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

 

 

Does Foradil Cause Asthma Related Deaths?
Q. Hello, My doctor has prescribed Spiriva, and Foradil to be taken at the same time. I am currently on Spiriva, but am unable to take Foradil, as I am too nervous because they have the warnings about asthma related death increased.

How can this drug Foradil cause an asthma related death? I just can't bring myself to take the drug. Currently I have been taking Spiriva, and using albuterol four times a day. Thank-you,

Terri

A. Foradil and Spiriva contains drugs that are quite compatible. I am not aware of any convincing study that indicates an increase of asthma related deaths from Foradil. I believe these drugs individually and together, are safe.

Dr. Tom

Want to Know What Spirometry Results Mean
Q. I recently was diagnosed with COPD. I had spirometry done, a week ago and as of yet, have not heard from doctor. The technician would only tell me that for my age (64), height 5'2" and weight 110, that my FEV1 should be 2.01 and mine was 1.98 first time and 1.93 second time, my peak flow he said was 540 and I also had hyperinflated lungs. He never told me the FVC so I do not know what all this means.

I am on Spiriva and albuterol (which, by the way, does not work very well for me). I get shortness of breath, but I can run up and down my stairs and never get out of breath, I walk six miles a day, and do breathing exercises. I just get nervous when I cannot catch my breath and I panic, and have an anxiety attack.

I do not understand why the doctor has not called me. I know I should probably call him, but I do not want to pester him. Can you interpret the scores that were given to me?

Peggy

A. Dear Peggy, Your FEV1 is within the normal range as is your peak flow. Hyperinflation cannot be diagnosed from a spirogram.

The FVC would be useful, but I believe we can conclude that you have normal airflow. The FVC would tell us if you have normal air volumes to exchange with the atmosphere.

I believe it is fine to "bug" your doctor for these two key numbers from spirometry and their ratio. Normal FEV1/FVC is 70% or more.

Dr. Tom

In Reference to Previous Answer to: Is it Safe to Take Combivent and Spiriva
Q. I read with interest your response of May 9th regarding using Combivent and Spiriva together. In the patient instructions for Spiriva it says it is not recommended. Although it may not hurt you should we not follow the manufacturer’s advice? I am confused. We all know our PCP doctors cannot possibly know everything. Is it Ok to show them this or is it considered in bad taste to question our doctors? Thank–you so much for your opinion and this column.

Steven

A. Dear Steven, It is fine to question your doctor about his diagnosis or treatment. In general it is wise to follow manufacturer's recommendations, but these are conservative and do not cover all uses of the drug being described. Take your doctor's advice after you are comfortable with his explanations.

Dr. Tom

Troubled Doctor’s Explanation of Sixteen Year Old Daughter’s Lung Problem
Q. Dr. Tom my 16 year-old daughter recently had to go to the doctor for chest pains. The diagnosis was that she had an air bubble in her chest where the lung had leaked air but now her oxygen level is running about 94 and the doctor is treating her for asthma although she has no signs of asthma. After the air pocket is completely gone the doctor is going to do a lung test.

The doctor says if it isn't asthma it could be something more serious like cystic fibrosis. Would we not have seen signs of this before now? The doctor just has me a little scared now and waiting six weeks for the lung test makes it even harder.

Shirl

A. Dear Shirl, The description of the chest x-ray does not suggest cystic fibrosis. You need a diagnosis that fits your daughter's findings.

It is likely that the "bubble" was a small defect on the surface of the lung that leaked air into the chest. This is known as a pneumothorax. It usually resolves spontaneously or the air can be removed by a small tube.

A test of her lung function would be appropriate.

Dr. Tom

Are There Any Medication Options for Severe COPD?
Q. My 82-year -old mother has moderate to severe COPD. Lately, her symptoms have worsened to where it is harder for her to breathe, she is on Spiriva, and Combivent to help with her symptoms and lung function. Sir my question today is, are there any other medications which could be of help and is the 14.7g Combivent the strongest available?

Mom, had a quintuple heart bypass in 1996, and had been on Atrovent and albuterol prior to switching to Combivent. Are there other treatments or are we nearing the end of our options? Any insight you may provide will certainly be helpful.

James

A. Dear James, There are options. Foradil, or the combination (anti-inflammatory corticosteroid and a long-acting selective beta2-adrenergic agonist) Symbicort are examples. There is no medication that will dramatically improve airflow in older patients with advanced disease, but many products help to improve symptoms.

Dr. Tom

Worried About the Effects of Wife’s Smoking and Effects on Children
Q. Hi Doc. I'm a concerned husband and father...and a healthy non-smoker.
Situation 1: To my knowledge, my wife has been a smoker since she was 17. She is 30 now. We have been married four years. Recently, she developed chemical pneumonia from excessive inhalation of household bleach vapors while cleaning. She quit smoking due to the chest pain from the pneumonia, though cravings and "nic-fits" are still apparent. I'm worried the damage is irreversible. Even if she stops smoking, I wonder, will she get cancer? What can I do to help?

Situation 2: My two children, especially my three year-old son, seem to suffer from colds and lung-related infections, A LOT! My wife claims she doesn't smoke around the children, but I've always had a hunch that their getting sick is somehow related to secondhand cigarette smoke exposure. How do I protect my kids and still be respectful of my wife's smoking?

Nick

A. Dear Nick, This is a tough problem, since you have somewhat competing responsibilities. Key is for your wife to stop smoking NOW. New drugs are available to help this. At her young age, you can prevent lung cancer. Get her to smoke only outside to help protect the kids.

Dr. Tom

Side-Effects of Antibiotic
Q. Dr. Tom, I recently took amoxicillin to treat strep throat. A couple of days after going off it I developed what I thought was a yeast infection, itching and redness of the genital area. This has happened to me before when taking antibiotics, so I took over the counter stuff and thought I would be done with it. It is now almost two weeks later...I still have itching and redness in the vaginal area and it is extremely uncomfortable. I have been to the doctor and he said he didn't see any signs of yeast? He treated me for bacterial vaginosis, but that didn't work either.

Could this be an allergic reaction to the amoxicillin? How long will this last? It is almost unbearable. It can't be an STD...as you actually have to have sex to get those, which I'm not. I am clueless as to what to do...the only relief I have found is by either taking Benadryl or using hydrocortisone cream. But the relief doesn't last. Please Help!

Melissa

A. Dear Melissa, I doubt this is due to amoxicillin. I am not a gynecologist and have no way of knowing what is best for your condition. See a gynecologist.

Dr. Tom

Prognosis and Course of Treatment for Atelectasis
Q. Chest CT shows no active pulmonary or pleural disease, no mass lesion or lymphadenopathy. There is bibasilar dependent atelectasis (collapse of the lung or part of the lung), scarring in the lingula of the right middle lobe. Could you explain my prognosis course of treatment and other tests I need? In October I had my thyroid removed. Could the intubation be a cause?

Jelitza

A. Dear Jelitza, The cause of the atelectasis needs to be found. I suggest seeing a pulmonologist.

Dr. Tom

Bullous Emphysema
Q. Dr. Tom: Welcome back! I am a 31 year-old male with a very heavy smoking history (2+ packs/day through my late-teens and 20's...roughly a 30 pack-year smoking history).

I quit in March (2007) when I received a diagnosis of "bullous emphysema" via a chest x-ray (report states there is a "single, large bullous on the right upper lobe"). I quit immediately.

I was tested at that time for Alpha-1 Antitrypsin Deficiency, and the test came back normal (no deficiency).

I have since moved to Denver and am being seen at National Jewish.

I had a basic spirometry test during my initial appointment at National Jewish, and am currently awaiting an appointment to have more detailed lung function tests and a chest CT done (both to be done in late August). The results of my basic, initial spirometry are as follows:
FVC = 5.95 L (114% predicted)
FEV1 = 4.64 L (109% predicted)
FEV1/FVC = 78%

I was told that while the FEV1/FVC ratio was a touch low (I gather that it should hover around 80-85%), my spirometry results are essentially normal. I know that I have done the best thing I can do for myself in quitting smoking...but I am still very concerned as I await further lung function and CT testing.

I have not been able to find much literature in terms of bullous emphysema in someone my age. What does a bullous lesion on my right upper lobe mean for my future? Life span? What things should I be on the "lookout" for? Is this something that will merely need to be monitored over the years, or something that needs surgical intervention/attention?

Thank you for your time, Dr. Tom! I hope this finds you well!

Jay

A. Dear Jay, Your lung function is normal. I doubt there is a reason to remove the single large bulla. Your prognosis is excellent.

Dr. Tom

Aching Hip During Exercise
Q. Dear Dr. Tom, I have just finished my rehabilitation at Westpark Hospital here in Toronto, under the direction of Dr Roger Goldstein. I did my six-minute walk and managed 508 meters, and for my endurance walk I managed 55 minutes. My problem is this. When exercising my hips ache. It is not a pain it is an ache, and sometimes but not always my legs are sore. I walk on the treadmill three times weekly. The ache is in the back area near both hips. It goes away when seated. I do have a groin hernia, and I am overweight. Could those be the cause of my hip problems?

Philip

A. Dear Philip, Your being overweight could be contributing to your hip problem. Do you have any osteoporosis? You are going to a good place for pulmonary rehabilitation.

Dr. Tom

Pulmonary Nodules Found on CT Scan
Q. I just had a baseline CT of my chest (four years out from papillary thyroid cancer and new doctor wanted this test). It came back with two pulmonary nodules (one in each lung 4 mm and 5 mm). They are noncalcified but it says little else other than continued follow-up is recommended. I am very worried about these findings. I'm 37, nonsmoker, healthy eater, avid exerciser. I see a specialist in two weeks. Could these be benign?

Gretchen

A. Dear Gretchen, Yes. These are most likely benign. I recommend a simple follow-up, as you are doing.

Dr. Tom

Does Chest X-Ray Warrant Further Testing?
Q. I had been unwell for several weeks and had an x-ray. The report said my lungs are hyper-expanded in keeping with the background emphysema. No focal lung masses or consolidation. No suggestion of interstitial fibrosis or pulmonary edema. The costophrenic recesses are well preserved. No pneumothorax. No obvious bronchial wall thickening or bronchiectasis.

I am 71 years old and smoked from when I was 17 to about 40. Do you think I should have further tests?

Genevieve

A. Dear Genevieve, No. The only thing you might do is get spirometry to test your lung function. Hyperinflation on a chest x-ray does not mean much.

Dr. Tom

Had Heart Transplant and Kidney Levels are Raised
Q. Had a heart transplant ten years ago. My Dr. said kidney levels are raised, what does this mean? Are my other organs starting to give up?

Elaine

A. Dear Elaine, I would need more details to be able to answer your question. What is your kidney function in numbers? What does your doctor advise?

Dr. Tom

Progression of Emphysema
Q. I was diagnosed with emphysema this past January. I am on Advair and Spiriva. I am 42 years old. I have been a very light smoker for years, one-five cigarettes a day, which I have quit.

My question is does emphysema have to get worse? If I quit smoking and exercise, adopt a healthy lifestyle—will it still progress?

Deborah

A. Dear Deborah, Emphysema does not have to get worse. Good that you stopped smoking and are on medications that potentially could retard the loss of lung function. Lung function goes down slowly and normally with age. Stay well.

Dr. Tom

Expected FEV1 Improvement and Albuterol
Q. Hello Dr. Tom. Using FEV1 as the marker, what would you define as a clinical response to albuterol? I looked in the NIH guidelines for this and there was mention of 12% and 200 mls as a measure for diagnosis. However, I already have asthma, so diagnosis is no longer relevant. If I were to take my inhaler what kind of change in FEV1 is relevant?

Chris

A. Dear Chris, These changes that you cite are relevant, but may be more if you have an asthma component.

Dr. Tom

Interstitial Pulmonary Fibrosis and
Q. Dr. Tom, Two years ago I was diagnosed with IPF. I took prednisone for about three months. It cleared up the coughing, low blood oxygen levels, everything. Since then I have been doing great. Only a couple of times during the cold weather I took it for a couple of days for coughing.

I was told that the interstitial pneumonitis is the first stage of Pulmonary Fibrosis, which is fatal. I heard a rate of 2-6 years.

Since I am feeling so good I was wondering if all of a sudden you just get really bad, and it's downhill from then. I would like another high resolution CT Scan to show any worsening in my lungs, but they tell me that a breathing test is a better test.

Is that right. Should I have another opinion on this?

Betty

A. Dear Betty, The breathing test tells about function. The CT Scan gives information on structure. They usually parallel each other. I think another CT Scan in your case would be useful.

DR Tom

Irregular Looking Non-Calcified Lung Nodules
Q. Hi Dr. Tom- I am a Testicular Cancer (TC) Survivor for over seven years now. I just moved to a new city and had a doctor order a pelvic and abdominal and a chest CT Scan for my annual exam. I've never had a chest CT Scan in the past just x-ray's.

My scan came back showing two small non-calcified nodules in my middle right lung (biggest being 5mm). The report said they looked irregular. I have spoken with a few doctors concerning recurrence of TC but they all seem to think it is almost impossible because of how aggressive I was in treating it and how early I caught it.

The rest of my scan is clean so my only concern is lung cancer. I am 31 years old and smoked about three years (18-21) very lightly. I understand the odds are well in my favor that these two tiny nodes are not cancer but I am a little concerned because the report said they are irregular. The report also says that they may represent scars.

Just want your thoughts.

Ben

Q. Dear Ben, These are almost certainly benign, and may well be scars. I would forget lung cancer as any significant risk. Stay well.

Dr Tom

Have Been Diagnosed with Costochondritis
Q. I was diagnosed with lymphoma cancer due to large lymph nodes increased white blood count, CT Scan and chest x-rays backing. I under went open lung biopsy. My lung collapsed and have had chronic pain due to the surgery for four years. They had a negative biopsy for cancer.

I was then told I have COPD, chronic bronchitis, asbestosis, silicosis.

I was a master mason for 18 years and would on a daily basis have exposure to large amounts of masonry and concrete dust, I’ve been dealing with the most horrific pain in my chest since ... and today I ended up in the ER in the Cardiac Care Unit, where they did EKG (no heart problems, thank goodness), and a chest x-ray and a CT with contrast. Astonished when the Dr. came and told me they found no scaring whatsoever and no asbestosis and no silicosis and I had use of full lungs. They are in good shape besides one tiny nodule.

In surgery when my lung collapsed some how I came out with the loss of my lower lobe. It was not working for almost four years now. My question is how can all this be possible? It’s almost as if I have been healed. Its now 3:22 am here in St. Petersburg and I can’t sleep because I’m overwhelmed I just don’t know what to think anymore. The diagnosis tonight was costochondritis.

Thanks for any information you can assist me with.

Alder

A. Dear Adler, Chronically collapsed lungs can re expand. Costochrondritis is a benign (not a threat to life or long term health) chest condition where the cartilages of the front of the chest are irritated or inflamed. This should resolve spontaneously.

Dr. Tom

Using Oxygen but Wake-Up Short of Breath
Q. Dear Dr. Tom, I am currently on two liters of oxygen at night when I sleep. Some nights I wake up and I am short of breath. Should I increase the number of liters I use? I also use a nebulizer with DuoNeb four times a day. Can I increase the times a day if I feel I need it?

Deon

A. Dear Deon, Shortness of breath is not usually a factor in low oxygen. This comes from altered mechanics of breathing. Ask your doctor about taking DuoNeb more often. I do not give specific advice on treatment in these replies.

Dr. Tom

Carbon Dioxide and Our Bodies
Q. Is it true that we need a certain amount of carbon dioxide in our body, and if so what amount? Could you tell me more about why it's needed and the symptoms of too much?

Alice

A. Dear Alice, Carbon dioxide is the normal product of metabolism, the "burning" of food stuff for energy production. This requires oxygen. Normal PCO2 is 40-44 mm Hg. The "P" refers to the pressure of the CO2.

Dr. Tom

Improving Lung Function after Chemotherapy
Q. I am 29 and I smoked about a pack a day for 12 years. I quit cold turkey in 2003 when I was diagnosed with Hodgkins. I was given the ABVD chemo for 12 months and I am now cancer free for 3 years. My lungs are in bad shape now and I am taking a test to become a police officer. So my question is. What is the best and quickest way to re strengthen my lungs so I can pass a 1 1/2 mile run in 16 1/2 minutes?

Randy

A. Dear Randy You can improve your conditioning by running. You cannot "strengthen" your lungs.

Dr. Tom

Experiencing Edema as a Side Effect of BiPAP
Q. I have been on a BiPAP machine for six years. I have had generalized edema and a lot of hair loss since. My abdominal girth can get as big as 50 inches or as small as 36 inches.

I was off my machine for two weeks due to forgetting it when I went on vacation. I noted that while I began to have symptoms of HA, sleepiness; my edema was no longer an issue. My abdomen softened, flattened, and my arms, legs, neck no longer were swollen and edematous.

My doctors seem stumped. Have you ever experienced this? Thank you for your time,

Michelle

A. Dear Michelle, I do not have much experience with BiPAP and do not have an explanation for your improvement. Accept it as a gift from God.

Dr Tom