Behavioral Aspects of

Respiratory Distress

Dr. Matthew Kraybill

Assistant Professor
Department of Behavioral Sciences
MatthewKraybill@Rossu.edu
ROSS UNIVERSITY SCHOOL OF MEDICINE
 Learning Objectives
After this lecture, students will be able to:
1. Recognize the importance of identifying respiratory distress in a clinical evaluation and identify
obstructive vs. restrictive lung diseases.
2. Explain the factors that contribute to chronic obstructive pulmonary disease (COPD), how it is
treated, and associated complications.
3. Summarize the behavioral symptoms and consequences of chronic reactive airway disease.
4. Review the significance of tobacco use and the psychological characteristics associated with
nicotine dependence.
5. Explain the importance of helping patients stop smoking and identify methods of intervention.
6. Apply the transtheoretical model for stages of behavioral change.
Reading: None required, see references for suggested reading.
Location of practice questions: eCollege.
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1. Recognize the importance of identifying respiratory distress in a clinical evaluation and describe the different types of lung diseases.

Clinical Case
• A 52-year old coal miner, presents with a history of coughing sputum
for the past 12 years. Coughing occurs every day for the past 6 years.
He has a 30 pack year history of cigarette smoking.

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1. Recognize the importance of identifying respiratory distress in a clinical evaluation and describe the different types of lung diseases.

Clinical Case (cont’d)

Prevalence of
Significant factors in patient’s baseline health? Age
tobacco use
• Age
• Family History 18-24 16.7%
Genetic disorders, cystic fibrosis, and alpha 1 antitrypsin
25-44 20.0%
deficiency
• Gender 45-64 18.0%
Men more likely than women to smoke (18.8% vs. 14.8%)
• Ethnicity (in the U.S.) 65+ 8.5%

American Indian /
Other Groups:
Alaska Native
30 • 1 in 4 (23.9%) lesbian, gay, or bisexual adults
29.2%
compared to 1 in 6 (16.6%) of heterosexual adults
20 Caucasian African American
smoke cigarettes.
… Hispanic / Latino
10
17.5% 11.2%
Asian American • Military service members are more likely to smoke
9.5%
than civilians, especially those who have been
0
Prevalence of tobacco use deployed.
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1. Recognize the importance of identifying respiratory distress in a clinical evaluation and describe the different types of lung diseases.

Clinical Evaluation of Respiratory Problems

Chief complaint Family History
“I have a cough” • Pattern of lung disease
(broad based etiology) • Related to smoking
“I feel like I can’t get enough air”
• Genetic disorders
(dyspnea, shortness of breath)
“I am having chest pain when I breath” Deficiency of alpha 1 anti-trypsin leads
(pleuritis) to emphysema (approx. 1% of people
with COPD).
Occupational History
Current use
• Coal miners pneumoconiosis (black lung)
• Pack years = number of cigarettes per day
• Asbestosis
divided by 20 x number of years.
• Silicosis
• Farmer’s lung
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1. Recognize the importance of identifying respiratory distress in a clinical evaluation and describe the different types of lung diseases.

“I Can’t Breathe!”
• Build up of carbon dioxide (C02) results in the
urge to breathe.
Normal person does not experience oxygen
desaturation by holding breath until after
about 3 minutes.
• Patients
Thewith breathing
experience ofproblems
needing tofeel of breath” even before 02 saturation falls
“short is
breathe
due tovery
effort it takes to
compelling move
after air through
30-45 secondsconstricted
since bronchioles.
• C02 levels
The “need rise immediately.
to breathe” or “air hunger” is a very unpleasant feeling and can trigger panic.

“I can’t breathe” “I feel like there is an elephant sitting on my chest”

“My chest feels extremely tight” “No matter what I do, I can’t catch my breath”

“I feel like I’ve been buried alive”

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1. Recognize the importance of identifying respiratory distress in a clinical evaluation and describe the different types of lung diseases.

Types of Lung Disease

Obstructive Restrictive
Difficult to exhale all the air in the Difficulty filling the lungs with air.
lungs. • Interstitial lung disease, idiopathic
• Chronic obstructive pulmonary pulmonary fibrosis
disease (COPD) • Sarcoidosis (autoimmune disease)
• Includes emphysema and chronic • Obesity
bronchitis
• Scoliosis
• Asthma
• Neuromuscular disease – muscular
• Bronchiectasis dystrophy or amyotrophic lateral
• Cystic fibrosis sclerosis (ALS)

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2. Explain the factors that contribute to COPD, how it is treated, and the complications associated with it.

Chronic Obstructive Pulmonary Disease (COPD)

http://www.nhlbi.nih.gov/health/health-topics/topics/copd
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2. Explain the factors that contribute to COPD, how it is treated, and the complications associated with it.

Chronic Obstructive Pulmonary Disease

• Progressive disease that makes it hard to breath.
• Most common symptoms: Coughing, mucus, wheezing, shortness of
breath, chest tightness, etc.
• Lung function tests (spirometry or lung diffusion capacity test), chest CT
scan, arterial blood gas.
• Cigarette smoking is the leading cause of COPD
Long-term exposure to other lung irritants (e.g., air
pollution, chemical fumes, dust, etc.) may also lead to COPD
• Treatment Goals: Relieve symptoms, slow progression of disease, improve exercise tolerance,
prevent/treat complications, improve overall health.
Lifestyle changes (quit smoking, avoid irritants), bronchodilators, combination inhaled
glucocorticosteroids, pulmonary rehabilitation, oxygen therapy, lung transplant (last resort)
http://www.nhlbi.nih.gov/health/health-topics/topics/copd
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2. Explain the factors that contribute to COPD, how it is treated, and the complications associated with it.

COPD Treatment
• Patients become extremely tolerant of high C02 levels and low 02 begins to create “air
hunger” or “shortness of breath.”
• Some patients require 02 therapy (portable tank) which poses significant challenges:
Highly flammable – requires great care
Limited mobility
Air travel (cabin pressure reduces the concentration of
oxygen in the air)
Symptom flare-ups cause emotional distress which
manifests as depression, anxiety, anger/frustration.

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2. Explain the factors that contribute to COPD, how it is treated, and the complications associated with it.

Other Complications
• Prone to other respiratory infections • Reduced exercise tolerance and
More likely to catch colds, influenza, and mobility affects:
pneumonia Work
• Cardiac problems Recreation activities
Increased risk for heart disease and Independence
myocardial infarction Relationships / sexual functioning
• High risk for lung cancer • Patients use great deal of energy to
• Pulmonary hypertension breathe and must adjust their caloric
• Psychological burden of chronic disease as intake accordingly.
well as emotional/behavioral changes that May need a supplement (e.g.,
result from the physiology of worsening gas Ensure) to maintain body weight
exchange in the lungs and muscle mass.
Depression, dysphonia, social withdrawal, grief and loss, • Some patients continue to smoke which
end-of-life issues
worsens their disease and symptoms
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3. Summarize the behavioral symptoms and consequences of chronic reactive airway disease.

Asthma
• Chronic, reactive disease that inflames and narrows the airways
• Causes wheezing, chest-tightness, shortness of breath, coughing (particularly at
night or early in the mornings)
• Affects people of all ages, but most often starts during childhood
• 25 million people in the U.S. (7 million children)
• Symptoms can be affected by stress, anxiety,
sadness, and suggestion as well as by
environmental irritants or allergens, exercise,
and infection.
• Higher prevalence of anxiety and depressive
disorders
https://www.nhlbi.nih.gov/health/health-topics/topics/asthma ROSS UNIVERSITY SCHOOL OF MEDICINE
4. Review the significance of tobacco use and the psychological characteristics associated with nicotine dependence.

Epidemiology of Cigarette Smoking

• In 2014, nearly 17 of every 100 U.S. adults (16.8%)

reported currently smoking cigarettes.
40 million adults
Higher rates among persons
o Living below the poverty level
o With a disability/limitation

• Leading cause of preventable disease – 480,000 deaths every year (1 of every 5 deaths).
• More than 16 million Americans live with smoking-related diseases
• Current smoking has declined from nearly 21 of every 100 adults (20.9%) in 2005.

Centers for Disease Control and Prevention: Tobacco Fact Sheet ROSS UNIVERSITY SCHOOL OF MEDICINE
4. Review the significance of tobacco use and the psychological characteristics associated with nicotine dependence.

Psychological Characteristics Associated with Tobacco Use

Personality Factors
• Extroversion, neuroticism, and psychoticism have been linked with smoking
• Sensation seeking and impulsivity traits have a strong association with smoking
• Tendencies toward antisocial, unconventional, risky behaviors
Psychiatric Disorders
• Strong evidence of comorbidity between smoking and depressive disorders
• Bipolar, anxiety, and psychotic disorders are at increased risk for tobacco dependence
Panic attack and panic disorder may present with respiratory difficulty and may
exacerbate certain medical conditions like bronchial asthma.
Attention Deficit Disorder
• Higher prevalence of smoking in adolescents and adults with ADD or hyperactivity
Alcoholism
• Strong association between smoking and alcohol abuse or dependence. Most studies suggest
that alcoholism precedes smoking.
Rondina, R. D. C., Gorayeb, R., & Botelho, C. (2007). Psychological characteristics associated with tobacco smoking behavior. Jornal Brasileiro de Pneumologia, 33(5), 592-601.

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4. Review the significance of tobacco use and the psychological characteristics associated with nicotine dependence.

Nicotine Dependence
• Most smokers become addicted to nicotine (as addictive as heroin, cocaine, or
alcohol).
• More people are addicted to nicotine than any other drug.
• People who stop smoking often start again because of withdrawal symptoms,
stress, and weight gain.
• Withdrawal symptoms:
Feeling irritable, angry, or anxious
Trouble concentrating
Craving tobacco products
Increased appetite

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4. Review the significance of tobacco use and the psychological characteristics associated with nicotine dependence.

Tobacco Use and Pregnancy

Tobacco use can:
• Make it harder for a woman to get pregnant
• Increase the chance of a miscarriage
• Cause placental insufficiency or separation
• Cause premature birth and low birth weight
• Increase risk for Sudden Infant Death Syndrome (SIDS)
• Increase risk for birth defects like cleft lip or cleft
palate
Even second-hand smoke is associated with:
• Low birth-weight
• Increased rate of ear infections and asthma attacks
• SIDS Centers for Disease Control and Prevention: Reproductive Health

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4. Review the significance of tobacco use and the psychological characteristics associated with nicotine dependence.

Tobacco Cessation
• Physicians (regardless of specialty) play a critical
role in addressing tobacco use with patients.
• Many smokers want to quit – getting started takes
support and motivation from trusted sources (like
doctors!)
• CDC National Tobacco Education Campaign for
health care providers offers:
Tips from former smokers (profiles real people
with serious long-term health problems such as
stomas, lung removal, heart attacks, limb
amputation, asthma, diabetes complications,
etc.)
Resources for waiting rooms and patient rooms.
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4. Review the significance of tobacco use and the psychological characteristics associated with nicotine dependence.

Health Benefits
• Tobacco contains more than 7,000 chemicals, about 70 of which are linked
with caner.
• People who stop smoking greatly reduce their risk for serious health problems,
any diseases, and early death.
• Stopping smoking is associated with:
Lowered risk for lung cancer and other types of cancer
Reduced risk for heart disease, stroke, and peripheral vascular disease
Reduced respiratory symptoms (e.g., coughing, wheezing, and shortness or
breath)
Reduced risk of lung disease like COPD

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4. Review the significance of tobacco use and the psychological characteristics associated with nicotine dependence.

Brief Tobacco Intervention - The 5 A’s

1. ASK ABOUT THE TOBACCO USE
“Do you currently smoke or use other 4. ASSIST THE PATIENT IN QUITTING
forms of tobacco?” If ready to quit: Provide brief counseling and medication
(nicotine replacement if appropriate). Refer patients to
other support resources that can complement your care (e.g.,
1-800-QUIT-NOW, Smokefree.gov, group counseling).
2. ADVISE THE PATIENT TO QUIT
“Quitting tobacco is one of the best things If not ready to quit: Strongly encourage patients to consider
quitting by using personalized motivational messages. Let
you can do for your health. I strongly
them know you are there to help them when they are ready.
encourage you to quit.”

5. ARRANGE FOR FOLLOW-UP

3. ASSESS READINESS TO QUIT Follow-up regularly with patients who are trying to quit.
“Are you interested in quitting?”
Centers for Disease Control and Prevention: Tobacco Intervention Pocket Card

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5. Review the Transtheoretical Model of Change

Transtheoretical Model of Change

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse
Prochaska, J. and DiClemente, C. (1983) Stages and processes of self-change in smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390–395.

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5. Review the Transtheoretical Model of Change

Stage Characteristic Strategies

The person is not even considering changing. They may be
• Educate on risks vs. benefits as well as
"in denial" about their health problem or do not consider
Pre-Contemplation positive outcomes related to change.
it serious. They may have tried unsuccessfully to change so
• Guide to “Contemplation”
many times that they have given up.
• Identify barriers and misconceptions
The person is ambivalent about changing. The person
• Address concerns
Contemplation weighs benefits vs. costs or barriers (e.g., time, expense,
• Identify support systems
bother, fear).
• Guide to “Preparation”
• Develop realistic goals and a timeline
for change
Preparation The person is prepared to experiment with small changes.
• Provide positive reinforcement
• Guide to “Action”
• Provide positive reinforcement
Action The person takes definitive action to change behavior
• Guide to “Maintenance”

Maintenance and The person strives to maintain the new behavior over • Provide encouragement and support
Relapse Prevention the long-term. • Provide positive reinforcement
Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A 'stages of change‘ approach to helping patients change behavior. American family physician, 61(5), 1409-1416.
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5. Review the Transtheoretical Model of Change

Why is understanding the stages of change model useful

for physicians?

• More realistic expectations (for the physician and the patient)

• Can help improve compliance and reduce non-adherence
• Increases the likelihood of long-term success
• Recognition of small accomplishments can improve rapport
• Less frustration and burn-out
• Increases resilience

Tabor, P. A., & Lopez, D. A. (2004). Comply with us: improving medication adherence. Journal of Pharmacy Practice, 17(3), 167-181.

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References and Additional Resources
• https://www.cdc.gov/tobacco/data_statistics/fact_sheets/index.htm
• https://www.cdc.gov/tobacco/campaign/tips/partners/health/materials/twyd-health-care-pro-fact-
sheet.pdf
• https://www.cdc.gov/tobacco/campaign/tips/partners/health/materials/twyd-poster-reasons-to-quit.pdf
• Celli, B. R., MacNee, W. A. T. S., Agusti, A. A. T. S., Anzueto, A., Berg, B., Buist, A. S., ... & Fein, A. (2004).
Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position
paper. European Respiratory Journal, 23(6), 932-946.
• Rondina, R. D. C., Gorayeb, R., & Botelho, C. (2007). Psychological characteristics associated with tobacco
smoking behavior. Jornal Brasileiro de Pneumologia, 33(5), 592-601.
• Prochaska, J. and DiClemente, C. (1983) Stages and processes of self-change in smoking: toward an
integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390–395.
• Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A 'stages of change‘ approach to helping patients
change behavior. American family physician, 61(5), 1409-1416.

ROSS UNIVERSITY SCHOOL OF MEDICINE