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

Worried About Lung Nodules
Q. Dear Doctor Tom, On 5/27/03 I had a CT scan of chest/thorax w/contrast as well as a CT Scan of abdomen and pelvis.  These tests were requested due to ongoing right-side chest and flank (side of body between the last rib and the hip) pain.

Findings were: Non-specific non-calcified nodule in the right middle lobe, 4-mm in diameter. Follow-up as described above (4 months) is suggested in order to assure benignancy. Generally, two years of stability is necessary to document benignancy (not malignant). End of the report. 

On 10/10/03 had a second CT. 

Findings: Lung windows demonstrate three small pulmonary nodules within the right middle lobe. In retrospect, all of these were present, the largest is unchanged, the next one appears to have increased slightly from prior study. Since it is so small though (1mm) is difficult to accurately measure.  The third lesion is sub-pleural (pleura, the lining that covers the lungs) in location and actually appears to lie within the right upper lobe. None of these appear to be calcified.  All three appear stable in size with the exception of the 1mm nodule, which is likely volume averaged.

Lung otherwise unremarkable for patchy atelectasis (collapse of the lung or part of the lung), which is unchanged, in the right middle lobe. There is linear atelectasis in the left lung base. Soft tissue windows reveal bilateral auxiliary lymph nodes with fatty hila nodes measure approximately 1cm in size and are therefore nonpathologic (not caused by disease or disorders). Unchanged from prior study.  Impression was nodules thought to be stable from last exam. But follow-up recommended in 3-4 months to document stability.

That was my last study due to the fact my doctor did not advise me that any follow-up  was needed.  I recently read these reports when taking my records to a new doctor due to ongoing right pain below ribs. 

Referred to gastroenterologist (doctor who specializes in diagnosis of the stomach, intestinal system and the digestive organs).

• Abdominal ultrasound was normal except for slightly fatty liver.
• HIDA-scan (Hydroxy Iminodiacetic Acid, a test for infections or other abnormalities of the gallbladder or bile ducts, or to evaluate unexplained abdominal pain).
• Colonoscopy (through the use of a scope a doctor can examine the colon for irregularities) and EGD (Esophagogastroduodenoscopy, an examination of the lining of the esophagus, stomach, and upper duodenum with a small camera, flexible endoscope, which is inserted down the throat) were performed. The findings were 1. diverticulosis (inflammation of an abnormal pouch in the intestinal wall, usually found in the large intestine, colon), 2. GERD (Gastroesophageal Reflux Disease), 3. esophogeal erosion (wearing away of the esophagus tissue), 4. gastritis (inflammation of stomach tissue), and 5. adhesions (fibrous bands of scarlike tissue that form between two surfaces inside the body) of the colon

I have not had any GERD problems that I am aware of and know what IBS (Irritable Bowel Syndrome) symptoms are, as have had in past. Now taking Prevacid and Klonopin for conditions. No change in pain. 

My sister was diagnosed with PPH (Primary Pulmonary Hypertension) three years ago.  Both of us took Fen-Phen (fenfluramine, phentermine, dexfenfluramine, a diet drug) many years ago and both had normal echocardiograms after that. I am now having bouts of breathlessness and wonder about PPH.

Do you feel the nodules in lung need to be checked again? I have never smoked but was raised in a home of severe second-hand smoke. Could you explain some of the other things they talked about in findings concerning condition of lung.

I realize this is a little strung out and lot of questions.  Thank you so much for your help.

Tina 

A. Dear Tina, It is very unlikely that these small nodules, which do not show a clear growth, are malignant. I would not follow up further on these.

Dr. Tom

 

Should Mother See a Pulmonologist?
Q. My mom has emphysema. She is 80. She is on supplemental oxygen. Her primary care doctor says there is no point seeing a specialist. I disagree. I just want her to receive the best care possible. Am I right?

Susan

A. Dear Susan, Your primary care doctor will not be knowledgeable about pulmonary rehabilitation. Take your mom to a pulmonologist and follow his advice.

Dr. Tom

 

Quit Smoking, Will My Lungs Improve?
Q. I am 74 years old and I have emphysema, and I have stopped smoking. My question: will the lungs improve or will they continue to disintegrate. I do deep breathing exercise, walk about five miles a week, can still climb stairs; I just do things differently. Should I look into some of the new treatments they are trying for lung reduction in order to make things better?

Mark

A. Dear Mark, We first need to know about your lung function. It must be fairly good for you to be so active. You are not a candidate for lung volume reduction surgery.  Your lung function will decline slower, now that you have stopped smoking. Stay active and “remember to live”!

Dr Tom

 

What are Lung Markings?
Q. Hi, my question is related to lung markings. I recently had a chest x-ray and my doctor told me that the results showed I had markings on my lungs. He didn’t really elaborate on this, nor did he tell me what the markings mean. After asking me many questions about whether or not I had a cough (I don’t), he simply told me that the markings were not a problem. Also, at the same time as the x-ray, I had a blood test that showed a very slight increase in my white blood count.

In terms of symptoms, I notice that I have to clear my throat quite often and I sometimes (every few days) cough up a small amount of clear phlegm. But that is all. I don’t have a cough/cold. I have never smoked, I have no trouble breathing, and  I don’t have any chest pain. I don’t suffer from asthma - though I did suffer from bronchitis as a child.

I can’t seem to find out what increased lung markings mean. Do they indicate some kind of pathology or are they a common occurrence and thus asymptomatic (no symptoms of disease or medical condition)? 

Mark

A. Dear Mark, All lungs have “lung markings.” They are shadows cast by the bronchial tubes and vessels. Sometimes radiologist comment about “abnormal lung markings,” but this is not diagnostic of anything.   

If you are concerned about your lungs, see a doctor who will do simple spirometry (see the National Lung Health Education Program for information on spiromerty) to measure your lung function.

Dr. Tom

 

Feel Tired Since Having a Bad Cold Two Months Ago
Q. Hi Dr Tom, I am a 30-year-old female.  Two months ago I had a really bad cold that kept me in bed for five days, and this has never happened before. I have been very tired since. Since then I have got another cold and I have had a productive chesty cough for three weeks with extreme tiredness and ache. My chest also hurts and feels tight.

I have been to see the practice nurse who is giving me a 7-day course of Amoxicillin (antibiotic).  

She also made me breathe into a tube to measure “peak flow” (a small device that measures how fast you can blow out your air). I did it three times and she said my reading was 280, and should be at least 430.

Should I be concerned about this number? I am normally very fit and healthy and take regular exercise.

Angie

A. Dear Angie, This is a low peak flow, but this is only a snap shot of airflow. Get a spirometry that will measure your air flow and volume.  You need an explanation for your symptoms if they continue.

Dr. Tom

 

Need Help with Understanding Spirometry Results
Q. I am a 38-year-old male. Recently, in December, I went to Heart Check America (a privately owned company that identifies facilities that perform scans, markets scans, and is in charge to billing and information) and had a scan done. I did this because I was having shortness of breath.

The results showed minimal emphysema. I took the results to my doctor who had a more intensive scan done and told me the results were accurate but that if I quit smoking and took care of myself that I should never experience the effects of the disease.

She also said that considering the early stages of the disease, that I shouldn't be experiencing SOB (shortness of breath). However, I am having SOB and she's not sure what else could be causing it. In the meantime, I had Spirometry done. Can you interpret these results for me?

Spirometry

	PRE MEAS	REF	PRE REF
FVC LITERS	6.15	5.64	109
FEV1 LITERS	5.09	5.64	119
FEV1/FVC%	83 75

 

(Editor’s Note: Extensive list of diagnostic numbers were provided and were edited down per Dr. Tom’s Commentary on Spiromerty.)

A. Dear Andy, These lung functions are all normal, except some subtle tests, which may have no significance.  

This list of numbers is the reason why people are so mystified about lung function.

Basically the only two numbers with clinical meaning:

FVC (Forced Vital Capacity)- a test that measures the volume of air you can blow from fully inflated lungs

FEV1 Forced Expiratory Volume in One-Second, measures the flow of air that you can blow out in the first second of exhalation

FVC/FEV1, normally this ratio which is >70%.

You are normal in these respects. The other tests are related to the air you cannot blow out and how well oxygen passes from the air sacs of your lungs into the blood, your results are also normal. Much too many numbers, which is not the best way to explain lung function.

But these tests do not explain why you are short of breath. Maybe it is just from inactivity.

Your lungs have not been damaged from smoking, and it is great that you have quit. Stay quit and exercise more.

Dr. Tom

 

How Long Does Amoxicillin Stay in Your Blood Stream?
Q. I believe that I have been experiencing some allergic side effects to Amoxicillin. I am finished taking my medicine. How long is the antibiotic in my bloodstream and how long will these side effects last?

Mike

A. Dear Mike, The Amoxicillin will be gone in about 12 hours, but some of the allergic reactions can last for days or weeks. You did not specify what these are, so I cannot make any further comments about them or whether they are related to Amoxicillin.

Dr. Tom

                                                               

Could Spiriva the Cause of My Hair Loss?
Q. I recently started taking Spiriva and have noticed my hair has been coming out every time I wash, brush or just run my fingers thru it. It comes out in large amounts. Is there any connection? Thank you

Kim

A. Dear Kim, None that I know of. This is the second question about this, but there are no reports of hair loss from Spiriva. This is probably a coincidence.  

Dr. Tom

 

What is the Latest Treatment for COPD
Q. This is a follow-up to my earlier e-mail and your reply.  I forgot to mention that I am already in Pulmonary Rehab twice weekly and it has improved my functioning a bit, but I still get very short of breath despite using diaphragmatic and pursed lip breathing techniques.

I would like some information on the latest medical treatments for COPD besides LVRS and lung transplant that might benefit someone who has had previous lung surgery.

Mary Ann

A. Dear Mary Ann, You did not mention oxygen. If you are a candidate for it, it would help. Many bronchodilators are helpful. You did not tell me what you are receiving already.

Dr. Tom

See Mary Ann’s question from last week...

Long History of Lung Problems
Q. I have a long history of various lung problems, and had a left upper lobectomy (surgical removal of the lobe of the lung) when I was 18 for atypical (not conforming to the usual type or expected pattern) TB (tuberculosis) that was unresponsive to meds and rapid growing. 

I did smoke for 43 years and quit 10 years ago.  I am now diagnosed with COPD - emphysema.  My CT Scan shows many large bullae (enlarged air sacks), diffuse but primarily in the lower lungs, worse on the left side.  Because of my prior lung surgery and diffuse bullae I am not a candidate for LVRS (Lung Volume Reduction Surgery).

 I get quite SOB and have a FEV1 in the mid-20% range.  Is there anything that could be done to help my symptoms, short of a lung transplant?

Mary Ann

A. Dear Mary Ann, The techniques of pulmonary rehabilitation should help you with SOB.

For more information on Pulmonary Rehabilitation see:

Frontline Advice for COPD Patients (PDF) - Pages 35-53

Get going and Take the First Step to Healthy Exercise:Pulmonary Rehabilitation is a Safe Place to Start an Exercise Program
Read and listen to stories of those with lung diseases who know the benefits of rehabilitation.

For more information on LVRS:

The National Emphysema Treatment Trial (NETT):
Evaluation of the Lung Volume Reduction Surgery for Emphysema
Source: Department of Health and Human Services
National Heart, Lung, and Blood Institutes
Medicare and Medicaid Services;

Lung Volume Reduction Surgery (LVRS) 
Source: U.S. Department of Health and Human Services:

Dr. Tom

 

Carbon Dioxide Retention
Q. I am a CO2 (carbon dioxide) retainer.  CO2 is at 45% and FEV1 is also 45%.  I am on 2-1/2 liters of oxygen 24/7.  Can this retention be dangerous and how do you get rid of the extra CO2? 

Leta

A. Dear Leta, This is really almost normal CO2 at sea level, (usual range 40-44). It is not due to your oxygen. It is not a problem, and you should not be concerned about it.

Dr. Tom

 

Lung Nodules, How Long do you Follow-Up with CT Scans
Q. Dear Dr.Tom, I have a 6mm nodule on my right lower lobe. This was found nine months ago. I have had 2 CT Scans with no change in size. My third is 3/31/06.

I am now having pain in my back - below shoulder blade. Could this be a sign that the nodule has gotten bigger and is now causing this pain? Am I being paranoid? Should I be seeing a pulmonary specialist? I am 36 year old female former smoker.   

Ann

A. Dear Ann, I do not believe you need more follow-ups if there is no change on your next CT. These small nodules are not the cause of your pain. It may be reassuring to see a pulmonologist.

Dr. Tom

 

Should I Consult a Specialist?
Q. Hello, I am a 25-year-old female who has been experiencing moderate shortness of breath for a over a year.  I have been told that I have bronchitis more times than I can count, chronic sinusitis with nasal polyps, IBS (Irritable Bowel Syndrome), and most recently exercise asthma. 

I explained my severe shortness of breath with exertion and the nurse practitioner decided to do a pulse ox reading while I jogged in place lightly.  After just one minute my oxygen saturation dropped from the 99% it was at rest to 87% and continued to drop so she told me to stop. 

She then ordered spirometry and most of my numbers were right at or below 3, whatever that means.  She is out of the office for two weeks and won't be back to look at the results so I am just wondering if this is normal for my age (5'3" and 103 pounds) and if I should consult a specialist because my chest pain has been getting worse daily. 

Amy

A.  Dear Amy, Yes, see a pulmonologist, for a better assessment of your symptoms.

Dr. Tom