Can a Nasal Cannula Deliver Oxygen at 6 Liters per
Minute, or More?
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?
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.
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
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.
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
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?
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.
RNs Supervising a Respiratory Department
Q. Are there any guidelines in AARC that would
prevent an RN from supervising a respiratory department?
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.
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
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.
A. Dear Craig, These pains are not due to silicosis.
They seem muscular in origin.
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?
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
Sister is a Non-Smoker; How Come She has
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,
A. Dear Mara, These x-ray findings are not specific
for any diagnosis, and in isolation, don't mean
What is the Normal Oxygen Saturation for
Q. What is the ideal / normal oxygen saturation
rate for a baby. My son is 1 month old.
A. Dear Michelle, About 98%. Infants have blood
that saturates extremely well, on air, assuming
no disease is present.
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?
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?
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?
Medications Used in the Treatment of Wegner's
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?
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.
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.
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
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.
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.
Q. I have COPD and am 59 years old. I need to know,
how long does one have?
A. Dear Nandy, It depends on whether you have stopped
smoking and what level your spirometry is now. See
Have Pulmonary Hypertension and Still Coughing
after Finishing Antibiotics
Q. I have secondary pulmonary hypertension (secondary
pulmonary hypertension isabnormally high blood pressure
in the arteries of the lung due to lung or heart
disease) which is better because of use of 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 ) and oxygen at night.
I also have diastolic heart failure.
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?
A. Dear Cindy, It may be significant. You need
a diagnosis that explains all that is going on.
Ask your pulmonologist.
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?
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
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
A. Dear Don, It makes sense.
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?
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
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
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?
A. Dear Anne, The likelihood of getting
high asbestos exposure is small. It is not causing
a scratchy throat.
For more information about Mesothelioma see:
Spot on Lung Has Grown Over the Past 9
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.
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.
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?
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