needed in our diet because of those empty calories that you get. No nutritional value to them, when it comes to sugars, I should say, because they always just empty calories. But again, it's a treat. And the key word for this presentation is moderation. Everything's in moderation. As I said, it's not cutting out one food group or cutting out one type of food that you really like because I told you to do it because then you're just going to crave it. You know, it's just being sensible with the foods you have and just having them in moderation.

  But when it comes to fats, things like your olive oil, you know, your omega threes, which is where we're looking at mainly, those are still part of our daily diet and play a crucial role in how our body works and functions.

  So alcohol can have a massive impact on your lung condition. COPD, when you take inside medications as well.  You do want to try and limit the 40 units of alcohol a week, you know, to reduce the risk. And that doesn't mean having 40 units of alcohol, all in one day. You know, you want to try and spread them out throughout the week. For some alcohol can decrease your ability to clear mucus from your airways so if you have trouble clearing a chest we would have gone through in the previous to account to clear your chest correctly, but have having alcohol kind of scupper that. Trying to increase your alcohol intake can also lead to poor dietary choices as well. And they kind can interfere with certain medications as well. I have been told red wine has antioxidant properties in it which is then good for heart health. So, yeah, therefore, a glass of red wine may be beneficial, but it's similar to sugars, alcohol is a treat, so again, it's just having them in moderation, throughout the week.

  So if we look at our units of alcohol. So you've got half a pint of beer is one unit of alcohol. You've got a small glass of red wine is one unit. 25 millilitres of spirits is one unit. And then you've got those alcopop bottles as well as one unit. So you can spread it out throughout the week in moderation as well.  

  And then diabetes as well. So COPD and diabetes can be hand in hand sometimes. So when it does come to dietary choices, and you have COPD and you’re diabetic, it's making those healthier choices, having these small treats occasionally and in small portions. But you may be in contact with a dietary nurse or nutritionist already, which is brilliant. I'd say, you know, stick to the plan that they would have set out for you. Well, there may be certain foods that you just can't have anyway. But what I would say is that there are always other options as well.

  Things like exercise and regularly can help manage blood sugar levels and help lower blood sugar levels. But then there are certain foods out there which can help manage our blood sugar levels as well, so like your leafy greens, veg, cinnamon, chia seeds, you know, Greek yogurt, nuts as well. Really good help in managing blood sugar levels. As we said, exercise can help manage both conditions as well.

  So if you are trying to lose weight. These are kind of the meal portions so that plate that we saw previously, that's just the general guideline. But if you are if you've got specific goals and targets or dietetic needs, then you can adjust that plate. It's about looking at our plate and then changing it, adjusting to suit your needs.

  So we've changed the plate here to look for weight loss. So you've increased the vegetables slightly, lower down the carbohydrates, you’ve lower down the proteins. But if you want to incorporate portions for weight gain. You can go a quarter veg, half starch, quarter protein, you know, so you'll gradually putting on weight that way. Plus others as well. So maybe incorporate into some more dairy based foods as well into a diet can help put on weight as well.  As I said, it's look ing at that initial food plate and adjustment to suit your requirements.

  We've got some meal ideas here. So if anyone would like this printout, then we can send it over to you. But you have got the right in front of you now, so you can maybe take some notes, write it down just to give you an idea of some good meal ideas, the majority of them go through each food group, so you go before each food group and each meal.  So just some good ideas there.

  And again, these are some good meal ideas here. If you are trying to maybe put on a little weight or just have a quick snack, maybe. So you've got some savoury options, some sweeter options, good choices there, and then you've got some savoury snacks and drinks there. So again, if you are trying to put on a bit of weight, lose weight, these small options here can help with that.

  So why is someone with COPD likely to become malnourished? Now, there's a number of reasons why someone with COPD might become malnourished. I mean, you can be overweight and still be malnourished because you're not getting an adequate nutrition for your body. So, yeah, increase energy expenditure due to breathing requirement. So if you’re breathing and you use in all of these additional muscles,  you're going to be using up a lot more energy and burning up a lot more calories as well.

  Medication plays a big part as well. Because you are going to take him hanger's your taste buds have changed slightly and things just don't taste as nice as they used to as well.  Just feeling full in general because your diaphragm is not working how it should. As soon as you have something small, you may feel full very quickly. Because of that, you're not getting the nutrition that your body actually needs. And then your frequent infections as well can play a part why someone can become malnourished.

  So how can we tackle malnourishment? Eating rich foods with protein and energy. Having these small meals throughout the day as well, which can give you the energy boost which can help replenish a lot of lost nutrients through lack of nutrition, can help with that, so five to six small meals rather than someone trying to put a big plate of food in front of you. You know, small meals throughout the day is going to be a little bit more manageable. Fortifying, which again, we'll touch on shortly. Opt for those foods that you are more likely to eat because you are then more likely to consume these types of foods.

  I know a lot of nutritional drinks out there, which you can give yourself a good nutritional boost as well. Drinks out there, which are more protein and maybe some that are more carbohydrates in them, you can get powders, you get nourishment drinks, lots and lots of different options out there to give you that nutrient boost that you may need. And if we can, if we need to, we can refer you on to a dietician to help with your nutrient plan.

  So fortified food is the idea that rather than increase in the size of the plate that you have in front of you, same size plate, if not smaller, but what's in there has got more nutritional value to them. So, for example, one pint of full cream milk, 400 calories, 20 grams of protein. If you add some skim milk powder to that, that bumps up the calories, an extra 200 and bumps up the protein, an extra 20 grams. So same size, but just more nutritional value. Same with your main meals, your breakfast. You know, you don't have to have a big plate of food. Same sized plate of food. But what's in that same plate has more value to it.

  So you got a shepherd's pie, for example. You can maybe add some cream, some cheese, add some extra vegetables to that as well, to really give it that nutrient boost that you may need to help you maybe put on a bit of weight or just give you that “get up and go” for the day.

  And here's just some lasting tips. So choose, soft, moist foods that do not require a lot of chewing. So, again, if you have got sore throat, dry mouth because of medications or any other reason, then, yeah, small foods that are more easy to consume. Maybe clear your airways before eating. For an hour or so going through your ACBT or active cycle of breathing technique to help clear your chest. So you are more likely to sit down to a full meal rather than feeling full sooner rather than later.

  Eat up while sitting to help ease the pressure on your lungs as well. So you've got more room to eat and breathe as well. Meal prep is really, really good. You know, you can prepare some foods, you can put them in the fridge or the freezer. So you know that when you're ready, you can take it out pop it in the microwave, put it back in the oven and you're good to go. You know, you've got a meal ready there, ready and waiting.

  But then also in supermarkets these days there are a lot healthier options out there. All it takes is maybe just looking on the on the back packaging and seeing what's in the foods, that it's not too high in salt, not too high and sugars, it's got everything that you need for yourself. And, yeah, you can take that home and have that as your main meal, absolutely nothing wrong with that. As I said, there are a lot more healthier options out there.

  Again, having that plenty of fluids, obviously not too much, because sometimes we have too many fluids, you do feel full, so then you don't have your main meal. So again, it's having increased fluid intake will help with like dry mouth and help thins mucus and taste changes, as well as trying different flavours and textures where maybe your foods don't taste as nice as they did. So just trying different foods to help to consume. Yeah.

  So just to summarize everything, if you are overweight, please refer to the healthy eating guidelines that we spoke about at the beginning of the talk. You know, so maybe adjusting that food plate to increase vegetables slightly, decrease your carbohydrates, decrease your protein slightly as well. If you're underweight, then maybe looking at fortified foods for added protein, added calories as well. And if you do need the extra assistance, then we can refer you on to a dietitian or a nutritionist to give you a bespoke plan.

  Here are just some useful links which you can go through, which may give you a bit more information about your diet, nutrition, BMI or how to manage weight as well.

  Thank you very much, everyone. If you do have any questions, I would love to hear them, please.

  At any point, you can give us a call. Let us know and we’re more than happy to help and support you. Thank you. And take care.

• Week 5 - Managing Exacerbation

  Hello, everyone. My name is Louisa, and I am one of the respiratory physiotherapists that worked within the pulmonary rehab team and today I'm going to talk to you about management of an exacerbation.
  

  Now, before we go on, let's talk about exacerbation. Now, a lot of you might wonder what that word means. It is essentially just a really fancy term for when you're having a flare up of your pre-existing condition. So for any of you that could be COPD, asthma, bronchiectasis, interstitial lung disease, all it means is that you're feeling unwell and you're just having a flare up with some symptoms, which is what I'll talk about as we go through this.

  But first off, I'm going to start with how to keep yourself well. Now, a lot of this you would have heard about as the other presentations that you've listened to has gone into some of this.

  So to start with, ensure a good diet. So by this, I just mean a balance. You want to make sure you're having a good mixture of your fats, carbs, your proteins, so that your body gets all the nutrients and the minerals that it needs to keep yourself well.

  You want to make sure you're avoiding coughs and colds. Now, this is more looking at when we go into the winter months when colds become really prevalent and really easily spread, especially, unfortunately, between family members, your grandchildren, friends that come over to visit. Now, when we say avoiding coughs and colds, it's just making that sensible decision that if somebody is going to come across and see you and they sound dreadful on the phone, or you have a son or daughter that says: “oh, I'm going to bring the grandkids over, but they've got the sniffles,” is making that decision of saying, well, as much as I would love to see them, their cold could turn into my chest infection. And for the sake of waiting a few days to be able to see them but you not picking up that chest infection. That's what we mean by making that sensible decision.

  Now, alongside that, you want to make sure you get plenty of sleep. So Claire would have talked about in her anxiety talk and her energy conservation, talk that the body needs to rest and recuperate, especially if you expended a lot of energy. Our body needs to be able to rest. So a good six to eight hours of sleep is really, really key to just helping our body to rest, relax, and then be ready for whatever we have to face the next day.

  Regular exercise is also key. Ian would have talked about it in his presentation all on exercise and how to keep yourself well and the benefits of exercise and how it can make our body feel really good and help us maintain that healthy lifestyle.

  So following on from pulmonary rehab, continuing with that regular exercise, is something that we really want you to continue with. And we really hope that you want to continue with it, because hopefully you have felt the benefits from exercising with us already.

  Now, for me, being a physiotherapist, chest clearance is my hot topic of what I would always say you want to use to keep well as well. So that is your daily clearance. So for those of you there, in particular, bronchiectasis, that can have a lot of phlegm, you want to make sure that your complete completing your daily chest clearance, because we want to prevent that infection from happening in the first place. So that's key. So if you need to look back at Helen’s talk on managing your chest, please make sure you do.

  Now medication. Hayley would have talked all about medication to you and about the different types and why you have them. So we just want to make sure that you're using the inhalers or any tablets or nebulizers that you have been prescribed as you are meant to, because medication is also key from a medical point of view of keeping yourself well.

  Now, also vaccination. So all of you every year should be offered your seasonal flu jab, but some of you might then also get offered your pneumococcal vaccine. So that's to try and prevent against pneumonia. And depending on your age, also shingles. So it's always one to make sure that you've spoken to your community team, to make sure you are up to date with all your vaccinations.

  Now, lastly, the one thing that we always advise you to look at and monitor daily, for those of you that do use a lot of phlegm, is just monitoring the colour, the thickness, and how much you're producing, of your phlegm. Because if you know what's normal for you, then, you know, if it starts to then vary and that can give you an early indication if something is brewing or if you're about to exacerbate.

  So that leads on quite nicely on how to recognize an exacerbation. So I tend to look at four main points. So the first one is if you breathlessness is worsening. Now, I don't mean “are you becoming breathless?” because as Helen has talked about. In her previous presentation, it is normal to be breathless.

  But what I'm talking about is if you do an activity and it doesn't normally make you breathless and all of a sudden you realize, “oh, wow, I am feeling really out of breath from doing that activity.” So, for example, going up a flight of stairs, I could go up a flight of stairs and feel absolutely fine. But if my asthma is playing up, I could run up a flight of stairs and just feel like I've climbed Everest. So I know that is my earliest indication that something isn't quite right.

  Now with that can come a cough. So for a lot of you, you might never have a cough. And as soon as you get a cough, whether it's a dry one or a chest-y one, that could be your real early indication that something's brewing and that you might be about to come down with a chest infection or have sort of that wheeze that can come if you're feeling unwell. So it's sort of listening to your body and seeing if your body is trying to tell you anything. Now, some of you might always have a dry cough or might always have a chest-y cough. So, again, we're looking for that varying degree of what's going on. So if it's becoming worse

  Phlegm I've talked about. So with phlegm, we are looking at the change of colour, whether it's gone from white or creamy to a darker yellow or green. So the darker it goes, that could be telling us that you've got a chest infection. It's normally a good indication that there is something brewing within your lungs, but also is looking at the thickness and the amount of phlegm that you're producing, because all of that is telling us something.

  Now, for some people as well, it's the fever, it's the lethargy you get. And the general “just don't feel right.” And sometimes you might not best put your finger on it, but you know, in yourself, you are not feeling well.

  So all of these are ways to recognize if you're exacerbating, you might get one symptom, you might get all of them. But it's knowing what are your tell-tale signs.

  So this feeds on really nicely to the types of exacerbations you can get. You've heard me mentioned chest infection, and that is the one that everybody knows about. So that is what we call our effective exacerbation, as it might suggest, you have an infection. So that's where those chest infections come into play.

  Now, the evidence that you've got an infection is where, as I've said, your phlegm might have changed colour. You might have a temperature and you might have a fever, because if you've got an infection, your body generally is trying to fight it.

  And that's why that raise in temperature comes. But because your airways are full of phlegm, you might also feel more breathless and more wheezy, because if you think back to Jenna’s talk where she's talking all about your airways or your tree trunks and branches, and then your grapes at the end of them. If they are full to the brim of phlegm, it's going to be pretty hard for air to get in and down, which is why that's kind of them make you feel quite breathless. And if you have a wheeze that could be from where that air is trying to get past that phlegm and it's whistling as it goes past.

  So that's an infection, and a non-infective exacerbation is where you feel not well. You'd notice that you're more breathless, you might be more wheezy, you might have a dry cough, but there's no signs of an infection.

  So by that, you might have no phlegm or the phlegm that you have is nice and white or clear or creamy, whatever your normal colour is, but you just don't feel right in yourself. Now, as you can imagine, the non-infective exacerbation is sometimes the hardest one to really pinpoint because you just don't feel right in yourself, but there is no clear indication that there's that infection. And that is really important for us to tease out from you, because we need to know the best way to treat how you are feeling.

  So that leads us on quite nicely to the treatment of an exacerbation. Now, as you can imagine, I'm going to say the infective one is the easiest one to note, because if you've had two or more days of worsening colour of your phlegm, more of it, it’s become thicker, you don't feel well in yourself, it’s that really easy determination to say you need antibiotics. So I would normally say if you've had two or more days of that change in phlegm, it's really thick and green. You need some antibiotics, but because you might have a ways and because you might be feeling more breathless because of how clogged up you are, you might then also need to use your salbutamol inhaler. So anywhere from two puffs up to four times a day to help relieve some of those symptoms.

  Now, along with this, you're going to have to do your daily chest clearance, so think back to Helen’s talk again, which talks you through the active cycle of breathing. That is key to helping you feel better because the quicker we get that phlegm out of you, the quicker that infection is going to clear up. So we need you to be having your medication alongside that chest clearance. That is what's going to help you feel better.

  Now, the one that's a bit more difficult is your non-effective exacerbation. So we would always say that if you're starting to feel tight and wheezy, you go for your blue inhaler. That, again, two puffs up four times a day. If that relieves your symptoms and you start to feel better, then great, you don't need to go a step further. If again, after a couple of days, you are not feeling any better, we need to look at the next step. Now, if your airways are really inflamed and they've become really tight, the only thing that's going to help open up these airways is getting a course of steroids. So steroids don't treat an infection. They just treat inflammation. So what we would say is you might need a course of steroids, but you don't necessarily need to start a course of antibiotics if there is no evidence of an infection. So if you have phlegm or the phlegm that you're bringing up is still the same, then do not start a course of antibiotics. Now, some of you are going to be screaming at the screen saying, “well, hang on, I get given bites, I get given antibiotics and steroids.” So if you’re given both because you say, for example, have a rescue pack at home, you can look at your symptoms and make the best decision. So if you know it's just an infection and other than green phlegm or your other symptoms aren't too bad, then you just go with the antibiotics or vice versa if you're really, really tight. But you phlegm is fine, then you can just go with steroids.

  However, sometimes what can happen. For example, if you've had a non-infective exacerbation, say, yet has become really, really tight. The steroids help to open up those airways, then all of a sudden you might have had this phlegm lurking down in the depths of your lungs that can now suddenly come up. And then if you notice after a few days that you're starting to get green phlegm, then fine, start your antibiotics or vice versa. If you've had an infection and it's then caused irritation to your airways, you then might need the steroids.

  But what I want you to understand is it's not a hard and fast rule. It's not a case of just treat it with both and hope for the best. It's listening to your body and making the best decision that you can for your treatment.

  Now, some of you may have been seen by consultants and they may have sort of had a look at all your infections or all your exacerbations and made that determination that if you're on one you have to take both, and then that's fine. You listen to what they've told you to do. But if you've just been given both and you're told to use them as best as your symptoms are telling you to use them, then that's when you really want to look at whether it's an infection or not.

  Now, you've heard me just mention a rescue pack and some of you at home will go, “yep, I've got a rescue pack. I know exactly what it is.” And others might be thinking, “oh, I'm not sure what one of those are.”

  So let me talk you through it quickly. A rescue pack is given for an emergency. So a GP or consultant or community nurses may have asked for you to have a rescue pack at home if you are prone to having these exacerbations.

  So if you have three or more exacerbations in a year, they might decide to issue one. So if you become unwell you don't have to contact your GP. You can just start it yourself at home. Now, like I've said before, it's two or more days of worsening symptoms before you should start to use that rescue pack, because we can all have an off day. We can all have a day when we wake up and we don't feel quite right or we can bring up a little bit of green phlegm. But then the rest of it might be fine.

  So we don't want you to act too early and you didn't need to take that treatment. But likewise, I don't need to wait a week or 10 days and get worse and worse and worse. So that's why I normally say it's two or three days of worsening symptoms. That's when you make that decision to start your rescue pack.

  Now, some of you may realize this, some of you may not. If you've got a rescue pack at home, you really should contact your GP to let them know you have started your rescue pack. It's just a courtesy call now for two reasons. One, they need to know that you've started it so they can reissue your next rescue pack because you wanted them for that next emergency. But also, if you are not getting any better and you're ringing up for your next rescue pack or you've started multiple rescue packs, really your GP surgery should be monitoring and say, “well, hang on a second, we need to get you in and review you because something isn't working.” They might want to take a sputum sample, which is where they analyse your phlegm, because you could be having antibiotics that aren't working for that particular bug, or it could be that you need additional treatment. So please always make sure that you do liaise with your GP surgery, just so that they're aware of the medication that you are using.

  Now, for those of you that do not have a rescue pack, like I said, it could be that you don't have enough exacerbations and your rescue pack, could run out, like anything there's a date on it. And if it's not used within a certain time, you would then need to get it reissued, so it could be the GP surgeries said “actually to know you very infrequently exacerbate. So just call us if it ever does happen and we will issue you with the medication you need”, which is absolutely fine.

  In your GP surgery, they are fully aware of the conditions that you have and the treatment that you need. But what you need to make sure is when you contact your GP surgery and you speak to the receptionist, they understand why you need an appointment and why it's urgent that you get that medication as soon as possible. So the receptionists listen out for buzzwords, and by that I mean words that will make them sort of go, “oh, OK, this person is important. I need to get them that appointment.”

  So if I use myself as an example, I don't have a rescue pack at home. So if I was to call my GP surgery, I would say I have asthma. I've had to start using my blue inhaler, which isn't normal for me. I'm bringing up green phlegm, which isn't normal for me. And I think I've got a chest infection. That receptionist will hear those words and go to asthma, blue inhaler, green phlegm, yep we need to get this person in. They need to get treatment. And it sounds so simple, and I know some of you might be rolling your eyes and thinking, “oh, yeah, but I can never get through and I can never get an appointment” but you can imagine there's lots and lots of people that are calling all to say I need to see a GP. So don't call to say you need to see your GP, because actually most of the time you don’t, it could be you just need a phone call. They might just be able to call you up and say, yeah, that's fine. I understand your symptoms will send a prescription to your pharmacist. Or it could be that they say they will book you in with the practice nurse. And actually the practice nurses are the ones that probably see you in the community to do your COPD reviews, your asthma reviews, so they are really, really used to seeing people and treating their symptoms.

  So I always say just ring up and say what your symptoms are and what you're trying to do yourself at home. And then the receptionist can make that best decision of what is needed on that day.

  Again, if you're at home and you have been given your treatment by your GP and you're not getting any better, you must contact them again to let them know what's going on. Like I said, if you do have a rescue pack at home, it's the same thing if you're not getting any better, they need to make that decision of what treatment you need next.

  Now, with medication, as I've already said, you must make sure you take all the medication that's been prescribed for you and that is key, and that will be reiterated from the previous talks you've had on medication. Now, depending on the condition that you've got, we are all given a different action plan to use. So some of you might have been told if you become unwell, start using your blue inhaler or start increasing some of your other inhalers that you have, to try and help get you through this exacerbation.

  Some patients are advised, if they have them at home to start using your saline nebulizer to help with your secretions, because saline can help make that phlegm shift that little bit easier. Some of you may have been given nebulizers with Ventolin or Salbutamol or if tiotropium, because it may have been determined that when you become unwell, you lose that inspiratory effort in order to get your medication in and down. And that's why you may have been switched over to a nebulizer.

  A nebulizer and an inhaler, they're giving you the same medication. It's just a different delivery. So if I give you an example, a blue inhaler with a spacer takes probably anywhere from a minute to 30 seconds to take and to get that drug in and down and then five to 10 minutes for it to take effect.

  A nebulizer can take anywhere from 20 minutes to get into your system. So it's not that if you're given a nebulizer, you're getting a better treatment, actually takes longer to get that treatment in and down sometimes. So if you've not been given a nebulizer, it's not because you're being withheld certain treatment, they've made that determination to you can get that drug in and down, which is the quickest way in and down. If you can't, that's when they then decide to give you that nebulizer instead. What I would always say is do not go out and start buying any devices, because if we truly feel that you need it, we will get this given out to you. The nurses at the hospital, the consultants, even GPS, will look at whether it is something that you require. But if you go out and spend money on these devices, one, you can't get them serviced regularly so you don't know if it's doing the trick it should be doing. But also you still don't have the medication to go in it. And the GP's do not have to give it to you if they feel that there is a better delivery for you.

  So I always say just speak to us, because it could be the reason why you feel like your blue inhaler isn’t working and you might not have the right technique with it. So that's why we always say, you know, please discuss all of your medication options with the most relevant professional, because we can help and we can help make sure that you're on the correct device.

  Now, when it comes to antibiotics and steroids, you're normally given five to seven days, depending, again, on your condition. So please make sure you take the whole course. Even if you start to feel better after a few days, you still want to make sure you take the whole course of your antibiotics or steroids. But some of you might be given longer courses because of your condition or if you've ever been seen by a consultant, they may have said, “no, you need 10 to 14 days, because we know that that's how long it takes to fight the bugs that grow within your lungs.” So that's fine. Just make sure you're aware when you start a course of how long you're meant to be taking it for.

  Now when it comes to food and fluid. Great news. This is the one time I say you've got to eat more and you've got to drink more, which in theory sounds great. But for any of us, when we've become unwell, we know how difficult it can be to eat when you're feeling really breathless or if you're coughing a lot. So if you think back to Ian's talk, where he probably would have said about ways you can swap foods, so if you wanted to lose calories, you can go for a healthier option, or if you want to add calories, you can swap for higher intake options.

  So this is where you want to look at your higher intake options, because if you're not feeling well, the likelihood is you're not going to eat as much. So we need to know that when you're eating, you're getting as many calories as you can for those first few days of when you're feeling unwell.

  So you might go for full fat milk rather than skimmed. You might go for ice cream because you think, actually, I can get that down. And that's quite easy to get down. You might go for tomato soup, add some cream in to make it cream of tomato soup that adds in some more calories.

  So you're going for foods that are easy to swallow. You're not having to worry about chewing too much, but they've still got those calories there. So you're not losing that calorie intake. Now, when it comes to fluid. Unfortunately, I'm talking about water, I know a lot of people struggle with intake. It's not sometimes the most easiest of drinks for people to have. If you like me, I prefer my tea and coffee. But if you're unwell we need you to be hydrated now. You can still put squash in. I'm not saying it has to be plain old water, but what we really need to make sure is that phlegm is coming out and we need you to be hydrated for that phlegm to start to shift. So if you can be really, really conscious at switching to making sure that you're not drying your body out and your airways out and you're really trying to up that water intake.

  Now, physiotherapy, I've already said this, but I'm going to say it again. If you are unwell, you're going to have to do your chest clearance more often. So this will be three, four times a day to try and get that phlegm up and out of your airways. The quicker we get that infection and that infected phlegm up and out of your airways, the quicker you are going to feel better. So it's in your best interests to make sure you know how to do this. So this is what I'm going to say again, go back to Helen's talk and make sure you know how to practice the active cycle of breathing. If you are unsure, you can always contact the teams. We can always happily talk it through with you.

  Now, exercise, this is the one time that we will say you can reduce the amount of the exercise that you're trying to do. But there is a fine line between doing nothing and doing too much. So what we want you to do is to be in the middle. I still want you to move about. So my favourite phrase is always “Potter.” Potter about your house. So if you can put a load of washing on or make the bed or move from one room to another, so you'll still move in. We don't want you to lose that muscle strength and that muscle mass that you've worked so hard to build with doing our exercise sessions , it only takes a couple of days when you're unwell of laying in bed for that muscle strength to start to go. So we don't want you to lose that. But what we want you to do is not burn yourself out by trying to push through. So find that happy medium. And then when you're starting to feel better, you can then gradually increase your exercise back up to what you were doing.

  Now, we've talked about managing yourself at home and in the community with using your GP or your community nurses. There are a couple of services up at the hospital. Should you feel that you need to use them or should your GP or your community nurses feel the need to refer you into?

  So the first one is the Acute Respiratory Assessment Service. Now, this is based up at the hospital, a specialist service at the L&D. And it is run by the respiratory nurses that are based in the hospital and the respiratory consultants. Now, this is where anybody can use it if they have been exacerbating and their treatment is not working. So some patients can self-refer if they've been given a card because they may have previously been seen in the service or your community nurses or your GP can refer you up to the hospital.

  What they will do is they will review you. They will look at a chest x ray. They'll get some blood done and they'll make the best decision of what is needed at that time. So for some people, is increasing your medication and they can send you home. For others, it could be: you need to see a physio and they need to teach you about your chest clearance. Now, for some people, however, it may mean staying up at the hospital. It doesn't happen very often. But if somebody comes up and the blood test comes back and the chest, x ray comes back, the consultant might take one look at it and say, “no, we need to keep you here, because what your bloodwork is showing is you’re too unwell to go home at this moment in time.” And that can happen to anybody. Anybody can, you know, do the best efforts to stay at home, take your inhalers, take your rescue pack, do your chest clearance. But sometimes the body just says, no, I need a little bit more. So for some people, they might have to go into hospital and just be monitored to see what's going on. So that's when you might have hooked up to the machines. You've got somebody taking your heart rates. They put the little stickers on, you've got a blood pressure cuff, you might have a stats probe on your finger and they just see what's going on. Sometimes that's all you need. And they might say after a couple of hours, OK, no, we can let you go home.

  Sometimes, however, they might need to increase your medication. So if they can increase your medication and let you go, they will. But sometimes they might need to give you I.V. medication where they hook you up to a couple of drips to just get that medication in as quickly as possible. So that might mean that you might have to stay in for a couple of days while you're having that.

  Now, for some people, oxygen levels can be a problem. So that finger probbe that goes on and we check your oxygen levels. They do that in hospital. And if that number comes back and they're not too happy with it, they might decide to do a different blood test where they take some blood from your wrist. Now, all of you at home, if you've ever had that test before, I can imagine your concern.

  It's not a nice one as some of you will know from where you've had it done before. But it is the best test to tell us what your true oxygen levels are. And if that comes back and it shows that it's low again, we might need to keep you in hospital for a short period of time to have you on supplementary oxygen until you feel a little bit better. Now, the problem with low oxygen levels is sometimes that can give you high carbon dioxide levels. And if that does happen, we have a bit kit called a BiPAP machine and it is a mask, so tight fitting masks that we would apply to you. And it just encourages you to take big, deep breaths. So if you're blowing out that carbon dioxide, then hopefully that will then bring your blood levels back to normal. So the problem with carbon dioxide is if there's too much of it in your blood, it can make you feel quite sleepy, quite drowsy. And that is what can make you feel quite unwell. So we have that bit of kit if it's needed to just bring your carbon dioxide levels back down to normal. Now, unfortunately, with that particular bit of kit, the nurses that are trained to look after it, they work on the high dependency unit in the hospital. So you would have to go up to that particular ward. So the nurses that know how to manage that machine can look after you.

  With going into hospital. It's also about knowing when it's the right time to discharge you from the hospital. So one of the other schemes they do have is the early supported discharge. Now, as I've said already, people with asthma, COPD, bronchiectasis, ILD, we're a bit more prone to picking up infections. So we don't want to keep you in hospital longer than is needed because you might be more prone to picking up infections from people that are coming into the wards. So with the early supported discharge the nurses and the consultants that work in the hospital will hopefully be able to come and see you and look at whether you could be accepted onto the early supported scheme.

  So what they would do is they would discharge you from hospital earlier than you would be normally, but with support. So this means that the nurses or physicians will be coming to see at home every single day until you are deemed well enough to be truly discharged from the hospital.

  Now, for some people, the thought of going home early from the hospital they don't like, but the way we always say to look at it is for any of you that's ever been into hospital, especially up at the Luton and Dunstable, it's a hive of activity. It's the hardest place sometimes to get to sleep, to rest, to recuperate, which isn't what we all need when we're feeling unwell. So if you're at your own home, you can sleep in your own bed, be in your own clothes, you know, go to bed, get up when you want to, which I think is always better for trying to help you get over when you're feeling unwell. So the nurses or physios will keep coming out to see you. And once they say, “yeah, you're you know, you're doing fine. You've been taking all your medication as you are meant to. And we think that you're fine.” They can then truly discharge from the hospital and then hope that you can then have follow ups, either within the community with your nurses or GPS or even with the pulmonary rehab team. So what we want to make sure is that you've got that seamless transition between being in secondary care, which is the hospital to then being looked after within the community.

  So I hope everything that I've talked about today makes sense to you all, is knowing what an exacerbation is, knowing how best to treat it. And hopefully from this, you'll understand a bit better about why you get given antibiotics and steroids or both, but also just how to manage your symptoms and how to keep going, but also knowing when it's right to access that extra help that you may need.

  Thank you for listening and I hope you enjoyed your talk.

• Week 6 - Help and support

  Hi, everyone, my name is Louisa, and I'm one of the respiratory physios, and I'm going to be taking you through today's talk, which is on help, support and future planning. Now, this talk is going to be a little bit different to some of the other ones that you may have already watched. A lot of this has content that you might want to jot down like web pages or some of the information that I'm saying. So although I'm still going to talk you through this, you'll find that there might not be a lot that I'm presenting to you. It's more just giving you some facts and signposting you to places that you might wish to have a look at.

  So some of the bits we're going to take you through, firstly, is some of the support groups that are out there that help anybody with any lung problems. So we've got Breathe Easy. The British Lung Foundation, some specific resources and information you might want to have a look at, the Disability Resource Centre, which you may never have heard of before. Some telephone numbers about adult social care, the Keech, some health and disability benefits that may be available for you. And then just to touch a little bit on the end about wills, powers of attorney and some of the advance decisions that you may just want to know about.

  So let's start with Breathe Easy now. This is the little logo that you're going to see pop up and its breathe easy, and they are a support group that do really informal meetings. And their aim is to just provide information for those living with lung diseases but also to support their carers as well, or any of your loved ones. Now, they are affiliated with the British Lung Foundation, so they are part of the network that help make up the support groups for you. And if you were to decide to go to it, breathe easy group, you going to find that you're going to meet other people similar to yourself that are dealing with lung conditions. So this is why some people choose to go to breathe easy just so they can meet others. And you can sort of share stories and experiences and you can just see that you're not the only one dealing with the lung condition. I know they also like to organize day trips and they organize them specifically for people who have breathing difficulties in mind, so they're not going to organize a trip, where you're going to climb Mount Everest, where everybody is going to really struggle to potentially do that. They will just look at what is going to be the most relevant day trip that you would all get the best time out of. Now

  Your local one for Luton and South Bedfordshire is the group that meets the the Peter Newton Pavilion. And they meet on the second Thursday of the month, and that's every month. And they meet from 2:00 to 4:00 PM. And at the bottom, you can see their website has just popped up there. So if this is some of the you'd like to have a look at, you would like to access the group that is the website that you can access and see if it's something that you would like to go to.

  So that's Breathe Easy. Now, that leads on quite nicely to the British Lung Foundation. Now, their website, which you can see at the bottom of this slide, which is W W W dot BLF dot org Dot UK is a fantastic resource that I would urge anybody to go and have a look on their Web page, because although they're a registered charity and they do support and they do a lot of research into lung conditions, they also give you real factual and relevant information about your lung conditions. So I know we can all do it. We can all type into Google and research anything we want to.

  But sometimes things that you might research might not always be very factual. If you're looking on the British Lung Foundation website, you know that you're going to get the most relevant and factual advice or information that you are looking for. Now, they  do lots of resource little booklets. They also do some DVDs and they like to do national awareness campaigns. So always look out for the British Lung Foundation.

  Now, for any of you that have pulmonary fibrosis, there is a specific Web page for them. So that's the Pulmonary Fibrosis Trust dot org. And their little logo is the lungs, as you can see in the corner, the blue lungs with the purple edge that goes with them. Now they are there to again help anybody and support anybody that may have been diagnosed with pulmonary fibrosis. But there's also the Action for Pulmonary Fibrosis, which, again, is a growing community of support groups so that they're there to help anybody with pulmonary fibrosis. Again, that's been affected, whether that's yourself or your carers. And they offer the opportunity, if bit like breathe easy to have a support group and a support network. And they have meetings every other month at the Peter Newton Pavilion, and that is normally the first Tuesday every other month from three till five. So, again, if this is something that interests you. Their website is at the bottom. That’s W W W dot action P F dot org. Now, if you need to pause these slides at all, take them down. That's the beauty of it. So don't worry if you think I'm rushing through, you can. Just pause if you want to jot anything down.

  Now for anybody that has asthma.You've got the asthma Dot org, dot UK. And again, they're a great little website that you can go on to if you want anything, any advice, or you just want to be able to connect with people. And we also have the same with bronchiectasis. So there's bronchiectasis dot me. And that is a fantastic little resource as well. If you want to have a look at anything more in-depth.

  Now, the Disability Resource Centre. Some of you may never have heard of this, but this is on Pointer Road, which is in Dunstable. And they are there for numerous different reasons. So as you can see on here, we've got the equipment. They do workshops. They’ve got benefit advisors that you can sit down and have a chat with them if there's anything that you think you might be entitled to or if you just need help filling in some forms. So they always say you can either pop in and see if there's anybody available there and then or there's the telephone number on this slide, and you can just give them a call and see if there is anything that they can do for you.

  Adult social care. There are two different numbers, depending on whether you fall under central beds or Luton Borough Council. Now with adult social care, if you just need that additional support at home so it could be help with washing and dressing or caring and whether it's for yourself or for somebody that you are living with. So, again, if you need any help at all, just knowing which one you fall under, whether it's central beds or Luton and the numbers are on the screen. But Luton also has that additional website page that you can look onto.

  Now, this is the picture of the Keech. Some of you may have heard of it. You may not have. And you might be wondering why. I'm talking about the Keech. The Keech is obviously well known for its support with cancer services. But actually, we also use the Keech to really help with symptom management. So the Keech care centre has all of this available. So symptom control, social workers. We've got music therapy, art. They've got a hydrotherapy pool, do complementary therapies. And they're really, really fantastic at helping people that in particular are really struggling to manage their symptoms of breathlessness. Now, we as health professionals can refer people in to the program up at the Keech. So then you can access any number of these facilities that they've got.

  Unfortunately, this is one of the programs that you can't self-refer to. But if you feel that the you breathlessness is becoming more and more and more of an issue and you want something additional to help yourself with, then we can discuss a referral up to the Keech.

  Now, when we are going to look at some of the health benefits that are available, these are ever changing. So as of June 2020, while I'm recording these slides, this is correct for the advice that we're going to give now. But what I would say is you can always have a look on the government websites, and this is where we've got all the information from. And you can always have a look at the most up to date information on that.

  So universal credit is there for anybody that that may be low on income or currently out of work. So you have to be 18 years or over and you've got to be under the state pension age or your partner has to be. Consideration is made on how much savings you and your partner could have. And your circumstances are assessed every month. And the universal credit payment is made up of a standard allowance. And then any extra amounts that apply to you. For example, if you have children, you have a disability or a health condition which prevents you from working or if you need help paying any rent. Now, the personal independent payments, which is shortened to PIP, has taken over from the disability living allowance. So some of you may have been receiving disability allowance or still may be, but it might gradually be converted over to the PIP payments. So, again, this is meant to help with some of the extra costs caused by Long-Term Ill Health or disability. They are for anybody that's over 16 years of age and has not reached state pension age. But the amount that you get depends on how your condition affects you, not the condition itself. So they look at every individual and how everybody's affected by it, it's not just a flat rate that's given out.

  So you'll be assessed by a health professional and they will work out the degree of help that you might need. So the rate, again, is regularly reviewed to make sure you're getting the right support, because as we know, as health professionals, our condition we have for life and for some people that can get worse rather than, unfortunately, getting better, so we want to make sure that if you need that extra help, you then receive it.

  So the good news, it's tax free and you'll get it whether you're in or out of work. And it's made up of two parts. You’ve got the daily living part, which is all of those activities we do in everyday life. Washing, dressing, toileting and reading, writing, all of those things that we take for granted that we can easily do.

  And then the other side of it is mobility. Now you get one part or both parts. It's all dependent on when your sense as to what they feel that you need the most help and support.

  You've then also got the attendance allowance. Now, again, it's to help with any extra costs. If you have a disability and somebody needs to help look after you. This, again, is also paid at two different rates, depending on the level of your disability. For those with a physical or a mental disability, you must be a state pension age or older. But in this one, unfortunately, mobility is not covered within this allowance. Now, there's also the blue badge scheme, which many of you might be aware of. We've got, again, two different options, whether you're in Luton or whether you're in Bedfordshire, again on the government website.

  Here's one of the easiest places to have a look at what is available to you and both of them say you can apply online. But if you find it difficult to do the application online, that's when you can look to the Disability Resource Centre and they can help you with making that application. Or I've got the phone numbers on this slide for you. Now, if you're wondering whether you are eligible for a blue badge scheme, there's two types of eligibility that they look at. So you've got those who automatically qualify and those who qualify and what they call the discretionary category.

  So many people with a lung condition qualify for the blue badge because you might have a disability that is permanent and it means that you can't walk or you have difficulty in walking. So what a lot of people will probably find is you might be get called to an assessment.

  So an independent health professional will assess you. They'll talk to you about what disability you have and they'll ask you to carry out a walking assessment. And then normally you're informed within a few days after that assessment whether you are eligible for that blue badge.

  And it normally lasts for three years. You want to make sure you apply to renew it before it expires. But you must return the blue badge to the issuing authority if you no longer need it.

  Now, we're just going to touch on some of the future planning parts that I talked about at the beginning.

  So firstly, we're just talking about wills now. A will should be done by everybody, regardless of age, myself included. If you've got property, if you're married, if you've got children. If you don't make a will, then nobody knows what your wishes are.

  So by having a will it’ll let you decide what happens to your money, your property and any possessions that you may own after your death. Now, if you make your will and you make it, probably make sure you don't have to pay more inheritance tax, then you need to.

  And you can write your will yourself, but if you haven't got a straightforward one they sometimes say that it is better getting advice to make sure that it's all written correctly. You need to make sure that it's formally witnessed and signed to make it equally valid.

  And if you want to update, your will you need to make an official alteration or make a new will. Now, every year there's a free wills month takes place. So twice a year, which is in March and October, to anyone that's aged over 55. And you can have your will written or updated for free. Legal solicitors taking part in the campaign are listed on the Free Wills Month website. So that's a really good place to go and have a look at if that is something that you think you either need to update it or you've never had the opportunity to go and write yourself one.

  Now, some of the things that you might want to have a look at, and again this might not be necessarily for you, but this could be for other loved ones. And it's always worth as strange as it sounds talking about these subjects is always good to have the knowledge, because knowledge is power. And if you know about what's out there, then you can make the best decisions. So power of attorney, you've got a lasting power of attorney, shortened to LPA.

  And it's a legal document that lets you appoint one or more people to help make your decisions or to make decisions on your behalf, so this is really out there for anybody that may have any particular conditions, not necessarily lung conditions, but for example, and if anybody was to get dementia and they want their wishes to be known and they can appoint people in order to carry out those wishes that they want them to be able to do. So, it gives you more control over what happens to you. So if you have an accident or illness, you cannot make your own decision, they class that as lacking mental capacity.

  But there are two types of power of attorney. So you've got your health and welfare and then your property and financial affairs. So you can choose to make one or the other or you can choose to make both, but you don't have to make the same person the power of attorney for both of them, you can choose to send it to different people or appoint different people.

  So health and welfare. This is looking into your daily routine, for example, washing dressing and eating your medical care, moving into a care home or any life sustaining treatments that you should or shouldn't wish to have. Whereas property and finances is more looking at managing your bank or your building society accounts, paying bills, collecting benefits or a pension. So they do differ, which is why you want to make sure that you know what is included in which one?

  And included in property and finances is also about selling your home. So you can very much set out your wishes as to whether you would want that to happen or how you would want that to happen.

  Now, a couple of the last slides that we're going to go through, one is about advanced decision and the other one is about an advance statement. So you may have heard the statements before, but it's really good to know what the difference between the two is. So an advance decision is the decision to refuse treatment.

  So you can make it now to refuse a specific type of treatment at some time in the future. So let your family, your carers, and any health professionals that you're under know what your wishes are about refusing certain treatment if you are unable to make those decisions later on down the line.

  So the treatments that you're deciding to refuse, you must name them all, because if it's not written down and it's not named, then those treatments, should they be needed, will be given to you. So it's just with this particular one it's just being very, very clear about knowing what you want. Now, the beauty with this particular living will, as they call it, is it opens up that opportunity to speak to your health care professionals or your loved ones about what you do and don't want, because you might know what you want, but others might not know. And having worked in a hospital for a very long time, I can see that these difficult discussions come up when you wouldn't necessarily want to be talking about them. So sometimes it is just easier to sit down and have this discussion when you're feeling very well. And it could be years in advance that you're looking at this. But if you have very strong decisions on what you want, then you should let others know.

  Now, an advanced statement is a written statement that sets out your preferences. So this is what your wishes, your beliefs and your values regarding your future care. So this is to multipoint guidance so that the people that are making decisions in your best interests, if you've lost the capacity to make those decisions, know how best to communicate what you would have wanted, so by writing down an advance statement, you can make things more clear for anybody involved in your care. So they're slightly different between the two, whereas the advance decision is solid and it's setting aside your advance statement is more just what you think you might want.

  So I know this is a whistle stop tour on help, support and future planning, but the whole point of this particular presentation is it allows you to go back, pause, and if there's anything you need to jot down, then you've got that ability to do so.

  So I hope everything in there is relevant for you or for anybody that you know and that there's hints and tips and websites that you can use that will hopefully be reliable, and valid to you. Okay. Thank you for listening.

  Take care. Bye bye.

• Week 6 - Relaxation and mindfulness

  Hello, everyone, and welcome to this presentation, all on relaxation and mindfulness. I don't know if you've heard of that term mindfulness before, but it's just the act of thinking in the present. Now, you may have been in a situation where you've gone upstairs and you've forgotten why you've gone upstairs. Or something that I've done is I've gone out of my house, got into my car, sat in the car. I think to myself that I lock the door, okay. So I have to go back and check and yeah, go about my day.

  OK, so mindfulness is, as I said, it's just about thinking about each individual step rather than worrying about the step, the next step or the steps that we've taken in the past. It’s about trying to be more present. And mindfulness and relaxation, they just go hand in hand. So for today I'm just going to play you a short relaxation CD. And it goes through just a few different types of relaxation and mindfulness techniques.

  So one is deep breathing. OK, another one is progressive relaxation. And then the other one is imagery or visualization relaxation. Now, some people may not be able to get into these relaxation techniques, and there's absolutely nothing wrong with that for us as long as you are doing something to de-stress, relax the body, relax the muscles especially, and relax the mind. It will give you that extra bit of energy which can be lost through tense muscles, tense body and tense mind. OK, so if you are doing something which you find relaxing, where you can be more present then we feel it will be beneficial to you.

  But with this relaxation, as I said it's about 15 minutes goes through the three main relaxation techniques. And we hope you enjoy.

  This tape is made up of a number of relaxation components, namely breathing muscle tension and imagery. Make sure you have made sufficient time for yourself when you will not be disturbed for at least 15 minutes.

  You may want to unplug the telephone or put a note on the door asking not to be disturbed. Make yourself as comfortable as possible. You may wish to remove spectacles, contact lenses, watches, shoes or loosen any tight clothing.

  Choose a position where you feel most comfortable. Either lying on the floor or on your bed or sitting in an upright chair. Make sure your head is supported by a pillow if necessary. If you're lying down ensure your back is in contact with the floor for bed. You may need to raise your knees slightly to do this or put a pillow under them. Sit right back into the chair if you are seated with your feet flat out on the floor in front of you. Your arms should be resting gently in your lap, or down by your side.

  Now close your eyes. Focus briefly on any sounds or movements you can hear around you. Then allow them to leave your mind. I'd like you to concentrate on your breathing. Try to breathe using your diaphragm to ensure you are filling your lungs completely with air.

  Expand your stomach area when you breathe in and contract your stomach when you breathe out. Breathe calmly and regularly. In through your nose. And out through your mouth, imagining that as you are breathing out slowly, you are breathing away tension from your body.

  In. And out. In. And out. Push your stomach out a little bit when you breathe in. And pull your stomach in a little bit when you breathe out. Breathe continuously and smoothly, making sure you're not holding your breath at any time.

  You may find it helpful to say an appropriate word or phrase to yourself when you are breathing out. Maybe the word peace, or relax, or calm. Something that makes you think: tranquil thoughts.

  Continue with your relaxed breathing, expanding your stomach when you breathe in and contracting your stomach when you breathe out.

  You can use this breathing now as you focus your attention on your body. You are now going to attend a variety of different muscle groups in your body and then release that tension as you breathe out.

  Concentrate on your feet. Curl your toes up and press your heels into the floor so as to recognize the tension. Feel that tension travel through your legs. As you breathe out, let go of the tension. And let your feet and legs go soft and limp. Focus on that feeling of relaxation. Bring your knees and thighs together to recognize the tension in the top part of your legs. Then let your legs drift apart. And move your knees until they feel in a comfortable and relaxed position.

  Recognize that new position. Squeeze your buttocks together. And feel the tension in your pelvic area. Now let go and breathe that tension away. Allowing your buttocks and thighs to go floppy and loose.

  Pull your tummy muscles in towards your spine and be aware of the tension in your back area. As you breathe out let go of your tummy and your back muscles so your body begins to feel heavy and relaxed.

  Clench your hands so you can feel the tension up through your arms. Now let go of that tension and keep your hands gently spread out on the floor or in your lap. Wherever feels most comfortable. Notice that feeling of relaxation in your hands. Tense your shoulders and your neck. By putting your shoulders towards your ears.

  Now let your shoulders drop while you breathe out. And recognize that new feeling of relaxation. Tense your face by gritting your teeth together and gently screwing up your eyes. As you let go of that tension make sure your teeth and lips are slightly apart and your tongue is loose in your mouth.

  Now that you have relaxed your body, continue breathing in and out. Calmly and regularly enjoying that feeling of relaxation you have achieved. And releasing a little more tension with each out breath.

  In your relaxed state, use your imagination. So picture yourself in a situation of peace and tranquillity. It can be somewhere you have been before or a new place you have created for yourself. Maybe a favourite beach, or garden, for wood, or room in your house. Think of all the sights, sounds and smells you might find which helps you to think of it as a place of sanctuary.

  Continue to breathe in. And out. Expanding and contracting your stomach area. Whilst you enjoy your time in your chosen place of solitude, completely relaxed and free from all cares and worries. Should thoughts arise in your mind which are not relevant to your peaceful state of mind, just push them away. And bring your attention back to your body, your breathing. And your chosen place of relaxation.

  Soon it will be time to leave this quiet haven and return very gently back to reality.

  I'm going to count from five to one. By the time I reach one you will have opened your eyes.

  Five. Four. Three. Two. One. Your eyes are open and you are wide awake. Take plenty of time to focus your attention on your surroundings. Noises around you. Items in the room. Yawn as much as you need to. And gently stretch your whole body.

  If you’re lying down roll slowly onto your side. And then gradually sets up. You may now feel quite sleepy. This is natural, and shows you have achieved total relaxation. Allow yourself time to recover from the relaxation session before going about your usual activities. And trying to carry these out in as calm and relaxed a manner as possible.

  You should feel energized and ready to take on the world within a very short space of time.