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Archive: Dr. Tom 10
Posted February 11th, 2005

Found the Article
Dear Dr. Tom,
This isn’t a question, but Ask Dr. Tom appears to be an address where I can be reasonably sure to reach you.

I am the person who asked you for the citation for the article about your experiences with an elderly emphysema patient. You said you had no reprints but kindly offered to send me a copy of a book including the article, or a fax of the article.

However, when you gave me the information that the article originally appeared in Annals of Internal Medicine, it took me less than 10 minutes to find it on line and the download it as a free PDF file. So you needn’t send me the book or the fax, but please accept my sincere thanks for sending just what I needed.

Copies will be in the mail tomorrow to my pulmonologist and his younger partner--not intended as criticism; I have great respect for them--but to allow them to share a truly inspirational account of what a doctor should be. If I had my way, it would be required reading for every physician or, even better, for every caregiver, and for the rest of us too.

As you might have suspected, I’m an emphysema patient too, but only78. Finally, I applaud the work you’re doing.

Ward

Dear Ward, Glad you found the article. Thanks for closing the loop.

Dr. Tom

 

Double Pneumonia
Q. Recently I had double pneumonia and the doctor gave me an Acapella breathing exerciser (a device that delivers vibrating air under positive pressure) while I was in the hospital. What I would like to know now is if I continue to use this, will my breathing get better. To my knowledge I have no other lung disease.

Betty

A. Dear Betty, The device was to stimulate deep breathing and to expand your lungs to full capacity. You should breathe fine after all the pneumonia has cleared. If not consult you doctor.

Dr. Tom

 

Respiratory Bronchiolitis Interstitial Lung Disease
Q. I am 35 and smoked socially with asthma all my adult life. Last March I was diagnosed with respiratory bronchiolitis interstitial lung disease, RBILD, (a rare form of interstitial lung disease) from a CT scan. My PFTs were normal apart from an increased RV 150%.

I have made a small improvement without oral steroids in the last year but all in all I still don’t feel good.

I feel my breathing is not good with long exhales and a feeling like I'm holding air back. On top of this my lungs feel irritated.

What are the chances of this resolving fully over say five years? If so what are the timescales involved?

I have searched the Net and find very little on RBILD.

Your thoughts would be appreciated.

Les

A. Dear Les, The only way to make a certain diagnosis of respiratory bronchiolitis and interstitial pneumonitis (lung inflammation), is by tissue biopsy. It is good that you are responding to treatment. You must stop all smoking.

Dr. Tom

 

COPD
Q. Dear Dr. Tom: I have COPD, considered moderate to severe, by my PC, but no comment from my pulmonologist regarding this.

Several other rather bizarre symptoms now accompany my COPD. Does nausea most every morning (I'm definitely not pregnant) have anything to do with COPD? I have developed a twitch type of motion in my hands, and occasionally a weird feeling in my neck like a twitch. Does any of this have anything to do with COPD?

I take flecainide for a corrected SVT; Oxycontin for a back injury that I shall shortly be able to stop; temazepam for sleep problems due to severe tinnitus, and occasional lorazepam (1 mg) because all of this is making me as nervous as a cat in a roomful of rocking chairs. Any help would be greatly appreciated. Thank you.

Priscilla

A. Dear Priscilla, COPD is not associated with nausea or the other sensations that you are experiencing. It may be too much medication. Check with your doctor.

Dr. Tom

 

Ventilation Profusion Mismatch
Q. Hi again, Dr. Petty. I met you at a recent NECA conference in Denver.

My question: after a PFT (pulmonary function test) showing little change after 2 years (good fitness with total dedication to exercise. I do a 5K walk) I have great FEV1 of 74-76%, but diffusion only 50%. I need high amounts of O2 (12-15L) walking 3.5 to 4 mph (yes, faster than most.).

It was suggested my ventilation and perfusion are mismatched. My “Googling” for answers isn't helping me. Can you explain what this means, or should I just keep using the amount of O2 to keep sat level above 94% and not worry?

Lyn

A. Dear Lyn, Ventilation-perfusion abnormalities simply mean a mismatching of airflow and blood flow. It sounds like this is going on, or else it is a ventilation-diffusion abnormality. This means the air gets to your alveoli (tiny ‘air sacs’, at the end of branching of lung tree, where oxygen is delivered to the blood stream and carbon dioxide is removed), but the transfer of oxygen into the circulation is impaired. Do you know what your diffusion test shows? You will need a pulmonologist who can do the necessary tests and examine you to get a better answer.

Dr. Tom

 

Emphysema
Q. I have just been diagnosed with emphysema and have taken my PFT (pulmonary function test). My #'s were all over 80 with the exception of FEV1/FVC= 73% and FEF25-75 = 58%. FEV1 was 82%. My test was interpreted as borderline obstruction with normal diffusion.

My cat scan showed severe bullous emphysema of the right upper lung as well as a bullae on the upper left lung. I am 42 years old, 5'11'' 210 lbs.

I have read a lot about you and your career and would like your input as to where this leaves me as far as my situation.

Robert

A. Dear Robert, Forget the FEF 25-75% tests. It does not show early COPD as many doctors think. Your giant bullae are probably from a congenital abnormality or an inflammation. They may occur without diffuse airflow obstruction. Sometimes their size requires removal. This can be safely done, often through a scope, called a thoracoscopy. You should remain healthy.

Dr. Tom

 

Fatigue
Q. My wife, 26, has a problem with fatigue. Throughout college, doctors attributed it to stress, but now she lives a pretty stress-free life and her condition isn't getting better. It's getting worse.

She wakes up frequently at night, and on occasion has woken up not being able to breathe properly. She's winded walking up the stairs.

In high school, she was diagnosed with an asthmatic cough, and her grandmother has COPD. She did a spirometry test at her doctor's office yesterday, but it turned out normal. Is it possible that her problems are a respiratory problem or would it be something else? She's tired of being tired all the time.

John

A. Dear John, There has to be an explanation for all of these symptoms. Being tired all the time and having episodes of shortness of breath, but with normal lung function, has a number of causes. I cannot speculate about these. Better have a long talk with your wife’s doctor.

Dr. Tom

 

COPD
Q. I am a 53 year-old female. I quit smoking 13 years ago. My father died of complications of emphysema at age 72. I obviously received secondhand smoke as a child and then at 14 I began smoking.

I woke up in the middle of the morning and could not catch my full breath. I always have to cough up when I get out of bed. So when I get out of bed in the middle of the night I cannot go back to sleep for a while because coughing up phlegm wakes me up.

I cough up phlegm throughout the day, especially after I have sat at the computer for awhile and then get up, or after I eat something or drink water. I cough up yellow mucus (green mucus at times) mixed with pure clear mucus almost daily.

I went to a pulmonary doctor and was given a test using the finger to see how much oxygen I was using. It was good. I had tests done in (the cage?) and was diagnosed with the beginning of COPD. I was told I did not have emphysema and was put on Theophylline 200 MG.

I guess it was not working because my general DO took me off of it and now I am on Advair, Allegra D, and Nexium (I have a hiatal hernia).

I get tired much easier than I use to. I have worked my whole life and just this month closed a clothing boutique because I cannot take stress of any kind.

I shake from the inside out. I am on Zoloft but I find that I am no longer the outgoing woman I have always been. I can't remember people’s names and a lot of times (too often) I cannot finish a sentence.

I have to concentrate very hard to keep focused or I will end up with a pile of paper on my desk which is totally not who I used to be. I used to be very organized and still try to be, but I find I can't remember.

Am I crazy? Do you think there is more than just COPD? Should I have more tests done? Should I rest more? Exercise more? Thank you.

Cheryl

A. Dear Cheryl, I am sure that this is NOT established emphysema.

The “finger test” just tells about the oxygen level, and nothing about your breathing capacity and lung volumes. The test that you had in a “cage” was probably done in what is known as a “Body Box,” used for measuring complex lung functions. If so, you should have all the values, and these should be interpreted by a pulmonologist. All you really need is a spirometry to measure lung capacity.

The shortness of breath and coughing up on arising from sleep suggests gastric aspiration. You should be checked for this.

The Zoloft may make it difficult to concentrate and stay focused. You need a good doctor, preferably a pulmonologist or an internist interested in the lungs, to help sort this out. Let me know what develops.

Dr. Tom

 

Sudden Shortness of Breath
Q. In the early morning hours of Monday Jan 24, I awoke with extreme shortness of breath. For the preceding days I was fine, no hint of anything amiss. I go to rehab twice a week, and use my treadmill at home twice a week.

However, when I woke up unable to breathe I called my pulmonologist who told me to call 911, which I did. I recall unlocking the door for them, and turning off my alarm. I remember them in my bedroom and that is the last thing I remember, until waking up in the ICU at Yale University, 12 hours later.

I have zero memory of the ambulance ride; breathing treatments, blood draws, or speaking with anyone. I live alone with no caregiver, so I was alone through all this.

I have two questions:

1. How come I cannot remember anything? Could I have been lucid through all of this? My pulmonologist says I wasn't unconscious or in a coma and I not was intubated. I do remember words like Respiratory Distress and Acute Bronchitis being used in the ICU. I was in the ICU for five days.

2. What caused me to go from fine one day, to 8 hours later calling 911? I have COPD E and B. I'm on high flow 02, using 6-8 liter per minute at rest and 12-15 with exercise using a nonrebreather mask.

Susan

A. Dear Susan, I wonder if you had a seizure activity to explain the loss of memory. There are many good pulmonologists at Yale who would be able to explain all this. One who is very well known is a former fellow of mine.

Dr. Tom

 

Shortness of Breath
Q. I belong to the COPD Alert group and also have your oxygen book (see description of ‘COPD Alert’ and Dr. Tom’s book below). The question I have is not covered in your book, nor was my pulmonologist able to adequately answer my question.

I was diagnosed with asthma and COPD in 2003. I have slowed my pace with activities (due to SOB), and breathe only through my nose, (save for talking, eating, etc.). I still get winded using O2 (24/7 @ 2LPM).

I hyperventilate easily if I breathe through my mouth as with jogging, which I have done for over thirty years. Suddenly I get short of breath or winded, I couldn't tell which, and found myself over breathing. Even pursed lip breathing doesn't help the anxiety regarding the over-inflated feeling.

I especially become hyperventilated when I use the Serevent and QVAR inhalers. I use an aero-chamber for the QVAR and I still get that over-full feeling. I was unable to complete a PFT test due to all the mouth/over breathing and can't even use nebulizers for the same reason.

Would you happen to know what could be causing this?

Margot

A. Dear Margot, This is a tough one. My guess is that your nervousness, tends to make you take big breaths and to “breathe at the top of your lungs.”

Your expiration to empty the lungs is impaired by the loss of elasticity from the emphysema, so air becomes trapped. You need to concentrate on full exhalation taking several seconds, before you use an inhaler.

My oxygen book, entitled “Adventures of an Oxy-Phile” is not on the Internet. Another book, “Frontline Advice for COPD Patients” is on www.NLHEP.org.

DR. Tom

*COPD Alert is a nonprofit, internet-based support and advocacy group for COPD patients, caregivers, medical professionals, and all those who care. http://www.copd-alert.com/index.html)

 

Feel Tired
Q. I have COPD...FEV1 42%. I use Spiriva in the morning and sleep 10 hours a night. I am still exhausted all day long. I keep on going exercising on the treadmill, and doing housework, but it’s a real push to do it. I could drop asleep at any time. I am only 54 and feel my life is over. What can I do to energize?

Lucci

A. Dear Lucci, I need more information. Is your blood normal, meaning your hemoglobin. You could be anemic. Is there a weight problem? Some hormonal problems such as low thyroid come to mind. Lots of things can cause fatigue. Your doctor will have to give you specific advice.

Dr.Tom

 

Oxygen
Q. I'm curious. In a breathing problem emergency, the Fire Department arrives prior to paramedics and the standard procedure is to administer O2.

If they don't have a pulse oximeter to show the oxygen level, is it dangerous to administer oxygen?
By the way, thank you for such an informative site. It's truly appreciated.

Jackie

A. Dear Jackie, Lots of people are concerned about taking too much oxygen, such as in emergencies. The risk and fears of too much oxygen are greatly exaggerated.

Dr. Tom

 

Eosinophilic Bronchitis
Q. Could you tell me more about eosinophilic bronchitis? What is the difference between this disease and Asthma? Is it considered COPD? I go to a specialist, but still cough and get short of breath. It is hard to find much information on this. Will it get worse?

Kathryn

A. Dear Kathryn, Bronchial asthma is an eosinophilic bronchitis. Eosinophils are the cells of the blood that are commonly involved in allergies. Eosinophils are not commonly involved in COPD, but may be a part of an acute attack.

Dr. Tom

 

Oxygen Saturation
Q. My oxygen saturation seldom gets to 80%. If I am under stress it drops to 64-70%. I'm on 4 liters of oxygen 24/7, and I know when I need to rest.

Both my primary care and lung doctor. never say anything; only shake their head's. My primary care doctor said maybe it's normal to be low for me, but I feel he may be just saying that. What do you think? I take one day at a time.

Jean

A. Dear Jean, If you mean your oxygen saturation never gets as HIGH as 80%, there has to be an explanation. This is very rare in COPD. It suggests some other diagnosis.

Dr. Tom

 

Sputum
Q. What does it mean when my sputum is yellow?

Jackie

A. Dear Jackie, It means that your sputum has the color of yellow. May mean an infection or asthma. It is not normal, but not a diagnosis in itself.

DR. Tom

 

Smoking
Q. Dr. Tom, I have smoked hashish joints regularly for a couple years now. Last year I moved to a drier climate and started having a rather annoying cough. I expel a mucus which I've since come to read is characteristic of hashish use.

I have taken what I believe are generic cough syrups (I just asked for it in the pharmacy) with little or no improvement.

I would like to know what would you advise to reduce or eliminate this problem besides stopping smoking. I am also considering inhaling the drug trough a vaporizer instead of burning it and I would also like to hear your opinion on that.

Hugo

A. Dear Hugo, Don’t be stupid. Stop the hashish. There is no way to stop the cough from the inhalation of the weed, except to stop completely. Protect your lungs. They have to last a lifetime.

Dr. Tom

 

Phrenic Nerve
Q. My mother has been diagnosed with unilateral phrenic nerve palsy. She can't do routine chores around the house without being short of breath.

Is there any therapy or treatment for this condition? It seems that people who have one lung removed are more adapted and perform tasks better than she is able to.

Gary

A. Dear Gary, Damage to one phrenic nerve, usually reduces lung function by only 20%. It should not cause many symptoms, unless there is something else wrong. What is the cause of the phrenic nerve damage? This may give an answer as to the cause of the unusual impairment.

Dr. Tom

 

Oxygen Saturations
Q. I have been on oxygen for a little over three years now. I feel better now than I did before. I almost died. But I now find that setting my oxygen at 2 liters for normal walking around is not enough. My saturations drop to 89-92.

Should I set my oxygen to 3 liters? When I exercise I use 4 liters. I do 2 mile on my treadmill at 2mph. Thank you.

Francine

A. Dear Francine, It is fine to increase your oxygen liter flow by one liter when you exercise. This has been studied and is quite safe and appropriate.

Dr. Tom

 

Too Much Mucus
Q. I have COPD and lung cancer. I recently bought some Mucinex to help with excess mucus. It seems to help but seems to make the coughing worse. I wonder what your opinion of that product might be? Thanks

Dan

A. Dear Dan, We don’t have any good medicines for excess mucus in this country. Some of the over–the–counter drugs help some people. Mucinex is one of these. It is an old drug with little proven value.

Dr. Tom

 

Air Purifiers
Q. I just received an ad for Ozone air purifiers and thought it sounded pretty good. I have COPD and have heard snatches of things about it not being good for us with COPD. Is this correct? Thank you.

Cheryl

A. Dear Cheryl, Ozone is irritating to the lungs, but I doubt if home purifiers do much.

Dr. Tom

 

Oxygen
Q. I was recently diagnosed with COPD. The pulmonary doctor has put me on oxygen 24/7, however, he has not scheduled my pulmonary function tests until the first of June. Just how does he know I need oxygen 24/7 at 3lpm if he has not done these tests?

Anne

A. Dear Anne, He must have done a finger test of your oxygen level or an arterial blood test that measure oxygen and carbon dioxide. If not, he should not have prescribed oxygen. He certainly needs to do a spirometry (pulmonary function test) as a starter.

Dr. Tom

 

Interstitial Lung Disease (ILD)
Q. In ILD, at what point does a patient become a pulmonary cripple? What DLCO number do you see as being an indicator of significant disease?

April

A. Dear April, ILD is a broad spectrum of diseases. In general, the diffusion test, DCO gets below 50% before significant impairment develops.

Dr. Tom

 

Chemical Stress Test
Q. My question concerns my heart. Recently while at rest my heart rate jumped to 162 beats per minute. There was no pain, just very tight around my chest area. I felt as though I was being crushed by a boa constrictor. This lasted for about two hours. I took two nitro, and within ten minutes it went down to 88 beats per minute.

I have seen a cardio doctor. He wants do a chemical stress test. But I am really scared to have had this done.

At this time, I have chronic bronchitis, emphysema and am on many steroids, inhalers, and pills.

Would you advise me, please? I am scared out of my wits. Thank you in advance for any advice.

Anne

A. Dear Anne, Sounds like you had a sudden rapid rhythm of your heart. The type of rhythm determines the significance.

Chemical stress tests raise your heart rate, like exercise does, and are used as “stress tests” in persons that are limited in their exercise ability for problems other than heart disease. Chemical stress tests are not particularly dangerous.

Another way to check on the rhythm disturbance is to wear an EKG monitor, known as a Holter Monitor, for 24-48 hours to see if it can catch the type of rhythm that you may get suddenly.

Dr. Tom

 

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