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

 

 

Swollen Glands
Q. Hi, my mum has been in hospital as she was diagnosed with blood clots on her lungs, she is now being treated for this. The doctors have now discovered that her glands in her chest are swollen, what could this mean?

A. Dear Katrina,
There are many different possibilities. Ask you doctor what he thinks.
Dr. Tom

Pulmonary Pressure
Q. What is pulmonary pressure and how do they measure it.

A. Dear Tommy,
These are the pressures within the blood vessels of the lung that connect the right heart with the left. They are only accurately measured by cardiac catheterization, but can be estimated by a cardiac echocardiogram.
Dr. Tom

COPD End of Life: What to Expect
Q. I have a very close friend whose mother is end stage COPD and the doctors told him there is no more treatment and to try to prepare themselves. Knowing that I work in hospice my friend came to me and asked me what to expect.

My friend really needs this so he knows what to expect.  it will break my heart to tell him myself without clinical info to back me up. He has asked me to be there for her at the end.  I know what to do I just need info for family who is preparing themselves so that her transition can be drama free and peaceful thank you so much.

My work does not have a specific list of end stage symptoms for COPD and I have had lots of trouble finding this information, I even mailed Mayo Clinic, they said they couldn’t help me!  Lissa

A. Dear Lissa,
Very end stage symptoms are stupor and sleep, from the buildup of carbon dioxide. There may be severe shortness of breath at the end of life, which can be improved with morphine. Most people with COPD are comfortable and at peace.
Dr. Tom

Caught Between a Rock and a Hard Place
Q. My lungs have become sensitive and something on my enclosed porch irritates them. Symptoms started at as irritated lungs only.  After using a dehumidifier to try to fix problem, then the irritated lung went away, but I got a bad headache & dizziness and shortness of breath upon exertion and a few times had heart palpitations.

Someone (not a doctor) suggested Vocal Cord Dysfunction (VCD).  I went to pulmonologist and allergy doctor and said Spirometry is fine.  One doctor said it should clear up in a week.  Never did.  Getting worse.  Tried airing house out. Didn’t work. Irritant doesn’t bother husband.

Pulmonologist’s office said they don’t do VCD.  I was told to call an Ear Nose and Throat doctor (ENT) and the ENT said since my lungs were sensitive that was not their office that would take care of it because they only do ears, nose and throat.  Everybody wants to send me to a different type doctor, but then that doctor’s office says it’s not there specialty that I need to be seeing.

I’m stumped as are the doctors since my spirometery was fine and I do not sneeze, cough,  have runny nose,  or have mucus.  I do have a lot of doctor’s office aggravation. Can you suggest what I should do?

A. Dear K.,
VCD can be suggested from the ‘breathing-in’ part of spirometry, called the inspiratory loop from the flow volume curve. Pulmonologists and otolaryngologists know about this. They can also directly look at your cords with a scope and see if there is obstruction during inspiration.
Dr. Tom

Valley Fever
Q. I’m 43 year-old female.  I’ve smoked on and off for 20 years.  MRI of breast found a lung nodule.  I was sent for chest x-ray yesterday, and a mass was found of medium density, not definitely calcified.

I am very healthy otherwise.  I’m scared to death and won’t smoke again.  My doctor has ordered a CT Scan and Valley Fever blood screen (coccidioides) because I’ve lived in Arizona much of my life.

I’m waiting for my insurance to approve the CT scan. Due to concerns about my cystic breasts, in last 60 days, I’ve had mammogram, ultrasound, needle aspiration, MRI, & follow-up ultra sound; I think I’ve had every kind of radiology possible.  I was so worried about breast cancer but the new lung issue really surprised me.

I’ve heard that CT scans have lots of false positives.  Is it likely that I have cancer?  Please provide your thoughts on this. Hopefully, it’s an old Valley Fever scar- that’s what my doctor is hoping for.  Please advise.

A. Dear Laura,
This is most likely an old Valley Fever scar. These rarely calcify. A simple follow-up down the line will settle this by showing no change. I would do this in about six months, since you lung cancer risk at your lung age is small.

Never smoke again.
Dr. Tom

Prednisone Makes Father’s Breathing Worse
Q. My Dad has emphysema and heart disease when they put him on prednisone 10mg his breathing gets really bad when he stops taking it, it goes back to normal, well normal  for him. Why is the prednisone doing this?

A. Dear Debbie,
There are paradoxical reactions to all drugs. I am sure your doctor does not want him to take prednisone if it worsens his breathing. Ask him.
Dr. Tom

Risks of Laparoscopic Surgery and COPD
Q. Hello, Currently I have COPD, and must undergo laparoscopic surgery for acid reflux, and hernia repair. Is this safe for a COPD patient? Thank-you

A. Dear Rene,
There are risks with all procedures. The degree of COPD may affect the risk. This will have to be judged by your doctors.
Dr. Tom

Chronic Dry Hacking Cough Driving Co-Workers Nuts
Q. We have a co-worker that is driving us nuts with her dry hacky cough. Doesn’t smoke, late 40s, overweight, walks everyday at breaks, and hacks away. I think there’s something wrong with her as it’s been going on longer than I’ve been here (3 years).

Any thoughts on how to approach this?
Thank-you, Debbi

A. Dear Debbi,
A diagnosis is needed. Could be asthma or something else. I cannot guess what it is from this limited information. She needs to see a pulmonologist.
Dr. Tom

Phlegm Tastes Salty
Q. Hi my first scare started with a headache, and then the following day I had a very strong chemical taste that was coming up from the back of my throat to my tongue and before I knew it I had a big problem breathing its been going on for three months and I feel very scared I never felt anything like this my phlegm even tastes salty. I feel as if I am poisoned it just won’t go away.

I visited my doctor almost once a week for this issue I had a neck ct with the die it came out negative I had ENT put scopes down my nose into my throat twice I also had a test done that I drank this white stuff and took x-rays .I went to an allergist they cannot figure this out and I feel it is getting even worse I am getting very depressed from this situation what do you think this sounds like?

A. Dear Esther,
Several possibilities have been ruled out by the studies your doctors did. You will have to wait and see what else develops.

There are many more tests that could be done. I suggest that a pulmonologist is best equipped to help to unravel the mystery.
Dr. Tom

I Have COPD: Should Entero Bacterium Be Treated?
Q. Dr Tom. Over the last five months I have given a sputum sample, and both times it came back that I had in the lungs (I have COPD). The first time I felt miserable and the doctor ordered Novo Trimel and took the meds for 2 weeks and felt great. The second sample came back with the same thing but I felt fine, so the doctor suggested not to medicate.

I had thought all bacterial infections of the lungs with people with COPD should be medicated. I am currently feeling fine. What is your take on this and how come I am susceptible to this entro -bacterium?

My doctor, Dr Tom seems to have met you at a convention, His name is Dr Robert Hyland, Physician and Chief of Medicine for St Michael’s Hospital here in Toronto Canada. Thanks for your help Dr Tom.

A. Dear Phil,
Sputum samples do not often accurately reflect the organisms that are deep in the lungs. The class of bacteria you mention is often an infestation and not an infection. This fits with your filing fine. Don’t need antibiotics for this situation.

Thanks for the word about Dr Hyland.
Dr. Tom

Persistent Pneumonia
Q. Hello, Dr. Tom.  I have a concern for my boyfriend and I’m in hopes of a better idea of what is wrong with him.  He is 29 years old and was always healthy and never had and any previous illnesses.  Never smoked in his life and was always in shape.  Four months ago he got sick and went to the doctor.  They diagnosed him with walking pneumonia and had a severe cough a sharp pain on the side of his chest when he would breathe.  He also had a very high fever.  He was given medication and got well pretty quick.

Then about two months later he suddenly got sick out of nowhere.  He had a very light cough nothing anyone would worry about. Suddenly one day at his job he just began to vomit blood and was sent to the emergency room. 

The doctors did x-rays and said the pneumonia was back or that it was never fully gone.  He was on some medication for two weeks and was scheduled a needle biopsy.  The results came out negative and they found nothing.  By then he was taken off medication and has not had anything to this day.

He then had another bronchoscopy procedure and the results showed nothing, again.  His doctor confirms no cancer cells and rules that out but wants to confirm it with another biopsy.  I don’t know the name of this procedure but is definitely a more extensive procedure.  It would be a direct sample of his lung tissue.

What worries me is that no medication is being given to him and he seems to be getting worse day by day.  He has lost a tremendous amount of weight in such short time.

I know doctors are doing their best but it has just been so long and no results are showing.  What also has his doctor concerned are his chest x-rays.  There seems to be a small cloud like form on his top right lung and that’s what makes it abnormal.  What can this possibly be and should he seek a second opinion by now?

A. Dear Adriana, 
He needs a direct biopsy of the shadow for a definitive diagnosis. A second opinion is always wise in difficult cases such as this.
Dr. Tom

Standing Respiratory Therapy Orders
Q. Dr. Tom, The hospital where I work has a thoracic surgeon that orders Duoneb, CPT, and Incentive Spirometry every four hours for all of her patients that come in as a trauma.

Not all of these patients have lung trauma or any problems associated with the cardiopulmonary system, they may just have a broken leg or may just be admitted for 23 hour observation. The doctor still orders all of these therapies to be done (the doctor sometimes orders Mucomyst and albuterol every 8 hours alternating with Duoneb every 8 hours for these same patients with the broken ankle or sprained wrist).

I understand the need for good bronchial hygiene, but only for patients who need it.   My question is: Are these orders beneficial to the patient and if they are, please explain or are they unnecessary and a waste of valuable time and money?  I feel that these orders are a waste of time for myself and my patients. The time I am spending doing this I could be spending more time with the patients that really need me. It makes me feel we are neglecting the real patients in need of respiratory therapy.

A. Dear Renee,
This is the problem with all standing orders. In this case you describe a pretty stupid use of these procedures.
Dr. Tom

Risk of Lung Cancer
Q. Dr, I am 20 years old and in good health. I am a social smoker if you can even say that. However, in the last three months I have smoked probably 4 packs. I have stopped since then, but my lungs feel tingly and I get occasional chest pain; nothing that really hurts, more annoying. I also have a cough once in a while, not daily. Is there a chance I may have lung cancer?

A. Dear Melissa,
No, you do not have lung cancer at your lung age and with only mild smoking. Quit it altogether and be safe.
Dr. Tom               

Nodule Seen on X-Ray but Not Seen on Follow-Up X-Ray
Q. I am a non-smoker and 46 year-old. Last week I went into to a local clinic to get a constant cough checked out for pneumonia.  They did a chest x-ray and the radiologist discovered a nodule on my right lung and to follow-up with my primary doctor for a CT scan. I went to my primary Dr. and he did a second chest x-ray and they (himself and radiology) did not see the nodule.

Should I still seek out a CT scan or could the first x-ray been a mistake?

A. Dear Todd, Apparent nodules may go away if they are from a mucus plug of an air passage, for example. A CT Scan will clear up the issue of a nodule, but your risk of lung cancer is very low. You could just wait and get a follow up in a year.
Dr. Tom

Mother is Short of Breath and Oxygen Saturation is 97%
Q. Dear Dr. Tom, My 75 year old mother is on oxygen therapy 2 liters 24 hour a day. She always exhales using the “pursed lip” technique.   Although her oximeter displays 97% she feels short of breath.  She takes Advair and Spirvira and Atrovent during the day when she feels the need.

My question:  Should she ALWAYS be exhaling using the “pursed lips”?   I am wondering if this is making her feel she is short of breath.  I have suggested that she inhale/ and exhale through her nose; and then use the pursed lip method for exercise.  What are your thoughts about this?

Thanks very much, Rose
A. Dear Rose,
The sensation of shortness of breath does not relate directly to the blood oxygenation. It is a function of how hard one works to breath. Pursed lips breathing on expiration helps reduce shortness of breath. It is not effective on breathing in.
Dr. Tom

Pulmonary Fibrosis
Q. Would you explain pulmonary fibrosis to me; what it does to the lungs, how it is treated and prognosis. Thank you.

A. Dear Raymond,
There are multiple causes of pulmonary fibrosis, which is a progressive scarring disease of the lungs. You will need a pulmonologist and probably a limited biopsy or at least a CT to find out what type of fibrosis you are dealing with and possible therapies.
Dr. Tom

Correct Timing for Inhalers
Q. Would there be a problem if a patient did not wait a full minute between the use of Advair and Spiriva inhalers? If so, what would be the significance?

A. Dear Mary Ann,
It makes no difference at all, whether you wait a minute or not. I wonder where that notion came from.
Dr. Tom

Asthma or COPD
Q. Dear Dr Tom, I am a forty two year old male, I did smoke up until the age of 23 and have always suffered from asthma; even though I am breathless I rarely cough. The last five years I feel like I have a “blockage” when I breathe in. I find that walking up hills and taking Seretide seems to exacerbate the problem.

I am under a specialist, awaiting CT Scan results. I had a spirometry test performed and after having a two-week dose of prednisone (50mg) and the results were the same, I did not respond to the treatment.

Does this sound like COPD? Any help is much appreciated.

A. Dear Glenn, It is possible that this is COPD. Certainly a response to a large does of prednisone for two weeks should have significantly improved asthma. However there are a few patients with asthma who do not respond to prednisone, for some complex reasons, that are hard to explain. Shortness of breath while “breathing in” suggests that your upper air passages or vocal cords could be involved. I would have a pulmonologist sort this all out and get your treatment on track.
Dr. Tom

Worried about Grandmother
Q. I am very worried about my 81 year-old grandmother. She has COPD. Her chest x-ray says lungs are hyper expanded. There is atherosclerotic disease to the thoracic aorta. Can you help me understand what this means, she has an appointment to see a specialist next week. Please, I’m very worried. Thanks, Iris

A. Dear Iris, Most people this age have some degree of atherosclerosis of the aorta. This only requires attention in unusual circumstances.
Dr. Tom

Diagnosed with COPD and Dr. will See Me in a Year
Q. Don’t know where I stand.
Went to the lung doctor so that he could read my CT Scan, he did a little exam asked some questions then he said he would see me in his office. He said the nodules were dead then told me I had Emphysema and He would see me in a year. No staging, nothing. Is this bad?

A. Dear Chuck, It certainly is terrible, if your doctor did not even do spirometry to see about your lung function. You did not state why you had the CT in the first place. I suggest you see a different doctor, preferably a pulmonologist.
Dr. Tom

Complications after Endoscopy
Q. Three weeks ago I went to my gastro due to sour stomach, reflux, gas and all sorts of problems, which I have had for years. He did an endoscopy (EGD) the next day. I don’t tolerate them well, so I begged for some extra Versed and Fentanyl. He also took 3 biopsies to see why medications were not working.

That night I got up with 102 fever bad chills. I called him told him I was going to the ER. They found nothing really wrong, fever was around 100, said they would not treat it until it was over 101.

 Two days later I went back to the gastro, he ordered a chest CT, AB CT and pelvic CT. MY chest came back with two enlarged nodes and two spots in the lower right lobe which were right next to each other. I do smoke, so he sent me to a Pulmonary Dr. My PFT’s were not bad considering I have been smoking for a long time.

CT Report says to follow up with a bronoscopy or PET Scan. Could this be an infection from the test or a bug I got at the hospital? I never hardly cough I am coughing now. No more fever, but a dry cough. I am scared of course about this PET Scan. My insurance is reluctant on paying; it’s 5 grand. What should I do? Sorry for the length, please help!

A. Dear Richard,   
It is possible that your recent symptoms are complications of the endoscopy and biopsies. I think you should sit tight if your symptoms and fever go away. Otherwise continue to pursue the issue. Your insurance has no right to deny you coverage for complications of a previous procedure that they did cover.     
Dr. Tom

Short of Breath but Tests are Normal
Q. I am 57 years old and have had shortness of breath since March. I have seen the pulmonary and ENT doctors have had tests done from MRI to spirometry and even had a biopsy done in my throat but, everything has come back normal. So, I would like to know why I am still having shortness of breath.

Some days are better than days. The pulmonary has had me do a peak flow meter and it has been running anywhere from 400 to 480. So, I am asking what else could be the problem. Would it help to have an angiogram done?

Thanks, Tommy

A. Dear Tommy, Your question raises the question of pulmonary hypertension. A cardiac echo would be the way to check on this possibility. There are others.
Dr. Tom

Choice of Medication for Patients with Low Lung Volumes
Q. Dear Dr. Tom, I perform PFT’s on patient with asthma and COPD. Some patients have very low lung volumes, i.e. FEV1<1.0L. Often these patients are on Advair, Symbicort, Flovent and the like. However with the low volumes are they as likely to benefit more from using a nebulized steroid such as Pulmicort Respules? What’s your opinion? Thank you.

A. Dear Paul, Response to these medications is variable and does not relate much to lung volumes.
Dr. Tom