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Archive: Dr. Tom 66
Q. I have a patient on 6 lpm by nasal cannula. He is end stage COPD; his typical resting SAO2 is in the mid 80's. What should I implement next? Is a nasal cannula designed to use with flows of 6 lpm and up? Gerry A. Dear Gerry, Six liters is about the limit a nasal cannula can deliver, depending on the design. You can use masks with cannula to get even higher flows to the mouth, but in an open system, there is a limit to the actual amount of oxygen delivered to the nose and mouth. Transtracheal oxygen delivery may be more efficient. Dr. Tom Can You Help Me Understand my CT Scan Results? Q. I had CT scans done on my lungs; one on 02/01/2006 and the follow-up on 05/17/2006. I want to know should I follow-up in another 3 months or wait 6 months? Also the findings on the breast? Can you explain the report? Date of Service 02/01/2006: CT of the Thorax with contrast. There is a 4mm pleural nodule seen at the posterior left upper lung just adjacent to the superior aspect of the major fissure. Series 3 Image10, which is essentially unchanged and not calcified. Previous tiny area reported 1.5mm calcified nodule in the left lower lobe is not identified. The area of bronchiolectasis in the lower lung fields are also not identified at this time compared to the prior study. A faint 1cm area of fibrosis is suggested on Series 3 Images 20-21, which is slightly more prominent than on the prior study. IMPRESSION: 1. There is a 4mm pleural plaque posteriorly on the left just above the level of the major fissure, which is unchanged. 2. A small area of peripheral patchy fibrosis is seen at the posterior lateral right upper lung. 3. Previously described areas of bronchiolectasis and tiny 1.5mm nodule in the left lower lung are not identified on this study. Follow-up report Date of Exam 05/17/2006 without contrast. A small subcentimeter pulmonary nodule is seen within the posterior aspect of the left upper lobe. There is mild thickening of the major fissure on the left. A small soft tissue density is seen within the medial aspect of the left breast. IMPRESSION: 1. There is a 5mm pulmonary nodule seen within the left upper lobe posterolaterally along the pleural surface. 2. There is a small soft tissue density seen within the medial aspect of the left breast. This measures approximately 5mm. This can be correlated with mammography if clinically indicated. Temperance A. Dear Temperance, This has to be interpreted by your doctor, depending on your risk factors for malignancy. These findings are not alarming in themselves Dr. Tom What Do You Think of the New Technology being Developed for the Lungs? Q. What do you think of some of the new clinical tests being done on such things as biological glue, and valves being used to reduce lungs, instead of surgery? Will it help to have the bad part of the lung taken care of? That is, will the remaining "Good Lung" get stronger, and help to reduce the shortness of breath? Mark A. Dear Mark, These topics are the subject of vigorous research right now. They could be helpful in reducing the lung occupied by poor lung tissue, and in reducing lung leaks. Fortunately many innovative ideas are being pursued that could help some people. Dr. Tom RNs Supervising a Respiratory Department Q. Are there any guidelines in AARC that would prevent an RN from supervising a respiratory department? Leslie A . Dear Leslie, Not that I know about. The RN, of course, should be knowledgeable and experienced in respiratory therapy. Some nurses achieve their registry in respiratory therapy. Dr. Tom Update from Craig Read past correspondence from Craig in Dr. Tom 62 and Dr. Tom 63 . Q. Hello, Sorry for being such a pain. I've emailed a couple of times before regarding my asthma/silicosis questions. I had the 48% decrease during my methacholine challenge. I've been on Pulmicort for almost 3 weeks, and have only had mild improvement. Cough is less, but I still hear the wheeze. I've been having more and more pain in my very low chest/upper abdomen that wraps around to my back. It feels sore, and achy. Comes and goes, but seems like it's been present more than not over the past couple weeks. No real pain in my upper chest to speak of. Of course I assume that it's all related, and it makes me worry about silicosis more, but could it be something else? Perhaps pleurisy? Let me know what you think. I'm trying to get back to my pulmonary doc in a couple weeks, but always value your opinion. Craig A. Dear Craig, These pains are not due to silicosis. They seem muscular in origin. Dr. Tom Please tell me about Bronchiolitis and How does this Happen to a 73 Year-Old? Q. Dear Dr. Tom: I have been diagnosed with "bronchiolitis." Although I have looked at articles on the Internet, they basically say it is "a childhood sickness." Could you please explain how I contracted this being 73 years of age? Any ideas for some proactive strategies for me? Rose A. Dear Rose, Bronchiloitis means an inflammation of the smallest airways of the lungs. This may be due to an acute viral infection, or have other causes such as immune reactions in your lungs. I cannot give you a simple answer, since there are a number of forms of bronchiolitis, both acute and chronic. If you are still having symptoms, you should see a pulmonologist. Dr. Tom Sister is a Non-Smoker; How Come She has Biapical Scarring? Q. A recent chest x-ray shows that my sister has biapical scarring of the lungs - what causes this? She is a non-smoker, healthy eater, not around smokers, has asthma. Mara A. Dear Mara, These x-ray findings are not specific for any diagnosis, and in isolation, don't mean much. Dr. Tom What is the Normal Oxygen Saturation for an Infant? Q. What is the ideal / normal oxygen saturation rate for a baby. My son is 1 month old. Michelle A. Dear Michelle, About 98%. Infants have blood that saturates extremely well, on air, assuming no disease is present. Dr. Tom Need Some Insight on Cytology Report Q. I've been diagnosed with pulmonary fibrosis (PF) and Stage IV sarcoidosis ( a disease of unknown cause in which inflammation occurs in the lymph nodes, lungs, liver, eyes, skin, or other tissues) . My doctor came to this conclusion after an open lung biopsy in March 2006. I haven't been told much. I have a copy of my cytologic diagnosis (the analysis of cells under a microscope): Negative for malignancy (that's good I know what that means). This part I don't understand what it means: "Reactive bronchial epithelial cells and pulmonary macrophages." Could you give me some insight on this please? William A. Dear William, These finding are consistent
with PF due to a number of causes, including Sarcoidosis.
Diprivan for Pain Management Q. Dr. Tom, My 89 year-old father recently was intubated (introduction of a tube into the trachea to keep airway open and can be connected to a mechanical ventilator) for 16 days due to a second bout with pneumonia. This was his third time on ventilator with the prior two times being one and a three-day period. He had already stated the pain and discomfort of the three-day experience. One of his nurses revealed to me that his current pulmonologist was only one known to him to not use a Diprivan drip (an intravenous sedative-hypnotic agent) to ease the torture. He passed away three days after weaning. Do you know of any benefit of denying a patient this medication for pain management? Ross A. Dear Ross, The use of Diprivan is common, but not employed sometimes because of various reasons. I really cannot give you a good answer about why his doctor did not use it. Why not ask him? Dr. Tom Medications Used in the Treatment of Wegner's Disease Q. My good friend has Wegner's disease ( Wegener's Granulomatosis is an uncommondisease, in which the blood vessels are inflamed) . He is on chemotherapy and steroids, and I was reading up on it and it just tells about the medications they usually take. Is he on chemo and steroids because they caught it too late and he is probably in the fatal stages? Kim A. Dear Kim, Steroids and chemotherapy are the standard of care for most patients with Wegener's Granulomatosis. It is often effective. There are a few other medications that are sometimes used. Dr. Tom Enlarged Uvula and Breathing Problems Q. I am male, nearly 63 and have never smoked. I have an enlarged uvula (the small piece of soft tissue that can be seen dangling down from the roof of the mouth over the back of the tongue.). I have had a cough and faint wheezing in my throat area. I snore loudly. I have awakened suddenly and must sit up quickly in order to cough, cough, cough until I regain enough air to take a breath and over-ride the need to cough. I feel like the enlarged uvula is closing my throat. I still have my tonsils. I got a chest x-ray and am told I have "mild to moderate" COPD. I drink 3 quarts of water a day. I do very little exercising but am active in the yard and walk some. Anything I should do? A. Dear Glenn, The chest x-ray cannot diagnose mild to moderate COPD. You need spirometry (see National Lung Health Education Program; https://www.nlhep.org/spirom1.html ). You should ask a pulmonologist about the uvula and the possibility of obstructive sleep apnea. He can do studies to confirm this and recommend a solution, which could include surgery. Dr. Tom Confused about Two Pulmonologist Thoughts about My Scan Results Q. I wrote to you in 10/05 because my DLCO had dropped significantly over a 15-month period, and I was concerned about the changes. You thought it was probably an error, and I am inclined to agree with you based on what I have learned in a pulmonary rehab class. However, because of the change in the DLCO, my pulmonologist was concerned about interstitial lung disease (ILD) and had an HRCT scan ( High Resolution CT Scan ) done. His impression was no ILD, but old scarring. When I returned for a follow-up visit, I was seen by another pulmonologist, in the same office, who looked at the HRCT and said he thought I had "suspected but not confirmed" ILD. I have severe osteoporosis and can't take prednisone, so he suggested I wait another year and have the CT scan done again. I don't know which of these doctors to believe. The radiology reading is as follows: "Evidence of scattered atelectatic/scarring changes within the right and left lungs, most prominent at the lung bases. Evidence of curvilinear opacities just 1-2 mm from pleural surface, paralleling the pleural interface consistent with subpleural lines, most prominent in the region of the posterolateral lower left lung. Pulmonary parenchymal scarring appears as irregular septal thickening with some distortion of the underlying parenchyma. Conclusion: Evidence of pulmonary parenchymal scarring characterized by primarily basilar interlobular, peripheral septal thickening, as well as subpleural lines. Findings are nonspecific in etiology." I had several bad lung infections in my 20's, and think the scarring is probably due to these infections, but obviously I'm not a doctor. Which of these doctors should I rely on? Should I find a third pulmonologist to look at the films? Should I be doing something more aggressive than simply waiting for the follow-up CT? Any help you can give would be appreciated. Sharon A. Dear Sharon, The remote infections could explain the scarring. If so, the diffusion test should not be falling. You should pick a pulmonologist who you like and trust and followhis advice. Dr. Tom COPD Prognosis Q. I have COPD and am 59 years old. I need to know, how long does one have? Nandy Dr. Tom Have Pulmonary Hypertension and Still Coughing
after Finishing Antibiotics I have been coughing and was given an antibiotic without being seen by the doctor. I have had the cough for two weeks - on my last day of antibiotic. My temp is 99.9 and my pulse doesn't go lower than 98. I am short of breath. I am scared. Does the high pulse mean anything? Cindy A. Dear Cindy, It may be significant. You need a diagnosis that explains all that is going on. Ask your pulmonologist. Dr. Tom Son Fell and Temporarily Couldn't Breathe, Are There Complications that I Should BeAware? Q. My 10 year old fell on skates today. He fell directly on his back. He was wearing those rolling heely shoes... he fell and immediately afterward couldn't talk and or breathe! It scared us so much I called 911. By the time the police arrived he was shaken up and in pain but able to thankfully breathe again! We were obviously terrified! I had heard of getting breath knocked out from a punch to the gut, but this was way worse than that. Do you know what may have happened? What should I look for? He seems okay although obviously his back hurts? Any suggestions? Betsy A. Dear Betsy, He probably did get "the wind knocked
out of him." He should be okay ow. If he gets short
of breath, see your doctor. Omega 3 and Effectiveness in Treatment of COPD Q. I have what my pulmonary doctor describes as very mild COPD. I scour the web to try to educate myself and I recently read an article about Omega 3 and its ability to reduce inflammation. The article stated improvements in lung function were shown and it went on to say another might start using much larger doses. The doses given to COPD patients were confusing to me. I believe this was reported in Medscape. I use Omega 3 for cholesterol with excellent results. Your thoughts please, on Omega 3 to reduce inflammation COPD. Don A. Dear Don, It makes sense. Dr. Tom Want to Quit Taking Hypertension Medicine Q. I have been taking Ziac ( used to treat hypertension ) for about 5 years at the lowest dose (2.5/6.5). I have quit my stressful job, and want to go off, but every time I try, my heart races and I have anxiety. Am I addicted to neurotransmitters? Is there a way for me to go off slowly? I hear these are time-released tablets and I cannot cut them in half. Can you advise? Pam A. Dear Pam, You will probably need to take antihypertensive to control your hypertension. There are a number of medication alternatives. Ask your doctor. DR Tom Concerned about Cancer-Causing Asbestos Q. I work in Sacramento at a hospital built in the 1960's. Part of my Human Resource package was a disclaimer stating, if I get mesothelioma (malignant mesothelioma is a cancerous tumor of the pleura [lining of the lung and chest cavity] or peritoneum [lining of the abdomen] that is almost always caused by sustained exposure to asbestos) working here, I won't be able to sue the establishment. I don't want to sue; mostly I don't want asbestos cancer. This building is worked on often and is tented and monitored by technicians taking down information and telling us that it's all safe. However I suffer from a scratchy throat and other allergic reactions when the work is being done. So tell me, what do you think? Anne A. Dear Anne, The likelihood of getting high asbestos exposure is small. It is not causing a scratchy throat. Dr. Tom For more information about Mesothelioma see: https://www.lunghealthonline.com/lung_disease/mesothelioma/ Spot on Lung Has Grown Over the Past 9 Years Q. In 1997 I had a 5 m spot on my lung. In 2002 a CT scan showed the same spot. Because it didn't grow, they said likely a granuloma. Last month I had another scan and this spot measured 9 m. My question, since I can trace it back 9 years of being there what's the chance of that spot being cancer? Also I raised a lot of birds. Liz A. Dear Liz, The chance is about zero. It may be a granuloma from a fungus carried by birds, known as histoplasmosis. It is healed and nothing more needs to be done. Dr. Tom Questions about Diffusion Q. Could you please tell me what number is the more important, the DLCO or the DLCO/VA? And if there is a normal range for the DLCO? My DLCO number is in the lower 70's but my DLCO/VA is in the upper 90's. My pulmonologist told me that means I'm ok, no sign of obstruction or restriction. Can I have your opinion please? Cindy A. Dear Cindy, The DLCO is the actual amount of tracer gas that crosses the lungs. The DLCO/VA makes an adjustment for the size of your lungs. Yours is normal. Dr. Tom |
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