Live Talk At Pulmonary Hypertension Association Canada


So our next presenter, maybe familiar to some of you from his online presence. Dr Noah Greenspan is a board certified clinical specialist in cardiovascular and pulmonary physical therapy. He has over 25 years experience in cardiopulmonary physical therapy and rehab earning his doctorate in PT 2006. Use your can, you can read about me. So dr Greenspan, I’m going to cut right to the chase, is going to be speaking on pulmonary wellness for pH patients through motivation and rehab. So please join me in welcoming.



So I do have a lot to say. I usually don’t take speaking engagements of less than eight hours, but I’m going to conception today. So I have a I really want you to leave here today with things that you can use right off the bat. And I, if you can’t tell, I think about things a little bit differently than other people. And I made this kind of open your eyes to some things that you’ve never heard before, something that you have heard before, but feel free to ask questions. If you have one, I want you to really leave here with something valuable. So I’m going to go wait, wait.



Alright. So these are a few of the things that I’m involved in. So I won’t go through this now cause this can take a little while, but if you can hear me okay, can you hear me now? Alright, so the problem, what is the number one problem that you have? Pulmonary hypertension. If you had to say, what’s your single biggest problem in life? Breathing. So this is it. Sob, shortness of breath, that miserable sob, right? So we know this is, this is lung man. So this guy right here that, that dark guy with the thing on his head is, is that sob. And he says, where’s your hero man? Now? And that’s Maria and Maria saying, I can’t breathe. And then there’s somebody that says tap miserable sob. And then little man says, I’m right here to you, son of up to lung man. Where did you come from?



And he says, nevermind that. Put that nice lady down and nobody gets hurt. And Maria says, Oh my God, I’m going to die. Now, if there’s one thing I want to tell you that’s really important to understand is that breathing is multifactorial. Okay? So what do I mean by that? It sounds obvious. Okay. But there are many, many different things that can contribute to how well or how poorly we breathe. And when you have a chronic illness, especially one where shortness of breath is the main characteristic, very often what will happen is everything will be attributed to pulmonary hypertension. So you say, Oh well I’m not breathing well. Is that pulmonary hypertension or you know what, I’m more, I’m having difficulty walking up the Hill. Is that my pulmonary hypertension or you know what my feet had been really sweaty is that my pulmonary hypertension.



And it’s not always like that. Sometimes it is, but it’s really important to consider what are the possible other claims. Does that make sense? So typically when people start to get short of breath, it usually happens at high levels of activity. So things like Sarah climbing, walking uphill, walking quickly. So in New York city it’s walking up some ways stairs. That’s what I hear most commonly. Then walking uphill, then running from the bus, that’s what we call the New York city pulmonary triathlon. So it’s run up a flight of stairs, walk up a Hill, and then run for the bus. And that’s it. So, but there’s many, many other factors besides lung function and besides the pulmonary hypertension that can make it better or worse. How do we know that? A lot of times I’ll see people a year later or six months later and they’re either much more short of breath or they’re much less short of breath, but their pulmonary function has remained exactly the same. And what that tells us is that there have to be other things that contribute. So what do you think some of those things are? And you won’t have any ideas



Exercise. So how well or poorly conditioned we are, right? So how your body uses oxygen is based on three main things. How good are your lungs at moving air in and out? How good is your heart at pumping blood and how efficiently do your muscles use oxygen? And all three can get better with activity. And all three can get worse within activity. What else? Wait, wait. Exactly. So we talk about overweight. Did somebody erase my picture? All right, so we’ve just set up a beautiful Picasa over here and it’s been a rape. But weight is very important, especially if your weight is central in your abdomen, right? Because when you think about it, every time you need to take a breath, you are having to elevate that weight. So if you have 50 extra pounds, think of it as 25 extra pounds on each side. And when you want to elevate the rent page, that’s not there. Likewise, if I said to you, here’s a bowling ball, carry this around all day, every day you would be more short of breath and you would be more fatigued. Anything else? What else contributes to shortness of breath?






Overexercise and seemingly overdoing it. Overdoing it. So you know, that’s a good point. That’s a supply and demand issue, right? So a lot of what I’m gonna talk about today is going to be resource based. So as you increase your activity and the demand is greater as you have a condition or anything else, the suppliers less. So how do we match that supply with the demand that you need? So it could be overdoing it or it could be doing it in the wrong way. And that’s some of the things that I want to talk about today. Anything else?



Air quality.



Air quality, definitely up here you guys are like breathing up beauty up here. This is like amazing. All of a sudden I realized I had two lungs, but but yeah, air quality. Absolutely. What else? Come on, I’m not giving a whole lecture. What else? Anxiety, right? How many people get more short of breath when they’re anxious? How many people get more anxious when they’re short of breath? So what you’re going to notice is that there’s a lot of cycle, right? And what we need to do is we need to break into the cycle. So I’ve given you two so far. Here’s one. You get short of breath at high levels of activity. And initially, you know, as we talked about, we said, well, you know, I’m probably getting over there. Well I haven’t been exercising as much. Well, I’ve put on a little bit more weight and we make excuses for this, right?



And that’s part of the reason why diagnosis is often late or unclear. But typically when people start to get short of breath or back pain or hip pain or any sign or symptom that makes them uncomfortable, they tend to avoid the activities that caused them discomfort, right? So if you know that walking upstairs makes you short of breath, you’re going to avoid the stairs. Walking up Hill makes you short of breath. You like, I know people who can map out Manhattan by where all the Hills are. Okay. I know other people who can map out Manhattan by where the public bathrooms are. But the idea is that we will avoid the activities that cause us discomfort. And as a result, all of the muscles that you use to do that, to do those activities get weaker and less efficient, but also all of the symptoms and the systems, while the systems that you use to do those activities also become less efficient. So again, our goal is to break into that cycle. And I just mentioned anxiety, which is that having a condition where shortness of breath is the number one symptom is very anxiety provoking. Okay. So it’s like if you don’t know, if you can’t swim, you’re not going in the deep end. Right? And what happens to a lot of people, especially early on, come in, come in.



You know, what happens to a lot of people is that it’s so terrifying, okay. That they will avoid these activities. And the problem with that is that there are often things that you can do. It’s not an all or nothing situation. Most things aren’t. And so a lot of times in healthcare training you’ll get a list of diseases and each disease will have a list of signs and symptoms associated with it. But everybody’s different. But education is a key to a lot of this stuff. And it’s knowing what’s going on, knowing what’s okay and knowing what’s not. Okay.






All right, so now here we say, and living with pH is other factors. So breathing, we’ve already said there’s a lot of things that can make breathing better or worse. Okay? But with pH there’s a whole bunch of other things that go along with it. So besides shortness of breath, whatever been in breathing, shortness of breath is the biggest problem. And four of them, when I asked the question, I don’t mean I’m not asking me, I’m taking a test, but I want to know for use of that. I know who’s in the room. How many people? Shortness of breath is your number one single biggest issue. Raise your hand. How many people were told you weren’t supposed to raise your hands? I didn’t say science as yet. Okay, so let’s say this, shortness of breath, number one, what’s number two? Fatigue. Okay, so fatigue. Let me tell you the surprise.



Fatigue is multifactorial, right? Because like dr Meda said earlier today, okay, these are nonspecific symptoms. So there are many different conditions that cause shortness of breath, fatigue. There are many conditions that cause fatigue. And when I say it’s a nonspecific symptom, I don’t mean we’re not clear what it is. Like everybody knows what shortness of breath is. Everybody knows what fatigue is, but these are not specific to a specific disease. How many people fatigue if fatigue is in your top three? Raise your hand if shortness of breath is in your top three. Raise your hand. What else?



Depression. Okay, so why depression? Okay. Is it a physiologic depression or is it behavioral depression or is it system or is it, is it situational? Okay. As we said, it’s very anxiety provoking to have a condition like this. Okay. Very often we will eliminate the things from our lives that we love doing because we’re afraid. Right? And that can become isolating and depressing after a while. Okay. I’m going to get to all that. What else? Any others? Give me two more good ones. Dizziness. Okay. Very, very common. So, so dizziness, lightheadedness. How many people here? Okay, what else? Give me one more good one. Chest pain. All right. So if this were family feud, you guys would to just one the top five answers on the board. So we’ll say shortness of breath, fatigue, dizziness, chest pain, depression, anyone passing out syncope, like fainting?



Not anymore. Okay. So those are all significant things, right? And those are all things that could definitely impact our quality of life. What’s the solution? First of all, how many people think that you can get better? Raise your hand if it’s not just you and you’re not a patient. If, how many people think that people with pH can get better? So I know who’s a family member and just not, not just not agreeing with me. So how many people think that they can’t get better? Anyone? Okay, good. That’s why you’re on here. But very often what happens is people get diagnosed with pulmonary hypertension and where do they go? They go to dr Google. Right? And what do they say? They say this is a chronic progressive disease that gets worse and then you die. Right? Very uplifting. It’s a chronic progressive disease that gets worse and then you die.



Okay. And that’s what will happen if you do nothing about it, right? So it’s like if you get, and you’re on the ocean, okay, if you do nothing, you’re going to go whatever, whatever way the current takes you, okay? You’re going to be prone to everything that goes on there. So if any fish want to come and take a bite of view, or if the sun is beating down on you or you know what I mean? Water to drink because he can’t drink saltwater. You heard of that in the last lecture. But the idea is that if you do nothing, if you do nothing, you will get worse. Okay? And that’s why I heard someone say before the new normal, right? What? This is your new new life. And I don’t like that word at all because it’s got this kind of air of giving up MIS.



This is my new life. I better get used to it, okay? But I say, no, no, no. There’s a lot of things we can do. And if you’re not doing something in each one of these areas, then you are not doing everything that you can in order to get better. And I’m going to tell you something, this is not disrespect to anybody, but a lot of times doctors aren’t going to tell you these things. Okay? there are, you know, in our society, okay, I don’t know how it is in Canada besides the funny voices and accents. Okay. You know, in America, okay, 90% of medical care is medicine, right? So it’s like, here’s the drugs, here’s the drugs. No offense to the pharma companies in the back. I was warned about my usual diatribe against pharma, but it’s okay. They were very nice.



But the thing is that 90% of it is medicine, right? And sometimes there is a medicine and sometimes there’s not a medicine. But what I’m saying to you is that very often lifestyle is equally important. Okay. And in my experience, there are five things that are the most important when it comes to living well with a cardiopulmonary disease. And those things are of course, medical. Okay. Medical is what I call having the right doctor, taking the right medications and taking the medications properly. Okay. But to me, that’s not 90% of that, right? That’s, that’s 20% that’s a fifth of it. Okay. How many people here are not patients or family members or supporters? Okay. So for the people that just raised their hands, let me ask you a question. Do you feel better when you exercise or don’t exercise? Do you feel better when you eat right or don’t eat right?



Do you feel better when you’re stressed out or calm and collected? There you go. So it’s the same for everybody, right? So whether you have pulmonary hypertension or not, we all know, okay. Then if we access, if I exercise every day, I feel great. If I don’t, I feel terrible. Okay? If I eat right and get in shape, I feel great. If I gain weight, I feel worse. If I’m stressed out of my mind, I feel terrible. Okay. If I do something to address that, I feel better. And that is the same thing for you whether you have pulmonary hypertension or pulmonary fibrosis or CLPD or if you’re just here with a friend. Okay. Either way those things work for everybody. Okay. So much do I believe this that I wrote a book about it called ultimate pulmonary wellness and these are the things that I think are the most important.



Okay. So medical, again, having the right doctor, taking the right medications and taking the medications properly. And as doctor medicine, it’s very important when it comes to pH because it’s a very, very specialized area of care. There’s a lot of misdiagnosis. There’s a lot of underdiagnosis, there’s a lot of slow diagnosis and then some people try to dabble in it. Okay. pH is not something you dabble in. Okay. It’s something that you really need somebody who’s a super specialist in and who’s super up to date and current on things. So these are average, these are kind of estimates. Okay. But I say 18% okay. Exercise. Super important. Okay. 18 to 20% now people, I spoke to a gentleman before and he said, you know what? I’m not exercising. It says last time I took a walk or you know, you don’t have to say who you are.



I’m not going to count you sir. Okay. But the idea is that you know, people say, well, how can I exercise? I can’t even breathe. I can’t even go to the bathroom without, without being short of breath. How do you expect me to exercise? I’m telling you, I do expect you to, I’ll tell you how. Okay. Other things, nutrition, we heard a great nutrition lunch before. I have a few things I’ll add to that in a little bit. Stress, anxiety, depression management. It just so happens that stress, anxiety and depression when you put the letters together to sell, it’s about sad. I don’t usually like things like that. But again, very, very important. And then prevention of infection. Okay. It’s very easy to, it’s very easy to get sick and it’s a lot easier for you to do things, to take steps in the right direction to prevent infection that’s you’re treated once you wind up in the emergency room of the ICU.



How many people use the bathroom since they’re here? How many people? Everybody keep your hands up if you use the bathroom. Okay, so how many people wash their hands after they use bathroom? I have like, Oh no one’s going to be like, right. But the idea is just by washing your hands five or 10 times a day, that’s going to make a big difference in prevention of infection. And one of the things that, one of the things I want to just be clear about, and Beth asked me to say this, okay, so this is from Beth. But one of the things that happens when people get diagnosed with a chronic illness, especially something like cardiovascular disease or pulmonary disease or pulmonary hypertension or pulmonary fibrosis or CLPD keep going for another hour, but, but is that very often people get his diagnosis and they become sort of these unique focal monochromatic versions of their former selves that are completely devoid of any color, aren’t fashion, music, culture, et cetera, et cetera, et cetera.



And their whole lives become about, well, let me go to the doctor, let me get a prescription. Let me take my prescription to the drug store. Let me take this medicine home. Let me take this medicine. I’m tired from all that. What am I going to do now? I’m going to go to sleep and what am I doing tomorrow? I have another doctor’s appointment, right? Sound familiar? Okay, but what I’m going to say to you is that it doesn’t matter if you’re going to live another week or another hundred years, okay? You must reclaim your life and you must ask yourself what are those things that make you uniquely who you are as an individual and don’t think about who’s sitting at the table with you. Now I want you to think back to when you were 20 years old, 25 years old, and you just got that new job and you’re like, how am I going to kick ass and move? Whoop. Sorry, unicorn. I didn’t mean to say that. Sorry. Sorry. My bad. Don’t do what I do. Very bad. Very bad. I could do some Trump up here. I have to be careful in the U S where I do my Trump in person.



What I say my preference is Obama. No, I’m just kidding. I’m not going to go, I’m not gonna go political cause I get lynched when I go down. Or to the U S but here, okay. You have to fight for this. Okay? You got shipwrecked and we’re hanging on to that little piece of driftwood and the idea is I could sit here, I could bake in the sun, I could be thirsty. Okay. I could take a drink, but the nutritionist said we can’t drink salt water because then our feet are gonna get swollen. It’s gonna be harder to kick. And the idea is that you can, if I’m going to go down and I’m going now fighting, okay, that means I’m not going to just sit here and wait for this ocean. Okay. Is peach is much like the ocean, right? It’s big, it’s strong.



It never gets tired, right? Which means that if you want to get better, there are things you have to do in order to, if you all get up and leave, it doesn’t matter. I’m still going to keep it. Video is going on HBO, whether you guys are here or not, but the idea is you have take it upon yourself and you have to say, you know what, there are things that I can do to make this better. All right? So we talked about this having the right doctor or doctors, okay. And again, shortness of breath is usually the first thing people feel. So of course we have to rule out the big thing. Okay? Most of what I know about medicine, I learned, well, first and foremost, I learned most of what I know from my patients. Okay? Second, I learned it from watching house, okay?



If you really want to know a lot about medicine, watch a lot of house, okay? Because the differential diagnosis is a lost art, okay? And the differential diagnosis is write down all the possibilities and things that it could be like I’m short of breath, shortness of breath could be heart disease, it could be congestive heart failure, could be asthma, it could be COPD, or it could be pulmonary hypertension or it could be something completely different as we talked about before. Okay. So you have to look and kind of check off the dangerous things first until you hone in on the diagnosis. But having the right doctor, having the right healthcare team. And when I say having the right doctor, you definitely want a pH specialist. But also pulmonary helps, okay. To have a cardiologist who specializes in pH D have a pulmonologist who specializes in pH.



But those may not be be the only things that come up, right? Some people think that, well, I’ve got pH, how could I have anything else? But other things come up too. And some people are lucky, they have many things wrong with them, right? So the more things you have going on, the more doctors you need to see. But the idea is start to chip away at each one of these things little by little. Because when we look at them all in a giant pile, it can be very overwhelming. And you can think to myself, you know what? This mountain is just too big. I can’t get over the mountain. But the thing is that you can, okay, there are things that you can do and I don’t care who you are. I look at every single person in this room and there are things that you can do to make your life better in some way or form. Okay? Questions.



Exercise. Okay. So when it comes to exercise, how many people in the room exercise? How many people don’t exercise? Alright, four honest people in the room. All right, one more time. How many people then wash their hands after they use the bathroom? All right, so exercise. Okay. So exercise is one of the single best things that you could do for yourself. And it can be free. Okay? And it doesn’t take a lot. It could take 10 minutes, 1520 minutes a day, even broken up. Okay. Even broken up a little bit at a time, okay. But it can’t be altered enough, okay. But this is very, very important. And when it comes to exercise, there are four ways that we can kind of divide it up. Frequency, intensity, time, duration, which is duration and type. So basically, how often should you exercise? Is the frequency. How often every day and every day.



It doesn’t mean you have to go to the gym every day. It doesn’t mean you have to go to cardiopulmonary rehab. Every day. Just means that you have to set aside 10 or 15 minutes where you’re going to do something every day. That is your little gift to yourself. And again, here’s one of those tricks, okay? Don’t imagine yourself, how it’s going to feel while you’re working out. Imagine how it’s going to feel after the gym. I always say the hardest minute in the gym is minute one because once you’re there, it actually gets better. I used to work at NYU medical center in Manhattan and I every day my gym was on 34th between third and Lex. My home, I can make a right and go up third Avenue to my home every day. It was a chore, okay? And I’d be like, well, and it’s easy to find reasons not to exercise, right?



It’s harder to find a reason to do it, and very often we are our own worst enemy, but how do we overcome that resistance? A lot of that resistance is built into us, right? It could be from childhood even. It can be things that your parents said to you. Okay, get over it. Be now. But the idea is we have to find a reason to do these things because you are worth it and they will make the change. Right? Intensity. Now, here’s something very, very interesting. Okay? Patients only raise your hand and I’m not looking to single hand. I’m not looking to send you to single you out or all which is in the room. Raise your hand, which is okay. So there’s one honest, which she also said she doesn’t exercise. How hard do you think you should exercise? Anyone have any idea or was there anybody given any guidelines for exercise?



Please tell me. As long as I can still talk.



Anyone else, as long as I can still talk. The exercise is good. Yes ma’am. One 40 okay. That’s a high number because usually I hear one 20 so I’m glad to hear one 40 how many people were told they should not allow their heart rate to go above one 20?



Nobody does that. [inaudible]



You could. Well they have, they have heart rate monitors. So you can do it with a pulsox. You can do it with an Apple watch, you can do it with a whole watch. There are ways to do it, but I’m speaking more generally. I could give you specifics on how we’re going to do it after. But here’s the thing. Okay. Very often I started treating pulmonary hypertension patients in about 1995 and at that time, the idea was don’t let your heart rate go above one 20, which doesn’t make any sense. Why? Because I have patients who are in their twenties with pulmonary hypertension patients in their eighties with pulmonary hypertension. So how could those two people, especially when heart rate is such an age mediated factor, how could those two people have the same heart rate? It can’t be right. So let’s forget that.



Okay. Can you say it as long as you can still talk, right? How many people get short of breath to where they can’t talk when they’re just going about their daily activity? Nobody. Okay. Some people, okay, so here’s the thing. If you look at the classic pulmonary rehabilitation or cardiac rehabilitation, it was usually low intensity exercise for a long duration, right? So you’d go into a cardiac monitor. We have, sometimes somebody will be doing this walking at one mile per hour, 1.2 miles per hour, and they’d be doing it for 30 to 60 minutes, right? But here’s a basic fact of life. I’m going to tell you right now, I’m gonna give you a few facts life. Is it just life, life skills? If your life requires this much activity, I could exercise you down here till the cows come home and your life is not going to get any better, okay?



So keep that in mind. So you have to get a little short of breath. They have to get a little fatigue. You have to push yourself a little bit, but within reason, okay? And safety. Okay. Safety is my number one priority for every single patient and person I speak to. Okay. But it’s communicating with your cardiologist, getting exercise tested. And you know, the six minute walk is a challenging test. We heard it before that everybody does it differently. Half the time, the people that treat pulmonary hypertension patients are just as anxious as the patient, right? And you wanna experience that calm down and it’s, it’s the person actually doing the test. It’s scared, okay? So that’s a problem also, okay. But it’s really important that you get the right workout, okay? And that, that workout is not too hot and not too cold. It’s like porridge.



We want to just, right. Okay. But you have to do a little research in order to make sure that you’re getting the right workout and you need the help of your healthcare team a little bit. So duration, okay? Again, it doesn’t matter where you are today, okay? It doesn’t matter where you are today. Again, I look around the room, I see all of you and you’re probably thinking to yourself, Oh, he hasn’t seen me. He doesn’t know about me. I’ve seen all of you before. Okay? I knew this for 28 years. I’ve seen you all before. I know all of you. So the idea is that you can get better, okay? But even if you can only walk on a minute today, next, so be it. Do it twice and then tomorrow do it three times and then walk a minute and a half and little by little, by little, by little, you build it up.



Okay. It doesn’t matter where you are today, you can get better. And there’s a great Chinese proverb that I love and it says the best time to plant a tree was 20 years ago and the second best time is today. So take this as a kind of challenge to say, okay, well let me look at my own life and see what I can do starting tomorrow or the next day or the next day to start making things better for myself. And then as far as type of exercise, what’s the best exercise? I didn’t even have any idea walking, walking. One person said swimming, there you go. So the best exercise is whichever exercise you’re going to do. Okay. So if you hate swimming, then don’t, then you’re not going to swim every day, right? If you hate walking. But there’s a lot of different ways.



If you can’t swim, definitely don’t choose swimming as an exercise. That’s going to be a pro. You’re only going to get one day of exercise. Don’t do it, okay? But the idea is that there’s many different ways to do this, okay? Now, one thing is very important is breathing. Retraining, okay? So shortness of breath. Very often. So what’s happening? You’re walking up a Hill, you start to get short of breath, right? So tell me if this sounds familiar. Here I go walking up Hill, maybe I’m carrying some groceries and then understanding why things are happening is very, very important in terms of dispelling the myth. It’s like you think there’s a monster under your bed, but then you look with a flashlight and you realize, Oh, it’s really just something else, right? So education is the key to everything. How many people have difficulty carrying packages?



Okay, why is that? Look, the weight is pulling down, right? So I want to take a breath, but what has to happen? I have to lift whatever’s in this packet, right? Or if I’m holding it here, everybody grab. Give yourself a hug. Take a deep breath. It’s hard, right? So imagine if you’re carrying groceries, okay, so that’s very, very important, okay? But here you are. You’re carrying your groceries home, you’re uphill. And then wait, you become aware of your breathing, right? So a little something changes your consciousness. As I’m short of breath, then what happens? Our brain kicks in, right? Wait, I’m starting to get short of breath. I hope that I’m not going to get more short of breath, right? But what’s happening is that happens. Your body is putting out adrenaline, right? The fight or flight response, right? So the fight or flight response developed millions of years ago, so that if a caveman was picking berries and a saber tooth tiger jumped on him, he could fight or flee except today, okay, we have this response to everything.



Someone cuts us off on the road, zero to 100 somebody writes a check in front of us on the checkout, like, whoop, is there a 100 right? And it’s becoming aware of these things so that you could quiet them down. There’s a concept that there’s a, there’s an idea that says zebras don’t get ulcers. Anybody here at this before? Alright, so if you watch the planes, okay, if you watched the planes and you see it’s basically zebras, animals, they’ll be grazing very, very peacefully, right? And then that’s interspersed with kind of like a, maybe a few minutes of terror where they’re either running for their lives. Okay. Or somebody else is running to eat somebody. So you’re either tying not to get eaten or you’re trying to eat something, right? But then you watch these nature shows and then very shortly after that, the zebras are braising again.



Right. And they say zebras don’t get ulcers because they’re not thinking about it. They’re not grazing and saying, Oh, I hope a lion doesn’t come. And they’re not saying, I hope I’m glad the line didn’t come. They’re not thinking about the past lion escape. And they’re not thinking about the future. Live escape. They’re being in the moment eating the grass. Right? Except for us. We think about what we should have done, what we should do with, to think about everything except what we’re doing now. But the idea is now we got this response to this fight or flight response, and now we’re starting to breathe faster, right? Because we’re getting nervous. So what happens when you breathe fast? It gets harder to breathe because the faster you breathe, the more shallowly you breathe. And the more shallowly you breathe, the faster you have to breathe.



And it’s cyclical. You see how this works? And for a lot of people, you guys get Sanford and son here in town. So you remember. So you remember what would be like Elizabeth? It’s the big one. I’m coming, right? So you’d be walking in the street and all of a sudden you showed of breath and you’re terrified that you might be about to have a heart attack and die, right? So if that’s your choice of either stay home or walk in the street where you might have a heart attack, a Pardot, if that’s your choice, you’re not going to go out and walk, right? So the idea is you have to get some control over this by learning better reading techniques. So how many people are familiar with pursed lip breathing? How many people are familiar with diaphragmatic breathing? Let me let Jane on a little secret.



All breathing is diaphragmatic, okay? So unless you have a paralyzed diaphragm. So the idea that these things are going to significantly make you less short of breath. So a lot of people think that these exercises, if they just sit and do these exercises for 15 minutes a day, that suddenly they will be able to walk up the Hill. The answer to that is no, these are tools, okay? These are tools to allow you to do the activity and the activity is going to actually make you better so you can get better, but it’s not going to be by doing these activities. What about pace? Breathing? Anyone know what that is? Supply and demand, right? So if you know that you’re about to carry some groceries, you were about to lift something up or you’re about to be more active, okay? That demand is going to go up.



And that’s where you load up the gas tank by doing these breathing techniques. And now finally, recovery from shortness of breath. And if there’s nothing else that you want them today, this is one of the most important things for you. So how many people get so short of breath that they just have to stop in their tracks and pant for awhile until it goes away? Right? Raise your hand. All right, so do you never feel like it might never go away? How many people have that experience? How many people feel like they have to just stop and wait and they say, Oh God, I hope this goes away soon. Right? It’s like when you’re on in turbulence on a flight, you’re like, Oh God, please let this stop soon. Right? But there are actually things you can do and there are positions that you can take that will immediately make you less short of breath.



How many people feel better when they’re leaning on something? How many people feel better? Say, well you know when I go to the grocery store I could walk all around the store cause you’re holding onto a cart or leaning on a car. Right? And let me tell you that there’s a physiologic reason for that. So this is what I call open chain activity, which is that my hands are free to move around in space and open chain activities, particularly of the upper body are very difficult for anybody with shortness of breath. Okay? And the reason for that is because this upper body activity puts your respiratory muscles in a very poor mechanical advantage, right? Anyone have trouble raising their arms above head? Anybody been told you shouldn’t raise your arms above head if you’ve been told you shouldn’t raise your arms above your head, raise your hand.



Okay. That was a joke. But it was, that’s how good I am. Right? They just come out naturally. I didn’t even, I didn’t even plan that one, but I’m going to use it. But nature, no joke, like any, so I’ve been told not to raise my hands above the head. Right. But sometimes you have to right to put your shirt on or to brush your hair or to shave and then you can’t do it. So very simple rule of life. Your body gets good at doing what you ask it to do. So if you ask it to sit on the couch, flip the remote, eat potato chips, watch rate down event. That’s what you get good at, right? That’s what you get good at. But if you ask it to move, okay, if you ask it to get going, it’s going to reward you with this. But the idea, again, open chain versus closed gene, is that when my arms are in open chain, my chest muscles do things like this.






My back muscles do things like this. My shoulders do things like this, right? Because they’re in the open chain, right? So the stabilizer is my thorax. But when I close the chain and think of the ways that you can just close this. A lot of times people do this when they’re short of breath, right? Does this look familiar or this right? Or this or leaning over a shopping cart or how many people walk better with a rolling Walker. The reason for that, okay is because you are closing the chain and when you close the chain, all of the muscles that I just told you about work in their reverse action to help you elevate the rib cage and get a deeper breath. Okay? So if you learn nothing else, the next time you’re in a gym, put your arms down, lean over, and by leaning over like this, we allow the abdominal contents to drop forward.



Clearing the way for the diaphragm, giving you a deep breath. And guess what? It’s like a kid who learns to ride a bike or who learns to swim. Once you have the sensation that you actually can do something about this, well then it’s not as scary anymore. Okay? So we have to kind of break these waves of thought. We kind of have to break this mindset and give you tools that you can use to start working your way back up the Hill. Okay? So we didn’t get here overnight. Like I said, we didn’t get in this hole overnight. We’re not getting out overnight. It’s about learning. Building it up little by little by little. Any questions about breathing? Shortness of breath, breathing, retraining. Question. Yes.



So what about banding at the waist? I know I can then at the wave has, how long can I stay?



So what people have difficulty bending at the waist? How many people get short of breath when they bend over? Okay, so here’s the thing. Think of it like an accordion, right? So here’s the accordion full of air, right out of air, full of air, out of air. Here’s the recording full of air out of air, right? So if you want to play the accordion, the time to really play the note is not when you’re compressing it, right? The time is you got to fill up and then play the note. So if you’re going to bend over, okay. And again, there’s different things. There’s different reasons. So there’s the idea of the Val salvia maneuver, which means that you’re kind of crunching everything up and that raises pressures and it also raises pulmonary pressures. Okay. But the idea is if I know I’m going to bend down for something and I know I’m about to squeeze the accordion, that means if I want to get the most bang for my buck, that means I’m going to extend the accordion by taking a deep breath in.



And then as I come up again, we open back up the accordion. I’m going to give you a time of how long can you bend over for. Okay. And everybody’s different. You know, like we’re looking for things that were like looking for a nice, neat list. Don’t do this, do this, do this. 30 seconds for this. Four pounds for this 120 beats first. It doesn’t work that way. It’s trial and error. Okay? But let me tell you this, how many people here have how many people here are over 40. Over 50. Under 10. Alright. Alright, so here’s the thing. Okay. You haven’t been killed yet, right? So you haven’t been killed yet? No one in this room has been killed yet. So the idea is like most things that you do, in fact, the overwhelming majority of things that you do won’t kill you.



Okay? So what I say is don’t necessarily jump into the 10 foot deep end, but going a little at a time and if, if four feet is okay, come back, then let’s see, four and a half feet. Okay? Don’t walk a 10 a 10 block walk outside and then you have no way of getting home, right? So I say walk a half block out, come back. If it feels good, do it again. Little by little by little, but you know it’s trial and error and everybody’s individual and a lot of the specific instructions that people get aren’t really accurate for that human being. So you have to find out what’s okay for you and always err on the side of underdoing that overdoing. Okay? But with the idea that we want to do more as we start to move forward, questions about this breathing pulmonary cardio exercise, right?



So everybody says cardiopulmonary, but the pulmonary is always like kind of the, the, the lower of the Tucson, made a pulmonary cardio treadmill bicycle upright for a company walking upper by your governor, which is this new step of elliptical and then walk about an armor size. So here’s the thing, it doesn’t matter which of these you do just do something. Okay? And the important thing about cardiopulmonary is that this is what’s going to make your body better at using oxygen and ultimately make you less short of breath. So the idea is that as we do less and less, the body becomes less efficient at using oxygen and you’re able to do less. And so initially stair Carney did it. We eliminate the stairs. Now we can’t climb stairs at all. And now walking up Hill mates are short of breath. So we eliminate that. And then this and this and this.



A lot of people think if we say, how does disease progress? You say how much can you do? And we say, how does your disease get worse? Most people think it’s like this, right? Same thing with heart disease actually. How does heart disease progress? Right? Like this linearly, it doesn’t work that way, right? Because if we knew that disease progressed in a very neat, organized way, then nobody would have a heart attack because we know exactly when it’s gonna happen, right? But what really happens is here’s they are climbing up here and we stop it and then we get to here, right? And then you have a kind of stable period and this is where you could walk uphill, but you can’t climb stairs and then you stop the Hills and then this and that and the other thing. But here’s the good news, okay?



In the same way that if you do the wrong things, and I’m saying the wrong things without any judgment at all, it’s not a good boy, bad boy, good girl, bad girl thing. But I’m saying if you do the things that are counterproductive to living well with a cardiopulmonary disease, okay? In the same way that those will make you spiral downhill, if you start to add in good behaviors, okay, then you start to spiral up the Hill again. I’m going to bet you that for either people could say, you know what, the last six months I’ve been getting worse and worse and worse. For some of you, absolutely. Maybe your pH has gotten worse, but for a lot of you, I bet we can trace it to behavior. Okay. Now is a really important time, more important for you guys than us guys, because it’s about to get real cold up here.



Okay, so winter is a bad time for people, right? And what do people do? They stay inside, they eat, they don’t exercise, they watch TV, they stay warm, they snuggle with each other if you’re lucky. Right? And the thing is that when it’s springtime, so you know, I’m going to start walking outside when it’s springtime, except now it’s springtime and you can’t do anything because you’ve just spent the last three months basically preparing yourself for hibernation. So this is a really important time. And what I say to people is that if you’re going to do rehab, now’s the time to do it. Do it during the winter time. Get moving during the winter time. I’m not talking about snowshoeing, I’m just talking about get moving now so that when you get through the winter and it starts to get warm outside again, you can enjoy, okay, so cardiopulmonary, if you can do any exercise, cardiopulmonary is the most important.



But here’s another important point that I never heard anyone except me talk about is that people would be like, you got to do the cardio, or you gotta do the strength, or you go to the flexibility or you gotta do the bat. They’re all kind of combined. Okay. So there’s very few activities that you don’t get some benefit in all areas by doing it. So people don’t know, don’t do cardio. You’re going to lose too much weight as if, right. Like that. That should be the problem, right? That should be the problem. Right? Or don’t do, don’t do weight training. You’re getting into muscular, right? As if, right. As if like you’re gonna wake up tomorrow and it’s going to be like, Ugh, I’m too muscular. I shouldn’t have lifted that yesterday. But the idea is that you will get some benefit from all of this by doing any of it. Here is



A little example. So this is from our online program and these are called, okay, so this is a video that we shot all over the world. And what is the walk about this people walk all over the world. Okay, maybe you don’t have to go in front of your kitchen through the world and you want to see me walking in place for 15 minutes, friends. But the idea is while you’re watching TV, get up 30 seconds walk there and the commercial side, all this stuff is different. Polio is good for strength. It’s good for flexibility if you get good enough, but the idea is you can do this anywhere. If you could go out and walk, awesome. If you have access to an exercise machine, awesome. But if you don’t walk about that, elephant was over 700 pounds when he first started on the program. And now let’s talk, come and talk after that one exercise and raising your arms to be able to appreciate things you diseased. This is what we call 10 minutes. 10 minutes. Exercise is particularly difficult.



All right, I’m going to have to speed now cause I have, I thought I’ve only been talking for like 10 minutes anyway. All right, so other things, breathing, exercise, balance, exercise, flexibility, training, strength. The key is like Nike says, just do it. Just do something. Okay. Get moving every single day. And incidentally, we have all this stuff on our website. We have all this stuff. We have a Facebook group with all this exercise, we have an online program, so it’s all available to you. I have hundreds of webinars available online, hours and hours and hours. Feel free to get our cards and do it. Let’s talk a little bit about I’m going to show you one video because you got to see at least one complete video. It’s only two minutes. It’s a good use of two minutes. But let’s talk about what prevents people from exercising.



Okay, so let’s have a little debate. It’s going to be all of you against me. Why can’t you exercise? Tell me your best reasons why you can’t exercise. Laziness. That’s a good one. Give me too busy. What else? Tired. What else? Afraid. What else? Short of breath. Dizzy. Right? I’m going to pass out. Right? But there’s things you can do about all those things. Okay? How many people have the experience where when you talk about dizziness and passing out or the fear of dizziness and passing out? Blood will always go. Blood is a liquid. Blood is always going to go with gravity, okay? So when I’m sitting, when you’re sitting down in a chair, you have some stops to the gravity, right? So our knees are the stop. Our hips are the stock. You stand up and guess what? Everything goes right down in your pressure drops and can cause you to get dizziness, right? Anyone sound familiar? Only Beth, these are, these are the people that haven’t washed their hands after the bathroom. I know it but, but does anyone experience dizziness when they first get up and they first stand up? Okay. When they first get out of bed. So what do you do?



You hold onto something and you wait for it to pass, right? So here’s the thing, you get up, okay? And think of it like you know, like a bottle. So you, you turn the bottle up in all this, all the water and all the blood goes to the bottom of the bottle, right? And you get dizzy. So most people will stand and wait for it to do nothing. But you know what would really make you less dizzy and it’s a risky prospect because of course we don’t want you to fall down. But when the heart pumps blood to the body, the way that the blood gets back up is by the calves pumping. Okay? So the heart pumps out, calves pumped back. Clark, fuck, fuck. But when you stand up, guess what your heart says, Hey, we got to do more activity. It’s pumping fast, but I’m just standing here so nothing’s coming back up.



So anybody who, so one thing right off the bat, let’s say that dizziness is a big problem for you. Compression stockings will help prevent that or will help prevent it from being as bad. Okay? So that’s one thing. Okay? The other thing is getting your calves strong, right? Because you thought the stronger calves are, the better the muscular pump and the more blood you can move so that the greater chance you have of offsetting that drop in pressure. But the other thing about it is that little by little, I believe you can reverse, you can affect vascular tone. So the more you do, okay, your body will get more used to these changes and be able to adapt to them more quickly. So what happens is, again, if you’re short of breath or you’re busy and you don’t do anything and you just sit and you know and sit around and do nothing, then every time you get up, your body doesn’t know.



If I’m about to get up and do exercise or if I’m getting chased by a bear. Okay. So it’s gonna throw out all the stops and it’s going to treat it like it’s an emergency. And little by little you can overcome that. So initially if you’re, if dizziness is a big problem for you, try and be high stockings. If that’s not doing it for you, try five high stockings. But that will help to support the pressure. And make sure that you don’t get as big. I’m gonna, I’m gonna. I know we’re really right at four minutes, five minutes. So I said I need at least eight hours nutrition. Okay. I want to talk about just a couple of little things that weren’t addressed in the last one. How many people are more short of breath after they, okay, why is that? Anyone now, many, many reasons.



Okay, so check this out. Somebody tampered with my drawing already, but these are your lungs right here. Okay. What’s underneath the loans? Well, in between the stomach and the lungs. Diaphragm, right. The diaphragm is the main muscle of inspiration, right? So the diaphragm contracts downward. That creates a negative pressure and that’s what inflates the lung. But if this is full, right, then this is going to push up and increase resistance on the diaphragm. Right? And that’s going to push up and not let you take a deep breath. And here’s something else. Your body doesn’t care if it’s liquid gas or solid. Okay? It’s, it’s if it’s filling your stomach, okay. I think of it like a suitcase. So it’s like this is your abdominal cavity, this is your thoracic cavity. If you overstuff your abdominal cavity, it’s gonna encroach on your thoracic cavity. If you overstuff your thoracic cavity, it’s going to encroach on your dominant cavity.



But again, there were some good ideas before about eating smaller meals more frequently. Okay. But the other thing is that after you eat, where’s the blood flow goes to your gut, right? And here’s something else that wasn’t mentioned before. So that’s the mechanical aspects of eating and breathing. But there’s also the chemical aspects of eating and breathing. And what a lot of people don’t know is that there’s something called and it just went out of my head, what it’s called, what’s it called? Breath. carbon dioxide. Okay. So here’s the thing, it’s not carving out that there’s stuff called the something index and literally it just flew out of my head. But check this out. So carbohydrate metabolism will cause the greatest amount of co two carbon dioxide production of all the nutrients. So carbon dioxide produces the most, protein produces the next most, and fat produces the least.



So if you have a high carb meal, okay, I don’t care. I mean, of course, if you’re gonna eat carbs, it’s better to eat healthy, good carbs, okay. But carbs will increase your production of carbon dioxide and make you more short of breath and make it harder for you to breathe. And I will think of what that’s called at some point probably tonight. All right, so stress, anxiety, depression management. As I said you know, it’s very stressful having a disease where shortness of breath you know, is your number one characteristic or chest pain or dizziness or casting app. And of course when you go to the internet and it says things like chronic progressive disease that never gets better and then you die, right? But education is the key to everything. And again, I wish I could, I wish I had more time. But anyway, infection prevention, handwashing antibacterial creams avoiding sick people where I’m asked when you’re going to come in contact with people or say flu shot, pneumonia vaccine and this is it in one quick video. Ultimately. Yeah,



The right doctor, taking the right medications, taking the proper exercise, nutrition,



Stress management, yoga, meditation,






And prevention of infection, treatment, hand-washing.



All right. Questions, questions? What time is it? 12 minutes past. Is this fun for you? We need to organize like an eight hour lecture, which will be next year. Can I get one more minute? We’ll have a vote. Who wants a vote? Who wants me to get two more minutes? Alright. Alright. This is buried. A problem on bearing and we’re going to do a little, we do a little exercise right now. Okay. Ending. Okay. So if you want, it’s tight quarters. You can stand up and do this if you want. Or you can sit and do this if you want. Barry’s going to teach a little bit of exercise, okay. But he doesn’t think, don’t overdo it, but don’t underdo it. Okay. Go with your own pace. Don’t worry. Document is in the back just in case I’m here. But let’s take it nice and easy. Go along. Go at your own pace. Go license club. And I want you to think about how you feel right this second. And I’m going to ask you the same thing when we’re done.



Alright? Well, first, nice and slow. Nice and slow. And breathe. As you do this, breathe as you raise your arms up, as you bring them down and blow out, just pick it up and everybody breathe in through your mouth. Mm. That’s an easy, deep breath in [inaudible] because you have pulmonary hypertension, pulmonary, it doesn’t matter. These are names. Okay? Can do this.



Everybody can do this. Alright, so sorry. I really, we scheduled too little time, but it won’t be time for questions at the end of the day. Okay. And like, I could stay up until outer limit. I can’t stay past 9:00 PM. But if anybody wants to ask questions afterwards, I’m happy to stay and answer them. Thank you.