Readers: Read Dr. Tom’s Commentary on Spirometry to understand the importance of this diagnostic lung test.

 

 

Sensation of Lungs Enlarging with Exertion
Q. Dr. Tom, I usually feel very good when I get up in the morning; but as the day progresses I seem to have more difficulty breathing and my lung feels as it has enlarged pushing against my rib cage making it difficult to take a deep breath.

I use O2 for sleep and exercise with a FEV of 26%.  Do the lungs actually enlarge when so much exertion is used to breathe?

Rose

A. Dear Rose, Yes, exercise may cause air trapping and hyperinflation. Drugs such as Spiriva have been shown to prevent this. Stay active.

Dr. Tom         

                        

Overnight Oximetry and COPD
Q. Dr. Petty, Do you feel that everyone that is diagnosed with COPD should have at least overnight oximetry? I've had several patients that did not have clinical symptoms of desaturating at night, and whose saturations were > 90 % during a six minute walk, that for various reasons I suggested an overnight oximetry and their saturations fell way below 88%. Also do you feel that it would be worthwhile to do a study on patients that fall into this category?

I was at your reception last year at the ACCP conference and enjoyed learning more about you as well as meeting you. You inspired me to promote COPD Awareness locally and I am now involved in helping form a statewide coalition in Texas.

Kitty

A. Dear Kitty, Nighttime monitoring for hypoxemia related to sleep is a good idea, particularly if there is snoring, and daytime somnolence, signs of sleep related hypoxemia. Thanks for your comments about our meeting in Chicago.

Dr. Tom

 

Recommended I Follow-up on Chest X-Ray
Q. I had an MRI in March 2007.  One of the results was irregular opacities in both apices which could represent pleural thickening.  My ENT had me take a chest x-ray which, showed biapical pleural parenchymal scarring.  She suggested that I have a chest x-ray every six months for the next two years.  I have chest x-ray for a year now with no change. 

I had an appointment with my ENT just to get a better understanding of this condition.  She said it is a very common condition and probably nothing to be concerned about. My concern is that my father just passed away from lung cancer and this diagnosis has made me apprehensive.  Should I see a pulmonologist or just continue with what she has suggested?

Jeanne

A. Dear Jeanne, I agree with your doctor, but you should have annual surveillance since your father had lung cancer. You may have smoked and certainly was exposed to secondhand smoke from your dad. This adds to your risk.

Dr. Tom

 

What is the Purpose of Advair and Sprivia
Q. Dear Dr. Tom, I was extremely gratified that you answered my previous question.  Thank you. 

I have COPD with a quite large reversible component.  My doc switched me from Spiriva to Advair, which I think revs me up, though I have been very anxious anyway since getting this diagnosis a month ago.  Is the reversible nature the reason to use Advair?  Also I notice some people use both, with me it was either or. 

You are doing a great service.  Some of us have more questions than limited contact with docs allow! 

Eric

A. Dear Eric, Advair is useful for the reversible component of COPD. It is safe. It can also be used with Spiriva if necessary.

Dr. Tom

 

Lung Recovery After Stopping Smoking
Q. I'm 39 years old and stopped smoking 10 months ago. I run three times a week now and compete in various running races.

I've read the list of typical improvements you get from quitting smoking but very little in detail about the road to recovery.  My question is where can I find more information about lung capacity for ex-smokers. Has there been any studies done on smokers who quit and if I can expect 100% recovery? Will running shorten the time needed to recover?  Any information would be helpful. 

Christian

A. Dear Christian, Stopping smoking will slow the rate of decline of your lung function to that of normal aging. Running will not change this, but will make you more fit. There are lots of articles in the literature about the time course of lung and other health improvements on stopping smoking. Never start again and avoid smoking environments.

Dr. Tom

 

Thoughts About Around the Clock Therapy
Q. I am facilitating a team that is attempting to standardize the care of a pneumonia patient when admitted to an acute care hospital.  The practice locally is that respiratory treatments are provided around the clock if a patient is admitted with pneumonia and has a comorbid condition, i.e. COPD, congestive heart failure, diabetes. etc. 

The practice at this facility is to only provide the therapy if the patient is awake.  When a patient is admitted with orders to receive therapy q 4 hours there are standing orders that allow the therapist, based on assessment, to provide the therapy around the clock or to change the order to while awake.

We would like to understand best practice.  The team felt that if the patient was sick enough to be in the hospital that they should receive their therapy around the clock especially if they had some other underlying condition, which would have a positive impact on decreasing LOS and mortality.

Kathleen

A. Dear Kathleen, Around the clock therapy seems most important in those with advanced or complicated disease. I would not waken a patient for a treatment, however. Sleep deprivation is one of the worst curses of hospitalization.

Dr. Tom

 

Dizziness and Oxygen Concentrator
Q. I get dizzy when I use my concentrator but not my portables, is there a reason for this? 

Sue

A. Dear Sue, You should check by oxymetry to be sure your concentrator is getting you adequately oxygenated. They all have limited outputs of about 1 liter per minute or less, but divided into demand breaths, which may be enough for many, but not all patients.

Dr. Tom

 

Use of Lidocaine for Reducing Cough
Q. In an ER setting can aerosolized lidocaine be used to reduce coughing in pediatric patients?

Tim

A. Dear Tim, I do not know much about pediatric practice, but know that lidocaine is sometimes used for this purpose.

Dr. Tom

 

Asbestos Exposure and Breathing Problems
Q. I was exposed to asbestos on a daily basis for about three years while enlisted in the US Navy as a Machinist Mate. I now use an Albuterol inhaler, a Foradil Aerolizer and Asmanex Twisthaler for difficulty breathing and shortness of breath. Can this be a result of my exposure to asbestos?

Raul

A. Dear Raul, This is not likely to be from asbestos. I suggest you see a pulmonologist. Sounds like asthma.

Dr. Tom

 

Carcinoembryonic Antigen (CEA)
Q. Hello Dr. Tom. I'm 30 years old. Last August I had got DVT from the Depo-Provera birth control injection. I am still swollen in my leg from this.

 I just went to the Dr. and they had ran some more diagnostic tests on me to further understand why it's taking so long for me to heal.  All of my labs came back negative except for the CEA lab which is 3.2.  I've been on the Coumadin ever since I was admitted in the hospital for DVT.

The doctor has told me to stop smoking and that I did, but reading on other websites has me so scared that I may have cancer. I know that the CEA is tumor markers but from my readings on the Internet can't blood thinners show high CEA levels?  Do I have cancer?  Please let me know, I'm so scared.

M

A. Dear M., I do not believe that your drugs are causing the elevated CEA level. I suggest seeing a specialist, i.e. an oncologist for explanation of this worry.

Dr. Tom

 

Nodule Follow-Up
Q. Hello Dr., I am a nurse and was recently in the hospital for a kidney stone, which I luckily passed. They did a CT of the abdomen and pelvis and I was shocked to see a 5.4 mm noncalcified nodule while reading the report. I am in good health and also read that in 1 lung only mild emphysematous bullous changes. I have no symptoms...never have had an upper respiratory infection in years and do not get SOB upon moderate exertion.

My internist said that the nodule is nothing to worry about due to the small size but a repeat can be done and that a lot of people have mild emphysema without symptoms. I am worried but I can't let this rule my life being that I have access to so much info in the health field. Can you advise me? I did smoke briefly more than 10 yrs ago and my husband quit with Chantix recently.

Kathy

A. Dear Kathy, The small nodule is almost certainly benign. It deserves one follow up in four to six months by CT.

Dr. Tom

 

How Long Does Bronchitis Last?
Q. I had bronchitis, where I was coughing up yellow mucus that was thick consistently. Then a few weeks later my cough got better but I am still coughing on occasion and instead the mucus is white and little less thick. I was wondering what is going on. I smoked for about 3-4 years, is this normal to last this long as a smoker and YES I quit.

James

A. Dear James, It can take weeks for the cough of an acute bronchitis to subside. If it does not, see a pulmonologist.

Dr. Tom

 

Looking for Care for Brother Who Has Pulmonary Fibrosis, Orange County
Q. I'm looking for a respiratory therapy program for my brother whose been diagnosed with pulmonary fibrosis. He needs to learn how to maximize his breathing. Dr. is not willing (?) or able (?) to refer him. Is there such program in Garden Grove, Orange Co. CA? He is on Medicare.

Shirley

A. Dear Shirley, I do not know the names of pulmonary fibrosis experts in your area. Your doctor does. INSIST on a referral.

Dr. Tom

 

Diffusion Capacity
Q. Dear Dr. Petty, I sure appreciate your taking the time to help all us COPD patients. I am 63 years young. Exercise three to five times a week. I used to smoke but quit three years ago.

I need help determining what my spirometry test is telling me. I’ve been diagnosed with bronchiectasis, chronic bronchitis, mild to moderate emphysema and asthma since 2003. These are all I know of at this point. I suffered a pulmonary embolism (PE) April 2007. Blood tests revealed I have APS and maybe Lupus or borderline Lupus diagnosis January 2008. I am wondering if this may be the reason for my crazy spirometry numbers? I am on oxygen, 2 liters for exercise/exertion. I was hoping my diffusion (DLCO) would jump up a lot after my PE but it didn’t.

My test dated Aug.6, 2007:
                  Ref.                  Pre Meas.                  Post Meas.          
FVC             2.76                   3.23-117%                  3.43-124%
FEV1            2.18                  1.78-81%                    1.87-86%
FEV1/FVC     79                     55                              55
DLCO           22.7                  5.6-25%
DL ADJ         22.7                  5.6-25%
DLCO/VA     5.00                  1.37-27%
DL/VA adj     1.37

I had another diffusion test on April 7, 2008
DLCO         22.7                  6.7-29%
DL ADJ      22.7                  6.7-29%
DLCO/VA     5.00                  1.83-37%
DL/VA adj    1.83

It is my understanding one cannot increase their DLCO %. Will it keep decreasing?

Nan

A. Dear Nan, Your diffusion test is stable. It's course depends on the disease progress and response to treatment. You should be seeing a pulmonologist.

Dr. Tom

 

 Is it Safe to Take These Medications?
Q. Can I take Spiriva and Advair and also do albuterol updraft treatments?

Harold

A. Dear Harold, Yes, these medications are well tolerated when taken together.

Dr. Tom

 

Straight Back Syndrome
Q. Dear Dr. Tom, I had asthma as a child and it returned with a vengeance at age 45 (I'm 65 now). I have always had good breathing tests but asthma is difficult to control. Because of being treated with total disrespect by the allergist and his refusal to believe my symptoms, I changed from an allergist to a pulmonologist. After x-rays, CT Scan, etc. she said I have Straight Back Syndrome. Can you explain how this causes my asthma to be so difficult to control in spite of good breathing tests?

Susan

A. Dear Susan, Straight back syndrome does not affect asthma. Find another pulmonologist who will take care of your asthma.

Dr. Tom

 

Salbutamol Inhaler and Cardiac Arrhythmias
Q. In patients with COPD and a concurrent morbidity of ischemic heart disease, is there any evidence that salbutamol inhaler might induce cardiac arrhythmias?

Paul

A. Dear Paul, Yes, this is a possibility, but many with ischemic heart disease tolerate salbutamol well. 

Dr. Tom

                

Son has Uncontrolled Asthma
Q. Hello, My son is 40 and has had asthma since he was 4. He has been in ER so many times getting breathing treatments. Lately he has had a very hard time breathing and has to go outside for fresh air because he feels like he is suffocating.

He has had a CT Scan and that breathing test and he has a 38% lung capacity from 68% last year. 

He panics when he can't get enough air and I think oxygen would  help but his Dr. seems to think 38% is ok. He works breathing liquid coal and works and sleeps. When he has time off he gets out  of breath playing a short time with the kids.

Can you give any advice on what his next step should be? Would the bronchial scope show what’s going on in his lungs more then a CT Scan?

Nancy

A. Dear Nancy, I do not advise either one for the evaluation of asthma. Your son should be seeing a pulmonologist who may have a different perspective. In any case there should be better control of his asthma. 

Dr. Tom