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Archive: Dr. Tom 91
Posted January 9, 2007

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



Night Time Coughing
Q. I am 22 yrs old and I have asthma. Sometimes at night I start coughing and cant stop. Usually cough so hard I get a headache. What causes this and how can I stop coughing? Keeps me up at night.


A. Dear Kelly, Cough is a very common and troubling symptom of asthma. It may be particularly troublesome at night, and long sessions of cough often cause headache. You need to find out if there are night time triggers, such as gastroesophageal reflux, or sinus drainage. Ask your allergist or pulmonologist about these possibilities. You also need more "controller medications" such as inhaled corticosteroids or leukotreine inhibitors.

Dr Tom


Mother-In-Law Coughing Up Blood
Q. My mother-in-law was seen in the ER yesterday for coughing up blood. They said she must see her M.D. ASAP. The report states, "There is bibasilar atelectasis".  It also states "There is soft tissue in the left and right hilum which may represent adenopathy.  There is a 17 mm lymph node in the AP window.  An eight week follow up chest CT is recommended. There is no precordial or pleural effusion.  There is a five mm soft tissue nodule in the right midlung field. There is no pneumothorax." 
Can you help me understand what this means? She is a refugee from Kosovo and does not know English.  The MD offices will reopen on Tuesday.  But I want to try and understand what this means.  Can you help? 


A. Dear Nawal, There are several urgent possibilities here. Since she is from Kosovo, she must be checked immediately for tuberculosis. Lung cancer is another possibility. See a pulmonologist immediately and get a diagnosis as the basis of treatment.

Dr. Tom


Suggestions to Update Pulmonary Function Skills
Q. I am returning to work in the PFT lab after a ten-year absence and would like you to suggest books, and seminars to update my skills.


A. Dear Pamela RRT/PFT, The ATS and OSHA have joint training programs. Also the ACCP.

Dr. Tom


When to Take My Medication
Q. I have the big "E". I use Spiriva once daily.  I now have Floradil to take also and would like to know when to take them?


A. Dear Ronald, Take Spiriva in the morning as well as Foradil, and also take the Foradil in the evening.

Dr. Tom


Can Scar Tissue Seen on CT Scan Show Up as COPD or Cancer?
Q. I am 58 years old and after CT scan in Dec, my GP diagnosed me with COPD. I smoked for 22 years, but stopped smoking in 1993. In 1983-4, my lungs collapsed three times...(spontaneous pneumothorax) which required surgery in 1984.
 Have an appointment with lung specialist in a couple of weeks.  Can scar tissue from the previous surgery look like COPD on my CT scan? What tests can be performed to determine if this is cancer instead of COPD? My father died in 2001 with lung cancer.


A. Dear Carla, Lung cancer can occur in scar tissue. A CT will distinguish between old healed scars and emphysema, and will also reveal any nodules that could be lung cancer.

Dr. Tom


Non Rebreather Oxygen Masks
Q. I've seen a lot of non rebreather masks being used that have one of the one-way valves missing but have not been able to find any literature justifying this practice.  When we are asked to place a patient on "100% non-rebreather" I feel we should do just that.  It seems I saw an article in Critical Care that showed these masks as only delivering 40-60% oxygen.  I'm an old-timer RT (32 years) and the physics of these masks doesn't work for me.



A. Dear Voitek RRT, NREMT-I, So called non rebreather masks, are open systems and have a reservoir to help flood the face with high flow oxygen. Achieving more than 40-60% oxygen is not possible with these open and loose fitting masks. This is plenty for most situations not requiring a definitive airway and mechanical ventilation.

Dr. Tom                              


Concerned that Medication is Causing Shortness of Breath and Pounding Heart
(Follow up from Dr. Tom 89)
Q. I am 52 year-old female never smoked. I was diagnosed with RA July 2005. I must add, I lost my twin brother 6/05 to COPD; older brother to lung cancer and father to emphysema. They did all smoke but one doctor believed there is a link. Alpha one test came back negative for me). I was put on methotrexrate from 10/05 until 11/06. I developed a worsening shortness of breath; thunder heart pounding. Did the PFT tests have a DLCO of 74 other tests were ok. Did the PFT stress test and did ok. I was off the methotrexrate about five weeks when I did these tests. My lung specialist is doing another CT scan in June (six months) for a 4mm subpleural nodule right middle lobe.
My RA doctor has started me on now leflunomide 10 mg every other day for one month then 20 mg daily.
I am CONCERNED that the methotrexrate caused the dyspnea and dry cough, which has receded somewhat and now this drug will cause it again. I have taken four doses and notice on day of dose I cough a lot. The week before I started the leflunomide; I was able to do a three mile walks three times a week.
In December when seeing the lung specialist I could not even walk from my car to the door of the building I work due to dyspnea and thunder heart pounding. Do I have reason to be concerned?
I have made a consultation appt with the lung specialist's assistant to discuss this, as I really got no clear answer on what is wrong but a mild reduction in lung and the nodule, which they did not go into detail over.
Watching three family members die slowly of a horrible respiratory illness makes me concerned, and lost my mom to colon cancer. My only vice is drinking red wine. I appreciate your time to read this and if you could respond I would appreciate it.


A. Dear Stephanie, Methotrexate may have adverse lung effects and may make breathing worse. I do not know anything about the leflumonide, except that it is used in rheumatoid arthritis. It may interact with methotrexate. You should consult a rheumatologist about this. You have ruled out alpha one deficiency as a cause of your arthritis.  A modest amount of red wine is probably good for you. 

Dr. Tom


Have had Asthma for Over 20 Years and Worried about Lung Cancer
Q. Hi. I hope that you can help me. I have had asthma for over 20 years but the last year it has really gotten worse. Recently I went for a chest x-ray because my symptoms will not go away.
I would like to explain first I have a bad cough from a cold; took antibiotics and prednisone, which I hate but the symptoms subsided. Cheat x-ray just showed that I have bad asthma.
But now I am so afraid that I have lung cancer and it was not detected. I know this is silly but when you are in pain this is how you think I have this nagging pain in my backbone.  Anyway any do you have any suggestions? 


A. Dear Peggy, A chest x-ray is not a good way to assess the severity of asthma. It also is not effective in diagnosing early stage lung cancer. CT should be done if you have been a heavy smoker, or if you have a family history of lung cancer.

Dr. Tom


Can “Over-Doing It” Cause Lung Infections?
Q. Is it possible for a bronchiectasis patient to trigger an infection by over doing it? Since the phrase 'over doing it' is relative, I wish to define it further. Not in terms of a decathlon athlete training everyday and his/her body breaks down from training too vigorously. But in terms of a person that has a normal everyday routine but then exerts more than normal.
For example: moves heavy furniture around. Could just that single spike in activity cause an infection in a bronchiectasis patient or if I physically exert beyond what I "think" my capabilities are, can that cause an infection to occur?


A. Dear Paul, No. Normal exercise as in activities of daily living actually enhances your immune responses against infection. Stay active.

Dr. Tom


Determining Significance of Noncalcified Lung Nodules   
Q. Dr. Tom, July 18th had a CT Scan because of lung nodule found on a chest x-ray.  CT confirmed an 8mm nodule noncalcified located in left upper lobe and lingula.  Indeterminate.  No enlarged lymph nodes within thorax Thyroid unremarkable.  No aneurysmal dilatation.  Boney thorax unremarkable. 
Repeated scan Dec. 7th and findings were.10 x 10 left mid lingular nodule noncalcified.  Nodule appears unchanged when compared to previous exam.  No definite mediastinal or hilar adenopathy.  Impression was Stable left lung nodule when compared to previous study.  PET scan may be helpful in evaluation of nodule.  Also mentioned on 2 reports Azygous fissure, normal variant. 
Do not know what that means.  My question is Why would the latest cat scan read stable and unchanged when the first CT finds an 8mm nodule and the second says 10 x 10mm.  Shouldn’t that be noted as a change because of size?  Therefore not being stable or unchanged?  I know determining the size growth is very valuable in these nodules.  My Doc does not seem to be worried, but did order a PET.  He wanted to just check it in six months but I wanted the PET because of the two reports not making total sense. 


A. Dear Nikki, You were wise to ask for a PET scan to see if the lesion is active. If so, it should be biopsied by removal.

Dr. Tom


Very Concerned about Practice of Giving Nebulizer Treatments to Multiple People at the Same Time
Q. As an RC department manager with 30 years experience I am very concerned about the current practice of "batching" bronchodilator treatments.  Due to staffing constraints, many hospital therapists have resorted to slapping mask nebulizer treatments on five or six patients at once. 
Most of these patients are nose breathers with shallow tidal volumes. I cannot find any literature that supports delivering bronchodilators through the nose, yet countless treatments are given this way throughout the country with little concern from doctors, insurance and drug companies, CMS or JCAHO.
Do you consider this a valid practice and do you know of any nasal delivery studies underway?   


A. Dear Mark, I am glad you asked this important question. This practice does not have a scientific foundation. It should be studied to see if it really does anything, and not just done as an expedience.

Dr. Tom


Can You Help Settle a Question about T-Pieces?
Q. Hello Doctor, maybe you can help resolve the following question. A fellow therapist and I were discussing the use of the T-piece during weaning. I maintained that the T-piece does not decrease the work of breathing for the patient and its function is similar to the high flow Venti mask; that is providing a flow of gas/mixed gasses to meet or exceed the patients peak inspiratory demand. In addition I posited that not only would this not decrease the work of breathing but that it also might increase it since the flow of gas moving perpendicularly past the opening of the ET tube would cause negative pressure via Bernoulli's principle (this was not my main point but the physics behind it seem to make sense). So in effect, leaving an ET open to room air with no T-piece would be the same as having a T-piece with 21% (room air) flow. 
My friend insists however that adding flow (even a flow of room air) to a T-piece would decrease the patient's work of breathing since some flow would be directed downward (does Coanda work at right angles?) into the ET and helps fill the patients lungs.
Can you help us resolve this issue please?


A. Dear Joel, A simple T-piece only ads the resistance of the ET tube itself. I do not believe that the flows are sufficient to make a difference.   
We used to use an extension piece of 12" on the exhalation side, in case the patient’s minute ventilation exceeded the oxygen from the delivery side. We monitored blood gases. I still think that a T-piece is the best weaning method, because it causes the patient to do the whole work of breathing, while separated from assistance. We published an article about this in the Archives of Internal Medicine about 20 years ago, by Mortharoth, et al.

Dr. Tom


Fearful of the Effects of Secondhand on Daughter’s Immune System and has Grave’s Disease
Q. Sir, My ex-wife and 16 year-old daughter are living with a man that smokes. My daughter had to have her thyroid killed a few years back, because of Graves Disease. She now takes medication for this. Right after her thyroid was killed she had to be put in the hospital because her immune system was zero.
My question is how is being around second hand smoke going to affect her thyroid problem and her immune system?


A. Dear James, Second hand smoke is not good for your daughter. All smoking should be done outside.

Dr. Tom


Teardropped Shape found on X-Ray
Q. My husband is 36 and smoked for a few years over seven years ago. He has had the same cough for over a year. He has had chest pain in the past and recently he coughed up, and kind of dry heaved some blood in his mucus (only once). He had an x-ray of his chest done and they found a small teardrop spot on his lung. Not sure were it was located. They have ordered more x-rays. His red blood cell count was normal. Should we be concerned?


A. Dear Diane, No. If the "teardrop" shadow is in the right apex, it might represent an azygous lobe, which is a normal structural variant of the lung. Ask about it.

Dr. Tom


Is Interstial Infiltration Something Should I be Worried About? 
Q. Dr. Tom, I went in for a routine annual physical a few weeks back. The physician gave me a chest X ray.... A few days later he calls to tell me that the radiology report indicates that I have interstitial infiltrations in the left upper lobe.... the report also mentions the PA film was slightly over penetrated.... I go back for a repeat chest x-ray week later...In addition, also take the spirometry test, results are normal ranges and chest x-ray indicates normal.... reviewed by same radiologist.... Do you think I'm fine?


A. Dear Dennis, Probably so. Better have it checked again in about six months to see if it has cleared or stabilized. It may be a scar from an old localized infection.

Dr. Tom


Ready to Move, Do You Have Any Suggestions an Area Whose Climate is Good for those With COPD?
Q, I currently live in San Angelo, TX. which has a predominately dry climate and can get high temps and very dusty. As a sufferer with COPD I am looking for a new location and seeking information on what would be the ideal climatically /geographical conditions for COPD. Can you help?


A. Dear Dave, You are leaving a good climate except for the dust. There is no ideal place. Avoid high humidity, altitude and cold winters.

Dr. Tom

What is APRV?
Q. What does APRV mean?


A. Dear Daisy, Airway Pressure Release Ventilation is a sometimes-used method of controlling mechanical ventilation that gives a constant inspiratory pressure, interrupted by a short period of zero pressure to allow for lung emptying. In this mode the inspiratory time is longer than the expiratory time. It is used in ARDS and requires sedation because it is very uncomfortable for the patient. 

Dr. Tom

Breast Cancer Survivor Worried about CT Scan Results
Q. Hi Dr. Tom, I had tubular breast cancer last year that was treated with lumpectomy and radiation and then Tamoxifen. 
I had a CT in August because of shortness of breath that my oncologist wanted to rule out embolism.  The results read:  1.  No evidence of acute pulmonary embolus, 2. Postoperative left breast/axillary soft tissue changes versus local recurrence.  Correlated with timing of previous surgery and/or previous postoperative studies.  3. Mild nodularity of left major fissure.  Consider reassessment short-term follow-up to confirm stability noting other findings suggestive of prior granulomatous infection.  In the body of the report it states:  3 mm right apical nodule on image nine series two is nonspecific, possible granuloma.  Should I worry that this may be a recurrence?


A. Dear Cristina, It will always be a consideration. These shadows may be benign, but warrant follow up.

Dr. Tom  


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