Sex in the 60 s. Breathless in Bed. SMX Convention Center. 06 May :00PM

Transcription

1 Sex in the 60 s Breathless in Bed SMX Convention Center 06 May :00PM

2 "What Does Clint Eastwood, Tina Turner, & Mick Jagger, Diabetes, Heart Disease, COPD and Cancer Have in Common?"

3 Its older age! Mick Jagger turns 70 this year;tina Turner is 73 and Clint Eastwood is over 80* In 2020, # of people over 60 will be 1 billion COPD is the fourth leading cause of death among men in Europe **( and in most countries) COPD is the fourth leading cause of death in the US in people between ages 65-84*** WHO estimates in 2002, approximately 210 million people worldwide suffered from COPD*** *Hammond, M. Developing and Marketing Therapies for the Aging Population, PharmaVOICE Webcast 03/ **París JM; Expert Review of Respiratory Medicine 7 (2 Suppl), 3-15 (Apr 2013) ***Medifocus Digest Alert on COPD 2011

4 The Burden of COPD COPD has become a serious public-health concern The disease, which may be life-threatening if not properly managed, often goes undiagnosed COPD accounts for significant healthcare, social and personal costs, as it can cause disability and lead to marked impairment in patients' quality of life París JM; Expert Review of Respiratory Medicine 7 (2 Suppl), 3-15 (Apr 2013)

5 The main objectives in the management of chronic disorders such as chronic obstructive pulmonary disease (COPD) To suppress or minimize symptoms To prevent and reduce exacerbations To avoid limitations in activities of daily living To enable the patient to lead a normal, or nearly normal, life París JM; Expert Review of Respiratory Medicine 7 (2 Suppl), 3-15 (Apr 2013)

6 The primary goal in the management of COPD To maintain patients' clinical stability. to lessen the impact of the disease by achieving an adequate patient control with as few limitations of everyday activities as possible by optimizing their quality of life, patients should be symptom-free or virtually symptom-free by preventing exacerbations, which involve a high consumption of both healthcare and personal resources París JM; Expert Review of Respiratory Medicine 7 (2 Suppl), 3-15 (Apr 2013)

7 Concerns What effect will COPD have on sexuality? Will sex be possible? Will it be safe? Will it be satisfying?

8 The Issue is Best Addressed by a Review: Pathophysiology of COPD Cornerstone of Therapy in COPD Concerns of a COPD Patient

9 ANNUAL DECLINE IN LUNG FUNCTION Susceptible smoker Moderate (II) (10-20%) Symptoms Severe (III) Non smoker Non-susceptible smoker Stopped smoking aged 50 yr 25 0 Disability Death Age (years) Fletcher C, Peto R: BMJ 1977 Very severe (IV) Stopped smoking aged 60 yr

10 COPD and Decline in Lung Function Stage I: 40 ml/yr FEV 1 (% predicted) Stage II: ml/yr Stage III: ml/yr Stage IV: <35 ml/yr Years Tantucci C, et al.international Journal of COPD; 2012:7; 95-99

11 PATHOLOGY OF COPD Peripheral lung Alveolar wall Small airway inflammation Correlated with Bronchiole diseased severity Inflammatory cell numbers Inflammatory cell exudate in lumen Peribronchiolar fibrosis Hogg JC et al: NEJM 2004 Loss of attachments EMPHYSEMA Fibrosis Inflammation Chronic obstructive bronchitis Dr Manuel Cosio Normal COPD

12 AIR TRAPPING IN COPD Normal COPD small airway alveolar attachments Inspiration Hyperinflation: air trapping TLC Residual volume FRC Inspiratory capacity BRONCHODILATORS Inflammation Exertional dyspnoea thickened airway Exercise tolerance loss of alveolar attachments loss of elasticity (emphysema) LAMA: tiotropium bromide, Expiration glycopyrrolate,.. LABA: salmeterol, formoterol, indacaterol. airway closure Normal Hyperinflation

13 Long-acting bronchodilators interrupt the Vicious vicious circle cycle in in COPD COPD Airflow Flow limitation Air Air trapping Long-acting bronchodilators Basis: Reduced exercise symptoms throughout the day impact on exacerbation Hyperinflation Dyspnea De-conditioning Activity Quality of life

14 BRONCHODILATORS IN COPD Tiotropium, LABAs Air trapping Airway stabilisation Inflammation? Symptoms Exacerbations Airway compression Fibrosis? Barnes, Peter Anticholinergics in COPD Jakarta SEA External Expert Meeting April 2013 Disease progression Mortality

15 What do our patients buy with that increased lung function? Effects of bronchodilators in enhancing exercise capacity Are there limits to the exercise improvement? Can we push the limits?

16 Effects of Bronchodilators on Exercise Capacity Increase ventilatory ceiling More comfortable, work of breathing is less Recover faster from the exercise Malthias et al CHEST 2005;128: O Donnel et al Eur Respir J 2004;24:86-94 Berton et al Thorax 2010;65:588-93

17 Acute Effects of Bronchodilators Increased exercise endurance time Reduced dynamic hyperinflation Reduced work of breathing Reduced symptom perception Reduced cardiac load Enhanced oxygen kinetics Improved peripheral muscle oxygen delivery Malthias et al CHEST 2005;128: O Donnel et al Eur Respir J 2004;24:86-94 Berton et al Thorax 2010;65:588-93

18 Intervention Mechanism Effect VEpeak Bronchodilators Dynamic hyperinflation Cardiovascular function isove ENDURANCE CAPACITY Troosters et al Eur Respir Rev 2010;19:24-9

19 Limits To Improvement Only about 44 ± 28% of the potential of a bronchodilator seems exploited Only a part of the increased ventilatory capacity is utilized From ventilatory limited (dyspnea) to peripheral muscle fatigue Magnussen et al Respir Med 2012;106;

20 Can We Treat Muscle Fatigability? Exercise training program Pulmonary rehabilitation program -abolish fatigability -no change in peak ventilatory levels -addresses the peripheral muscles Synergistic with pharmacotherapy Casaburi et al CHEST 2005;127: Kesten et al In J COPD 2008;3:127-31

21 sustained bronchodilation may improve, in a dose-dependent way, the ability to perform greater physical activity than normal, and this may improve the clinical course of the disease

22 Intervention Mechanism Effect VEpeak Bronchodilators Dynamic hyperinflation isove Functional Exercise Stimulus (e.g. Walking) High intensity Exercise stimulus (e.g. Cycling) Cardiovascular function Movement efficiency Skeletal muscle oxidative capacity VE@ isowork VE@ isovo2 ENDURANCE CAPACITY Resistance training Skeletal muscle strength Troosters et al Eur Respir Rev 2010;19:24-9

23 We Can Treat Muscle Fatigability Exercise training program Pulmonary rehabilitation program -abolish fatigability -no change in peak ventilatory levels -addresses the peripheral muscles Synergistic with pharmacotherapy Casaburi et al CHEST 2005;127: Kesten et al In J COPD 2008;3:127-31

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25 The Challenge Not only to enhance exercise tolerance BUT to alter behavior! Behavioral intervention may further improve the success to enhance physical activity

26 INTERVENTIONS ARE NEEDED TO ENHANCE PHYSICAL ACTIVITY AS THIS IS CRUCIAL FOR SUCCESSFUL LONG-TERM DISEASE MANAGEMENT All COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active!

27 What happens in Mild COPD? All COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active!

28 ENHANCED AIRWAY CLOSURE IN MILD COPD Does airway Single closure breath cause N 2 washout peripheral airway injury? Compression of airway epithelial cells Release of inflammatory and fibrogenic mediators? Nitrogen concentration (%) What is the effect Mild COPD of bronchodilators? Phase III TLC CV/VC = 30% Closing volume CV/VC = 20% 0 RV Expired volume (L)

29 ENHANCED AIRWAY CLOSURE IN MILD COPD Does airway Single closure breath cause N 2 washout peripheral airway injury? Compression of airway epithelial cells Release of inflammatory and fibrogenic mediators? Nitrogen concentration (%) What is the effect Mild COPD of bronchodilators? Phase III TLC CV/VC = 30% Closing volume CV/VC = 20% 0 RV Expired volume (L)

30 FUNCTIONAL IMPAIRMENT IN MILD COPD Dyspnoea score GOLD stage 1 patients (n=21): FEV 1 =91 ± 7% predicted FEV 1 /FVC = 61 ± 6% COPD Control 20% in oxygen consumption Power output Exercise limited by dyspnea Closing volume (N 2 washout) IC with exercise Ofir D et al: Thorax 2007

31 Does the Respiratory System Limit Exercise in Mild COPD? Peak oxygen uptake and ventilation were significantly lower in COPD than in health by 36% and 41%, respectively The COPD group failed to increase peak EILV and had a significantly smaller increase in peak VT during DS At 60W, a 50% smaller increase in VT (p<0.001) in response to added DS in COPD compared with health was associated with a greater increase in dyspnea intensity (p=0.0005) Conclusions: These results show that the respiratory system reached or approached its physiological limit in mild COPD at a lower peak work rate and ventilation than in healthy participants. Chin R, Guenette J, Cheng S, Raghavan N, Amornputtisathaporn N, Cortés-Télles A, Webb K, O'Donnell D; American Journal of Respiratory and Critical Care Medicine (Apr 2013)

32 Intervention Mechanism Effect VEpeak Bronchodilators Dynamic hyperinflation isove Functional Exercise Stimulus (e.g. Walking) High intensity Exercise stimulus (e.g. Cycling) Cardiovascular function Movement efficiency Skeletal muscle oxidative capacity VE@ isowork VE@ isovo2 ENDURANCE CAPACITY Resistance training Skeletal muscle strength Troosters et al Eur Respir Rev 2010;19:24-9

33 What happens in COPD? With Intervention

34 The ten commandments to Redemption in COPD

35 Concerns What effect will COPD have on sexuality? Will sex be possible? Will it be safe? Will it be satisfying?

36 Does A Diagnosis of COPD Mean Is it goodbye to sex or other forms of physical My Sex intimacy? Life is Over?

37 Chronic Obstructive Pulmonary Disease (COPD) COPD is a debilitating illness Symptoms like coughing, wheezing and shortness of breath will affect the patient and the partner Dramatically affects many areas of their life, including their sexuality

38 Chronic Obstructive Pulmonary Disease (COPD) & Sex Life Good sex is not automatic To get things right, it is essential to talk with your partner( if single, prospective partners) Approach the subject openly and directly

39 Partners and carers How will my condition affect my spouse/partner/carer? Inevitable at some stage the spouse/partner/carer will feel anxious or frustrated about the breathing problems Important to talk about worries together The partner may react by doing everything for the patient -----not the best approach Important that they remain as active as possible and continue to enjoy things together Keeping fit will help achieve this

40 Keeping Fit Join or rejoin a pulmonary rehabilitation program! Build exercise tolerance Pulmonary Rehabilitation Center...a safe place to exercise......that exercise is safe!

41 Sex and Energy Requirements Doesn t require lots of energy Similar to doing other things If you can walk up two flights of stairs or walk briskly, you can probably handle sex May need scheduling Make scheduling sex an erotic game, not a chore

42 The COPD Patient and Sexual Concerns For many couples, sex and COPD do not go hand in hand, primarily because of the fear of shortness of breath during times of sexual intimacy Fear can become so great, that people with COPD may begin to avoid sexual intimacy altogether Moreover, if they do encounter intimacy, they may be unable to maintain sexual arousal or to reach climax

43 The COPD Patient and Sexual Concerns The non-copd partner may also experience hesitation towards sexual activity, thinking it to be in the best interest of the COPD partner Fear and anxiety surrounding these types of sexual issues can often lead to feelings of frustration, loneliness and isolation for both parties

44 The COPD Patient and Sexual Concerns Avoiding sexual intimacy is not the answer Being diagnosed with COPD does not mean the end of your sex life! A patient partner and some sound advice regarding COPD and sexuality is needed They can enjoy sexual intimacy once again and rekindle the flame that once burned so brightly

45 The Ten Commandments( tips) to Redemption

46 Tips for Enhancing Sexual Intimacy Some things to keep in mind about sex and COPD designed to enhance sexual intimacy: First and foremost, talk with your partner honestly regarding your feelings about having sex Second, keep the lines of communication open and allow your partner to express their feelings in return Third, use a bronchodilator immediately prior to and during sexual relations, if necessary, to avoid bronchospasm during intercourse Adherence to Maintenance Therapy is Essential!

47 Tips for Enhancing Sexual Intimacy Fourth, avoid sexual activity immediately following a heavy meal...this may increase your fatigability Fifth, if you use supplemental oxygen, plan on using the same amount during sexual activity.....use extended tubing so there is enough to allow you to place the oxygen tank away from the bed or completely out of the room

48 Tips for Enhancing Sexual Intimacy Sixth, make sure the room is at a comfortable temperature prior to engaging in sex....use a fan during intercourse to keep from overheating Seventh, avoid alcohol prior to having sex as it can interfere with sexual abilities Eighth, bronchial secretions need to be cleared prior to engaging in sexual activity...this may lessen the severity of breathlessness during sex. Having difficulty clearing the airway, controlled coughing technique may be done

49 Tips for Enhancing Sexual Intimacy Ninth, choose easy sex positions that require the least amount of energy... laying side to side during intercourse is much more comfortable and uses far less energy than the top-bottom position Tenth, plan to have the able bodied partner assume more of an active role during sex so that the COPD partner will be less fatigued

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51 Spoon Position

52 Cross Position

53 Side to Side Position

54 Woman on Top Position

55 Intersection Position

56 Scissors Position

57 Kneeling Face to Face Position with Pillow Support

58 The Ten Easy Steps to Reach Heaven!

59 Advice for Clinicians : Ask

60 Additional Tips Because sexual activity takes energy, plan to engage in sex when you are feeling most rested If necessary, take short breaks during sex, while you continue to be intimate Focus on hugging, kissing and touching, rather than on the sexual act itself Incorporate sexual aids if need be, to achieve a more satisfying experience (only if both partners agree)

61 Additional Tips Now that you know how to enhance sexual intimacy in the bedroom, there are some aspects of sex and COPD that may be of further interest to you: Beginning an exercise program will help you build your activity tolerance which in turn, will make sexual activity easier and reduce your shortness of breath, both in and out of the bedroom

62 Additional Tips While COPD may decrease the frequency and duration of sexual activity, it does not diminish sexual ability Many medications have side effects that may affect your sex drive. Be sure to ask your doctor or pharmacist for a complete list of medications and their side effects Remember that some changes in sexuality are a normal part of the aging process and have nothing to do with COPD, such as slower arousal time or delayed orgasm

63 Advice Summary Avoid sex immediately after a heavy meal and after drinking alcohol Some changes in your sex life are from getting older - not because of COPD Slower erections and delayed orgasms are normal in middle and later life Conserve energy Learn about how your disease and your medicines might affect you Let your medicine work for you Communicate with your partner and stay open-minded Explore what you both like sex Remember that simply touching, being touched and being close to someone helps a person feel loved, special and a true partner in a relationship

64 Remember Your Goal Good sex isn t about giving and receiving orgasm It s about intimacy! To have the most intimate experience that you can manage Simply lying together and cuddling Running your hands through your partner s hair can be an intimate act!

65 Breathe out when you're making a big effort stretching your arms above your head reaching for something on a shelf bending down going up a step or stair standing up During the hardest part of any action BLOW as you GO! 'Blow as you go!'

66 Thank You!

67 Reduce Shortness of Breath During Sex With Breathing Exercises Breathing Techniques: Getting the Most Out of Your Breath The How To's of Diaphragmatic Breathing Pursed-lip Breathing Made Easy

68 Managing Shortness of Breath: The First Step Imagine not being able to catch your breath. People who have COPD or other chronic lung diseases live with this fear everyday of their lives. If you become short of breath, it helps to be able to know what you can do about it: Stop what you are doing and rest in a quiet, comfortable place. Lower your head and your shoulders and try to relax. Breathe in and out as fast as necessary, through your mouth.

69 Managing Shortness of Breath: The First Step Start to slow your exhalations by making them longer. Don't force them. Use pursed-lip breathing if it helps. While you are trying to slow your breathing, start to breathe through your nose. Begin diaphragmatic breathing when you are ready. Stay in this position for 5 to 10 minutes until you have completely caught your breath.

70 Most Comfortable Positions for Managing Shortness of Breath Just can't get comfortable when short of breath? Here are some positions for you to try to help ease your discomfort: 1. Sitting: Find a comfortable chair to sit in. Sit with your back against the chair, while allowing your head and shoulders to drop forward. Rest your forearms on your thighs with your palms facing upwards. Make sure that your feet are flat on the floor with your knees rolled slightly outward. Do this until you are able to catch your breath. 2. Sitting With a Pillow: Sit in a comfortable chair. Place a pillow on a table in front of your where you are sitting. With your feet on the floor or on a stool, rest your head and arms on top of the pillow. You can also do this position while standing, with your arms resting on top of the kitchen counter, back of a chair or a high tabletop. If standing, remember to keep your knees slightly bent, with one foot slightly forward while you avoid leaning. Do this until your breathing is normal again.

71 3. Standing: With your feet slightly apart, stand with your back to a wall or pole. Keep your feet a comfortable distance from the wall, with your head and shoulders in a relaxed position. Do this until you are able to catch your breath.

72 How to Control Your Breathing The main thing to remember when you become short of breath is to stay calm. This may be difficult for you to accomplish, at first, because gasping for breath can be a frightening experience. The following breathing techniques will become almost second nature to you, if practiced for 5 to 10 minutes, several times each day. This will allow you to use them calmly and effectively during periods of distress: Pursed-Lip BreathingPursed-lip breathing is a breathing technique designed to help you control shortness of breath. Learn to master pursed-lip breathing so you can better manage your life.

73 How to Control Your Breathing Diaphragmatic Breathing Slightly more complicated than pursed-lip breathing, diaphragmatic breathing helps strengthen the diaphragm and the abdominal muscles allowing more air to move in and out of your lungs without tiring your chest muscles. Discover the technique of diaphragmatic breathing so you can improve your exercise tolerance and feel better.

74 Clearing Your Airways: Controlled Coughing A primary symptom of COPD is increased mucus production. The presence of mucus in your airways contributes, in large part, to your shortness of breath. If the mucus continues to obstruct your airway, your breathing will become increasingly more difficult and an infection may occur. That's why it is important to know how to clear your airways, which can help you get rid of unwanted mucus. Used in conjunction with diaphragmatic breathing, controlled coughing helps you clear the mucus from your lungs, allowing you to breathe easier. Here's how to do it:

75 Used in conjunction with diaphragmatic breathing, controlled coughing helps you clear the mucus from your lungs, allowing you to breathe easier. Here's how to do it: Sit upright in a comfortable, quiet place. Allow your head to lean forward slightly. Place your feet firmly on the floor underneath you. Using diaphragmatic breathing, inhale deeply. Try to hold your breath for at least 3 second when you inhale.

76 Open your mouth slightly, place your hand on your abdomen and, while gently pressing inward and upward against your diaphragm, cough once. The first cough should have moved the mucus to your throat. Now, cough again to remove the mucus from your throat. Spit the mucus into a tissue. If the mucus is green, brown, pink or bloody, contact your healthcare provider as this may indicate the presence of infection or other problems. Take a break and repeat as needed.

77 Wash your hands using proper handwashing technique. While treatment of COPD should be governed by a competent health care provider, anything that you are able to do to help yourself along the way, like breathing exercises and airway clearance techniques, will only serve to make your life with COPD more enjoyable and easier to manage.

78 Techniques for when you are more active Try these gently - don't force yourself You can combine techniques - they're all helpful for when you're short of breath If you feel wheezy or tight-chested, try taking your 'reliever' inhaler And remember, never hold your breath - you need the oxygen!

79 'Blow as you go!' Remember that simply touching, being touched and being close to someone helps a person feel loved, special and a true partner in a relationship

80 4. Paced breathing This is useful when climbing the stairs (or walking). Breathe in, in time with the steps you take. Do this in a rhythm that suits you and how breathless you are. For example: breathe in when on the stair, and breathe out as you go up a stair (blow as you go!), or breathe in for one stair and out for one stair, or breathe in for one stair and out for two, or breathe in for two stairs and out for three

81 Pursed lips breathing Breathe out with your lips pursed, as if you're whistling. This slows your breathing down and helps to make your breathing more efficient

82 Pursed lips breathing Breathe out with your lips pursed, as if you're whistling. This slows your breathing down and helps to make your breathing more efficient

83 Relaxed slow deep breathing Gently slow down your breathing. Breathe more deeply. Breathe in through your nose and breathe out through your mouth.

84 Having an illness like COPD can upset any relationship. It will also make you feel tired. And it can also make you feel anxious and depressed. Also, COPD sufferers will experience breathlessness during sexual activity at some stage, which can be worrying. All of this means that your sex life can suffer.

85 'Blow as you go!' Breathe out when you're making a big effort, for example: stretching your arms above your head reaching for something on a shelf bending down going up a step or stair standing up During the hardest part of any action BLOW as you GO!