Need Help Finding Resources to Back Myself Up!
Q. Dr. Tom, We have been having discussion at our hospital about extubations for medical patients at night.

I was taught that extubations at night were to be avoided for medical patients due to the depression of respirations at night. Should medical (non-surgical) patients be extubated at night?

I am having some trouble finding any research to back myself up.

Ed Bradley

A. Dear Ed, Yes, extubation can be done, when the patient is ready to breathe without mechanical ventilator support. The old idea that it had to be in the morning is a myth.

Lots of patients are extubated in the afternoon, when they are awake, alert and can move enough air on their own. Testing for adequate air movement can be done by simple bedside tests.

I have had this experience as a patient too, on five occasions.  

Dr. Tom

* An endotracheal tube (breathing tube) can be connected to mechanical ventilators for the purpose of delivering air and/or gases into the lungs. Extubation is the removal of a breathing tube from a person’s airway.                

 

Could I have Restrictive Lung Disease?
Q. Dr. Tom, I complained to my Dr. about shortness of breath (SOB) that came on all of sudden while walking up one flight of stairs at my home.

Back in Oct to Dec I was running 1.5 miles 3x a week, along with push-ups, crunches and stretching exercises. Right before this happened I had used the cross trainer machine at the gym 3 or 4 days in a row for 30 min sessions with no problem at all, then all of a sudden I couldn't catch my breath walking up a single flight of stairs.

Also, I don't feel sick at all; just tired after physical exertion and SOB if I tried to push myself a bit too far. I walk between 3 and 6 miles a day at about 3.5 to 4 MPH and don't feel SOB after doing it.

My doctor, who is not a pulmonologist, did two PFT's (Pulmonary Function Tests) on me two months apart. The results were:

April 20
	Base	%pr
FEV1	1.43	38
FVC	1.82	40
FEV/FVC	78.6	95
FEF 25-75	1.19	29
June 21
	Base	%pr
FEV1	2.03	53
FVC	2.47	54
FEV/FVC	82.2	99
FEF25-75	1.91	47
FEF25	3.85
FEF50	2.31	48
FEF75	.84	43

The doctor said it was a restrictive lung problem. I am in the military so they are working on getting me an appointment with a Pulmonary Specialist.

The doctor told me to take Combivent 4 times a day and lose some weight because it seemed as my diaphragm was pushing up against the bottom of my lungs. So, between the two tests I dropped 20 pounds. I am 5'7" and weigh 200 pounds.

Is restrictive lung disease like pulmonary fibrosis, and other serious restrictive lung problems? Can the lung function be improved like mine was? 

Robert       

A. Dear Robert, Yes, your pulmonary functions show a restrictive breathing problem. This is not just due to your weight.

You need a diagnosis from a pulmonologist. There are many possibilities.

By the way, only the FVC, FEV1 and the ratio between the two, are what you should look at. All those other numbers are unnecessary, and often confusing.

Dr. Tom

 

What are the Hazards of Breathing in Chlorine?
Q. My husband works in an area where he must inhale a lot of chlorine.  He says it sometimes feels like it's burning his lungs.  He seems to have a lot of sinus problems and persistent coughing.  What are the hazards of this?

Dianna

A. Dear Dianna, Inhaling high concentrations of chlorine is irritating to lungs, nose and sinuses. Better try to avoid this.

Dr. Tom

                         

Feeling Short of Breath (SOB)
Q. Dr. Tom, I am a 33 year-old male.  I take Prilosec daily for heartburn. I took Pulmicort, Serevent and Albuterol five years ago but since moving to a new state found I didn't need them. 

I occasionally have SOB when working around dust. Cleaning the garage for example. This usually subsides in a day or so. 

However, this time I have had SOB for about a week...worse at night. Should I go to the doctor or expect it to subside as it usually does?

Donnie

A. Dear Donnie, If you are having allergic reactions to the dusts, this should subside within days of avoidance. If the symptoms continue, see your doctor. Also avoid these dusts, if you can.

Dr. Tom

                  

Should I Drop One of My Medicines?
Q. I am at this time using Spiriva and Atrovent. Should I drop the Atrovent?

Robert

A. Dear Robert, Yes. They are the same type of drug. The Spiriva is a 24-hour drug. The Atrovent lasts only about 6 hours.

Dr. Tom 

 

BiPap (Bi-level Positive Airway Pressure)
Q. Is a BiPap* delivery mask safe to use on a person who is mentally and physically disabled who has a vomiting problem, and unable to secure their own airway?

Anthony

A. Dear Anthony, It is dangerous to use in patients with mental impairment and vomiting. 

Dr. Tom                   

*BiPap is a technique that is often used to treat sleep apnea and to provide airway support with a face mask rather than tracheal tube that is attached to a mechanical ventilator.    

 

The Big E.
Q. Dr. Tom, I thought I broke my rib and my doctor decided to do a chest x-ray. 

He called the next day said result of rib fracture was normal, but I had the beginnings of the big E.  No further tests, medicines or information.  What do you think?

Diane

A. Dear Diane, I don't know what “the big E is”.

If your doctor is referring to emphysema, forget it. The x-ray for a broken rib, it will not show emphysema.

Dr. Tom

 

Spots of Blood in Phlegm
Q. I am away on business now in DC. While in Miami last Sunday I was feeling congested and I walked into a clinic and where they diagnosed me with acute bronchitis. The Dr gave me antibiotics for five days, now all taken, and an inhaler to use every 4 hours and a respiratory therapy every 4 hours.

Yesterday morning I had red blood spot in my phlegm. This morning about 10 spots, meaning with each coughing up of phlegm.  I had red blood.

I travel tomorrow Sunday back home and I am concerned. Can I wait until I get back home to run in to the hospital? I will be taking two flights to get home, each about 2 1/4 hours each?

First time in my life that I’ve seen blood, red, like this in my phlegm. I feel fine and unless I make an effort there is no wheezing in my breath, until I cough, etc.

Unnar

A. Dear Unnar, This may be due to the acute bronchitis. If it continues you need to see a doctor for a diagnosis. You can continue your travels, but get advice on return home.

Dr. Tom

 

Guidelines for Changing Tubing and Nebulizers
Q. What are the standard guidelines for changing tubing and nebulizers?

Mary Jayne

A. Dear Mary Jayne, The usual practice is a change every 48 hours. There are some studies that suggest that a change at greater intervals is safe from the standpoint of infection occurring in the delivery tubing.

Dr. Tom

 

Dad is Very Worried about Daughter’s Chronic Cough
Q. Dr. Tom, I have a two year-old daughter that has a chronic, hard cough that has persisted for the last year.  I can feel her chest rattle from the wheezing.  The cough is hard and wet. 

We moved from Jacksonville, Fla to Portland Oregon about a year ago.  She is in daycare.  We have a dog and no one smokes.  She has a good appetite from time to time.

The cough is very persistent and is even more so at night.  She has a runny nose that is green to clear almost everyday.  No fever with the cough. 

She has seen the Doctor countless times over the past year.  The Doctor has placed her on Albuterol, Qvar, Claritin and Cheratussin.  She is on these meds everyday.

If we miss a day of her meds, she is miserable and the cough will keep up with crying.  The doctor was hesitant to call her condition as Asthma, saying she was too young. 

Why can't she get rid of this cough?  What haven't we considered as a treatment?  What can we do for her?  How can I get this cough to go away?  Please help, Please advise, we are desperate. 

Also, about a month ago she developed a strong stutter.  Thank you.

Brad

A. Dear Brad, Sounds to me like she has asthma. Asthma may begin at any time in life.

Better see a pediatrician for another opinion. Her condition should be controllable.

Dr. Tom

 

Questions about a Lung Mass
Q. Recently, I had a CT scan reflected a 8mm mass (about the size of a green pea) on my lower left lobe. A previous CT scan was done in December of 2004—and it apparently was not there at that time—although there were several subcentimeter nodules.

I am in the process of having a PET scan scheduled, as I did not want to have a needle biopsy. 

My question is whether or not a bronchoscopy* biopsy would be possible in lieu of a needle biopsy? Or, if with 8mm it would be possible to wait another 3 to 6 months and have a follow up CT Scan?

Fran

A. Dear Fran, These small nodules will need a follow-up. They are too small for a PET scan to be of much value.
If one or more of them grow, you need a biopsy. Such small nodules are hard to reach by bronchoscopy.

Dr. Tom

*A bronchoscopy is a diagnostic procedure where a doctor uses a scope (a tube with a camera on the end) to take a look at the inside of the airways and lungs. Lung tissue biopsies, can be obtained during a bronchoscopy.