Tag Archives: FAARC

Mark Mangus Tells the COPDer How to Live – EXERCISE

Pulmonologists and COPDers – take note – patients really do WANT to be educated and too many physicians are shy about encouraging patients to exercise and WHY WE MUST EXERCISE to have a life.

Following is the noted exercise guru for the COPDer, Mark W. Mangus, Sr., BSRC, RRT, RPFT, FAARC of San Antonio, TX answer to a patients question about her FEV-1 and FVC decline.  Mark’s answer was posted on my online support group, EFFORTS.  www.emphysema.net.

A gentle reminder that Mark had to move beyond traditional COPD treatment because his daughter, Kim, born with Cystic Fibrosis was not helped by traditional medicine methods for lung patients.  Kim’s only hope was to stay alive until she was old enough for a lung transplant.  She has had double lung transplants now and currently works for Vanderbilt Medical Center.

Hi _ _ _,

First, let me say that there is nothing you can do to stop the decline you

are experiencing in your FVC and FEV-1, though you CAN slow the inevitable

progression to some (unknown) degree by exercising increasingly VIGOROUSLY

as you embark on your pulmonary rehabilitation effort.


Your stress testing and echo tell a story of long developing pulmonary

hypertension which has advanced with poor intervention with regard to timely

detection of hypoxemia and earlier oxygen therapy support.  Your breast

cancer bout and treatment are potentially responsible for part of what you

are currently experiencing.  Radiation treatment is notorious for triggering

a process of radiation fibrosis, though it usually happens more profoundly

in treatment of lung cancer than more superficial cancers like breast

cancer.  But, if lymph nodes under your arm were irradiated – in other words

– the radiation was applied broadly over an area larger than simply the

breast tissue, chances are that you are seeing some effect from that.  A

high-resolution CT of your lungs, maybe with enhancement, if deemed helpful,

might better illuminate the presence of fibrosis and its extent and progression.


Your FVC has dropped disproportionately with your FEV-1, the FVC dropping by

almost double that of the FEV-1 during the same period.  This is also

suggestive of the possibility of fibrosis.  As well, your DLCO being reduced

to around 30 % of what it should be AND the confirmed and significant

hypoxia discovered with your walking and sleeping oximetry tests correlate

with the reduced DLCO and FVC.  The reduction in FVC is yet further

suggestion of a restrictive process being combined with your obstructive

lung disease process.


I am disappointed that your 6 minute walk was conducted as it was, but,

unfortunately, not surprised, as it is one of the most variably conducted

tests done in this area of medicine.  You SHOULD have been allowed to

continue – hypoxia detected or not – as long as you were able to AND at a

pace that YOU chose.  If monitoring was to be done, then it should have done

no more than to document the extent of changes – NOT signal a point at which

the clinician decided to stop you and THEN to totally alter the validity of

your test by setting your pace!  So, the 620 feet you walked is meaningless

to determine anything with regard to the clinical state of your disease

and the limitations it imposes upon your ability to ambulate or to

extrapolate any determination of functional adequacy.  None of that is your

fault.  It is due to the poor understanding of the test purpose and method

on the part of the clinicians.


Your sleep saturations are very telling of significant hypoxemia that is

more likely associated with your fibrosis and pulmonary hypertension.

Pulmonary hypertension aggravates hypoxia, making it worse, which in turn

makes the hypertension worse, which in turn, makes the hypoxia worse . .

You can see where that is going. That is why you bottom out so low at 78 %

during sleep.


First, I hope that 2 liters during sleep is keeping you saturated to at

least 88 % as a bottom low point.  If you have not had a follow-up sleep

study to determine the effect/benefit of the oxygen during sleep, you should

push for it to be done.   You should ALSO be using oxygen for ALL ambulation

and exertion – and possibly more like 4 to 6 liters – as I’m doubtful that

any less will saturate you adequately to counteract your pulmonary

hypertension.   Treatment of the pulmonary hypertension should be a point of

primary focus for you and your medical team.  Oxygen, at this point is the

most powerful and effective treatment you can use to slow the inevitable

progression towards profound heart failure you can expect if the pulmonary

hypertension is not controlled a LOT better than it has been over the recent

past.  That wll likely ‘do you in’ a whole lot sooner and with much interim

misery than the combined lung disease process that has caused it.


It is good that you are starting a pulmonary rehab program.  I am surprised

that they don’t have a pulmonologist directing the program.  Do you know

what kind of doctor is acting/serving as their medical director?  Make the

most of it.  Push hard to learn to work against the difficulties of the

breathing symptoms that accompany your disease, especially at this point.

Don’t let the staff hold you back because of hypoxia.  Push them to give you

all the oxygen you need to be able to push yourself to the maximum.  Short of

such an effort and you will be mostly spinning your wheels.  Working hard to

breathe and overcoming the difficulties and fear it can impose upon you are

not easy.  NEVERTHELESS, working hard to breathe – even when it makes others

uncomfortable to watch you work so hard – will NOT harm you, despite what

many might opine.  It may ‘feel’ like it’s gonna kill you.  HOWEVER, it will

NOT!  It is not an easy path you must travel.  But, others have traveled the

same path.  The good news is that you still have 29 % FEV-1.  That might

creep back up to 35% with hard work.  AND, it would be worth it because that

little 5 % raw change represents a 20 % change in your overall FEV-1.


If you have further questions as you go along, I am happy to try to answer

them for you.       Best Wishes,                                  Mark


Mark W. Mangus, Sr., BSRC, RRT, RPFT, FAARC

San Antonio, TX


COPDers, a new study indicating what I have shouted about for years – recumbent cycling (trike)…

“…This study showed that an eccentric cycling protocol based on progressive increases in workload is feasible in severe COPD, with no side effects and high compliance…”

COPD. 2011 Jul 5. [Epub ahead of print]

Eccentric Cycle Exercise in Severe COPD: Feasibility of Application.

Rocha Vieira DS, Baril J, Richard R, Perrault H, Bourbeau J, Taivassalo T.


Respiratory Epidemiology and Clinical Research Unit (RECRU), Montreal Chest Institute, McGill University Health Centre, Montreal, Quebec, Canada,1.


Eccentric cycling may present an interesting alternative to traditional exercise rehabilitation for patients with advanced COPD, because of the low ventilatory cost associated with lengthening muscle actions. However, due to muscle damage and soreness typically associated with eccentric exercise, there has been reluctance in using this modality in clinical populations. This study assessed the feasibility of applying an eccentric cycling protocol, based on progressive muscle overload, in six severe COPD patients with the aim of minimizing side effects and maximizing compliance. Over 5 weeks, eccentric cycling power was progressively increased in all patients from a minimal 10-Watt workload to a target intensity of 60% peak oxygen consumption (attained in a concentric modality). By 5 weeks, patients were able to cycle on average at a 7-fold higher power output relative to baseline, with heart rate being maintained at ∼85% of peak. All patients complied with the protocol and presented tolerable dyspnea and leg fatigue throughout the study; muscle soreness was minimal and did not compromise increases in power; creatine kinase remained within normal range or was slightly elevated; and most patients showed a breathing reserve > 15 L.min(-1). At the target intensity, ventilation and breathing frequency during eccentric cycling were similar to concentric cycling while power was approximately five times higher (p = 0.02). This study showed that an eccentric cycling protocol based on progressive increases in workload is feasible in severe COPD, with no side effects and high compliance, thus warranting further study into its efficacy as a training intervention.”

PMID:     21728805

[PubMed – as supplied by publisher]



COPDers–talk to your doctors- get educated and educate them to what patients CAN DO.

Thanks for reading… Sharon O’Hara

Meet a COPDers Guru and Lifesaver Mark W Mangus, Sr. BSRC, RRT, RPFT, FAARC

Meet Mark and daughter, Kim, the Cystic Fibrosis girl who started it all and has helped countless thousands of COPDers from a life of medical ignorance.

First…Today I walked upright across the shallow end of the pool.  No walking sticks or the normal hunched over posture and limp.  I walked upright, my bone on bone left hip locked in muscle tightening of my left bun.

Awed and surprised, I walked back and forth three or four times.

Saturday, 5 February 2011 I walked upright through the water without walking sticks or a walker or floating.  It was the first time in two or three years.

Today was my third session with Marilyn, a real swimming coach and I didn’t intend to mention it until much later but I’m still jazzed about walking the end of the pool.

Another time on what we’re doing and why – but what I do today goes back to my online support and advocacy group, EFFORTS and Mark Mangus, Sr.

Baby steps as Marilyn says … and reach beyond shortness of breath to improve according to Mark.  YES!


A problem I developed that I discovered at a family Thanksgiving some six or seven years ago was laughing hard gives me a splitting headache at the base of my head and I have trouble breathing– this from a person who rarely gets a headache.

I’ve never known why until I asked Mark recently.  Following is my question and his answer.  Additionally I asked him what made him stretch out so far beyond and disprove what medical sources ignored about COPDers.  We CAN get better!


“….You also just opened the door to something that bothers me whenever I laugh hard… the back of my head -occipital bone, I think- feels like its going to split wide open with the pain of a massive headache…something I rarely, ever, get.  It is only in that spot and only when I laugh hard.


What can I do about it?  Sometimes something tickles my funny bone so hard,

I can’t stop without great effort though pain is a great incentive to stop.

I used to laugh a lot, all the time…now I don’t want to.

What do you think?

COPD isn’t for sissies!”


“On 1/3/2011 8:59 PM, Mark Mangus wrote:

I would surmise that you are experiencing increased intracranial pressure
when you laugh and that it is backing up the blood in your brain.  It could
be from a few different causes, not the least likely of which could be
attributable to increased right-heart pressures which would be transmitted
‘retrograde’ (backwards) through your jugular veins and to your brain,.
That slows drainage of blood from your head which is trying to make it back
to your heart and then your lungs.  If you have increased pulmonary artery
pressure from long-standing hypoxia, that could easily cause such a

In any case, it is most likely increased vascular pressure in your brain,
whatever the precipitating cause might be.  Unfortunately, for you, laughing
seems NOT to be a ‘laughing matter’, in view of the unpleasant side-effects you suffer.  Worse yet, there is likely nothing you can do about it, unless
you find oxygen use to be helpful in reducing or relieving the problem.  It
is a tough problem, no doubt.  I’m sorry you experience it!  Laughing ‘can’
be so therapeutic under better circumstances!”

Mark W Mangus, Sr. BSRC, RRT, RPFT, FAARC

San Antonio, TX



This post is about an RRT extraordinary, Mark W. Mangus, Sr., BSRC, RRT, RPFT, FAARC individual.  It was reading his posts in my online COPD support and advocacy group that helped me understand that we could help ourselves through exercise – going beyond what any doctor would prescribe for a COPDer.

His championship of patients going beyond – way beyond what they think  they can do and the support of EFFORTS’ites are probably a key reason I’m still going today – start and stop though it’s been over these years of piling on medical conditions – since I was hospitalized at Harrison in 1997.

COPDers aren’t helpless – even though we’ve now progressed to the third leading cause of death in the United States and fifth leading cause of death in the world.

Meet an extraordinary dad, Mark and the girl who started it all, daughter, Kim.


“You asked me to speak to how and why I’ve become such an advocate for patient education – there are several reasons and influences.

First, when I became an RT, instead of pursuing medical school and an MD, I decided that my life’s quest would be to become the best RT I could and hopefully, with hard work and a bit of luck, along the way, to ultimately be considered one of the top RT’s of my era.  Now that’s pretty ambitious and can be construed as a bit cocky.  But, as with most all who enter the health care profession, I believe we all have a desire and even a calling to ‘help our fellow man’ and to try to be the best we can be.  At least, we start out that way, for the most part   In our particular positions, we choose to do that through delivery of health care and to foster better health.

Dr. Thomas L Petty is one of my great heroes and a source of greatest inspiration.  As a pioneer in so many aspects of pulmonary medicine, he was not afraid to take on daunting projects and challenges, many of which resulted in our ground-level information on some of the most important lessons we’ve learned about pulmonary physiology and disease to date.  I also decided that to become the best RT I could envision, I had to go beyond the simple boundaries of standard RT education.  So I have studied extensively to include medical knowledge beyond the boundaries of RT.  As a corpsman in the USAF, I was exposed to many non-respiratory aspects of disease and its treatment.  Being assigned to Wilford Hall Medical Center, the Air force’s premier institution in the world, at the time, I also was given opportunities for training and experience that I would not have been afforded anywhere else.

So, I have to say I’ve been fortunate to have been in the right place at the right time many times in my career, with regard to training opportunities and those who have taught and mentored me along the way.  I have had the opportunity to learn much that other RT’s never get a chance to experience.  Having participated in what was the pilot program for physician’s assistants while I was in the Air Force, I was given training and opportunities that are simply not a part of RT training.  That has given me an edge that others have not had opportunity for.  I was one of a group who were present and part of studies in what was at the time, cutting edge respiratory research and received unique training and experience during that period, again, not available to RT’s then or in the same scope for years after those early days.  That training and experience instilled in me the realization that I had been given a special gift; one which I was compelled to build upon and utilize to the best benefit of people I could.

With the birth of my daughter and the discovery of her affliction with Cystic Fibrosis, I both realized the extent of the blessing of knowledge I had gained, in being the one who, while others were pooh-poohing my suspicions, indeed diagnosed her as having the disease.  That came through having had the good fortune to work with the disease for two years before she was born and to work to learn more and understand the disease sufficient to recognize and suspect it before any obvious signs had manifested.  This was actually a bittersweet realization of the knowledge I possessed at the time, as it included both the angst and horror of learning of her problem and the gratitude for knowing enough to discern it before she suffered any serious effects of the disease.  Treatment was started quickly and my wife and I set out on what has become a 29-year journey to give her the best care and advantage in life possible.  That has, as you know, included two double lung transplants in addition to the many events over the years preceding her first transplant.

When I was asked to take on the task of formulating the first comprehensive pulmonary rehabilitation program, I felt like a fish out of water.  To that point, my understanding of COPD was very mainstream; ‘you simply can’t do anything with folks whose lung function has gone south as it does when COPD advances’.  Yet, I chose to look at it with an open mind in an effort to try to learn “why” their plight was so ‘dead-end’ and hopeless and to ‘maybe’ find a way to make the inevitable easier for them and even help them to find a better way to live within those conditions they could not change.  Today, I am ecstatic to acknowledge how wrong I was back then, along with the majority of others in medicine, having been taught some of the greatest lessons of my career during these past 25 years of study and work in pulmonary rehabilitation and ‘disease management of lung diseases’.

The more I dug into COPD, the more I learned that most everything about the disease was “theoretical” knowledge that had not been supported by evidence-based study.  As I learned more about what was empirically known, I increasingly saw the incongruities and contradictions in the real world to what was presumed gospel knowledge about lung disease.  Then along came lung transplantation and then LVRS and the advances in medications and research into cause and effect.  The undeniable truths and tragic fallacies about COPD and other lung diseases became glaringly apparent.

\Unfortunately, too many of those in health care, continued – and still continue – to hold to false ideas about what can and should be done about lung disease and how to improve life with these diseases.  So, I joined Dr. Tom and the many others who ‘crusade’ for a better lot in life with COPD.  And, because there is still such disparity and nilistic attitude toward COPD, in particular, added to the fact that as with several other kinds of chronic ailments, patient knowledge and ‘active’ participation in their own care have demonstrated improved living, longevity and reduced infirmity with chronic disease, I long ago decided that I had to play a leading role in my capacity to educate patients and bring them “into the loop” of their own care, even to the chagrin of many health care professionals – yes; including “doctors”!

So, for the last 20 years, I have become increasingly involved in the educational front on a widening scale to the international stage.  I join a host of others in our effort to do our part, simply because it’s the ‘right thing to do’.  It’s not for fame or financial gain, though that is always nice, if it comes with helping folks.  Lord knows, I’ve not become a rich or even modestly wealthy man in my endeavors.  That’s OK with me.  I have what I need and can look back with satisfaction knowing what I have contributed.  And I can look ahead to what still needs to be done.  That’s my focus and my ongoing quest.

Would I like to see ALL RT’s hold the same outlook and attitude?  SURE!  But, I, too, have read Plato in my studies of many years ago.  And I understand that there is no “Utopia” in the ‘real world’.  Nevertheless, as I endeavored to explain and encourage in the chapter I contributed to Dr Tom’s last book: “Adventures of an Oxyphile2”; a chapter written for RT’s and about RT’s, I hope I can help at least some of my colleagues become better than they might otherwise have been, had they not encountered me in some way.

Photo taken at Kim’s graduation party when she finished her BSRC degree August 2010.

Thank you Mark and Kim!

More later… Sharon O’Hara