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Produced by the Lung Disease Center of Central Pennsylvania


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his 8th Edition of Breathe Magazine may be the most innovative since we began publishing. Not only does it contain information about the Lung Disease Center and Foundation, but it also has two significant articles worthy of your time. The extensive article on sleep disorders during the stages of reproductive life in women is particularly interesting and important. Most of the medical information about sleep disorders comes from studies in men, but women may be affected in many more ways. I should note that some of the comments in this article are from an interview I had with a prominent local OB/GYN physician, one of my sons, Dr. Ryan J. Zlupko,


a member of Altoona OB/GYN Associates. His collaboration was most helpful. When I proposed the content of this article he was quick to recognize the importance of this information for women. He has my thanks. The article on hospice has particular meaning for me. As the medical director for the 365 Hospice agency, I know firsthand the issues surrounding the use of hospice and the need for more utilization of this valuable service. I would like to thank 365 Hospice for supporting this article. They do a great job in the community and I highly recommend their services. Lastly, I would like to bring the readers’ attention to the update on the Lung Disease Foundation

of Central Pa. It has agreed to take on some new responsibilities so that a number of vital services may continue in Blair County. It also continues to be involved with tobacco control and cessation programs in Blair and Bedford Counties. Enjoy this 8th Edition of Breathe Magazine.

BREATHE 2019 • 3

Altoona Lung Specialists


ltoona Lung Specialists has experienced a number of changes over the past year. Change is scary for some, but thanks to our experienced and caring team of physicians and staff, we worked together to conquer the challenge. We have said goodbye to some of our staff, whom we wish the best of luck in their new endeavors, and have welcomed new team members to our staff, who will work hard to make sure our patients receive the best care available. We have initiated a new “Team” concept in how we work with patients to ensure that each patient receives the best care and customer

service available throughout their relationship with Altoona Lung Specialists. As has always been the case, each of our physicians has a patient population whose care has been entrusted to them. Each physician is now working with a “team” to care for their patients. Each team consists of the physician, a member of our clinical personnel and a medical secretary. This allows the patient to become familiar with, and form a working relationship with the medical team assigned to their care. You will be introduced to the entire team of employees who

provide for your care at Altoona Lung Specialists in this edition of the magazine, and can learn more about them by visiting our website at In additional to the new “teams” caring for you, we also have three receptionists waiting to take your calls or check you in or out during your visit; two x-ray technologists; two sleep technicians; a medical secretary in our Sleep Disorder Network; and technicians trained to perform pulmonary function studies and cardiopulmonary stress testing. If you have questions concerning medications, oxygen, or symptoms which you are experiencing, we encourage you to contact your clinical team member. If you wish to schedule an appointment, change your demographics in our records, or call for a sick visit, you should contact the medical secretary assigned to your physician’s team. We are confident that this new “Team” concept will be a positive experience for our physicians and staff, and most importantly for our patients.

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The Lung Disease Center of Central Pennsylvania


s the Lung Disease Center of Central PA approaches its 8th birthday it may be time to reintroduce the Center and the growth that has occurred over these eight years. The Lung Disease Center is a 15,000 square foot, state of the art facility located at the corner of 8th Street and Chestnut Avenue in Altoona. The facility contains two complete pulmonary function laboratories capable of some services not available anywhere else in the region including cardiopulmonary exercise testing and impulse oscillometry. A digital x-ray unit and in-house CT scanner make it convenient for patients, particularly those who travel some distance, to have their studies done at the time of their visit. The Lung Disease Center also houses the practice of the Altoona Lung Specialists, the Sleep Disorder Network, and the Lung Disease Foundation of Central Pennsylvania. The Altoona Lung Specialists see a large volume of outpatients, both physician referred and self-referred. They also consult on in-patients at the UPMC Altoona Hospital and at the Van Zandt Medical Center, as well as providing specialized services such as fiberoptic bronchoscopy, navigational bronchoscopy and endobronchial ultrasound. The Sleep Disorder Network provides a comfortable inhouse sleep laboratory, but is also capable of providing home sleep testing as well. The physicians in charge of the Sleep Disorder Network are Board Certified in Sleep Medicine. The Lung Disease Foundation of Central Pa. continues to grow and provide services to the surrounding community and you can read more about this in the accompanying pages of this magazine However, the Lung Disease Center is not just a building. It also is involved with the local community and events. The annual Health-O-Rama at the Logan Valley Mall attracts vendors and sponsors from all aspects of the medical community. The Altoona Lung Specialists provide lectures on topics of interest and, of course, the Zlupko father/

son cooking contest always draws a big crowd. The Lung Disease Center is also an entity that is providing telehealth services to smaller hospitals in need of advice and consultation on critically ill patients. Lastly, the Lung Disease Center also participates in research projects sponsored by the pharmaceutical industry, which often offer patients the opportunity to have free evaluations and medications, and in some studies a stipend for participation. The Lung Disease Center of Central PA looks forward to providing continuing pulmonary, sleep, and community services for all those living in the central Pennsylvania region.

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The Lung Disease Foundation of Central Pennsylvania


he Lung Disease Foundation of Central Pennsylvania has experienced a very busy and exciting year of initiatives aimed at assisting our community in improving all aspects of lung health and the quality of air in an effort to reduce lung disease. The Foundation continues to be designated as the Tobacco Control Service Provider, through a grant from the American Lung Association, for both Blair and Bedford Counties. This grant has enabled us to offer Freedom From Smoking programs, free of charge, both at the Lung Disease Center and various other organizations and agencies upon their request; to award TRU Mini Grants to the Family Services Teen Shelter, Blair Regional YMCA, and Joshua House in an effort to educate and prevent use of tobacco products among our youth; Advocate for stronger legislation relative to the purchase of tobacco products by our youth, known as Tobacco 21; and have services available to worksites and multi-unit housing organizations for policies, education and cessation. The Foundation held a ribbon cutting ceremony in August at its new office in the Bedford County Chamber of Commerce facility at 203 South Juliana Street. The addition of this office and a parttime employee in Bedford will allow us to provide Freedom From Smoking tobacco cessation classes, as well as all of the other resources available through the Tobacco Control Service Provider grant, free of charge, to the Bedford County community. Through the educational arm of the Foundation, Dr. Zlupko was invited to speak to school officials, nurses, and teachers in both

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Ribbon cutting ceremony for the Bedford County office.

Cambria and Centre Counties about e-cigarettes, the health issues of vaping, and the epidemic among teens of utilizing a relatively new device called a Juul (known as Juuling). The Foundation made donations to several health organizations in order to ensure the availability of Pursed Lip Breathing Devices “PBDs” for those participating in Pulmonary Rehabilitation programs. The Foundation, upon hearing about the closing of the Blair County Respiratory Disease Society, made the decision to apply for partnership with Cribs for Kids and was made an official Partner in August of 2018. Thanks to a grant awarded by United Way of Blair County, we have been able to purchase cribs and provide safe sleep education and a safe sleep environment to parents of newborns in an effort to alleviate the occurrence of SIDS cases in our community. We have also provided flu vaccine clinics for Blair Senior Services to ensure the availability of flu vaccines to seniors in our community. The Foundation continues to work with the Healthy Blair County Coalition’s Tobacco Free Work Group by hosting meetings of the


work group and as a sponsor and participant in the Second Annual Healthy Resolutions Expo held in November at the Logan Valley Mall. This past year we created several podcasts to help Mary Grattan, volunteer, and educate the public. Sherri Stayer, Executive Director The podcasts are of the Lung Disease Foundation available at http:// of Central Pennsylvania, at lungdiseaseHealthy Resolutions Expo. podcast. The first podcast was created in collaboration with the Healthy Blair County Coalition; the second consisted of detailed information about the Freedom From Smoking program; and a third podcast entailed a discussion with a local employer about their efforts relative to tobacco within their organization. November of each year is National Lung Cancer Awareness month and the Foundation annually publishes a full page flyer to inform, empower and educate individuals. We also participate in the Healthy Resolutions Expo to encourage individuals to think about healthy resolutions for the upcoming New Year, such as participating in a tobacco cessation program, getting One of the groups participating better sleep, in Freedom From Smoking exercising more, or classes. eating healthier. In November, we again held two “Dining to Donate” events at Applebee’s in the Logan Valley Mall, who generously donates 15% of a diner’s check, upon presentation of a coupon, to the Foundation. Are you looking for a charity to donate your good fortune to? The Lung Disease Foundation of Central PA provides vital services throughout the region. A donation of any amount is appreciated. Please visit our website at to find out more information about our Foundation or to donate.


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BREATHE 2019 • 7

Women and Sleep — The Stages of Life — Sponsored by


leep and sleep disruption or sleep disorders have become a significant issue for both men and women. The data surrounding sleep dysfunction has, for the most part, been obtained though studies in men. The reasoning being that changes in the hormonal shifts of women presented more problems with study design and the interpretation of results. Women, from menarche to menopause, report more problems with insufficient sleep and insomnia than men. Women report more difficulty in initiating sleep, difficulty staying asleep, and more frequent early morning awakenings. Women appear to need increased amounts of sleep to function at their best

during the day compared to men. These gender differences in sleep complaints suggest that women have a higher susceptibility to sleep symptoms. Hormonal and physiologic changes, which begin in puberty and continue through the menstrual cycle, pregnancy, perimenopause, and menopause, influence a woman’s circadian rhythms, sleep architecture, and sleep quality. Moreover, these changes can contribute to a wide range of sleep disorders. Women’s sleep architecture and quality can be affected by many different factors, such as weight gain, especially during pregnancy. Women are also exposed to many different life pressures due to their gender.

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Childcare responsibilities, work-life balance, and the caregiver role for the elderly, as well as general stress, can impact a woman’s sleep quality and daytime functioning. This article will review the problems women have with sleep based on the stages of their lives. Addressed in this article will be three main stages of a woman’s life and the difficulties these times may present for healthy sleep. The stages to be considered are: 1) sleep in women of reproductive age, and this will include sleep during the menstrual cycle and perimenopause; 2) sleep during pregnancy and the postpartum period; and 3) sleep during the perimenopausal and menopausal stage. Menstrual cycles are not uniform in duration for any individual woman, and can vary considerably between women. Hormonal fluctuations play an important role in sleep quality during the entire menstrual cycle. Estrogen levels are high just prior to ovulation and progesterone levels rise following ovulation. Sleep fragmentation is thought to be associated with the rise in progesterone levels. A significant number of women of reproductive age are affected by what is called the premenstrual syndrome. Alternatively, premenstrual dysphoric disorder (PMDD) is characterized by more intense mood and anxiety swings, along with a variety of somatic symptoms. Women affected by PMDD report sleep problems such as insomnia, frequent nighttime awakenings, disturbing dreams or nightmares, fatigue, and daytime sleepiness. Changes in thyroid and cortisol levels, along with melatonin, have been found to be present in PMDD leading to light therapy and melatonin as some of the treatment options. A rare disorder, menstrual hypersomnia, is characterized by excessive sleepiness and can be


associated with compulsive eating, sleep architecture and quality. Progesterone levels may be the sexual disinhibition and depression. “Use of oral contraceptives has been culprit in causing hypersomnia. Estrogen levels have been shown to found to be helpful in patients with reduce the period in the sleep cycle menstrual hypersomnia, as well as known as the rapid eye movement PMDD.” Says Dr. Ryan J. Zlupko of phase (REM sleep). REM sleep is the Altoona OB/GYN Associates. period when we dream and without The most common endocrine REM sleep we all experience daytime disorder in women of reproductive age is the polycystic ovary syndrome sleepiness and fatigue. Pregnant women report more (PCOS), affecting between 5 and 12 problems with insomnia than percent of women. Women with non-pregnant women. Pregnant PCOS have enlarged polycystic women with a chronic sleep debt ovaries, but may also exhibit are more likely to hairiness, obesity develop gestational and infertility. diabetes, Obstructive sleep preeclampsia, “Use of oral apnea is more than hypertension, nine times more contraceptives and postpartum likely to be diagnosed depression (PPD). has been found in PCOS patients, Appropriate likely related to treatment for to be helpful insomnia is obesity. Since important to OSA is associated in patients help moderate with an increased the development cardiovascular with menstrual of PPD. Women risk and diabetes, notice an increased hypersomnia, as treatment with frequency of continuous positive well as PMDD.” snoring during airway pressure pregnancy. The (CPAP) is important in prevalence of – Dr. Ryan J. Zlupko, this young age group. sleep Altoona OB/GYN obstructive Pregnancy apnea (OSA) is is frequently Associates. twice as common associated with during the third sleep disturbances. trimester compared More than 79% of pregnant women to the first. Maternal OSA has been indicate that their sleep patterns associated with preeclampsia, are different than at any other stage pregnancy-related hypertension, gestational diabetes, increased of their lives. The most common risk of pre-term delivery, increased cause for sleep awakenings during risk of neonatal ICU admissions, pregnancy is nocturia (getting up low birth weight, and intrauterine at night to pee), agrees Dr. Zlupko. growth restrictions. OSA is often This problem is most common misdiagnosed during pregnancy. during the third trimester. Pregnant The use of CPAP is the treatment of women also report increased choice and is safe during pregnancy. insomnia, restless leg syndrome Dr. Zlupko advises expectant (a disorder characterized by an mothers to sleep on their left side unpleasant tickling or twitching and elevate the head of the bed to sensation in the leg muscles when avoid compression of the inferior sitting or lying down relieved only vena cava (the main vein bringing by moving the legs), snoring and blood back from the abdomen to the hypersomnia (increased sleepiness heart). A type of CPAP (continuous and the need for more sleep). positive airway pressure) called auto Progesterone and estrogen levels titrating, is the best to use because rise progressively during pregnancy of the weight changes and fluid shifts occurring during pregnancy. and exert significant influence over


An auto titrating CPAP will adjust on a breath by breath basis to compensate for any dynamic changes in the airway. Restless leg syndrome is a feeling that one must constantly move the legs when in bed. Gestational restless leg syndrome may occur in as many as 30% of pregnant women, with the frequency increasing from the first to the third trimester. Interestingly, iron deficiency is often associated with this syndrome. 18% of pregnant women have been shown to have iron deficiency due to increased maternal requirements which include demands from the fetus and placenta and expansion of the maternal blood volume. Unfortunately, many of the medications used for restless leg syndrome in non-pregnant women and men have not been shown to be safe in pregnant women, or little is known about their affect. Sleep walking, sleep talking, and nightmares have all been reported during pregnancy. Treatment here is also limited because of the sideeffect profiles of therapeutic drugs during pregnancy. In the postpartum period, hormone levels fall and the usual unpredictable infant sleep patterns can affect the women’s sleep patterns. Maternal sleep patterns are affected regardless of whether the baby is bottle or breast fed. Some unusual disturbances have been reported, and these are called parasomnias. Postpartum parasomnias include sleep walking, arousals at night associated with confusion or total amnesia about the event. A confused arousal of the mother when the baby is in the bedroom exposes the infant to potential inadvertent harm from the confused mother. Adult non-pregnant women have higher rates of parasomnias than men, with night eating and sleeprelated eating disorder (SRED). The women often need to eat in order to fall asleep and this behavior may be associated with partial or complete amnesia. CONTINUED ON PAGE 10

BREATHE 2019 • 9

CONTINUED FROM PAGE 9 Sleep disturbances are common during the menopausal transition from perimenopause through menopause and post-menopause. During the perimenopausal period wide hormonal fluctuations occur with some increasing and some decreasing, most notably progesterone and estradiol. The diagnosis of the perimenopausal period cannot be made by measuring hormone levels but rather by clinical symptoms and signs. Dr. Zlupko indicates that the common symptoms during this period include hot flashes, vaginal dryness and sleep disturbances. Hot flashes can be associated with frequent nighttime arousals and hormonal replacement, and non-hormonal medications have been found to be helpful. For example, the role of melatonin as a cause for some menopausal sleep

disturbances and as a treatment for some, is currently being debated. Insomnia in the postmenopausal period may be associated with a variety of causes including advancing age, depression and fibromyalgia, with hormonal factors playing a role as well. Obstructive sleep apnea (OSA) continues to increase during the menopausal and postmenopausal period. Weight gain and hormonal changes are risk factors. Progesterone loss can increase the collapsibility of the pharyngeal dilator muscles leading to an increased risk of OSA. Sleep disturbances are common in women of all ages. Sleep disturbances across a woman’s life span are associated with major changes in hormonal levels and physiology. More study and insight is needed in how to address sleep disturbances, such as restless leg syndrome (RLS) and insomnia in pregnant and postpartum women

who are breast feeding. How to deal with sleep issues associated with postmenopausal stress levels in women placed in the caregiver role for elderly parents, or who need to care for grandchildren abandoned by their parents, is a growing area of concern. Sleep disorders and disturbances in women need to be correlated with their stage of life to be fully understood. Finally, Dr. Ryan J. Zlupko recommends “Women should discuss any sleep problems with their family physician or OB/ GYN physician.”

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We can all agree that good sleep is essential for good health. Recognition and treatment of sleep disorders can significantly improve whole body function and quality of life. We at Altoona OB/GYN Associates are proud to help women throughout all phases of life. We hope that you find the article on page 8 informative, and are reassured that sleep issues can be addressed and treated.

— Ryan J. Zlupko, MD

Dr. Patricia M. Hoyne, MD

Dr. David R. Lee, MD

Dr. Liang R. Bartkowiak, MD

Dr. Ryan J. Zlupko, MD

Dr. Gamal Saleh, M.D.

Altoona OB/GYN Associates provides a full range of obstetrics and gynecology services for women of all ages. Obstetrics covers your health needs from conception, through your pregnancy, delivery, and postpartum. Our gynecological services cover a broad range of women’s reproductive health, including procedures, exams, diagnostics, and tests.

814-944-5062 | 1701 12th Avenue, Suite A, Altoona, PA 16601 Monday-Thursday: 8:00am - 4:30pm, Friday: 8:00am - 4:00pm

Our Doctors

George M. Zlupko, M.D., FCCP

Timothy A. Lucas, M.D., FCCP

Alan J. Kanouff, D.O., FCCP

Michael C. Zlupko, M.D.

Dr. George M. Zlupko is the senior partner and founder of Altoona Lung Specialists. He is the Director of the Lung Disease Center of Central Pennsylvania, which he founded in 2011. He also founded the Lung Disease Foundation of Central PA. Many of the current advanced procedures used locally in pulmonary medicine had their beginnings more than thirty years ago when Dr. Zlupko arrived in Altoona to add knowledge, direction, and expertise to the critical care unit and respiratory care department of the, then, Altoona Hospital. He brought with him the techniques of fiber optic bronchoscopy, followed by navigational bronchoscopy, and the new technique of Endobronchial Ultrasound most recently introduced by his son, Dr. Michael Zlupko. Dr. Zlupko’s mission has been to provide high quality pulmonary medicine services which would rival tertiary care facilities, close to home for more convenient patient care.

Dr. Timothy Lucas joined Altoona Lung Specialists in 2000. He received a Bachelor of Science Degree in Biology from the University of Pittsburgh. Dr. Lucas attended medical school, performed his internship, residency, and fellowship training, all at The Pennsylvania State University College of Medicine in Hershey, Pennsylvania. Dr. Lucas is certified by the American Board of Internal Medicine in Pulmonary Disease, as well as the American Board of Sleep Medicine. He enjoys the distinction of being a Fellow of the American College of Chest Physicians. Dr. Lucas has privileges at UPMC Altoona and is the Medical Director of the Sleep Disorder Network in the Lung Disease Center of Central Pennsylvania

Dr. Kanouff received his education at the Pennsylvania State University spending his first two years in Altoona before finishing up at University Park. He completed his medical education at the Philadelphia College of Osteopathic Medicine. He performed his residency at Conemaugh Valley Memorial Hospital in Johnstown, Pennsylvania, and underwent his pulmonary training at Allegheny General Hospital in Pittsburgh, Pennsylvania. He joined the Lung Disease Center of Central Pennsylvania in 2009. Dr. Kanouff is certified by the American Board of Internal Medicine in Sleep Medicine and Pulmonary Diseases. He is also certified in Critical Care Medicine and Internal Medicine, and is licensed by the State of Pennsylvania as a Doctor of Osteopathy. Dr. Kanouff has the distinction of being a Fellow of the American College of Chest Physicians.

Dr. Michael C. Zlupko joined the Altoona Lung Specialists in 2013. He graduated summa cum laude with a Bachelor of Arts in Biology from Franklin and Marshall College in Lancaster, PA.  Dr. Zlupko received his medical degree from the University of Pennsylvania School of Medicine in Philadelphia, PA.  He performed his internal medicine residency at the University of Virginia in Charlottesville, VA and completed his pulmonary and critical care training at the Cleveland Clinic Foundation in Cleveland, OH. Dr. Michael C. Zlupko is Board Certified by the American Board of Internal Medicine in Internal Medicine, Pulmonary Disease, and Critical Care Medicine.  He is licensed to practice medicine by the State of Pennsylvania with privileges at UPMC Altoona, Tyrone Hospital, HealthSouth Rehabilitation Hospital of Altoona, and the James E. VanZandt Veteran’s Memorial Hospital.

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Getting More Not Giving Up


ne of the more difficult tasks in medicine is interacting with patients whose disease no longer has any options for treatment. The families of these patients often find themselves unable to deal with the physical and emotional stress of the home care the patient requires. Most families want to do their best, but have never provided 24 hour care and emotional support to someone who is failing and actively dying. The need for help at these times is obvious, but often families do not know where to turn. Using a hospice agency at times like this can be of great comfort to the patient as well as all concerned. Hospice is indicated when no additional active therapy will be helpful to the patient and life expectancy is short. However,

the patient is often conscious and aware of their surroundings and wants to live as comfortably as possible, and get as much quality of life their disease will permit. Some may feel that having a hospice agency involved in the care of a loved one is giving up but, in reality, it is really giving more. A good hospice agency can provide customized care for each patient within the home setting. Medications for the patient are continued and emergency packs for pain relief and other symptoms are available. Agencies provide socialization and stimulation that enhances the quality of the patient’s life while providing peace of mind to families. Indeed, Medicare requires that hospice services benefit both family and patient. Spiritual counseling can

help the patient and family deal with the fears associated with dying. Regardless of religious affiliation, spiritual services are well received. The comfort and hope a hospice agency can provide to the patient and family in their time of need cannot be overemphasized. Starting hospice service early in the course of events when curative therapies are no longer helpful will help provide the comfort and quality of life patients want and need in their remaining time. Consider hospice services for yourself or a loved one when the need arises. Consider these services early in the course of events. Being cared for by a hospice agency is not giving up, but getting more. State College Office

220 Regent Court, Suite E-2 State College, PA 16801 Phone: 814.946.5017 Fax: 814.946.5323 WWW.THELUNGSPECIALISTS.COM |

Carrolltown Office 119 S Main Street Carrolltown, PA 15722 Phone: 814.419.4901 Fax: 814.419.4902 

Belle Vernon Office 411 Rostraver Road Belle Vernon, PA 15012 Phone: 1.844.365.4677 Fax: 724.268.3994

Monroeville Office

2549 Mosside Blvd Monroeville, PA 15146 Phone: 1.844.365.4677 Fax: 412.372.5926 BREATHE 2019 • 13

Thank You To Our Team! We would like to thank each member of our experienced and caring team at Altoona Lung Specialists for their dedication to the needs of our patients. It is our team members who play an integral part in the success of the practice. Each Receptionist, Medical Secretary, Medical Assistant, Radiology Technician, and Sleep Technician is dedicated to being compassionate and providing excellence in their effort to insure that each and every patient of Altoona Lung Specialists receives the best care and customer service available. Thank you!


Clerical Supervisor




Practice Manager

Kylie Clerical


Check-Out Receptionist

Clinical Supervisor









Nicole Clinical



Sherri Stayer



Clerical, Sleep Disorder Network



Sleep Disorder Network

14 • BREATHE 2018 




Sleep Disorder Network


Don’t reach for your inhaler, reach for your

PURSED LIP BREATHING DEVICE Shortness of breath is one of the most difficult symptoms suffered by patients with COPD. Relieving this discomfort most often does not require medication, but a simple maneuver called “pursed lip breathing”. This is one of the most important techniques patients must remember to do when confronted with shortness of breath on exertion. Unfortunately, when confronted with this shortness of breath many, if not most, patients will panic and forget this important maneuver, or they do not do it correctly, and can be embarrassed to do it in public. The PBD or Pursed-Lip Breathing Device offers a unique method to help patients remember to use this technique. The PBD offers security, comfort, and relief when used as instructed in difficult situations. You are encouraged to go to the website at to listen to and see a brief video explaining the device and why it is helpful. Orders come with instructions and you can view the video as often as you like to help understand and follow the instructions for use.

Dr. George M. Zlupko, Inventor of the PBD

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Breathe Magazine 2019  

Breathe Magazine 2019