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Archive: Dr. Tom 65
Posted June 5, 2006

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

Consequences of Inhaling a Patient's Nebulizer Treatment Mist During the Patient's Exhalation

Q. My wife is a medical technologist. While drawing blood the patient frequently is receiving a treatment of aerosolized medication. There is no filter on the exhalation side and she breathes in the patients' exhalation that contains aerosolized medication and possibly pathogens.

Have there been any studies indicating that inhaling this aerosol can be a risk to those employees who inhale it? Is the use of a filter on the exhalation side of the nebulizer a common standard in the respiratory care field?


A. Dear Tom, I assume you are tal king about the exhalation port of a ventilator, used to support ventilation. It is possible to put a filter on the exhalation port, but it is not commonly done.

I know of no studies that show risk from the exhaled medication to the technician working at the bedside in these situations. There is always an infection hazard whenever aerosols are produced by patients as in coughing, sneezing or laughing, or from the ventilator side in a patient with a dangerous infection. Precautions are used for these possibilities, which include isolation of the patient in contagious disease states.                                                    

Dr. Tom                                                    

Family History of Lung Disorders, Should I be Concerned about My CT Scan?

Q. I recently had a CT scan done on my neck for a lump I have back there that showed fine, just lymph nodes. However during this scan they found Minimal Biapical Pleural Parenchymal scarring of my lungs. Could you please explain what this means.

I'm only 24 years old and a bit worried. My mother has had her right upper lobe removed due to Nontuberculosis Mycobacteria and my grandfather died of COPD last year. Do I need further testing?


A. Dear Shannon, This x-ray finding does not have any specific significance. It suggests some remote inflammation in these areas, but this is not certain. You should not smoke. You do not need any other tests if your breathing is normal.

Dr. Tom                                                    

The Effect of Low Oxygen Levels On Other Organ Systems

Q. I monitor my O2 level and I worry when I am at 86 or lower.  What damage does the lack of O2 do to my other organs especially my heart?  I do have an O2 concentrator for exercise and sleep.  Should I use O2 more; but as soon as I sit down my level goes up to 92-94. 

Thanks for this excellent informative column.

Rose Ann

A. Dear Rose Ann, These oxygen levels are not low enough to cause organ system damage in otherwise healthy people. A saturation of 86% is normal at altitudes of 10,000 feet, such as in Leadville, Colorado. But your heart has to work harder to deliver oxygen to the tissues. It is best if you can keep your oxygen saturation above 90% at both rest and exercise. DR Tom                     

Is There a Mechanism that will Mimic Incentive Spirometry in Neonatal Patients?

Q. Is there anything that can be used besides a positive pressure breath to mimic incentive spirometry for a neonatal patient on high flow nasal cannula?


A. Dear Resp, Not that I know of. A baby takes a deep breath to be able to cry, which helps to recruit alveoli.

Dr. Tom                                                                                                            

Numbness of Arms and Legs, Could this be a Reaction to Coumadin?

Q. In February I spent 8 days in the hospital with right upper quad pain. An earlier CT scan showed Portal vein thrombosis in 3 places, a cyst and hemangiomia on liver (benign, non-cancerous, tumor consisting of dilated blood vessels. When a hemangioma occurs in the liver it is called a hepatic hemangioma). In hospital MRI showed only right portal vein thrombosis. Heparin was started, and Coumadin. One hour after Coumadin my arms and legs went numb. Doctor in hospital said it was in my head.

The next 2 nights the same thing happened, I insisted on a reason and neurologist checked PDR said it was a reaction, not in my head, and it went away in about a week.

Ever since I left the hospital I have had sharp tightness in lower ribs on both sides, sometimes in my upper back and side higher on my chest it comes and goes. My doctor said it's in my head! I am also on Nexium 20 mg a day, along with the Coumadin 7.5 mg/day.

I think I am having a reaction to Coumadin. It's been 10 weeks now. I still exercise and weight train and do regular work. This is really a problem at times. I'm in great shape, so what's the problem? 


A. Dear Chris, I do not believe that Coumadin is the cause of these symptoms. They sound muscular in origin. They should go away as you improve.

Dr. Tom                                           

Is There a Lung Hazard by Breathing Indoor Swimming Pool Chemicals?

Q. Could swimming in an indoor pool pose a respiratory health risk to children?  My son takes lessons at our local YMCA and in only that 1/2 hour there, I can feel the chemicals when I breathe for the rest of the evening.  I would like to get a membership there, but could it pose a risk for my 4 year old son to breathe the chemicals in a few days a week?


A. Dear Amanda, Chlorine vapor may be irritating. Also some swimming pools have organisms that cause inflammation of the lungs. You should ask the swimming pool company about how they control for these possibilities.

Dr. Tom                                                    

Need Advice Regarding being Startled Awake Gasping for Air 

Q. My boyfriend has been startled awake in the middle of the night 3 times this past week, and is gasping for air, and is unable to breathe.  After a moment or two, he is able to regain regular breathing pattern, but, when he is abruptly awoken, he is panicked, as he can't seem to breathe, as if his air passage is blocked. 

What directions should we take with this, and what could possibly be causing this problem? We are concerned that perhaps his body will not wake him if this continues to occur.  Please advise as to options we should do/review to stop this from occurring.

He does not snore or have any previous condition to irregular sleep patterns or any other medical condition at this time.

Thank you.


A. Dear Jen, This sounds like it could be obstructive sleep apnea, even without snoring. Or it could be some aspiration of stomach contents. Better see a pulmonologist and see if a sleep study is needed. Also studies for acid reflux can be considered.

Dr. Tom                                                                                        

Need a Clear Explanation on the Subject of Alveolar-arterial Gradient (Aa gradient)

Q. I couldn't remember how to figure the Aa gradient. I found the equation but I'm looking for a clear explanation that explains the steps and why. Can you please help me?


A. Dear Kay, The alveolar- arterial "gradient" is really a difference. It is due to ventilation-perfusion mismatching, or some abnormality of the alveolar membrane. You can use the formula to calculate it, or you can do an alveolar air sample, if you have the sampling device and compare it with the measured arterial oxygen tension. The factors are the FI02 (fraction of inspired oxygen, the percent concentration of oxygen in the gas entering the lungs), RQ (Respiratory Quotient measures the ratio of the volume of carbon), and PACO2 (Carbon dioxide tension, i.e. pressure, in arterial blood), but you can take the PaCO2 as a surrogate for the alveolar number. Clear?

Dr. Tom                                                                 

Metered Dose Inhaler (MDI) Protocols for Use in Mechanical Ventilation

Q. Are there specific protocols for MDI use via ventilator?


A. Dear Lee, Yes, Look in a respiratory care textbook.

Dr. Tom                                                    


Need Help for the Chronic Pain Following Sixteen Spontaneous Pneumothrax

Q. I am writing to you in hopes that you will be able to help me where others have failed.  My history is as follows:

5 diagnoses of Pericarditis (is a disorder caused by inflammation of the pericardium, which is the sac-like covering of the heart) in 2001

3 diagnoses of a Spontaneous Pneumothorax (Spontaneous pneumothoracies - lung collapse occurs where there is no clear cause)

1 chest tube

2 more Spontaneous Pneumothorax

Chest tube

Pleurodisis Procedure, (a procedure to prevent recurring fluid build-up between the lung linings) orthoscopic

2 more Spontaneous Pneumothorax

Pleuradisis Procedure non orthoscopic

4 Spontaneous Pneumothorax, on Left Side

Chest Tube

2 more Spontaneous Pneumothorax

Pleurodisis on Left Side

3 more Spontaneous Pneumothorax

 ALL this in 4.5 years.

I now have chronic pain with both of my lungs having been operated on.  And I still deal with popping blebs (an air- or fluid-filled sac in the lung, a blister).  I am on a regimen of painkillers and ibuprofen.  Have been for three years. 

Now they want me on either Dilaudid or Methadone.  I want neither of these drugs and want this all to stop.  What can I do to stop getting sick and dealing with pain and taking addictive narcotics?  Hope you can help.


A. Dear Chris, You need to tell me the underlying diagnosis that explains all these spontaneous pneumothoraces. It sounds like you have pleural pain from all these procedures. I would consult an acupuncturist and see if he or she has any ideas. 

Dr. Tom                                                                                                                    

What is Your Opinion of Oxygen Conservers?                       

Q . I have been tested and am eligible to use an "oxygen conserver."  However, my physiotherapist is opposed to it saying that the company just wants to make money since I need to purchase it (not covered by our health plan).  I was anticipating greater freedom and mobility with the conserver. What is your opinion? Currently, I am on 2L 24 hours a day.  I am 73 years old.


A. Dear Rose, Oxygen conserving devices give you more range from portable devices, i.e. bottles or liquid oxygen. You get the best range from liquid devices such as the Helios or Spirit. These have built in conserving devices. Medicare pays for these, but suppliers are slow to admit this. They make more money from concentrators and e-cylinders, which I assume you are using. If so, insist on changing to liquid oxygen. Most Helios type systems will give you 6-8 hours away from home. Insist on being active.

Dr. Tom                                              

Update on Mother' Condition and a Few More Questions

Q. Dear Dr. Tom, Thank you for answering my question regarding my mother ( Worried and at a Loss about How to Help Mother Chronic Lung Problems ) last week.  You have no idea how encouraging it is to have a doctor respond to questions when someone is ill.  I am happy to say my mother is going for a fifth opinion regarding her undiagnosed problems with a pulmonologist next week. 

I was wondering if you know of instances where prednisone has helped sufferers of Vocal Cord Dysfunction (VCD) thereby squashing claims that a diagnosis of VCD could not be made if prednisone did help.  Also, do you have any thoughts or experience with Empty Nose Syndrome occurring in patients that have had sinus surgery? Is there any validity to this syndrome as most of the symptoms match hers?  Thank you in advance for taking the time to respond.


A. Dear Christine, Prednisone does not help vocal chord dysfunction at all. I am not familiar with the "empty nose syndrome".

Dr. Tom                                

Have Had Both Upper Lung Lobes Removed, What Should My Oxygen Level Be?

Q. I have had the upper left lobe 3 1/2 years ago, and the upper right lobe removed 3 weeks ago. All the cancer was removed from both lungs. I came home last week on oxygen.

I'm feeling good but am wondering what my oxygen level would be without oxygen.  What is the average amount of oxygen that I should read at all times with this condition to function properly? Should I have an oxygen meter at home? Thanks for reviewing this. Looking forward to your answer.


A. Dear Guy, There is no way to guess what your oxygen level will be with your remaining lung tissue. You should get your doctor to order, prescribe, a personal oximeter (a device that measures your oxygenation) for your daily use. Insurance will reimburse in many instances.

Dr. Tom                                                                  

Nebulizers Versus Meter Dose Inhalers (MDI's)

Q. My hospital where I work is thinking about switching from nebulizer treatments to MDI's. Could you tell me if there is a benefit of one over the other or is this just a productivity maneuver? Another hospital in my area has already switch so I feel we won't be to far behind


A. Dear Janie, The comparison trials show that the same result is achieved by metered dose inhalers as with powered nebulizers. This can be a great saving in time and money.

Dr. Tom                                                  

Is Lupus Visible on a Chest X-Ray?

Q.   I was very sick for about a week and a half before going to an urgent care center.  I had started a really bad cough and the left lung had a "twinge" in it.

The doctor ordered a chest x-ray and showed me the results.  She was very puzzled, as she saw a very large mass in the right lower lobe.  It blocks the outline of the heart on the frontal view x-ray.  She immediately said it was lupus.  Is this possible to see and should she have ordered a second x-ray? 


  A. Dear Johanna, Lupus can involve the lungs, but it does not produce a large mass. It can cause a localized accumulation of fluid, called an effusion. Usually this is on both sides of the lungs.

Dr. Tom                                                               

Normal Breaths per Minute

Q. How many breaths do average persons breathe in one minute at rest?


A. Dear Joseph, About 12 to 16.

Dr. Tom                          

Should I be Concerned about X-Ray Showing Minimal Biapical Pleural Thickening?

Q. I recently had a chest x-ray and the results said " Minimal Biapical Pleural Thickening." I looked on the Internet to see what that means, but it is very confusing. It sounds like I have the beginnings of lung cancer. Is this true? My dad just died from lung cancer in Oct. of 2005.


A. Dear Kim, We have had several similar questions recently. These x-ray findings are not specific for any diagnosis and may not mean anything. Sometimes there is a residual of a remote inflammation.

Dr. Tom                                     

Worried about Husband's Recovery from Lobectomy

Q. My husband found out that he had lung cancer when he got a knot on the side of his neck that would not go away. It was CT Scanned, his chest, just because he was a smoker and found a 3cm.cancer Stage I., upper left lobe.

         A lobectomy was performed seven months. He has had 3 follow-up CT Scans. The last one showed a spot in the left parotid gland, which was benign. But now the knot on the side of his neck is back. He is on Levaquin but if he is not better soon, he has to go to an ENT.

Ever since surgery he has coughed more and coughed up more stuff than he ever did. He still loses his breath upon doing much at all.

         He did have a second surgery the day after his lobectomy because the bottom 1/2 lung had broken open, 30 stitches were required. So we are sure the healing time will be more but he has good and bad days but never has a day that he does not lose his breath at least once. He is tired and coughs up so much phlegm. He is back to work but so much worse than before the surgery.

         He did not appear sick at all at the time. Any Ideas?


A. Dear Phyllis, He may still be in the healing phase from the lobectomy. He could also have some underlying lung disease such as COPD, which is common in lung cancer patients. The "knot" in the neck needs explanation.

Dr. Tom

Electrical Lung Massager

Q. As part of my "homecare treatment" the physiotherapist has recommended a "massage of the particular the lower lobes."  As a result of the massage, I am coughing a great deal, and although the mucus amount that I am spitting up has increased, it is not really significant. I am to have the massager (electrical) twice a day for a period of about 10 to 15 minutes. What is your opinion of this lung pummeling method? 

A. Dear Rose, This may help mobilize secretions from the lungs. It is not usually necessary for prolonged periods of time.

Dr. Tom

2024 American Association for Respiratory Care