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

 

 

I Have Bronchiectasis, How Can Keep My Airways Healthy?
Q. I have recently received a diagnosis of bronchiectasis is there any thing I can do to stop the destruction of my airways?  I am 70 years old and had a bad case of whooping cough as a child.

C

A. Be sure you get an influenza shot each fall. Get antibiotics for any chest infection that gives you colored sputum. Eat lots of fruits and vegetables for their antioxidants, and avoid all smoking or smoking environments. You will likely be able to prevent further destruction of your lungs by following these simple suggestions.

Dr. Tom                                 

Can Horrible Sweats and Panic Feeling be a Symptom of COPD?
Q. DR. Tom, I am a 48 year-old female with COPD. My question has to do with my heart and sweating, on and off 24/7.  I break out in a horrible sweat; comes on suddenly and soaks me from chest to top of head. I also get a feeling of panic when this happens that I can’t explain. Only lasts a minute or two then gone till the next round.
I have lost three brothers to heart attacks so I went to the doctor. Had stress test and test called echo I think. He said I have extra beat and fast heart rate that he felt was due to COPD. Said he would give me something for this if it bothers me. I forgot I also wore monitor for 48 hours at home.
He said sometimes my heart rate really got up there, referred to it has my heart going into over drive. What do you think about all this, it just left me confused? I am on maintenance dose of prednisone. 10 mg a day, neb machine 4-x day.

Kathy

A. These symptoms are not part of COPD. Be careful about any beta blockers, which cardiologists like to give for rapid heart beating, if you have COPD. Beta blockers can caused bronchospasm.

Dr. Tom

White Spots on Chest X-Ray
Q. I had a chest x-ray today and saw some white spots. My Dr. said I have bronchitis. When I asked about the white spots, he said they could be the tips of the blood vessels or calcium deposits. How does he know it can be either of those versus cancer? Do I need a second opinion or CT Scan?

Mary

A. Dear Mary, There is no problem with distinguishing vessels on end, from calcium in nodules. Better get another opinion from someone more experienced.

Dr. Tom

What does the Word “Possibility” Mean in X-Ray Report? Dr. Tom 81 Follow up
Q. First let me thank you so much for answering a question I submitted to you a few weeks ago. I can't tell you how helpful it is to have someone as knowledgeable as yourself actually take the time to help others with their concerns.

 I'm afraid I had no real hope of a response in my earlier question so I did not thoroughly express my entire question. My CT scan shows " a possibility of a very tiny nodule 1-2mm posteriorly right mid lung area". The doctor reading the scan just said " possibility " 

Is this typical wording in such a report do they say possibility to cover them in case of an error? Should I ask they re-read their scan?

The report also notes minimal juxta pleural thickening posteriorly upper left lobe most likely post inflammatory in nature. I have no idea what that really means.

I have no symptoms of any illness at this time. The scan was done in May when I complained of chest pains. After many negative tests my doctor concluded the pains were costochondritis Now that I know I may have a lung nodule I can think of nothing else.

I am a 47 year-old female former smoker. My doctor says to have scan done again in 6 months. I went for a 2nd opinion to another doctor he said wait a year. I am so confused.

How likely is this to be cancer? If cancer, is treatment ever successful or just prolonging the end?

Thank you very much for your help, as I’m sure you can tell I’m quite upset over this

K

A. Dear K., The "possibility" of a tiny nodule is meaningless. It is either there or NOT there! Such a tiny nodule would most likely be benign, anyway. I suggest another CT in six months, or even better, in a year.  Put your mind at ease.

Dr. Tom

Hypobaric Chamber and COPD
Q. Has there been any research into using a hypobaric chamber (not hyperbaric) to help treat emphysema patients?
I have emphysema and was wondering if it would be feasible to reduce the pressure inside a chamber to, say, 0.9 atm so that the higher pressure inside the body would make it easier to breathe out, releasing trapped air and deflating hyperinflated lungs. It should be possible to keep the overall pressure low while maintaining a good O2 flow.

Dave

A. Dear Dave, No! This would be like going to a mild altitude such as Denver or Salt Lake. It would reduce your oxygen, and not assist you with your breathing.

Dr. Tom

My Grandfather was Prescribed Oral Mucomyst for His Lungs
Q. I am a respiratory therapy student, so I have some background. My 94 year-old Grandfather was prescribed oral Mucomyst TID because the pulmonologist heard bubbly sounds in his lungs today. Is this treatment correct? I have never heard of Mucomyst being administered orally except in overdose or renal problems, none of which, he has.
A. Dear Mary, Oral mucomyst, acetylcysteine, is commonly used in Europe as a powerful antioxidant to help prevent lung damage. It is safe and has a fairly good scientific basis.

Dr. Tom                                                                 

Bronchodilators for Respiratory Syncytial Virus (RSV)
Q. Could you tell me where I can find information that either backs up or disputes the use of bronchodilator therapy with the RSV patient whose breath sounds are not wheezing?

Rosaly

A. Dear Rosaly, It is commonly used for the wheezing of bronchiolitis due to RSV infection in pediatric practice. I do not know a reference I can quote from memory.

Dr. Tom                                                           

Importance of Oxygenation
Q. I am looking for research online on the importance of oxygenation; can you help me out with some good sources? 
A. Dear Samantha, Oxygenation is necessary for high energy production in all-living animals. The literature is full of this information.

Dr. Tom 

Why is Scarring Seen on a Chest X-Ray Biapical Rather Than in the Bases?
Q. With COPD why is there biapical scarring on CXR rather than in the bases? I have scoured the Internet and textbooks trying to find the answer to this. Please help.

Ben

A. Dear Ben, Apical scarring is most commonly due to old inflammatory processes from fungus diseases in this country and tuberculosis elsewhere in the world. The apices favor the growth of these organisms, through complex mechanisms. 

Dr. Tom

DME Company is Discontinuing Liquid Oxygen Service
Q. My DME Company has advised me they are discontinuing liquid oxygen service.  They also say the other companies in my town are also discontinuing this service. 
Is there, to your knowledge, a national movement among DME to discontinue liquid oxygen?  I think this move on the DME's part is in response to Medicare's new home oxygen reimbursement regulations. 

Martha

Dear Martha, No! Get a new DME; yours is ripping you off. Today, CMS (Medicare) pays the same amount of money for either the liquid oxygen system or oxygen concentrator/E-cylinder systems. This is known as "modality neutral reimbursement".
However the dealer makes more money providing you with concentrators and cylinders system rather than the liquid oxygen system (the DME must make periodic trips out to the home to refill the system). Hopefully, before long there will be specific reimbursement for liquid and other portable oxygen systems
Liquid oxygen systems are far superior for the active patient as they are lighter and have more range for an ambulatory device. Additionally, liquid oxygen has been proven to improve the length and quality of life in the Nocturnal Oxygen Therapy Trials.
In fact there is a steady movement toward MORE use of liquid oxygen.

Dr. Tom

Protective Lung Strategy
Q. I am trying to find research trials utilizing, closed loop ventilatory strategies, to present to our critical care intensivists. I would like to raise their interest in the utilization of protective lung strategy modes. ASV, AvTS, PRV. I enjoyed the hype and presentation of the Hamilton Medical Corp. But these MDs are sticklers for studies.

Rusty

A. Dear Rusty, There are a lot of such studies. Sorry, I am not a library. You will have to look them up as I would.

Dr. Tom

Worried that Discontinuing Medication, When Patient is on Protocols, is Harmful to Patients
Q. I have been unable to find any research that answers my question so I thought I would see what you think.
We discontinue Advair and Spiriva when patients are on our protocol, since they are getting albuterol and Atrovent on the protocol. 
My question is... Is it really necessary to discontinue these meds and could it actually be harmful to the patient to stop their maintenance meds?

RT

A. Dear RT, In general, I believe it is not good practice to let a treatment protocol override the patient's own medication program. I do not believe much in protocols in any case.

Dr. Tom

Cardiac Medications and Erectile Dysfunction
Q. I have two questions
1. Which is more likely to cause ED; Diovan, Tricor, or obesity?
2. Would 500 mg IR niacin (instant release niacin) after dinner, then 500mg Niaspan before bed be a safe way of both raising HDL and lowering Triglycerides and LDL? Should the dosages be progressively higher?

Dee

A. Dear Dee, This question is beyond my expertise. Obesity and many drugs can lead to erectile dysfunction.  

Dr. Tom                           

Medications for Pulmonary Fibrosis
Q. What medications would you suggest for someone who has the beginning stages of pulmonary fibrosis?  He was prescribed nebulized albuterol, but feels no benefit from this.  Very SOB with exertion, yet 02 sat are fine.  He is 82 years old. 

Bill

A. Dear Bill, There are no established medications for idiopathic pulmonary fibrosis. The dyspnea is probably from altered pulmonary mechanics. You did not mention his spirometry. Dyspnea is not directly related to oxygen level.

Dr. Tom

How do Asthma and COPD Differ?
Q. What' s the difference between COPD and
asthma?

Art

A. Dear Art, This is a simple question to which there is no short answer. Asthma commonly affects the young and is not related to smoking like COPD, which occurs mostly in older people. Asthma can come on at any age, however. Both are reversible with bronchoactive drugs, but asthma is generally more reversible. There are different mechanisms of inflammation in asthma compared with COPD.

Dr. Tom

Albuterol and Atrovent Use in the Emergency Room (ER)
Q. Dr. Tom, Is it common practice to administer albuterol and Atrovent in the ER in the pediatric practice as the initial treatment? 

Vanvalor

A. Dear Vanvalor, I am not a pediatrician. But the combined use would be reasonable.

Dr. Tom

Uncontrolled Asthma
Q. Hi Dr Tom. I am 20 years old and about seven pounds overweight. For several months now (6-8) I have been having regular asthma attacks. Sometimes as many as three times a day. If I walk upstairs, cough, or laugh I begin having a full- blown wheezing episode that causes chest tightness and then develops into an asthma attack. Even when I yawn and stretch my arms above my head the same thing happens.

I have seen my GP several times and I was last told I had a chest infection with a lot of mucus in both of my lower lungs. I was prescribed steroids and antibiotics, which helped the first two days, and then it came back again.

My chest in constantly tight and I am already on so many medications. I am currently taking Ventolin, Seretide, Beclazone and Singulair and Telfast for allergies. I avoid all of my triggers and don't miss any medication but I am still having severe uncontrollable asthma.

I have never had an allergy test in my life and I've had asthma since I was nine years old and I have only seen a pulmonologist once when I was a child and had double pneumonia. I've had pneumonia 3-4 times and I have scarring on my lungs too.

I suspect I may have had pneumonia five months ago because I fainted and was admitted to hospital and an X-ray was performed because I had a high WBC. The X-ray showed up scarring in my lower lung which I put down to past regular chest infections and pneumonia and also that it looked like I had recent pneumonia which I had recovered from. I didn't tell my GP about this because they never listen to me anyway.

I am scared. Very scared because my father had chronic bronchitis and then it developed into COPD and I lost him a year ago. I'm scared this may happen to me in the future, especially when my Asthma keeps playing up like this.

What do you advise me to do? Should I see a pulmonologist? Is there a better treatment/medications that what I am currently on?

My peak flow is usually around 250-350 and I’m 5ft 6 inches.

Trisha

A. Dear Trisha, You did not mention smoking in your long question. No smoking! You should see a pulmonologist and get complete control of your asthma. This is always the goal, which can usually be achieved.

Dr. Tom

Breathing Gets Worse as Day Progresses
Q. Dr. Tom, I've been having a problem with shortness of breath for almost seven months now.  It feels like the only way I can breath is if I yawn, sneeze or brace myself so I can get a deep, satisfying breath.  My airway feels constricted and irritated.  
I've had chest x-rays, CT scans with contrast, echocardiograms, full on stress tests and breathing tests and nothing has shown up as abnormal. 
I assumed it could be anxiety so started a round of Lexapro and it's not getting any better.  It almost seems like when I go to sleep it "resets" itself and throughout the day my breathing gets worse and worse. 
This is a feeling I've been experiencing every day, all day for the past seven months and it's very frustrating.  My pulmonologist is lost.  Any ideas?

Tara

A. Dear Tara, If your shortness of breath gets better with mild exercise such as walking, your shortness of breath is likely related to anxiety. Try to exercise daily and see if this helps.

Dr. Tom

Maximum Ventilatory Volume (MVV) and Asthmatics
Q. Dr. Tom, is it necessary to perform a MVV test on asthmatics, it seems to wear them out. What significant data can be obtained from this test?

Vanvalor

A. Dear Vanvalor, No, Don't do it. It may elicit bronchospasm. The old MVV test is valuable as an overall lung function test in COPD, but rarely done today.

Dr. Tom

Need Help Finding Information Resources for Sarcoidosis
Q. I treat a large percent of young patients with sarcoidosis; I'm unable to find much useful information for my patients. Most of them are African American and under 50 years old. 90% wear continuous oxygen at better than 4 lpm and three waiting lung transplants.

Can you help me find information about the disease and treatment? I have all of these current patients in my pulmonary rehab program.

Tonir

A. Dear Tonir, There are several textbooks on sarcoidosis. Your patients are unusual for sarcoidosis. Most run a more benign course. Consult DR Omar Sharma, who is a sarcoidosis expert. I believe he has a textbook, and has many review articles.

Dr. Tom

Trouble Keeping Patient’s Oxygen Saturations Above 85%
Q. Our Pulmonary Rehab program includes lung transplant patients. We have one patient that uses NC @ 8lpm with an Oxymizer Pendant. It is hard to keep his O2 Sat% over 85% during exercise. How safe is this? His exercise ability is very saturation limited. His present exercise prescription states to keep him at 85% or above.

Meryl

A. Dear Meryl, You may want to consider transtracheal oxygen, for a patient with such high oxygen requirements. This allows the reduction of oxygen flow by about 50%, or improves oxygenation better at high flows.

Dr. Tom