Featured Question:
Worried about Tuberculosis Risk in Children and the Use of the BCG Vaccine
Q. Dear Dr. Bruce,
My two year old has had a cough for six weeks now; I am up all night with my child. All I do is worry and complain to my pediatrician, who seems clueless. I am upset.
I worry that tuberculosis (TB) is more common and that HIV is on rise again. Children are at risk, period. I feel helpless about disease prevention.
If my two year-old caught TB there is no guarantee the antibiotics would work; he is on antibiotics several times a year for ears, sinus, etc. She could catch possible an antibiotic resistant bacteria/strain.
Is it good to get the BCG vaccine? I worry about vaccine risk, what mother does not in this day and age. Yet, I am more concerned with TB rates than pertussis.
How can you help me find peace about the possibility of my child getting TB?
It's tough being a mom, trying to take care of your child. I need your expertise so I can do a better job at my job, would like to enjoy motherhood as well.
Mary
A. Dear Mary,
The BCG vaccination was created more than 80 years ago to try and decrease the spread of tuberculosis. It is not a very effective vaccine and babies who get BCG can still catch TB. It also has more side effects
than most other immunizations.
For these reasons, BCG is only given to babies at high risk, where there is a lot of TB in the community and where it is difficult to get to medical care. Most countries in the world do NOT routinely give BCG to most babies.
Dr. Bruce
Nebulizing Fortaz
Q. Do you have any information on nebulizing Fortaz? I have
heard that it has been done but not sure where to look for the information.
Marie, RRT
A. Dear Marie RRT,
I have no information about this. Sorry.
Dr. Tom
Does Air Trapping Mean Emphysema?
Q. Hello, I am 51 years old, have never smoked, and was put
on 2 liters oxygen in May 2008 after hospitalization for hypoxemia. I was
labeled with Idiopathic ILD/UIP (Interstitial Lung Disease/Unusual Interstitial
Pneumonia) after a lung biopsy in Nov 2008. I was discharged with diagnosis of
unknown viral pneumonia after they eliminated bacteria and Influenza A and
B.
My latest non-contrast CT scan showed air trapping in
February and my respiratory therapist, at pulmonary rehab, says this means
emphysema.
How can I have emphysema if I never smoked and haven’t been
exposed to second hand smoke in the house for 35 years?
Aline
A. Dear Aline,
Air trapping cannot be equated with emphysema. It may occur
in ILD/UIP.
Dr. Tom
Q. Can Isoniazid (INH) cause problems with the disc in your
back?
I've never had problems with my back until I was diagnosed
with INH induced hepatitis, now I've had four discs fused in my neck and am due
to have two more in my lower back.
Joseph
A. Dear Joseph,
NO. These disc problems are not related to INH.
Dr. Tom
Help, Husband Is Not Taking Care of Himself
Q. My husband was told he had COPD six years ago and was
told he had emphysema four years ago.
He is 69 years old, has high blood pressure and told he has
diabetes. About a year ago he started having angina, since he was told that he
has given up all medical care and takes no meds except his Combivent, which he
over takes (can go through 200 inhalations in less than a week).
The angina has gotten so it is almost a daily thing and the
last two weeks he has started to cough a lot and now is coughing up a mucus
which is sometimes white to a green looking color. He coughs so hard now it
makes him throw up.
I have begged him to let me take him to a hospital but he
refuses any care. Can you give me any insight as to what I am about to deal
with or what is happening to him? I am so in the dark. I have read a lot about
COPD/emphysema but nothing really seems to tell me anything.
By the way, he still smokes and has since he was about 18
years old.
Jennifer
A. Dear Jennifer,
At least a major part of his current problem is smoking. He
must stop or the symptoms will continue.
Dr. Tom
Cause of E. Coli in the Lungs
Q. Dr. Tom, My grandfather recently passed away from
pneumonia. He had bacterial pneumonia, which consisted of Moraxella and E.
coli. I later learned that my grandfather had eaten raw blood sausage,
which he loved.
Could this have been how he obtained E. coli in his lung or
do you think it was a secondary bacteria, due to the fact he was on a vent
until he passed away?
Amanda
A. Dear Amanda,
The E coli was not from the sausage. It was probably due to
the use of an airway and mechanical ventilation.
Dr. Tom
Having a Hard Time Getting a Oxygen Saturation
Q. I am a respiratory therapist, currently working doing
Pulmonary Rehab. We are having difficulty getting saturations via pulse
oximetry on a patient with scleroderma.
We have tried and tried with the finger probe and ear probe.
Do you have any suggestions? He desaturates easily and we
really need to monitor him.
Susan
A. Dear Susan,
I have no experience using oxymeters in the case of
scleroderma.
Dr. Tom
No Explanation from Doctors
Q. My attending physician sent me to another doctor for
allergy testing because they could not find out why my white cell count kept coming
up elevated and why I had some allergic reactions to some tests.
This other doctor sent me for a CT Scan and diagnosed me
with emphysema. My doctor just wrote it off and never discussed anything with
me.
What should I do?
Lynne
A. Dear Lynne,
Get another doctor who will explain things to you.
Dr. Tom
Can You Trim a Nasal Cannula?
Q. Is it safe to trim a nasal cannula for an adult patient
to minimize nasal sores? Can you give me a resource that backs it up medically?
Theresa
A. Dear Theresa,
You can trim for comfort. There is no specific formula.
Dr. Tom
Pain After Pneumothorax Treatment
Q. Hello Dr. Tom, Seven months ago, at the age of 39, I
suffered what was thought to be a spontaneous pneumothorax (5'10", 118 lbs.). It was over 30% of my lung, but was left to resolve on
its own. I should also note that I had smoked for approximately 22 years
(< pack/day) prior to the first collapse. I have not smoked since that day.
I suffered another collapse approximately a month later, and
underwent VATS mechanical pleurodesis with resection of apical left upper lobe and a parietal and visceral pleurectomy. My CT scans at the time showed
multiple blebs on both lungs. The
pathology from the surgery indicated emphysematous changes and subpleural
blebs, so I would imagine my collapses were due to bullous emphysema and not
really spontaneous.
I am now six months out from surgery and still have
significant "pulling" pain at the bottom of my rib cage on the
surgery side. I also have very little strength in my stomach muscles on that
side as well.
I have asked if a "Sniff
Test" is in order, but my pulmonologist doesn’t seem to think that's
necessary.
What could be causing such pain? Is it possible an adhesion
was formed between my lung and diaphragm? Any opinion on this would be
appreciated.
Thanks for taking the time to read this.
Susan
A. Dear Susan,
Adhesions could explain this. Sometimes VATs correction is
needed.
Dr. Tom
Treatment for Idiopathic Pulmonary Fibrosis
Q. Hi, My father has been diagnosed with Idiopathic Pulmonary
Fibrosis (IPF) yesterday. For about a year he had been complaining of
difficulty in breathing, which used to happen when he took some walks. But that
was neglected all these days as some minor problem. Now it is diagnosed as IPF
after CT Scan.
We live in India and my father's age is 74 years. My father
has a history of smoking in his younger days, but it is more than 30 years
since he got rid of that habit. He is diabetic for over 25 years, but has
maintained good health till now with his strict dietary habits.
Nowadays he is complaining about difficulty in breathing
even for a short walk of, say like 100 yards or so. He is not having any cough
symptoms, though once in a while he does cough.
What are the possible treatments available at present and
what could be the best one to follow for a person like him at least to keep the
situation under control? What are the options available in homeopathy or any
other type of medications?
What care should be taken and is there any particular diet
he has to follow? Please let me know about the best possible treatments. I’ll
be desperately waiting for your reply. Thanks a lot.
Zafi
A. Dear, Zafi,
There is no proven treatment for IPF. See a pulmonologist to
see if there are any experimental drugs.
Dr. Tom
Tubing Length
Q. I am using D size tanks with a Chad pulse dose
conservator. What is the maximum length of cannula tubing that I can use with a
setting of two or three liters?
Macel
A. Dear Macel,
Up to about 50 feet.
Dr. Tom
Concerned about Husband's Medical Care
Q. My 64 year-old husband has COPD with 20% lung function.
He had a severe bout of bronchitis in December, so bad the Dr. said that he
really should have been hospitalized.
His GP and his pulmonologist never ordered an x-ray or CT
(at the time or afterwards for follow-up) nor scheduled a follow up appointment
for three months. When I called his GP the week before his appointment to tell
him that I could still hear significant wheezing and wondered if one or both of
the tests should be done before the appointment so as to have them for
reference I was told no.
Should we be concerned? We have good insurance. Given his
status shouldn’t he have regular x-rays and CT scans?
Also the times he has been on antibiotics (maybe once a
year) the five day never seem to take care of it. The ten day does better but
they keep prescribing the five day stuff.
Is it time to seek different medical care? Even when we tell
the doctors of our concerns it seems like no one is listening.
Cindy
A. Dear Cindy,
He should have a chest x-ray and a CT to see if an
underlying additional problem is present.
Dr. Tom
Diffusing Capacity and COPD
Q. Have you ever heard of an increased diffusing capacity in
a severely obstructed (COPD not asthma) patient?
Harold
A. Dear Harold,
Yes, in states of marked hyperinflation. There is no
significance to this finding.
Dr. Tom
Bad Smell in Oxygen Tubing
Q. I use supplemental O2 at night for low O2 saturation
levels. My problem is that I am reacting to something in the tubing. It starts
out as just a bad smell of the plastic, which I try to ignore. However, when I
finally fall asleep, I wake up with burning in my nose, throat and chest.
I have been advised to use a nasal lubricant, a nasal spray,
and use a humidifier attachment (with distilled water which I change every day).
I have had the concentrator checked out and it is operating properly. I also
use a room humidifier. (I live in the dry Southwest.)
It has come to the point that I have stopped using the O2,
as I really need to get some sleep. My physician has explained the danger in
this, but I really do not know what to do. My oxygen supplier knows of no other
type of tubing. Do you know of anyone else who has had this reaction and what I
can do?
Zara
A. Dear Zara,
Sorry. I do not know of any other type of tubing for long
term oxygen therapy.
Dr. Tom
Mold Found in Air Handler Unit
Q. I have lived in my apartment for one year. I have been
hospitalized twice for breathing problems, both times gasping for breath and
not able to fill my lungs. I have asthma.
Last week we discovered dense mold on the inside of my air
handler unit. I need to decide in a few days whether to move out, or see if a
new unit fixes the problem. If I stay here over 3-4 days I get the breathing
problem again. When I stay somewhere else I don’t have it.
What do you think? I am 70 years old. I have read so much
conflicting info; I am undecided as to the best action. Please help with your
two cents.
Corky
A. Dear Corky,
You must avoid the mold, which will continue to damage your lungs.
Do it now.
Dr. Tom
Medications
Q. My Dad is 86 years old and has COPD. He is under the care
of hospice and he feels that they are trying to finish him off by giving him
medications that the doctor says he needs. He takes Mucinex, Xanax, Lortab, Flomax,
theophylline, Advair, Duoneb, and he is on oxygen.
He constantly complains of pain all over so they recently
prescribed Morphine orally because he said the Lortab was not helping and he
has refused the morphine because again they are trying to kill him.
He is constantly sick at his stomach, has a headache, cannot
urinate like he thinks he should, complains about his bowel movements and on,
and on and on. He is just about to drive my Mom and me crazy so my question to
you is this are this just things go along with the COPD?
Oh and by the way he still smokes!! THANKS FOR YOUR HELP.
Loretta
A. Dear Loretta,
Unfortunately these are the nagging problems that accompany
COPD, particularly in the elderly. A controlled amount of oral morphine
such as 15mg twice a day in a sustained release tablet is safe and often very
helpful.
Dr. Tom
Fatal Asthma Attack
Q. My husband was an asthmatic, when he died his lungs were
hyper inflated and overlapped. He had his rescue inhaler in his hand. Was this
just a fatal asthma attack or something else? He was in good health.
Carla
A. Dear Carla,
This was most likely a fatal asthma attack.
Dr. Tom
Dangers of Second-Hand Smoke to Children
Q. I have a seven year-old nephew with primary ciliary dyskinesia. His parents smoke,
but outside.
What harm are they doing to him? How is the second and
third hand smoke dangerous to his health? What are the dangers of having it on
clothing and in the cars?
I have begged them to stop smoking. I need information to
show them it's hurting him. Please help. Thanks
Lori
A. Dear Lori,
The dangers and risks of second-hand smoke are very real.
Secondhand smoke is especially harmful to young children. Secondhand smoke can
also aggravate symptoms in children with respiratory disorders as tobacco smoke
lingers in the air, fabrics and clothing for hours after cigarettes have been
extinguished.
Second-hand smoke exposure on top of impaired ciliary
function with reduced or absent mucus clearance abilities, can lead to chronic
recurrent respiratory infections, including sinusitis, bronchitis, pneumonia,
and ear infections.
Tim BS, RRT-NPS
Grandsons have Trouble Breathing at Night
Q. My grandchildren, ages four and six, have not been
breathing through their noses at night, and some of the day. Their doctor wants
to push up the palette in their mouths. What do you know about this? What
problems can this bring about?
Barbara
A. Dear Barbara,
It's not clear what the doctor means by pushing up the
palate. The palate is made of bone and cannot be pushed. Surgery on the palate
is done in some adults with severe sleep apnea as a last resort, but this is
not done in children. I think you should talk to the doctor to get a better
idea of what she or he has in mind. There are certainly many things that can be
done to relieve nasal stuffiness and these should be done before considering
any surgery.
Dr. Bruce
Is Medication Safe for a Four Month Old?
Q. My four-month old son has a cold that causes him to cough
and the doctor has prescribed Montelukast Sodium. I have seen a big improvement
just after 1 dosage but cannot find anything on the net that says it is ok for
his age. Is this medicine suitable for a baby of four months?
Gabriel
A. Dear Gabriel,
Monteleukast (Singulair) has been approved for children age
12 months and older but it has been safely used off-label in several research
studies to treat infants as young as one or two months of age with bronchiolitis (generally without success).
Many medications have not been specifically approved for
infants and young children but can be used safely and often effectively in the
very young.
It sounds like this worked well for your son and that is
good news.
Dr. Bruce
Pre-Term Baby's Oxygen Requirements
Q. Dear Doctor, May I ask how much oxygen is a preterm baby
(35 weeks, 1.790 Kg) getting if he/she is receiving 0.025 LPM of pure oxygen in
one minute if the baby is breathing 40-60 breaths per minute?
Roel
A. Dear Roel,
I love questions like this!
There are two good answers. When I am teaching students it
give me the opportunity to build equations to calculate the fraction of
inspired oxygen (FIO2) based on tidal volume (about 7 mL/Kg) and respiratory
rate giving minute ventilation, then taking into account dead space and how
this changes with increasing respiratory rate, and ambient air (0.21 oxygen)
entrainment we can derive a rough approximation of the inspired oxygen. Whew!
But this is great for teaching physiology.
The second answer is really the correct answer - It doesn’t
matter. Babies will have changing airway surface area, minute ventilation, and
dead space so what we try to do is give the least amount of oxygen necessary to
keep the oxygen saturation greater than 90%. Give just the amount of oxygen
that it takes and you will support that infant. Beware that if the baby's
oxygen requirement to maintain saturation is going up, this probably means
trouble.
Dr. Bruce
