Tracheoplasty
Q. I am going to Boston to have tracheoplasty (plastic
surgery of the trachea) via thoracotomy surgery
(incision of the chest wall).
Could you explain how this surgery is performed
and what the recovery is like?
Carol
A. Dear Carol, A tracheoplasty is a repair of the
main air passage in the neck and upper chest. By
going through the chest, in your case, there must
be damage or some other form of problem in the lower
“windpipe,” just above where it divides
in to the main air passage for each lung. I cannot
speculate what the procedure is for. You need to
discuss this with your surgeon.
Dr. Tom
Follow-Up Question about Continuing Symptoms
Please see a previous question from David.
Q. This question is a follow up to one I asked a
couple months ago. I have been experiencing a constant
mild wheeze, periodic cough, and mild SOB since
early January and along with a short exposure to
silica. I've had chest x-ray, complete PFT's, and
examination by a pulmonologist at St. Luke's Medical
Center, and everything comes back normal. He reviewed
my x-rays and PFT's. My oxygen saturation was 98%
in his office, and after a brisk walk around the
testing area, it remained at 97 or 98% the whole
time.
My SOB is super mild, and I don't have any trouble
or any noticeable change in my breathing while exercising
or being active. I'm a healthy (besides this crap)
28 year-old male who has never smoked, and is in
moderate physical condition.
I'm growing tired of clearing my throat constantly,
coughing, and wheezing on every breath. Same pattern
of morning cough with very little sputum production
(kind of a white/yellow in small little pieces),
then mild cough and all day wheeze that seems to
go away when I lay down at night. I'm It just feels
like there's something constricting my breathing,
albeit mildly.
I'm just hoping this goes away, but it's the same
every day all day. It's lasted for four months now,
so it doesn't appear to be going away on its own.
I am going in for a metha-something challenge at
my pulmonary doctor's office next week. Any thoughts
for me on what this could be?
David
A . Dear David, With the symptoms you describe,
this could well be mild asthma, with normal lung
function and oxygenation.
The methacholine test is designed to provoke your
air passages to constrict. The pulmonologist can
measure airflow before and after the methacholine
challenge, and determine if you have airway hyperreactivity,
one the hallmarks of asthma. If positive, this test
will help confirm asthma, and be the foundation
for asthma treatment, which should end your symptoms.
Let me know the results.
Dr. Tom
Normal FEV1 and a Low Diffusing Capacity (DLCO)
Q. I hope this finds you well, what a Godsend you
are to us, you and Mary.
I wonder why - if the only numbers with meaning
in a spirometry test are FEV1 and FEV - a person
with a high FEV1, but low DLCO can't breathe without
supplemental oxygen?
What does it mean when one's FEV1 stays the same,
but the DLCO number plummets AND the patient's 'normal'
blood/oxygen drops to 92, 93 and she has a tougher
time breathing...?
Please take care of yourself.
Sharon
A. Dear Sharon, The FVC and the FEV1 are the key
number from spirometry. The DCO is different, it
measures the transfer of gasses across the lungs.
Some of the scarring diseases of the lungs are characterized
by oxygenation problems, but still normal lung “mechanics”,
which is what spirometry measures.
Dr. Tom
Treatment for Bronchiectasis
Q. Could you please tell me if bronchiectasis should
be treated the same as bronchitis or asthma?
John
A. Dear John, In general, yes. Both antibiotics
and bronchodilators may be useful in chronic bronchitis
and bronchiectasis, but in bronchiectasis there
is more need for antibiotics and a greater spectrum
of infectious bacteria.
Dr. Tom
Can Medications be Used Together?
Q. Can Foradil Aerolizer be used in conjunction
with Combivent?
Howard
A. Dear Howard, Yes, but Foradil, is a long-acting
bronchodilator in the Beta agonist class. The albuterol
component of Combivent is a short-acting Beta agonist,
so the side effects of the two drugs may be additive.
The other component of Combivent is ipratropium;
a different kind of bronchodilator, in the anticholinergic
class and it is compatible with all Beta agonists.
Dr. Tom
Worrried about Hyperinflation and COPD
Q. I recently had a PFT to assess shortness of breath.
Prior to today I had thought this was probably just
mild and due to anxiety. However, being a former
smoker I asked my doctor if I could have a PFT.
I am a 28 year-old male, 5'9”, 130 lbs. I
smoked a pack a day for about 7 years and also have
a history of marijuana use. I quit all smoking 3
years ago and now exercise regularly. My results
are as follows:
FVC: 6.54
FEV1: 5.64
FEV1/FVC (%): 86
Pulse Ox: 96% (I've seen mine range from 95-99%)
TLC: 8.93 (131% of predicted—5.09)
RV: 2.28 (152% of predicted—1.50)
DLCO 44.32 (135% of predicted—32.88)
The PFT report states: “The FVC, FEV1/FVC
ratio and FEF25%75% are within normal limits. The
airway resistance is normal. The TLC, FRC and RV
are increased indicating over-inflation. The diffusing
capacity is normal. However, the diffusing capacity
was not corrected for the patient's hemoglobin (the
last time I had it checked it was 47%). CONCLUSIONS:
Over-inflation without concurrent obstruction is
of uncertain significance.
The chest x-ray shows bilateral hyperinflation of
lung fields.
My understanding is that hyperinflation is a sign
of emphysema. And isn't this a very late sign and
poor prognostic indicator? Is it ever possible to
have hyperinflation without emphysema or other COPD
diseases? Does my FEV1/FVC % mean I don't have COPD?
I am worried to death about this, and it's going
to be weeks before I see my doctor. Please, pardon
my desperate tone, but I don't think I'll even be
able to sleep tonight. I realize you cannot answer
all questions and are busy, but I'd be extremely
grateful for your input.
Feel free to edit any of this if you wish to put
the information on your website.
Mike
A. Dear Mike, You do NOT have emphysema. You are
just able to take a very large breath. Your ability
to empty your lungs is normal. Hyperinflation in
your case does NOT mean emphysema. Your diffusion
test is normal. Your doctor should not worry you
so. Stay healthy and enjoy life!
Dr. Tom
Questions about CT Scan Results and Previous Lobectomy
Q. I'm a 58 year-old male who has never smoked.
I was diagnosed with stage III colon cancer in 1996,
which metastasized to my left lung in 2000. An upper
left lobectomy was performed in June 2000.
A recent full body CT Scan revealed the following:
Impression: Heart and mediastinal structures appear
unremarkable. Mild COPD is seen with chronic lung
changes with apical pleural thickening. No acute
infiltrate seen. Mediastinal node is not enlarged.
Scarring left upper lobe seen anteriorly and in
the left lung base. Left upper lobe scarring more
prominent compared to previous study. No discrete
lung mass seen.
Because I do not have a cough, nor do I cough up
sputum and I do ride a bicycle vigorously daily
for 1.5 hours without shortness of breath so the
radiologist's impression leaves me with the following
concerns and questions
(1). What would be the origins of mild COPD if I
never smoked? I did have unprotected exposure to
asbestos from 1976 to 1981 on a fairly routine basis.
I also had unprotected exposure to a polyurethane
concrete crack sealer which contains trace amounts
(according to the material safety data sheet for
this product ) of Toluene Diisocyanate for two days
in February 2006. Although the garage door and windows
were open during this process, I did almost pass
out at the wheel while driving shortly after using
this crack sealer.
(2) Why does the radiologist make reference to the
upper left lung lobe if it was surgically removed
in 2000?
(3) Once a lobectomy is performed, what fills the
space where the lobe resided?
Rick
A. Dear Rick, The lung changes following removal
of the left upper lobe, should not be interpreted
as emphysema. The lower lobe expands to fill up
the space, and there may be some accumulation of
fluid that leaves a scar. Spirometry would tell
you about your lung function (see National Lung
Health Education Program https://www.nlhep.org/ ).
The chest x-ray does not tell about lung function.
Dr. Tom
Lost Mother to Lung Cancer and is Concerned about
CT Scan Results
Q. I am a 34 year-old female with a smoking history
of 22 years off and on. I lost my mother to lung
cancer on Nov. 2, 2005. I have been sick since October
with a horrible cough, fatigue all the time, chest
pain I thought it was caused by all the coughing,
weight loss, headaches. My doctor put me on an antibiotic
for two weeks, which didn't help. New symptoms since
Jan. 2006 include right shoulder/back/neck pain,
numbness to my right arm leading all the way down
to my fingers. (said it was a pulled muscle), and
a weight of 25-30 lbs. since Oct. 2005. Upon my
return visit I was then told it was allergies.
This all becoming a horrible nightmare for me. That's
what my mom thought was wrong with her. I requested
a chest x-ray. There was a left lower lobe mass
that appeared on the chest x-ray; I was scheduled
for a CT with IV contrast the very next day which
clearly showed a tiny noncalcified nodule in the
left upper lobe anteriorly which measures 5 x 4
mm in size, additionally in the right middle lobe
there is a focal irregular soft tissue opacity which
has the appearance of post inflammatory change.
Additionally there is a tiny noncalcified nodule
present in the right middle lobe, slightly inferior
to this region measuring 3-4 mm in size. Of course
the report said the noncalcified nodules that are
present are indeterminate by CT criteria, and suggest
a repeat CT scan in three months to document stability
of these findings.
At my follow-up doctor visit I was told that there
would be another CT scan in three months, and was
sent home. I was called by the doctor's office the
next day, which was a Saturday, telling me to come
in for more blood work. They ran a TB test, a fungal
test, an HIV test, and they were all normal. My
CBC was sent to the Mayo Clinic a week ago today
and the results are not yet in.
They also did a sputum culture that showed a heavy
growth of Hemophilus Influenzae so now I am being
treated for bacterial pneumonia, taking Sulfonamide.
Can you shed some light on all of this?
Since I just lost my mother who had just turned
56 I am a little freaked out by all of this and
I feel as if I am going crazy trying to analyze
this report. Can these noncalcified nodules that
have been found be a direct relation to the bacterial
pneumonia? I can't find any direct studies on the
internet that will back up the cause of noncalcified
nodules being caused by this bacterial pneumonia.
Can you give me your opinion on what I should do
next? Should I consult with a lung doctor. My repeat
CT scan is scheduled for May 9 to determine if the
nodules have grown. Should I skip the CT scan and
request a PET scan? Your help and opinion is appreciated.
Mrs. McCarthy
A. Just get the follow-up CT. I would suggest waiting
six months to give time for possible growth. Very
small cancers grow slowly at first. Most small nodules
are benign, i.e. about 90% of them. Some of these,
or all could be mucus plugs associated with your
hemophilus infection.
You are wise to follow up, but do not be frantic
about this. Waiting will not be wasting time, and
you will get more useful information.
Dr. Tom
Worried and at a Loss about How to Help Mother Chronic
Lung Problems
Q. My mother, who is 63, has been having chronic
lung problems for 10 years that cannot be diagnosed.
She is chronically short of breath, coughs violently,
has terrible sinus head aches, wheezes so loudly
through her nose and what sounds like her throat,
she wakes herself up, and is exhausted all of the
time.
She has had the sinus surgery, countless chest,
sinus and thoracic x-rays and CT scans all with
unremarkable results. About six years ago she received
a diagnosis of bronchiectasis, but all subsequent
CT scans show no progression.
She has seen, and still sees, allergists, pulmonologists,
general doctors. She has been prescribed inhalers,
nebulizers, saline irrigators, etc. and the only
drug that offers her any relief is prednisone-which
she will not take for any length of time because
of the side effects.
I suggested getting tested for Vocal Cord Dysfunction
since she has similar symptoms, but her doctors
say if that is what she has, the prednisone would
not help her.
All of her doctors are at a complete loss. I have
watched my mother go from a woman who was full of
life with boundless energy, to a virtual shut-in
who cannot work and is depressed because of her
condition. She is open to alternative therapies,
she's open to anything, but a lot of alternative
medicine recommends licorice which can raise the
blood pressure.
I purchased a pepper inhalant after reading about
people with similar symptoms using it with great
results, however her doctor recommended against
it because he advised it could damage her sinus
cavity and she did not want to risk it.
I understand you cannot diagnose someone you have
never seen, but I am begging you for any suggestion
so I have some hope of getting my mother back. Thank
you in advance for any advise you are able to provide.
Christine
A. Dear Christine, Some doctor, most likely a pulmonologist,
should be able to make a diagnosis. Insist in flow
volume test to see if vocal cord dysfunction is
present, a simple breathing test done by pulmonologists.
Has she been bronchoscoped (a diagnostic procedure
in which your doctor uses a scope, a tube with a
camera on the end, to take a look at the inside
of the airways and lungs). Again this could be done
by a pulmonologist. Do not have her inhale pepper.
It is too irritating. Get an answer.
Dr. Tom
Inhaled Dry Clay, How Worried Should I Be?
Q. About six months ago I started taking a ceramic
class using stoneware. On several occasions I heavily
inhaled dry clay that was on my hands into my lungs
and felt strong burning in my lungs. I have learned
since to wash my hands after working with clay,
but nevertheless I did have this happen at least
six times. The final time I was coughing for over
an hour.
I have learned that the clay has free silica, which
is a carcinogen and the particles bury deep in the
lungs. How worried should I be about the damage
done to my lungs and is there anything that can
be done about it, other than being careful from
now on?
X .
A. Dear X., I doubt if you inhaled enough small
particles to cause what is known as silicosis. The
dry or wet clay on hour hands is made up of large
particles. You should remain well. Dr. Tom
Non-Viral Pluerisy
Q. You may recall my previous letters to you: I
have had normal spirometry for the last three years
(I am male, 37 and 181cm my FVC varies between 5.42
and 6, My FEV1 can vary from 4.15 to 4.66 and my
FEV1 / FVC is always constant at between 75-77).
I have also had a host of other tests, all normal.
I am a past smoker with childhood asthma but a host
of symptoms including cough, SPB, sputum production,
inability to get a deep breath and chest ache. I
have also been worked up by a Rheumatologist.
I now have had a recent bout of Non Viral pleurisy
(is an inflammation of the pleura, the lining of
the lungs, causing pain) which really knocked me
out for a few day. My PCP (Primary Care Physician)
maintains it is from a deep breath I took while
taking my Symbicort inhaler. This is not the first
time this has happened. I have had two HRCT thorax,
the last being a year ago.
Considering all my tests I am without diagnosis;
however my breathing is without doubt compromised.
Up until this incident I was agreeing with the doctors
and telling myself I was normal however the non
viral pleurisy does concern me, what do you think
this could be? My Pulmonologist and PCP have told
me in the past that they do not have all the answers.
Conn
A. Dear Conn, I do not recognize non viral pleurisy
as a specific entity. It could not have been due
to your inhaler. You could still have asthma, with
your symptoms.
A bronchial provocation test could help establish
this diagnosis. In this test, you inhale a drug
aimed at provoking your airways into a spasm. Airflow
is measured before and after the challenge, and
again after a bronchodilator.
If asthma is the diagnosis, in spite of normal airflow
when you are tested, this test can be confirmatory
and forms the basis of maintenance asthma treatment.
Dr. Tom
What does Clinical Improvement Mean?
Q. In 2001 I was put on oxygen as my oxygen level
went to 88%; since then I have quit smoking. In
August 2005, I was taken off the oxygen after they
gave me a lung test, and I was 97% at rest, and
94% on exercise. Since then I have been getting
along fine without oxygen.
My current medication is Spiriva, and Albuterol
inhaler for shortness of breath.
If I may I will give you the test results of the
spirometry:
The FEV1 is mildly reduced and FVC is minimally
decreased. The static lung volumes are significant
for increased RV, which is suggestible for airtrapping.
There is a mild reduction in DLCO (a test that measures
the transfer of gasses across the lungs ). There
is no significant reversibility after bronchodilators.
IMPRESSION: Mild obstructive airways disease with
evidence of air trapping noted. Loss of alveolar
capillary interface, which is evident by the decreased
DLCO, could be to smoker lung damage. Underlying
interstitial disease cannot be ruled out. The patients
present study compared to a prior study dated 4/17/01,
the FEV1 (bronchodilator) has improved from 1.25
liters in the prior study to 1.49 liters presently.
The FVC remains unchanged. Presently, the DLCO also
does not show any significant difference. Clinical
correlation is recommended.
The doctor has written on my medical record that
I have been clinically improved for a year. My question
is what is that my medical record says that I have
been clinically improved for one year, and I just
got off the oxygen in August. Could you also tell
me exactly what this test reads? The test was taken
in 6-21-2005. Thank-you so much for taking the time
to write me back. I really appreciate it.
Terri
A. Dear Terri, Your lung function is significantly
improved. You will probably maintain this level
of lung function with no more smoking, except for
the slow decline related to age. Stay well.
Dr. Tom
Worried about Mother's Recovery; Following Lung
Cancer Surgery
Q. I am very concerned about my mom, who has diagnosed
for lung cancer. She went into surgery, removing
two lobes from her right lung. This was exactly
5 weeks ago. Until today she has not fully recovered,
feels weak, and has pain when she coughs, yawns,
or sneezes. Is this normal and what an she do to
feel better? How long will it take that she will
fully recover?
We have given the biopsy to an oncologist and we
are waiting to see what treatment will be.
Sandra
A. Dear Sandra, It may take longer for your mother
to reach her maximum improvement following major
lung surgery. A significant amount of lung tissue
was removed. I do not know the status of her lung
function prior to the surgery. She should have simple
lung function measures by spirometry (see National
Lung Health Education Program https://www.nlhep.org/
) after about 3-6 months.
Dr. Tom
Conflicting Opinions about Side-Effects of Bronchodilators
Q. I was diagnosed with asthma a little over a year
ago.
I have symptoms daily and take Advair 500 to help
control it. My question is regarding albuterol;
I tried an albuterol inhaler twice several months
ago that resulted in worsening of my symptoms-I
got more short of breath for 6 hours both times.
My doctor said that it was probably the propellant,
so prescribed a nebulizer for me. The other day
I tried albuterol via nebulizer and had the same
effect; when I asked a nurse about it, she said
that I maybe needed to take more, that is what they
do in the hospital.
Are some people sensitive or allergic to albuterol
or to short-acting bronchodilators in general? Is
there an alternative I can try?
Angela
A. Dear Angela, Some people have worsening of their
asthma, from short acting albuterol. You could try
a fast acting but long lasting bronchodilator in
the same class, formoterol, prescribed as Foradil.
Dr. Tom
Trouble Catching Her Breath after Quit Smoking
Q. I quit smoking two months ago after almost 30
years. Quitting was much easier than I expected
and I have no desire to smoke again.
The only problem I'm having is breathing. When I
was smoking breathing was never a problem but since
I quit I'm having problems catching my breath. I've
been on some sites that say it could take 3 to 6
months before breathing is normal. Is this correct?
If so why, and is there anything I can do to get
some relief in the meantime?
A. Stopping smoking should not cause shortness of
breath. If you were short of breath from COPD related
to smoking, the lung impairment will usually stabilize
or slightly improve in a matter of months.
I suggest getting you lung function measured by
simple spirometry (see National Lung Health Education
Program https://www.nlhep.org/ ) to see what impairment
you may have.
Dr. Tom
CT Scan Shows Atelectasis
Q. I am currently being treated with Levaquin (antibiotic)
for a bronchitis which did not clear up after 10
days of Zthromycin (antibiotic) treatment. I was
having pain in my lower left back upon breathing
in and coughing and so went for a chest x-ray which
seemed to indicated actelectisis ( collapse of the
lung or part of the lung) or scarring in the lower
lobe of the left lung. I had a CT Scan today which
came back negative to tumors, pulmonary embolism,
etc and seems to still indicate linear scarring
or atelectisis.
The internist has advised me to follow up with an
x-ray in 4 months and if it has cleared up then
we will assume it was atelectisis, if it is unchanged
we will assume it is linear scarring. He is checking
in with me at the end of the week to see if my other
symptoms are improved.
I am still coughing (although much less) and am
very tired even though I have been resting for four
days (normally work 10-12 hours a day/6 days per
week.) I am also still experiencing sweats and chills
periodically throughout the day and night. Granted
this may clear up by the end of the week.
Should I be concerned about the CT results? Should
I seek out a pulmonary specialist or does the course
prescribed seem appropriate? I am a 42 year old
female with a long history of bronchitis and bronchial
asthma--as an adult I am likely to take an antibiotic
once or twice per winter season along with albuterol.
Otherwise, I am very fit and healthy.
Susan
A. Dear Susan, You should have responded to antibiotics
by now, and also feel better, if your problem is
a common infection. The linear atelectasis should
not be a cause for concern right now. It may clear
in time, if it was a result of a bronchial infection.
You should see a pulmonologist if you are not better
soon.
Dr. Tom
