Increasing Need for More Oxygen and Poor Reimbursement for Oxygen in Nursing Homes
Q. My father is on 8 liters per minute by nasal cannula for COPD. Often times, he feels this is not enough so the nursing home staff turns up the concentrator to 9 or 10L/min.
I have heard this can be very detrimental because at some point the brain “forgets” to make the body breathe. At what point can this happen?
What is the next step if 8L/min is not sufficient? He has a phobia about using a mask and I'm not sure he'll consider that option.
Is liquid oxygen a better option? What do you do when he maxes out at 10 liters per minute? The durable medical equipment company doesn't have machines that go higher than 10.
Last, why is it that Medicare will not cover 80 percent of the oxygen cost when a patient is in an intermediate care facility? If he were at home, in assisted living, or in skilled nursing, Medicare covers that cost. It's an abomination.
A. Dear L.M., Forget about the old notion that high liter flow will shut off the brain to breathe. This is not correct. But higher flow than 8 liters for COPD is highly unusual.
Few people with COPD require more than three liters per minute. I doubt if this much is really needed, if monitored by his oxygen saturation with a pulse oximeter.
Oxygen does not relieve shortness of breath, as many people believe. The shortness of breath comes mostly from the work involved in the act of breathing. People may feel relief because of the flow of air around their face. Try to put a fan by his bedside. It can give great relief.
I have a simple comment about what Medicare will and will not pay for. At times it is an arbitrary decision, and without reason. It is very hard to change Medicare.
Questions About “Pulmonary Markings”
Q. Dear Dr. Tom, My doctor suggested I go for a chest x-ray sometime ago and the radiology report stated “there is increased pulmonary markings in the inferior segment of the lingular in the region of the cardiac apex anteriorly—lingular pneumonitis.”
Can you explain what this means. Also this episode followed an extreme exposure to household bleach. Do you think this would have had any connection? I have never suffered in the past with any problem with any serious chest infections.
Can I do anything to keep my lungs healthy, and will this scarring be permanent? I am a non-smoker.
A. Dear Sarah, These descriptions do not have a diagnostic meaning. The just refer to abnormal shadows, which could be old or new. You should have a follow up x-ray to see if it clears. Otherwise it needs an explanation.
I doubt if it is due to bleach. You can protect your lungs by breathing clean air at all times, if you possibly can. Avoid second hand smoke too.
Hints for Test Taking
Q. Dear Dr. Tom, I have taken the CRT (certification examination for respiratory therapists) exam twice now and failed it. I know all the information but I have really bad test anxiety.
My memory is not that great and I was just wondering if you knew any secrets to remembering information especially for the exam. I have all the Kettering books (preparatory information for exam) but I am still failing the exam can you help?
A. Dear Hopeless, You are not “hopeless”.
Some people just don’t do well on exams. In most cases your immediate answer in a multiple-choice test is the correct one. Do not ponder the question. You either know the answer or you don't. Don't outguess yourself.
Try it again. You will probably pass next time.
Worries About Her Daddy’s Smoking
Q. Dear Dr. Tom, I am nine years old and I have two questions for you:
1. What will help my Daddy to stop smoking?
2. If he started smoking when he was about 18 and now he is 49, and if he keeps on smoking, about how many more years before he dies?
A. Dear Molly, You have asked a very good question.
The best way to get your daddy to stop is to tell him that you love him and that you are scared. Many people that smoke do not die young.
Give him a special hug and ask him to try again.
Corticoid Steroids and Asthma
Q. Hello. I work almost full time in a Pulmonary Function Lab. I have just earned my asthma educator certificate.
I listened to the ALA (American Lung Association) and all the other expects about asthma management. It almost always points to the course of taking inhaled corticosteroids.
How do you respond to parents of young children worried about the side effects versus the benefit of this drug? Also middle age women worried about bone loss and other side effects.
I understand that inhaled corticoid steroids are the most clinically proven way to control asthma but does it out weight the side effects? Thank you so much for your time.
A. Dear Patricia, Yes, in most cases the benefits from inhaled corticosteroids far outweigh the side effects. These are minimal in children. Children will grow better if their asthma is controlled.
Very few adults get bone loss from inhaled corticosteroids. They are quite safe, in most patients.
Q. I have a question about the need to occlude a tracheotomy tube when a patient is eating to prevent aspiration. The tracheotomy tube that I have a question about is an uncuffed fenestrated tube that is capped.
Our MD says that it does not matter if it is the uncapped or capped; if the patient aspirates uncapped he will aspirate when it is capped. Our Speech therapist disagrees. Her opinion and training teaches her that fewer patients aspirate when the tracheotomy tube is capped or occluded.
What are you opinion or any suggestions on where to look this up? During the blue dye test the tracheotomy tube was capped and no dye was suctioned. However, the next morning the patient took his cap off and drank cranberry juice and the juice was later coughed out of the tracheotomy tube.
Any information is greatly appreciated. Thanks
A. Dear Stacey, Your doctor is right. It makes no difference if the tube is capped or not.
Your speech therapist is wrong. For some reason speech therapists have it wrong. I have never found out who taught them this wrong information. But if wrong information gets in the textbooks, it is very hard to remove it.
Breath Actuated Nebulizer
Q. We are about to trial BAN, breath actuated nebulizers (produces aerosol only during the inspiration) from Monaghan in our Emergency Department at Maine Medical Center in Portland, Maine.
Do you or any of your colleagues have experience with this device? I am impressed with 81% respirable volume compared to the 20 % with our current hand held nebulizer.
Rhonda RRT-NPS, AE-C
A. Dear Rhonda, Sorry, I do not have any experience with these nebulizers. They sound good.
Vitamins and Supplements
Q. I have had asthma for about 10yrs. I don't smoke now, I quit 13 years ago. I have been on prescribed medicine all that time.
I found out about Qxy-Caps from Earth’s Bounty, I have not had any side effects and have been taking these capsules for several months.
I am able to be outside and weed, I can walk without having to stop and get my breath. This is the first time in the past few years that I haven't had bronchitis nor have I had to use my breathing machine.
It isn’t USDA (United States Department of Agriculture) approved and I showed my doctor. His only comment was that they where not USDA approved. He didn’t say not to take them nor did he tell me go ahead and continue taking them. What is your comment?
A. Dear Patricia, If they help, take them.
Q. I work in a PICU (Pediatric Intensive Care Unit) where we give nebulized Tobramycin (antibiotic). We have to move the child into a negative pressure room (isolation room). The Center Disease Control (CDC) does not have guidelines for this procedure.
Is it necessary to have a negative pressure room to administer this type of nebulizer therapy?
A. Dear Jeffrey, Not because of the Tobramycin.
Maybe the concern is that the pseudomonas (infection caused by bacterium) carried by the patient is contagious. It probably is not, under normal conditions.
Tuberculosis and Pulmonary Function testing (PFT)
Q. Do patients with tuberculosis need a PFT? If so, what kind of results would show up?
A. Dear Michelle, All patient who have smoked or do smoke at age 45 should have spirometry. Also any person with chronic cough, shortness of breath on exertion, wheeze or excess mucus, should have spirometry.
TBC (post-tuberculosis lung disorder) will affect spirometry if there is major lung damage. Spirometry is not diagnostic of TBC. It only measures the function of the lungs.
Pneumothorax, Collapsing Lung and Pregnancy
Q. My 26-year old daughter began having Spontaneous Pneumothorax, I now imagine it was Catamenial Pneumothorax, when she was 14. Multiple collapses eventually led to pleurodesis (substance is put in between the 2 linings of the lung) on both lungs at age 18. She has not had another collapses since although she has had occasional “bleb bursts”.
She also had frequent nosebleeds around the time of the pneumothorax, as well as other times. Now she is pregnant (due in Oct. ’05) and we are wondering what the effect of the pleurodesis (iodine) will have on the pregnancy and her health.
Last measured capacity was about 60% and no other health problems (she does aerobics). Her OB/GYN sent her to an intern for evaluation who sent her immediately to a pulmonologist.
She filled out long questionnaires before going to the pulmonologist. When she got there asked her if her asthma really acted up when she had allergies. She said she didn't know what he was talking about she does not have allergies or asthma.
He then looked at her file and said, oh. She asked him what he thought and he said he had never seen anyone with pleurodesis and pregnant. But he offered her some nasal spray… for what; we have no idea why he gave her the spray.
Maybe we have nothing to worry about, but these type episodes don't help. Can you please give us any kind of guidance? Help would be greatly appreciated.
A. Dear John, She will do fine. Her reduction of lung function to 60% of normal, gives her a lot of "room". Women who have lost a whole lung usually do well with pregnancy.
She does not need a nasal spray for this. Look forward to this great event, of the creation of new life!
How Does Exercise Affect Asthma?
Q. Hi Doctor, I have suffered for many years with asthma. I am 40 years old.
I had an occupational exposure a number of years ago to solder fumes. Over a few years and this made my asthma more volatile and severe.
I find now when I exercise aerobically my breathing is good for the rest of the day. When I do not exercise I find myself short of breath and not feeling 100%. I am fully compliant with the instruction of my doctor regarding my Seretide inhaler (of which I am on the max dosage).
What could this pattern regarding exercise demonstrate?
A. Dear Jill, It means you do well with exercise. Keep it up.
So-called “exercise induced asthma” usually comes on immediately following exercise. You don't have this.
Catching her Breath
Q. I am a 46-year old woman who has frequent “catching my breath” during the day. Is this normal, I have asthma?
A. Dear Diana, The usual symptoms of asthma are; cough, wheeze and shortness of breath. The feeling of a need “to catch your breath,” by itself, is probably not due to asthma.
You need to have spirometry done to see what your lung function is at the times when you feel short of breath. And if this turns out to be asthma, the feeling should improve with inhalation of a bronchodilator.
Tracheotomy Tube for Speaking
Q. Is it possible for an ALS (Amyotrophic Lateral Sclerosis) patient who is on a ventilator to have a fenestrated tracheotomy tube (tracheotomy tube that has a hole in it for airflow through vocal cords and upper airway to allow speech) so he can talk? He is in his 30's and can be off the vent for up to about an hour. Do you have any other suggestions to enable him to talk? Presently we use a letter board.
A. Dear Pamela, Yes, the patient should be able to talk easily. A fenestrated trach tube with the orifice plugged, lets the air come upward to the vocal cords. Even when the patient is on the ventilator, he can talk during the exhalation phase, if the balloon that surrounds the trach is deflated.
Many ALS patients talk well by this method and some do not need a balloon, or so-called cuffed tube at all. As air passes around the trach tube it flows upward towards the vocal cords for the ability to speak. Hope this works for your patient.