Remember to Breathe

The year 2020 has been a challenging year. A global pandemic, global warming, the current socio-political climate and a looming presidential election with its potential social and economic consequences have been plastered on our news feeds, discussed (or more accurately announced) on social media platforms, broadcast on television networks and have been at the forefront of everyone’s thoughts and discussions. Things are incredibly polarizing these days. This has led to increases in stress, anxiety and depression in the general population and in frontline or healthcare workers.1-3 It’s often difficult to identify, diagnose or treat these challenges.

As a pediatric pulmonologist, I have encountered an increase in what I believe to be anxiety or stress related respiratory symptoms since the pandemic’s onset. While it’s not always easy to identify or establish these challenges, I’m often able to rule out other more obvious diagnoses (e.g. asthma, allergies, respiratory infections etc.). When it comes to treating these conditions, if suspected, it can be even more challenging. There are times when a psychiatric professional may be helpful and even necessary, however there may be other options.

Remembering to breathe may have more benefits than you think. We continue to better understand the physiology and the biology of stress and how it impacts the body. Through this improved understanding, we’re also able to identify novel ways to intervene, including the use of breathing and meditation techniques.4, 5  When we are stressed out (e.g. being chased by a lion) we breath very quickly, leading to short, sometimes shallow breaths. This is a manifestation of the sympathetic response (the fight and flight component of our autonomic nervous system). When we’re relaxed (just after eating a meal, when we’re sleeping), we breathe deeply and more slowly, and this has been correlated to an increase in parasympathetic activity (the rest and repose component of our autonomic nervous system).

While the science isn’t perfect, there are several studies that highlight this relationship between breathing and the brain. It appears Sudarshan Kriya yogic breathing (cyclic breathing ranging from slow, calming to stimulating and fast) and pranayama (slow, deep breathing) have been associated with reductions (improvements) in negative emotional states including stress, depression, PTSD, anxiety and insomnia (reviewed in accompanying citations).4-6 While the biology or physiology behind this isn’t entirely clear, there is more and more evidence supporting the mental and physical benefits to controlled breathing techniques.

I suspect that we can all benefit from some form of stress reduction through controlled breathing. If there are substantial benefits to our mental and physical health with almost no side effects (except that we have to commit time to the practice), then I believe it’s really something we should consider prior to initiating anxiolytic medications. The trick is, how to implement the breathing techniques?

There are many resources available to help learn how to be mindful, how to meditate, or how to practice some form of controlled breathing. There are also great resources for helping you understand the impact stress has on our bodies. I suggest reading/listening to a few resources and choosing what works best for you. Below are a list of some that I have used:

Books:

 

Podcasts/Apps:

I’ve also found the process of focusing on my breath or thinking about nothing/emptiness incredibly challenging. For me, it was helpful to grasp onto something physical to promote or dictate how my breathing might manifest during these sessions. I’ve appreciated using The Shift, a wearable (low-tech) device made by Komuso Design (www.komusodesign.com) that helps to slow down my breathing (NOTE: I do not have any financial relationship to Komuso Design). It’s a physical object that helps me to focus on my breathing, something I’ve found quite difficult to do with my wandering mind.

We have a long way to go, as we work to recover from the current challenges to our society. As we move forward, please remember to breathe. It may help in more ways than you think.

 

Additional Helpful References:

  1. Antonijevic J, Binic I, Zikic O, Manojlovic S, Tosic-Golubovic S, Popovic N. Mental health of medical personnel during the COVID-19 pandemic. Brain Behav. 2020:e01881.

  2. Gallagher S, Wetherell MA. Risk of depression in family caregivers: unintended consequence of COVID-19. BJPsych Open. 2020;6:e119.

  3. Pfefferbaum B, North CS. Mental Health and the Covid-19 Pandemic. The New England journal of medicine. 2020;383:510-2.

  4. Jerath R, Crawford MW, Barnes VA, Harden K. Self-regulation of breathing as a primary treatment for anxiety. Appl Psychophysiol Biofeedback. 2015;40:107-15.

  5. Jerath R, Edry JW, Barnes VA, Jerath V. Physiology of long pranayamic breathing: neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system. Med Hypotheses. 2006;67:566-71.

  6. Jerath R, Beveridge C, Barnes VA. Self-Regulation of Breathing as an Adjunctive Treatment of Insomnia. Front Psychiatry. 2018;9:780.

Why children with lung disease should exercise

Having asthma, or other lung conditions, should not excuse children from exercise. The benefits of exercise are well known and the consequences of not exercising, perhaps, are even more well known. Without exercise, we are at risk of gaining too much weight (when coupled with an unhealthy diet). Being overweight or obese increases your child’s risk for developing obstructive sleep apnea. Both obesity and obstructive sleep apnea can both make other inflammatory conditions, like asthma, more troublesome and difficult to get under control. But there is a vicious cycle where an overweight child may be more prone to exercise induced asthma, limiting their willingness or ability to exercise, leading to a worsening of their obesity and all of the medical complications associated with obesity (diabetes, high blood pressure, obstructive sleep apnea etc.). It is this cycle that needs to be interrupted.

There are many benefits to exercise. Most of what we know comes from studying adults, however we can translate these findings to children as well. Regular exercise has been associated with reduced cardiovascular disease including systemic hypertension and heart attacks, reduction in type 2 diabetes, and a reduced rate of dying (mortality) from various cancers or heart disease.[1] There are notable improvements in memory, cognition (thinking and problem solving) and school performance in children.[2] We also know that regular exercise, in the form of pulmonary rehabilitation (exercise monitored and prescribed by an exercise physiologist or physician) can improve endurance and overall well-being in patients with chronic lung disease, most notably chronic obstructive pulmonary disease, a condition with similar challenges to that of asthma.[3]  

This form of “prescribed” regular exercise (pulmonary rehabilitation) allows for a strict and regimented escalation in exercise intensity while monitoring for worrisome changes in heart or lung health. The process also allows the physician or exercise physiologist to monitor improvements in fitness and exercise tolerance. But we know this works in healthy individuals, we just call it something else: “training”. Start running 3 miles today, doing so every day for 6 months, and you’re bound to have a faster or at least easier run at the end of the six months than when you started.

The term “rehabilitation” implies a loss of function or an attempt to return to a baseline and may be required in progressive conditions of the lungs. Cystic fibrosis may be one such condition where, if not well controlled, there can be significant, ongoing lung disease. Exercise (amongst many other therapies) has long been a recommended therapy for people with cystic fibrosis and may improve aerobic exercise capacity, pulmonary function and health related quality of life with no or limited risk.[4] With the overwhelming evidence pointing towards the benefits of regular exercise, why then has this not been regularly prescribed for other respiratory conditions? After all, exercise is medicine!

The truth is, pediatricians, pediatric pulmonologists and pediatric cardiologists have long been recommending exercise for children with lung disease. But why not “pulmonary rehabilitation”? Unfortunately, it’s not very easy to study, and insurance companies have a hard time paying for anything that is not scientifically proven to be beneficial. Dr. Stephen Kirkby and his colleagues at Nationwide Children’s Hospital in Columbus, Ohio may have finally solved that problem with a recent publication in the journal, Pediatric Pulmonology.[5] Dr. Kirkby and his colleagues looked through their prior records for children who underwent pulmonary rehabilitation for various reasons and identified several with asthma. Following a 6-8 week regimented rehabilitation program, those with asthma had a significant improvement in the distance they could walk in 6 minutes (a routine test of everyday activity tolerance) and forced expiratory volume in 1 second (FEV1; a common lung function test monitored in asthmatics). They also reported an improvement in quality of life following the completion of the study.

While this study had some limitations, including a relatively small group of children, many of them with obesity (74%) and reported exercise limitations (69%) already, it is none-the-less exciting to see that regimented pulmonary rehabilitation may be helpful in our asthmatic population. This, along with the neurologic, metabolic and cardiovascular benefits of exercise, should make regular exercise an important part of our daily routines. We as physicians, and more importantly, as parents, should always be encouraging our children to exercise.  

  1. Warburton, D.E.R. and S.S.D. Bredin, Health benefits of physical activity: a systematic review of current systematic reviews. Curr Opin Cardiol, 2017. 32(5): p. 541-556.

  2. Diamond, A.B., The Cognitive Benefits of Exercise in Youth. Curr Sports Med Rep, 2015. 14(4): p. 320-6.

  3. Ries, A.L., et al., Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest, 2007. 131(5 Suppl): p. 4S-42S.

  4. Radtke, T., et al., Physical exercise training for cystic fibrosis. Cochrane Database Syst Rev, 2017. 11: p. CD002768.

  5. Kirkby, S., et al., Benefits of pulmonary rehabilitation in pediatric asthma. Pediatr Pulmonol, 2018. 53(8): p. 1014-1017.

 

Environmental Impacts on Lung Development

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As it is the first Breathing Blog post, it’s only fitting that we start at the beginning. We are almost never exempt from the environment we live in. We hear the sounds, we smell the scents, see the sights and we breathe the air. A fetus in a pregnant woman is not exempt from the impact of the environment on one’s health. In fact, exposures during the critical period of lung development in utero (gestation) can leave lasting effects on the future respiratory health of your child.

Prenatal Impact:

Lung development begins within the first month or two of gestation and believe it or not, air pollution can impact lung development quite substantially. Over the next few months of the pregnancy, a baby’s lungs begin branching, elongating and maturing. Pollution that you inhale can actually impair some of this development. Often this is challenging to identify at birth or even early on in infancy, but these exposures have been associated with the later diagnoses of asthma and allergies. In fact, there is an increased incidence of asthma in children born to non-smoking mothers whose grandmothers were smokers. While it’s generally understood that tobacco smoking, second hand smoke exposure and even third hand smoke exposure is detrimental to lung development, there is evolving evidence that other pollutants impact lung development as well.(1) 20% of children born to mothers exposed to the Great Smog of London in 1952 went on to develop asthma and another 10% developed asthma later in adult life.(2)  Burning fossil fuels such as oils or gasoline produce particulates such as PM10 (particulate matter less than 10 ng in size) and PM2.5 (less than 2.5 ng in size), as well as NO2, benzene, polycyclic aromatic hydrocarbons (PAH) and CO all of which have been linked to impaired lung function when exposed in utero.(1,2) 

Impact During Infancy and Childhood:

After birth, the lungs continue to grow and develop well into our teenage years and probably into our mid 20’s. Our lungs begin to inhale our environment as soon as we’re born as air is ubiquitous and impossible to avoid. Any pollutants inhaled have to face a number of protective mechanisms in our airways, but these are not perfect, and can easily be overwhelmed. Particles with a larger size, such as PM10, land in our larger airways and cam get caught in our airway’s muco-ciliary escalator (little hair like projections lining our airways that move mucous and debris up the airway). The body also has an air-blood barrier that can act as a filter to prevent absorption of pollutants. Further, we have white blood cells, called macrophages, in our lungs that help to digest larger particulates. Unfortunately, these defense mechanisms are easily overwhelmed and consequences of exposure to pollution can occur.

Increased Risk for Respiratory Infections:

  • Exposure to air pollution increases the risk of acquiring respiratory infections, often these are more severe than in non exposed persons with similar infections. This is quite common in larger cities where a high NO2 and particulate matter (PM2.5 and PM10) burden were associated with an increased amount of influenza and other viral respiratory tract infections.(3)

Increased Airway Inflammation:

  • Ozone, diesel exhausts, PM10, polyurethane foam (building insulation, electronics, bedding, surf boards etc.), toluene diisocyanide (used in making polyurethane foam) up-regulate several types of white blood cell activity within the lungs increasing the propensity for airway inflammation and chronic cough.(4)

Increased Risk for Developing Asthma and Allergies:

  • Similar to pre-natal exposures, post-natal exposure to pollutants has been associated with the development of chronic respiratory conditions such as asthma, allergies or chronic cough. Notable pollutants that increase sensitization to aeroallergens (such as dust, pollen or cockroaches) include NO2, diesel exhausts and PAH and unfortunately, an increased sensitivity to aeroallergens increases the risk of developing asthma.(5)

Asthma and Allergy Exacerbations:

  • Not only do children exposed to high levels of pollution have an increased risk of developing asthma, but ozone (O3), CO, NO2, SO2, PM10, PM2.5, dust mite, pollen, pet dander and smoke can all exacerbate asthma and cause a more severe allergic response.(6) (7) (8)

 Air pollution is a significant problem that all of us are challenged with increasing the risk of abnormal lung development and worsening respiratory conditions such as asthma and allergies. These challenges begin early and really persist throughout life if exposures continue. It is imperative that we seek ways to reduce exposure to our most vulnerable population, our infants and children.

References

  1. Air pollution during pregnancy and lung development in the child. Insa Korten, Kathryn Ramsey, Philipp Latzin. 2017, Pediatric Respiratory Reviews, Vol. 21, pp. 38-46.

  2. A retrospective assessment of mortality from the London Smog Episode of 1952: The role of influenza and pollution. Michelle L. Bell, Devra L. Davis and Tony Fletcher. 2004, Vol. 112, pp. 6-8.

  3. Air pollution and acute respiratory infections among children 0-4 years of age: an 18-year time-series study. Darrow LA, Llein M, Flanders WD, Mulholland JA, Tolbert PE, Strickland MJ. 2014, American Journal of Epidemiology, Vol. 180, pp. 968-970.

  4. Air pollutants and early origins of respiratory diseases. Dasom Kim, Zi Chen, Lin-Fu Zhou, and Shou-Xiong Huang. 2018, Chronic Diseases and Translational Medicine, Vol. 4, pp. 75-94.

  5. Environmental determinants of allergy and asthma in early life. Allison J Burbank, Amika K Sood, Matthew J Kesic, David B Peden and Michelle L Hernandez. 1, 2017, Journal of Allergy and Clinical Immunology, Vol. 140, pp. 1-12.

  6. Impact of air pollution on the burden of chronic respiratory disease in China: time for urgent action. Wei-Jie Guan, Xue-Yan Zheng, Kian Fan Chung, and Nan-Shan Zhong. 2018, Lancet, Vol. 4, pp. 75-94.

  7. The dangerous liaison between pollens and pollution in respiratory allergy. Schiavoni G, D'Amato G, Afferni C. 2017, Annals of Allergy, Asthma and Immunology, Vol. 118, pp. 269-275.

  8. Pulmonary health effects of air pollution. Kurt OK, Zhang J, and Pinkerton KE. 2016, Current Opinions in Pulmonary Medicine, Vol. 22, pp. 138-143.