Dry Nasal Passages and Traveling with Oxygen on Airplanes
Q. I actually have two questions. I have a very dear friend who is 80 and has lived with emphysema and now pulmonary hypertension for 20 years in Santa Fe, NM.
She is using supplemental O2 (liquid oxygen) 24/7 at about 4 liters/min. For a long time she has suffered from dry nasal passages. They crack and bleed. I believe that it is secondary to the nasal cannula that delivers the O2. Do you have any suggestions of a salve or cream that might help?
Also, is there a way people who need O2 can travel by airplane? I realize I could get her a local supplier out here in California for her liquid oxygen but what would she use on the plane and between her home and the airport and the airport and my home. She currently fills a small concentrator that she carries for short trips around town.
A. Dear Kendra, Dry nasal passages with cracking and bleeding are a problem. All inflammable ointments must be avoided. Water washable lubricants, such as KY jelly are worth a try.
Also nasal “douches” with warm salt water held in the hand and “snuffed” up in to the nose may help clean out the crusty material.
Question 2. Today patients cannot take their own oxygen on board aircraft. This may change soon. There is a preliminary approval to take lightweight oxygen concentrators that are battery-powered, and can use the DC current supplied to many seats.
The two concentrators are the LifeStyle and the Inogen. Right now, you have to get the air carrier to supply the oxygen, with a doctor's prescription, at a substantial extra cost. This is not satisfactory, and the small concentrators represent a solution.
Indoor Pollution and Asthma
Q. Would you please let me know if old wall-to-wall carpet and water-logged wooden cabinets can increase asthma and bronchitis? If so, do you know how I could get my landlord to allow me to remove these dirty old carpets and cabinets?
I have bad asthma and my 11-year old daughter has developed bronchitis.
A. Dear Edie, Old water-logged carpets and other furniture often contain molds that can precipitate asthma. They must be removed, and replaced with dry floors (wood, tile) that are wet mopped to reduce dust.
Fibrosis and Emphysema
Q. I have emphysema, and it is called severe, however I'm not on 02. I use albuterol, Advair and Spirvia and do quite well. I am very active and still do yard work etc.
However, I seldom cough, but when I do I always bring up green mucus. I also have fibrosis. Could this be the reason for this green mucus?
I have no other symptoms of an infection. I feel great, just have to take lots of rest time and pursed lip breathing when I'm trying to do a lot of things but I get them done.
This fibrosis has me really worried, wondering will it shorten my life?
A. Dear Wanda, fibrosis is not present in emphysema. It is present in small air passages. Sometimes another disease known as bronchiectasis is associated with fibrosis.
Bronchiectasis is an enlargement of the major air passages that get scarred, from frequent infections. These passages are often infected and result in green sputum.
Your doctor should advise you about taking antibiotics, when the sputum increases and is particularly colored.
Need Help with Understanding Spirometry Results
Q. Hi, Dr. Tom, I was wondering if you could help summarize my recent spirometry results?
I am a 34 year-old male who in past years was a heavy smoker. I am currently on a program to quit with a cognitive behavioral therapist. I have cut down greatly and am now working on getting down to zero.
Anyway, my spirometry results were:
Measurement Predicted - %Predicted
The test was done once - without a comparison before inhalers or anything. The estimated age of my lungs was 64 years old...yet at the end of the report it said “normal spirometry results.” I also had a chest x-ray, which was “normal.”
My doctor said that my results indicated COPD - both emphysema and probably chronic bronchitis.
Any help with this would be greatly appreciated, as I am confused as to where I stand in terms of my lung function.
A. Dear Danny, Your tests are normal, and you do not have emphysema. The only tests of value are the FVC, which is the volume of air, expressed in liters, that you can blow out of a fully expanded chest. The FEV1 is the amount air that is exhaled in the first second of a forced exhalation. Your results are expressed as percent of normal for your age and height.
With a normal chest x-ray, it all sounds good.
Could Medication Affect Eyesight?
Q. I have always worn glasses for both near- and far- sightedness. Lately seems my eyesight is worse. It has been suggested it may be caused by my medications. I take DuoNebs and Advair. Could this be the problem and if so will they continue to get progressively worse? What would you recommend?
A. Dear Carol, The Advair contains a small amount of anti- inflammatory medicine known as a “corticosteroid”. However, not much of this drug is absorbed by your body. Corticosteroids can hasten the development of cataracts, but I doubt this is the explanation of your vision problems. Better see an ophthalmologist.
Sister has Genital Herpes, Can I Catch Them?
Q. Hello, I am a young 16 year-old female who has an older sister in her 20’s who about three years ago, I would say, got genital herpes.
She’s a totally unorganized person. She leaves her dirty clothes all over the bathroom floor, laundry room, her room, which is next to mine, etc. I stress myself to death wondering if I stepped in her underwear, dirty clothes, her dirty towels she uses, etc.
I do not want herpes and I just get so scared I might catch them or I am dirty because of this. How risky is it living with her? Are my feet dirty if I step in those objects I named? If I step in her clothes on my way out of the shower then come in my room and put my underwear on is that ok? Are my feet dirty for the day? I don’t even want to walk around my house barefoot.
How am I supposed to know if she has an outbreak or not... that’s it I don’t, so I never know! I am stressed to the limit and think about it constantly.
Can you please help me out with all the advice you can give? Thank you so much
A. Dear D., You won't get infected by the accidental contact with clothes on the floor. But why not have her be more tidy?
Mechanical Ventilation for Volutrauma
Q. I was not practicing from 1994 to 2003. When I started again there was a new issue called volutrauma (lung damage due to high volumes of airflow while on a mechanical ventilator). I feel that 6ml/kg does not adequately distribute gas to peripheral alveoli.
Am I incorrect? I have no way to test my idea. Good gases can be achieved in a wide range of ventilatory parameters but I seem to see more patients with atelectasis (or not).
A. Dear Gerald, Low tidal volume ventilation has been well studied in the Acute Respiratory Distress Syndrome (ARDS), but not in other diseases where mechanical ventilation is needed. Higher tidal volumes such as 10-12cc/kg may be needed to help reduce atelectasis in some patients.
Q. I would like to know your opinion about using Furosemide (Lasix) via a nebulizer. Have you used it in the USA? Will be approved in the near future?
A. Dear Dr. Pola, Nebulized furosomide is not used in the USA except in some research situations. I have no experience with it.
Usefulness of Repeated Pulmonary Function Tests (PFTs)
Q. I am a manager of an acute care RT department in Rockville, Md. There’s a pulmonologist, on our staff, who orders multiple Pulmonary Function Tests (PFTs) throughout a patient's admission. Most of the patients are already diagnosed with a specific lung disease.
Is it beneficial to the patient to have several PFTs throughout their stay after being diagnosed? Should the physician treat the patient based on their clinical assessment and/or signs and symptoms?
When I say several PFTs, I mean at least three or four within a seven-day period. Just curious and wanted your opinion on this matter.
A. Dear John, I see no reason to do repeated pulmonary function tests, such as several times a week in a hospitalized patient that is not in a steady state condition.
Maybe twice during a hospital stay, to see if the initial therapy is working.
Best to wait until discharge and to see maximum improvement and then document the benefit objectively with spirometry.
Q. I'm in my mid-twenties and diagnosed with asthma this winter. I have been coughing since November with little improvement from my inhalers, Advair and Albuterol. I constantly feel the need to take a deep breath and most of the time I have to force a yawn to catch one.
My allergy tests have all come back negative and the only pattern I see is an increased tightness in my chest with weather changes. I guess I'd like to make certain that
1.This is indeed asthma?
2.If so, what else might I do to control my symptoms?
I really appreciate the opportunity to ask my question and thank you so much for your time.
A. Dear Kate, I do not know if you have asthma, from the information you gave me.
Your doctor should know by measurements of your airflow, whether the inhalers are working. But you should expect complete relief of your symptoms.
Be persistent and get more information about the evidence for asthma. Also get your doctor to consider other diagnoses.
Help! When Will the Craving for Cigarettes Stop?
Q. I have been a smoker for 40 years. I have MS and have had a stroke. I am on Betaseron medication for the MS (I am on my second month of that) and I take one baby aspirin per day for the stroke.
I was a very light smoker but as the years went on I did end up smoking a pack a day of ultra lights. I have always smoked the light brand, as the other ones were too heavy on my lungs. About 1/2 of my pack a day would end up burning up in ashtrays or flicked out the windows or smashed outside of grocery stores. So I would say I was only 1/2 a day smoker. WHY IS IT SO HARD?
I just up and quit about two weeks ago. I was tired of the messes, the burned bedding, bedclothes, and carpets. Why I did not burn my house down I will never know.
However, I only quit cigarettes because I was tired of them-only to find out that I have Emphysema! I went and had a lung test & breathing test. I was shocked and cried so hard as I took care of my Aunt until she died from this horrible disease. I don't want to end up like her and so far I am ok. I have been very short of breath.
What I want to know, and I am so serious-WHEN DOES THE CRAVING STOP FOR THE CIGARETTES? I am screaming for a cigarette!!!! I can't sleep at night.
When will it end? I have quit drinking beer, no problem, I quit over eating, no problem, I have quit so many things but nothing as hard is this.
Please someone help me-please.
A. Dear Cathy, Nicotine addiction is stronger than narcotics, alcohol or excessive eating. But you HAVE stopped, and for a good reason.
Now your lung will not deteriorate so fast. Stopping smoking may also help the MS. The craving will slowly subside. It will be a lot better in two more weeks. Hang in there!
Fire Hazards with Smoking
Q. Recently, you had the following exchange with “Cathy” regarding smoking. One part of her question was troubling and needed to be addressed:
"I just up and quit about two weeks ago. I was tired of the messes, the burned bedding, bedclothes, and carpets. Why I did not burn my house down I will never know.”
I think that the reference to burnt bedding etc. raises an important point that needs to be discussed. Patients who are smokers and who experience these happenings absolutely need to be counseled and evaluated. Chances of serious property and physical damage are much to high to not act with very assertive instruction.
Homecare practitioners should question all patients regarding the existence of such episodes. We continue to get periodic reports of home fires fed by home O2 sources. We need to be vigilant and forward thinking in this area.
Paul PhD, RRT, FCCP, FAARC
A. Dear Paul, I agree with you. Oxygen is not dangerous, unless directly ignited. Fires can be avoided by simple precautions. But many smokers are careless.
Your admonition to be vigorous in trying to avoid fires is important.
Chest Physiotherapy Therapy (CPT) for Pneumonia?
Q. What do you think about CPT/Vibration treatments on mechanically ventilated patients with the diagnosis of pneumonia?
There are not a lot of data available advocating for or against this, but many therapists like myself have their own opinions which seem to vary depending on when they finished their Respiratory education.
Ramon, BA, RRT
A. Dear Ramon, Although a common practice (the use of vibrating, pounding, etc in treatment of pneumonia) to help mobilize secretions is not well established by scientific studies. It may be worth a try in patients that are struggling to raise copious secretions.
Small Airway Disease, Is it Reversible?
Q. I had a Pulmonary Function Test and was told it indicated small airway disease; it was 51% even after an albuterol treatment. Can this be reversed?
A. Dear Sharon, Yes, small airways disease can reverse on stopping smoking. Probably nothing else works as well.
Oxygen Conserving Devices
Q. Why do you promote oxygen conserving devices (devices that control the delivery the flow of oxygen only during inhalation) that produce such low Sp02 in most patients that try it? If the patient is not going to get enough 02 to maintain satisfactory Sp02, would nothing be even smaller and lighter than Helios.
Thanks. I have no financial interest in any conserving device, just my opinion based on my experience in homecare.
A. Dear Mike, Conserving devices aim to reduce the waste of oxygen that is flowing during the expiratory phase and pause before the next inspiration. But all the oxygen flowing during exhalation is not wasted.
Many of the new light weight devices, are quite parsimonious in their oxygen delivery. The control numbers are NOT in liters. They are arbitrary numbers that do indicate more oxygen per breath. The light weight concentrators and ultra light weight liquid system deliver less than the equivalent of one liter per minute on most flows, except the high continuous flow on one of them. The Sp02 will keep us honest, and should be used by all who use ultra light systems.
Reusing Tracheotomy Suction Catheters?
Q. I work as an RN in home health in California. I was taught that tracheotomy suctioning was a sterile procedure and that the suctioning equipment was used only once and then thrown away. The next time you suction you use a new suctioning kit.
I am being told that in home health we can use the same suction kit including the suction catheter (a small tube is put inside of the tracheostomy to suction out excess mucus) for a 24-hour time frame. After 24 hours you replace it with a new kit.
This is done because Medicare/Medi-Cal only covers for a fixed amount of suction kits per month. Is this protocol acceptable?
Rudy, RN, RCP
A. Dear Rudy, I suppose it is okay, but not ideal. Tracheal suctioning is not really sterile, but “clean”. The reused catheters should be cleaned in some way.
Predicted Pulmonary Function Values for Achondroplasia Patients
Q. Do you know of any predicted values in Pulmonary Function Tests for Achondroplastic (Achondroplasia is the most common type of dwarfism, in which the child's arms and legs are short in proportion to body length.) patients?
A. Dear Steve, Sorry, I do not know. When patients have lost their legs, the arm span can be taken as roughly equivalent to the height. But this will not work in achrondoplasia, where the arms and legs are equally involved.
Suddenly Short of Breath
Q. Dr. Tom, Although, I haven't been officially diagnosed with COPD, my doctor says that it seems signs are leading up to it and I have some scheduled appointments in the next few weeks.
I am an ex-smoker but smoked for 20 years. It happened “all of a sudden.” I noticed that I was out of breath just walking up the stairs. BUT...one day before this happened I was going all out on a cross trainer for 30 minutes and had done this three or four days in a row with no problem at all. Do symptoms of COPD usually come on this fast?
A. Dear Robert, No, symptoms of COPD are not usually sudden or rapidly progressive. There are lots of causes of shortness of breath. I doubt, from what you say, that COPD is the answer. You need a diagnosis and spirometry to tell about your airflow.
Q. I am a supervisor at a large hospital. I was a patient assessor for six years before taking this position five years ago. I would like to find out info on things other patient assessors are up to.
A. Dear Leslee, What is a patient assessor? A respiratory therapist, nurse, and/or doctor, could be considered a patient assessor. Please enlighten me.
Bilateral Vocal Cord Paralysis
Q. I have bilateral (both sides) vocal cord paralysis. I scored very low on my pulmonary function test.
I have since had three laser surgeries to open my airway for breathing. Would I be considered as having COPD?
A. Dear Angie, No, this is not COPD by any definition. What is the cause of the bilateral vocal cord paralysis? There are several possibilities.
Cough for Two Weeks
Q. For the past two weeks I have been coughing every five minutes or so. The worst time is when I lie down so I haven’t been able to sleep very well.
I have pains in my chest also and cough up phlegm. I have asthma and allergies but they haven't bothered me for awhile. I have taken allergy pills, a puffer for the asthma, butnothing seems to help. I am 48 years old. Please help.
A. Dear Dolores, A severe cough like this requires and explanation. Has your doctor considered whooping cough (pertussis)? This is more common in adults than most people believe.
Q. What is the dosing protocol used with continuous nebulizers, such at the EZflow Max?
A. Dear Marcia, Most nebulizers are used four times a day, with various doses of medicine. Depends on the prescription.