American Association for Respiratory Care's

Spring 2004

Editor & Chair
Mary Hart, RRT, RCP
Baylor Asthma and Pulmonary Rehab Center
4004 Worth St., Suite 300
Dallas, TX 75246
FAX (214) 841-9799
maryhar@baylorhealth.edu

Chair-elect
Cheri Duncan, RRT
(214) 820-9792
cherid@baylorhealth.edu

 

In This Issue...

Notes from the Chair Mary Hart, RRT, RCP
Intimacy and Lung Disease Nita Pack, RRT
Section Connection
   
   
   
   
   
   
   
   
 
   
   
 
 
 
 

AARC Education Section Bulletin

Notes from the Chair

by Mary Hart, RRT, RCP

As I sit down to write this column, it is springtime. Flowers are popping out of the ground almost before my eyes, trees are renewing their leaves, and everything is turning green. It's that time of year when you either want to start fresh new projects or just play! Please don't ask me which I feel like doing at the moment!

The latest information from the section on pulmonary rehabilitation concerns coverage for pulmonary rehab with lung volume reduction surgery (LVRS) and the long awaited "national coverage policy."

According to the major pulmonary medicine societies, the Centers for Medicare and Medicaid Services (CMS) is still wrestling with the question of which benefit category authorizes pulmonary rehabilitation. Ironically, CMS has not been able to identify any benefit category that authorizes its coverage of pulmonary rehab as an integral part of LVRS. In response to the CMS stance, the AARC joined with the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Chest Physicians, and the American Thoracic Society to set an arbitrary deadline of March 15 to hear back from CMS. All of these organizations are currently asking their leadership to write to their senators and congressmen, strongly urging them to contact CMS to suggest that they act on the year-old formal request for a coverage decision related to pulmonary rehabilitation.

I hope that by the time you receive this Bulletin a national coverage policy for pulmonary rehab will be closer to reality so that we can all rest easy knowing our patients will continue to receive the care they deserve.

In the meantime, we all need to continue to support our programs and our patients by working together and sharing information on what works and what doesn't when it comes to reimbursement and other key issues. One of the best ways to accomplish that goal is through this Bulletin. If you have information to contribute, please consider writing a short article and submitting it to Mary Hart. Your ideas and articles are always welcome.

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AARC Education Section Bulletin

Intimacy and Lung Disease

by Nita Pack, RRT, Cardiopulmonary Rehab Specialist, Methodist Dallas Medical Center, Dallas, TX

Sexuality is an important part of life from the time we are born until the time we die. Concerns about sexuality are common and perplexing for seniors and for all people with lung disease. It is natural for our patients to have questions, and it is important for us as respiratory therapists to help them find answers. Unfortunately, both health care professionals and lung disease patients tend to overlook sexual needs. Neither will broach the topic. Possible reasons for this are:

Health care professionals:

  • Knowledge or training deficits
  • Time limitations
  • Social taboos
  • Discomfort

Persons with lung disease:

  • Social norms that suppress sexual expression
  • Past frightful and uncomfortable experiences
  • Sense of failure
  • Low self-esteem
  • Helplessness
  • Depression

Definitions

Before continuing, let's define a few terms that are associated with sexuality:

Intimate or Intimacy:

  • According to Webster, "closely acquainted or associated; very familiar. Promoting a feeling of privacy, coziness, romance, etc."
  • Honoring and being honored.
  • Sharing, caring, devotion, openness, and love.
  • Involves the total person.

Sex:

  • According to Webster:
    1. Either of the two divisions, male or female, into which persons, animals, or plants are divided, with reference to their reproductive functions.
    2. The character of being male or female; all the attributes by which males and females are distinguished.
    3. Anything connected with sexual gratification or reproduction or the urge for these; esp., the attraction of those of one sex for those of the other.
    4. Sexual intercourse.
  • Something everyone avoids in conversation.
  • Contrary to popular belief, the primary sex organs are not below the belt!
    1. "A" for attitude (outlook)
    2. "S" for sensitivity (emotions)
    3. "K" for knowledge
  • Attitude, sensitivity, and knowledge are all in the head, not in the sex organs.

Sexuality

  • According to Webster, "sexual drive or activity."
  • Involves the total person.
  • The masculinity or femininity that all of us experience throughout our lives. It is seen in the twinkle of an eye, the greater care of grooming, and the spark that we begin to see in our partner.
  • There is no age limit on sexuality.

The effects of aging

While the frequency of sexual activity and the ability to perform sexually generally decline with the normal physiological changes that accompany aging, reports show that the majority of men and women between the ages of 50 and 80 are still enthusiastic about sex and intimacy. The vast majority of older people maintain some sexual interest and, at times, intense sexual desire. Aging results in a number of predictable changes in sexual response that can lead to psychological distress if the individual is not aware of them.

Changes as men age: Older men tend to need a longer arousal time and more direct penile stimulation to achieve an erection. Erections are also less firm, and a decrease in swelling occurs more readily and rapidly. Although it is easier for older men to delay ejaculation, the force of semen expulsion and the number of muscular contractions during ejaculation are decreased. Older men generally exhibit an increase in their refractory period, such that they may need several days between orgasms. Medications such as antihypertensives, tranquilizers, and antidepressants can affect erectile functioning and libido (the sexual urge).

Changes as women age: The physiologic effects of aging on sexual function are primarily caused by decreased amounts of circulating estrogen after menopause. Post-menopausal women experience genital changes, including a reduction in the size of the clitoral, vulvar, and labial tissue; decreased size of the cervix, uterus, and ovaries and some loss of elasticity and thinning of the vaginal wall. Hormone replacement can restore normal vaginal function. Women require prolonged stimulation to produce vaginal lubrication, as the amount of lubrication is decreased. With orgasm, the woman's sensations are the same, but fewer and weaker pelvic muscle contractions occur.

Although changes in sexual response occur in both sexes with age, under normal circumstances, they should not interfere with sexual activity. Unfortunately, when individuals lack knowledge of these age-related changes, they may become distressed.

Changes due to lung disease

Sexual function in a person with lung disease depends on a number of variables. These include age, personal health, sexual history, the nature and severity of the illness, the effects of medications and surgery, social circumstances, the partner's reaction to the illness, and the person's coping ability. Obstacles to sexual health in people with lung disease can be classified as follows:

  • Personal: shortness of breath, coughing, and medication side effects
  • Intrapersonal: decreased self-esteem and altered sex role
  • Interpersonal: fear of sexual failure and loss of independence

Probably the most damaging factors leading to the avoidance or failure of sexual expression by persons with lung disease are poor self-image, fear of rejection, and fear of failure to perform and satisfy. However, the greatest fear of the person with lung disease regarding sexual activity is shortness of breath.

Despite the absence of data on how often sexual dysfunction is due to the disease process itself versus how often it is due to psychological factors experienced by the person with lung disease, it is usually attributed to the shortness of breath and fatigue associated with the disease.

Sexual dysfunction associated with lung disease can be divided into four categories:

  1. Inhibited sexual desire
  2. Inhibited sexual arousal
  3. Inhibited orgasm
  4. Other problems

Inhibited sexual desire

People with lung disease expend a lot of energy just performing daily activities.

  • Patients may be short of breath, fatigued, or have low oxygen levels.
  • Patients may experience decreased libido (sexual urge).
  • They may fear shortness of breath during sexual activity.
  • Changes in body shape make the person feel unattractive and undesirable.
  • Medications also play a role: Theophylline - nausea, restlessness, headache, irritability; Corticosteroids - truncal obesity, fluid retention, bruising.

Inhibited sexual arousal (refers to the inability of an individual to achieve erection or lubrication)

For men:

  • Impotence due to depression about chronic illness, loss of self-esteem, fear of not getting enough oxygen, and relationship conflicts.
  • Lack of knowledge of the effect of aging on erectile functioning.
  • Antihypertensives can cause erectile dysfunction.
  • Phenothiazines can interfere with both emission and the sensory experience or orgasm.

For women:

  • Few studies on the effect of lubrication in females with lung disease have been done.
  • Depression.
  • Loss of self-esteem.
  • Medications.
  • Concern about shortness of breath.

Inhibited orgasms

  • Occur less frequently than impairment of the excitement phase.
  • Concomitant neurologic disease.
  • Antidepressants.
  • Psychological issues.

Other problems with sexual functioning

  • Premature ejaculation.
  • Pripism - persistent erection.
  • Dyspareunia - painful or difficult intercourse (women).
  • Vaginismus - spasm of the vagina.

Common myths about sex and lung disease

Myth 1 - Disabled persons are asexual. On the contrary, disabled people have sexual needs. Although sexual activity may be absent or infrequent during acute exacerbations of lung disease, thoughts, fantasies, and feelings about sex do not disappear. Sex is an activity of daily living that affects the patient's self-concept and ability to cope with pulmonary disease.

Myth 2 - The elderly are asexual. We often hear the following: "Impotence is a natural consequence of aging," "sexual activity can be dangerous for the elderly," and "the sex drive or libido diminishes with advancing years for both men and women." None are true. Older people not only have sexual needs, but aging is not a primary cause of sexual dysfunction. Satisfying sexual activity and, in the cases of some men, procreation, may occur into the seventh and eighth decades of life. The myths surrounding sexual intimacy in the later years are finally being put in their proper place - behind us. As a result of the pioneering work of Masters and Johnson, the subject of sex and the elderly has "come out of the closet." It is now a frequent topic of great concern to the more than 21 million American men and women who are over 65 years of age.

Myth 3 - Sexual problems are due to lung disease. Most sexual problems experienced by lung disease patients are due to the person's adaptation to lung disease rather than the disease itself. The four most common situations associated with sexual dysfunction are:

  1. Increasing shortness of breath and fear of suffocation that turn sexual activity into a nightmare experience, causing the patient to abstain completely.
  2. Aesthetically unappealing symptoms - wheezing, coughing, and sputum production - may interrupt or interfere with sexual activities, or may interfere with sexual arousal, orgasm, and satisfaction for both partners. Although symptoms may be minor, the patient is unwilling to resume sexual activity for fear of uncontrollable shortness of breath.
  3. An altered body image causes the person to develop excessive body preoccupation, sometimes leading to impotence or lack of sexual desire. Unaesthetic physical clinical manifestations of lung disease cause the patient to feel unattractive. At least half of all single adults with cystic fibrosis see themselves as physically unattractive due to their thin or short stature, clubbed fingers, or stained teeth. Similarly, an emphysema patient with a weakened, thin body and barrel chest may feel unattractive and unworthy of sexual attention. The person may become depressed and irritable and may blame sexual dysfunction on his lung disease, his or her partner, or the effects of aging.
  4. Other psychological problems cause the following sexual dysfunctions:
  • Boredom or anger with the sexual partner.
  • Preoccupation with career or work.
  • Mental or physical fatigue.
  • Overindulgence in food or drink
  • Fear of failure.

A minority of persons with lung disease may have a physical reason for sexual dysfunction, although exact incidence is unknown because of sparse research on the topic. Some persons with lung disease claim sexual dysfunction, ranging from decreased sex drive to complete impotence, generally coinciding with the advancement of signs and symptoms associated with lung disease. At least some of the decline in sexual function may be related to a decreased level of oxygen. Correction of the decrease in the level of oxygen will allow otherwise impotent persons to become sexually active again.

Myth 4 - Sexual problems are due to pulmonary medications. Pulmonary medications generally do not cause sexual dysfunction in those with lung disease. Tremors, a side effect of some medicines, may interfere with erection, but they may be avoided by appropriate medication adjustment. However, the person may be on other medicines that affect sexual functioning, such as antidepressants, sedatives, and antihypertensives.

Myth 5 - Sexual activity will precipitate respiratory distress. Shortness of breath during sexual intercourse is a natural response that can almost always be tolerated by people with severe lung disease, provided they are on appropriate medications. Sexual intercourse itself requires expenditure of few calories and is relatively non-stressful. It is the associated anxiety and fear that causes respiratory distress.

Myth 6 - Short of breath, disabled persons are fragile and need to be protected. Short of breath, disabled people can learn how to control their symptoms and lead relatively normal social and sexual lives.

Myth 7 - A spontaneous and active role in lovemaking is essential. Any type of satisfying sexual behavior is acceptable. To adapt to lung disease, partners will need to communicate needs and experiment with new sexual patterns and a passive rather than an active lovemaking role for the partner with lung disease.

Communication

An unfortunate type of communication that couples frequently engage in is a game called, "I hope you can read my mind." That is, one partner wishes something would change in the relationship and hopes the spouse or significant other will comply with the unspoken wish.

Communication between partners is a very important part of dealing with the effects of lung disease on their sexual relationship. It is common for people to find this difficult, but there are several things your patients can do to make it easier. Once they have "broken the ice" on the topic, they are likely to discover that it becomes more comfortable each time they try to talk about it.

Suggest they try the following:

  • Find a time and place that will be free of distractions such as television, telephone, children, etc.
  • Discuss changes and adjustments that may need to be made in their sexual functioning.
  • Discuss the best time or place for sexual relations.
  • Another change for many people is the need for more openness about what gives them physical and emotional pleasure or discomfort.
  • Discuss the possible need for alternative positions for sexual intercourse that will pose less threat to the affected partner's breathing process.

While patients may find it initially difficult to talk with their partners, opening up will help them rebuild intimacy in their relationship.

Suggestions for enhancing sexual relationships

Provide your patients with the following list:

  • Communicate openly before, during, and after having sexual intercourse.
  • Be physically and emotionally rested, such as in the morning or after a nap.
  • Choose a time free of distractions - turn off the television, unplug the telephone or let the answering machine pick up (and be sure to turn the volume down), wait until there are no pets or children around.
  • Choose a best breathing time, such as 30 minutes after a breathing treatment.
  • Avoid alcohol and heavy meals - alcohol decreases sexual function, and eating a heavy meal or gas-forming foods may cause bloating and discomfort.
  • Be creative and romantic - put on soft or relaxing music, dim the lighting.
  • Concentrate on touch, such as caresses, stroking, partial or total body massage, soft touches and kisses (but avoid prolonged kisses).
  • If you use oxygen for activity, plan to use the same amount during sexual relations. You may speak to your physician about increasing the flow rate during sexual activity.
  • Keep the room temperature comfortable.
  • Your partner may need to assume a more active role so you will be less fatigued or anxious.
  • Avoid allergic elements in the environment - hairsprays, perfume, scented lotions.
  • Practice pursed-lip breathing.
  • Avoid time limits. Go slowly and give yourself time to be aroused.
  • Try modified positioning - on your side or propped up on pillows. Try to find a position that allows you to breathe freely and uses the least amount of energy.
  • Slow, easy movements and experimentation will help you find what is best for you.
  • Avoid the "touchdown mentality." Not all intimate times need to end in orgasm to be fulfilling.

Intimacy

It's also important for patients to know that the sexual act is only one way to express their love and attraction for their partner. Physical closeness is tremendously important to feeling loved. So encourage them to be near their loved one - hold hands, hug frequently, snuggle - even if they haven't done this for a while. They can set the mood by putting other thoughts and cares out of their minds, concentrating only on their partner, or even taking a relaxing bath or shower together with dimmed lighting and soft music. Soft, gentle massages are another way of achieving an intimate atmosphere that can be relaxing and fulfilling. And they may lead to further activity. The important things to remember are that an intimate relationship:

  • Includes a partner
  • Gives as well as receives pleasure
  • Is more than orgasm
  • Has many expressions
  • Is not physically limited
  • Involves the whole person

Points for patients to remember

  • Lung disease does not diminish sexual ability; it is only the frequency of sexual activity that is limited, as are all strenuous activities.
  • The physical effort required for sexual intercourse is approximately equal to that required to climb one flight of stairs at a normal pace.
  • An exercise program will help build up tolerance to activity and, in turn, will help to reduce shortness of breath.
  • Some changes in sexuality are not related to lung disease, but are normal changes with aging.

Lastly, help your patients realize that lung disease does not lessen the ability to hug, kiss, and caress. Each step along the way to intercourse - snuggling, hugging - can also be enjoyed as an end in itself. If these intermediary activities create a wonderful feeling of closeness and contentment, it is critical to discard any sense of pressure to go beyond them and consummate. Achieving intimacy and feeling loved are the ultimate goal of it all.

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AARC Education Section Bulletin

Section Connection

Recruit a new member: Know an AARC member who could benefit from section membership? Direct them to section sign up. It's the easiest way to add section membership to their overall membership package.

Specialty Practitioner of the Year: It's not too early to be thinking of worthwhile members to honor in 2004! Start brainstorming nominations and submit them online

Section E-mail list: Start networking with your colleagues via the section e-mail list.

Bulletin Deadlines: Winter Issue: December 10; Spring Issue: March 10; Summer Issue: June 10; Fall Issue: September 10.

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