COPD

[jennyj1979]

As a few of you know from my threads my father is dying of COPD He has recently been hospitalized because he keeps falling as he gets really dizzy. They said it was because of "orthotic blood pressure" or something like that. My father is now in a rehab facility. I just found out the place does not have air conditioning. I called my father and he sounds so bad... part of his care requires that he not be exposed to high temps and humidity. I have called the facility and three of my fathers doctors to ask them to please push to have this installed asap.

So if someone can explain to me if this Orthotic Blood pressure thing is related to his COPD that would be great. We have requested assistance from hospice as we just want him to be comfortable and know he is not.

Thanks!

[Davy9]

It is also called "orthostatic syncope" and at one time or another most of us have experienced it. It is that light headedness that happens when we sit-up or stand up too quickly after having been flat for awhile. It is caused because the quick change in posture brings the head up and the arterial system responds too slowly to keep adequate blood supply to the brain. If the blood supply to the brain is too limited people actually do faint (that's called syncope).

It is not peculiar to end stage COPD and it may reflect a combination of things such as low overall blood volume, inadequate arterial tone, poor cardiac performance and/or the interactions of any number of drugs. Your father needs to move slowly and deliberately so that his blood pressure can keep up with the demands he places on it whether they be related to posture changes or physical work.

An overheated environment will further place demands on the blood volume as the body will try and control its temperature using the skin or sweating. This can further diminish the circulating blood volume making his already sluggish circulatory responses worse. You can get a fan to help control his body temp. Be certain that he is adequately hydrated (not over hydrated). If he loses too much water his orthostatic pressures will be negatively impacted. Fluid balance in end stage COPD can be dicey so do not over do it. You might want to discuss his fluid balance with his doctors.

[jennyj1979]

Thank You Davy. I raised a little hell yesterday with the administrators where he is currently at and he now has an AC. He told me he could feel his chest loosen up as the AC started to do its work. Of course it saddens me to see him struggling with everything... you have really answered all my questions...

As far as his fluid balance goes.. you are not joking when you say it can be dicey. His ankles and feet are so swollen, and his face too. I know its fluid and it worries me that he is carrying around all this extra weight. He takes a water pill that is supposed to help it but it really does not seem to do much. He is always thirsty though... always drinking water... is this something that should also be monitored more closely?

Thanks again for your support Davy!!

[Davy9]

I will try to explain the fluid management problem.

Our vascular system is comprised of arterial outflow and venous return-flow. Our heart is comprised of 2 pumps. One pump (the left side of the heart) receives venous blood from the lungs and pumps it out to the body through the main arteries. The other pump (the right side of the heart) receives venous blood from the body and pumps it out to the lungs through pulmonary arteries.

The left side of the heart meets a high workload and is designed to accommodate that workload. It pushes arterial blood out against a starting pressure of around 70 mmhg up to around 120 mmhg on the high end. The right side of the heart sends blood to just the lungs where the pressures are normally very low. The right ventricle pushes arterial blood out against a starting pressure of around 9 mmhg up to around 25 mmhg.

The right side of the heart is not designed to accommodate high workloads and that is the problem in end stage COPD. The vascular beds in the lungs become seriously compromised because of the disease. That causes high blood pressure in just the lungs and it overworks the right side of the heart (that is called cor pulmonale) and it goes into failure. The right heart becomes unable to manage all the blood coming back to it from the body so the extremities start to 3rd space. That is the swelling you see in the feet, legs and hands. If it backs up in the body too far the left side of the heart is affected and that can cause a back up of fluid into the diseased lungs (pulmonary edema). The addition of pulmonary edema to the already diseased lungs is not good.

That's the fluid management problem in COPD. They need enough fluid to sustain life without getting so much on board that they overwork a pump system overburdened by a diseased pulmonary vascular bed.

Your fathers fluid intake and output should be kept track of to some degree. It can be done to a fine degree by measuring all the intake and all the output (that's called I and O's) but that may not be necessary. They can do daily weights and any large change in weight can usually be ascribed to a change in fluid balance. They can also routinely listen to the lungs using a stethescope and will hear the beginnings of pulmonary edema as fine inspiratory crackles in the lungs bases. If pulmonary edema does occur it can usually be treated by increasing the dosage of the water pills so the excess water is taken off by the kidneys.

In summary fluid balance is a fine line to walk in end stage COPD but it is understood and manageable. But, in this case where blood flow to the brain is also an issue the fluid balance needs to be considered. You did not want his body trying to keep cool by trying to shift blood volume to the skin to dissipate body heat. That was just something his system did not need and could be easily avoided with environmental controls. You have taken care of that.

[jennyj1979]

It seems as though my fathers condition is only getting worse. Today I received a call from the care facility he is in for "rehab" and they advised us that he would most likely never walk again. Today while walking with a walker not even 10 feet his oxygen level fell below 80%. This was just in a matter of seconds. He seems okay while in bed, however any physical activity at all literally just about kills him. It breaks my heart to see him this way... I just wish there was something I could do to make him better but I know there is not. My mother and I have both called his doctors and asked if they feel hospice would be appropriate at this point. If he can never walk again there is no way either of us would be able to take care of him at home. Of course his Doctors do not return our phone calls. The only way we get any answers is on here. So Davy and anybody else who has replied to any of my posts.. thank you for all the information. It has been extremly helpful.

[Davy9]

Hello Jenny,

The fact that he desaturated when being ambulated may not mean he's getting worse. He's being physically challenged and they are learning his limitations. I have to assume that they know how to interface the ventilator to accommodate this level of work. In other words when we exercise we increase our respiration as we need to. Your father will need additional support when he is being exercised from the ventilator. This can be additional breaths on demand and additional oxygen.

As you describe he does sound quite marginalized with an ambulation exercise. They could trial him on bicycle ergometers and work to build up his leg strength. Bicycle ergometers can look like regular exercise bikes, they can be recumbent or they can be set up to work while he's in bed. They will support his weight while he works just his legs. This way he could try to improve the efficiency of his leg muscles to the point where he might be able to resume active ambulation.

Let's assume that he will not be able to walk or even wean from the ventilator. As long as he's on the ventilator he is comfortable (not short of breath) and can enjoy things (television, video games, getting outside, cards, etc....). They make wheelchairs that have ventilator pans designed to accept portable ventilators. These wheelchairs can also be motorized with controls that he can command. The entire set-up becomes autonomous when using portable oxygen. He could be relegated to being ventilator dependent with such a lifestyle. He can be mobile using the equipment. He gets up each day, gets dressed, transfers from the bed to his wheelchair along with his ventilator equipment and away he goes. He does not even attempt any physical work but rather works to maximize his quality of life as a vent dependent COPD'r.

Whatever facility he is in will have social services. You can discuss hospice or any issues you want with the medical social worker. I would also suggest that you enlist their help in getting better communication with his physicians.

Absolutely, this is a tough road to be one for all of you. I cannot adequately express the anguish I feel for these situations. Given the number of times I have dealt with them I am very angry and frustrated with a government that refuses to coral up tobacco products.

I hope you find this information helpful.