Administering 1/2 a unit dose
Q: What are your thoughts on giving “half a unit dose” of albuterol, atrovent, xoponex, etc. Our doctors act like the whole unit dose might be too much! Feels like we are wasting our time. No clinical changes seen.
A: Dear Chuck
Dosing by the inhaled route is very imprecise. Only about 10% of the material inhaled actually lands in the air passages of the lungs.
Some is exhaled, some remains in the nebulizer, and the other factor is the pattern of inhalation, which helps determine the amount deposited. One half a unit will obviously deliver less drug, but probably much more than by a metered dose device that doses in micrograms.
Even this tiny amount of beta agonist is effective.
Q: I have sleep apena and COPD. I also have fibroids and my doctors says it is very risky for surgery, could you tell me why and if there is another solution.
A: Dear Helen,
There are non-operative methods of dealing with uterine fibroids, that involve interrupting their blood supply. Ask you gynecologist about this.
Q: Have you knowledge of a TRACOE trach tube? Thanks
A: Dear John,
Sorry, I do not have any experience or information about this type of trach tube.
Q: I sent you a question about Tracheomalacia and I did see a pulmonologist in regard to putting a stent in. Unfortunately I am allergic to the nickel in the stent.
He is going to ask the manufacturer if a non-metal stent could be made. Do you know of any stents that are not metal?
A: Dear Thelma,
Sorry, I do not know of a nonmetal stent. There are other ways to deal with trachealmalacia.
Sometimes removing the loose tissue in the back of the trachea, is helpful. Check with your experts in Boston on this.
Chemicals and Lung Disease
Q: Dr.Tom, I am 43 and a non-smoker. About 10 years ago I painted a few automobiles and had a moderate reaction to some di-isocyanate that was in the paint. My physician at that time thought I could have had chemical pneumonitis.
Have I seriously damaged my lungs from the chemical structures in the paint, and will it get worse with age? Some days I feel fine and can exercise no problem. Other days, I fight to get a deep breath.
A: Dear Bob,
I doubt if your airways have persistent damage. Sometimes the di-isocyanates cause sensitization, and you may then react to other inhaled materials. See an allergist or a pulmonologist about this.
Q: I have COPD. If I wear a good respirator can I do some welding?
A: Dear Ron,
Some tight-fitting masks give protection. Ask a welder who does this work for a living. Also an environmental expert.
Pulmonary Function Testing
Q: Can you over-exert and collapse your airways and get a lower than normal PFT result? I can get a small differential on FEV1 but a 50% increase in FVC.
A: Dear Jim,
Excellent question! You can actually force your breath out too much and collapse your airways. Usually this is seen in the FVC more than the FEV1. Do both a forced and slow maneuver to empty your lungs from complete inspiration. If there is a big difference, you are collapsing your conducting airways during a too forceful maneuver.
Q: Dear Dr. Petty,
What is the story on nebulized glutathione. I read a lot about it in alternative sites but not a word anywhere else.
A: Dear Hilde,
Glutathione is a potent antioxidant. It is in blood. I do not know of a commercial product of glutathione.
Q: What is your opinion of Serevent in light of the recent adverse news concerning it? I take it twice a day (along with Spiriva and Flovent) have considered dropping down to once in the morning only (weaning off).
A: Dear Gerri,
I am aware of the cautions about Serevent. I still believe it to be a useful and safe drug.
Q: I would like to start a asthma clinic. Do you have any information, guidelines, CPT codes on this.
A: Dear Lois,
I cannot answer your question.
What kind of asthma clinic do you envision? For adults and children? Any special focus, such as occupational asthma?
Asthma is a heterogeneous disease or, more likely, a group of diseases. An asthma clinic requires well-trained pulmonologists, allergists, and others. You can look up the codes in an ICD 9 codebook.
Q: I have been diagnosed with severe Emphysema for l0 years. I use 02 at night for sleeping. I notice my oxygen saturations drop upon exertion now...but when I am resting, they are at 94 or 95.
My doctor doesn’t prescribe 02 for daytime use. How can I safely use 02 in the daytime? I got the impression from my doctor that using it all the time could be dangerous for me? I think I need the 02 but not when resting?
A: Dear Dot,
Unfortunately, we don’t even know how or why oxygen works so well in emphysema with low oxygen. It is okay to use it all the time, even though you may have normal saturations at times when you are at rest.
Oxygen is the only treatment, for advanced emphysema, that has been proven to improve the length and quality of life of most patients with chronic oxygen deficits.
Pulmonary Function Testing
Q: Could an FEV1/FVC% of 86.44 indicative of restrictive lung disease when the FEV1 108% and FVC 103%, DCLO is 118%, FEV 25-75 is 82%.
I am having a lot of problems getting a satisfying deep breath, getting SOB on mild exercise to the point where I just can’t get a breath at all. SOB at rest at times too.
A: Dear Con,
Your lung function is normal. The fact that your FEV1/FVC % is in the mid 80s, is simply that you empty your lungs well. Forget the FEV 25-75%. It is misleading and should not be done, now that we know that it has no special value.
Leg and foot cramps
Q: Why does Albuterol cause such painful leg, foot and toe cramps?
A: Dear C.,
Albuterol and other beta-agonists stimulate the beta 2 receptors in your muscles as well as your lungs and elsewhere. This is probably the reason for muscle aches. Not dangerous.
Q: I have recently been diagnosed with emphysema. My oxygen saturation is 95%. I’m told it is progressive and I’ll need oxygen when my saturation drops to 90%. Just how progressive is emphysema?
A: Dear Bob,
Emphysema worsens with age. The progression of the emphysema depends on your FEV1 (the volume of air forcefully exhaled in one second), not your oxygen. I would encourage you to get a test called spirometry. It is a simple test that will test your FEV1 and give actual numbers and percent of predicted for your age and height.
Normal decline in nonsmokers is about 30cc per year, three or four times this rate of decline in smokers. I assume you have stopped smoking.
Benefits of Weight Loss
Q: Dear Dr. Tom,
I have had COPD for over 13 years and been on 02 for at least 9 years at 2 liters.
Recently I have lost 70 lbs and have felt better than ever and was wondering if losing weight can help that much with your 02? I don’t seem to desaturate as much and as quickly. Thank you for all you do.
A: Dear Betty,
Congratulations on your successful weight loss. Do not lose below the normal for your age and height. You are breathing better, because you have lost excessive weight. I wish more overweight patients with or without COPD could follow your example!
Q: Which lung consists of three lobes?
A: The right lung has three lobes, upper, middle and lower. The left lung has only and upper and lower lobe.
Q: What do you know about retinoic acid research in the treatment of Alpha-1 emphysema?
A: Dear Ruth Ann,
Retinoic acid has been under study to learn whether or not it can promote repair, in emphysema, not just limited to Alpha-one. The idea is based on a rat model of emphysema where it stimulated repair. So far it has not worked in humans. I do not know if any studies have been directed to the emphysema associated with Alpha-one, but I doubt it.
Q: I was told a year ago that I have COPD. I use O2 at night. I was told that a nebulizer with Combivent and Advair would be better and I should go to pulmonary rehab. Could you tell me some on this?
A: Dear Judy,
Combivent is a combination of albuterol with ipratropium, and is marketed in a metered dose device. The same drugs are also provided as Duo-Vent for nebulizer use. Both are bronchodilators that work through different mechanisms.
Advair is a combination of salmeterol, like albuterol, but longer lasting. Advair also contains fluticasone, and inhaled corticosteroid aimed at reducing inflammation in COPD in the long term.
Both may be prescribed by your physician and are often used during a period of pulmonary rehabilitation. Pulmonary rehabilitation is exercise and breathing training, and learning coping skills for shortness of breath. All provide a comprehensive program for COPD.
Q: I have Alpha-1 Deficiency and am on weekly Prolastin infusions. I am told even with this therapy, the disease is likely fatal. Is there other therapy to halt my emphysema?
A: Dear Gary,
The Prolastin or equivalent drug will probably slow the rate of decline in lung function and may help to prevent flare-ups. It is the best thing we have beyond smoking avoidance, to help stabilize Alpha-1 Emphysema. The prognosis is generally good. Stay well and enjoy life.
Q: I am an Alpha-1 patient taking Prolastin. I am considering using an immune-boosting supplement (ImmPower) whose active ingredient is AHCC.
The advertising says it promotes the activity of Alpha-1 killer cells.
Since I am A-1 antitrypsin deficient, would you advise me against taking it in spite of its other benefits? Many thanks for your help.
A: Dear Joel,
I do not know anything about this product. It may contain antioxidants, which would be good for Alpha-1, but I would be more comfortable with antioxidants in food, such as fruits and vegetables, or vitamin and mineral supplements.
Q: I a 25 year-old male trying to get a job with a fire department. I have been successful enough to make it past all of the phases of testing and today I had a medical exam done. I passed all of the components in the exam but the doctor was concerned that I had a spontaneous pneumothorax.
The pneumothorax occurred five years ago and since then I have been very healthy with no other occurrences. The doctors were concerned because of the use of SCBAs (Self-Contained Breathing Apparatus) associate with fire fighting.
The doctor took chest x-rays and said he would do some research and let me know next week.
What are my chances of passing?
A: Dear Michael,
Your lung has healed, and it is unlikely that a spontaneous pneumothorax will return. It is probably safe to use the equipment, since you are otherwise healthy and only had one episode.
Asthma and COPD
Q: Hi Dr. Tom, There seems to be a lot of controversy about listing asthma under the COPD umbrella. As we know asthma has a different etiology than that of COPD (emphysema - bronchitis) and has a reversible component.
What school of thought is correct? Should asthma be listed as a separate entity than that of COPD due to its characteristics?
A: Dear Peter,
Good question. While asthma and COPD have different mechanisms, they share inflammation of the conducting airways and bronchospasm. This is usually reversible in asthma, and also somewhat reversible in COPD. When asthma is poorly controlled, fixed airways changes take place and the reversibility, such as with bronchodilators, becomes incomplete, and may act just like COPD. Both diseases are common and cluster in families, so it is possible to have both. It the disease starts with reversible asthma, and progresses to an only partly reversible state, asthma is still the correct diagnosis, particularly if smoking is not in the picture.
Order of Inhalers
Q: I have COPD. I use Sprivia, Foradil, and Flovent220. In what sequence should I be taking them?
A: Dear Harry,
Spiriva is a once a day bronchodilator, in the anticholinergic family. Take it in the morning.
Foradil is a long-acting bronchodilator, given twice a day. It is a beta agonist and is usually taken morning and night.
Flovent is a corticosteroid and is taken morning and night. Thus it is simple. You inhale three things in the morning, Spiriva, Foradil and Flovent. In the evening just Foradil and Flovent. Sweet dreams.
Q: My father has been on oxygen over two years. Just recently he is able to maintain an oxygen level of 94-95 without it during the daytime. He is 83 with heart failure and an ICD also.
He relies on the oxygen and doesn’t want to quit it. I am not sure his insurance is going to pay for it anymore. Is there any reason he needs the oxygen when he can maintain a 94% level without it?
A: Dear Pam,
It may well be that you father has benefited from what is known as the “restorative effect” of oxygen. Oxygen may have some kind of drug effect on the lung, making it easier to transport oxygen from the air to the blood.
This is NOT the reason to consider discontinuing the oxygen. It is a desired effect, like the lowering of blood pressure with antihypertensive drugs. Also your Dad may have lower levels of oxygen during exercise and sleep. These measurements could be made with an oximeter, under these conditions. Your dad should continue to “live and breathe” with the assistance of oxygen.
Medications for COPD
Q: Are there some COPD patients for whom meds offer no relief? My FEV1 is 45% and DLCO is 22%. Only supplemental 02 has helped with shortness of breath (SOB) while vigorously exercising.
A: Dear Helen,
Some patients with COPD do not get symptomatic relief or increase in lung function from medications. Good that you are getting more active with oxygen, which is the only "medication" proven to improve the length and quality of life in selected patients with moderate to advanced COPD.
Q: I have COPD and have just finished pulmonary rehabilitation and will continue to exercise.
Would my breathing improve by taking:
1). CQ 10
2). Chinese Medicinal Cordyceps Mushroom
3). Chinese Medicinal Reishi Mushroom.
I'm not looking for a cure because as I understand to date there has been none has been discovered.
Thank you for all of research and studies that benefit all of us. James
A: Dear James,
Vitamin Q10 is a powerful antioxidant, and is used by some that claim relief. Since oxidants are one of the mechanisms of lung damage this makes sense, as do other antioxidant vitamins and minerals.
Some studies suggest benefit from antioxidants. Antioxidants are also available in foods and may be more effective in the pure form. I do not know of any studies that support the use of herbs.
COPD and Pneumonia
Q: My dad is 67 years old and has severe COPD. He was in hospital in August with pneumonia.
He was much better when he first got home from hospital, but now can not even walk from room to room without being really short of breath. Prior to the hospital stay he was not on oxygen now; he uses it 24/7.
Why would he come home from hospital doing better, even after all that trauma, and now is going down so rapidly? Do you think this is normal? I don't understand why he would be better after hospital stay then go down hill over night.
A: Dear Lisa,
Your father should be getting better after the hospitalization. Something else must be going on. Your doctor will have to sort this out.
There are complications following complex illnesses that take time to improve, but things should be getting better, not worse, if your father is on the right track. Don't get discouraged and find out from his doctor what is going on now and what to do about it.
Q: I am an 18 year-old girl with a history of two pneumothoracies, both in the left lung. The latest pneumo was repaired. I had pleuradesis to stop new leaks.
I am now on my ninth day in the hospital with severe lung pain, mostly on the left side and in the exact location as the former pneumo pain. My CT scans are clear.
What else could be causing pain? Is there a possible post-surgical cause? The surgery was three years ago, and this is the fourth episode of pain, but clearly the worst and longest. Any thoughts?
A: Dear Marcy,
You may be still having irritation of the pleura from the recent procedure. Pain long after an operation for pneumothorax may be due to rib and nerve damage in the past. This should resolve over time. Believe it will get better and it will!
Q: I am 59 years old my blood gas is 62. I was told that it is not as good as it should be. Thank you.
A: Dear Betty,
I assume the 62 refers to oxygen tension. If so, the amount of oxygen in the blood, i.e. saturation is near normal. Oxygen tension is determined by the altitude where you live. An oxygen tension in Denver of 62 is close to normal for a person your age.
Q: I have bronchiectasis and have had frequent pneumonia (five times total) twice in the past two months.
I have been informed that there is a product called "The Vest", do you feel that this would help me. If so, can you give me any specifics, references, etc.
Can you also tell me anything about a product called "Limou Muy", a plant grown in the Pacific Ocean? I am told it builds up the immune system and if so, would you advise my taking it?
I will be most thankful for any information you can provide.
A: Dear Connie,
The "Vest" is a vibrating system applied to your chest that helps to clear secretions. It can be quite helpful in bronchiectasis. I have never heard of limou muy.
Surgical Risk and Alpha-1 Antitrypsin Deficiency
Q: My sister has a diagnosis of Alpha-1 Antitrypsin Deficiency and asthma. She needs to have some surgery done. What would be the safest kind of anesthesia she should get in order to preserve her lung function.
A: Dear Dale,
It depends on what kind of surgery she is having. Most patients with Alpha-1 disease can tolerate most anesthetics well, even those given through a tube placed in the windpipe (trachea) as used in general inhalation anesthetics. This is required for most major operations. Other anesthetics are used in minor operations.
Q: Dr. Tom, I have been diagnosed with usual interstitial pneumonia (UIP) at one leading hospital with nonspecific interstitial pneumonia (NSIP) at another leading hospital, all based upon same biopsy slides.
My CT scans show multiple enlarged lymph nodes, about 11 of them. They are about 1.5 cm, and are scattered about the trachea, and also hilar region. In 2000 my CT showed the lymph nodes, albeit smaller in size. Additionally, I was diagnosed with Sjogren's syndrome 43 years ago.
Does NSIP or UIP occur with enlarged lymph nodes of this number and size? How would the nature of these nodes be determined?
A: Dear Stryze,
This is a complex question. UIP and NSIP are not usually associated with multiple enlarged lymph nodes. Cancer, lymphoma, sarcoidosis and even Sjorgen's syndrome can have enlarged lymph nodes. You need a biopsy of one of the nodes to be able to sort this out. Whatever the pathology shows, therapeutic decisions will follow.
Q: I take fluid pills for heart failure but they are not working. Can I reduce fluid without taking pills?
A: Dear Vantine,
A major factor in persistent fluid accumulation is the consumption of excessive salt. Salt is present in almost everything, so you really need to read labels. Try to take in less than 1000 mg of sodium per day. Look at labels of soup, anything else that is canned, bread, milk, all condiments, etc. There are some no salt or low salt canned materials and low salt bread.
Q: I recently had an echocardiogram done and it indicated I had mild pulmonary hypertension, with a small amount of regurgitation. It also said my heart was pumping at 50-55% and was strong.
My family physician says it is nothing to worry about but wants me to continue to lose weight. I was wondering if maybe I should see a PH specialist for a second opinion? Thanks
A: Dear Vonda,
It depends on how high your pulmonary pressures are right now and the probable cause. Pulmonary hypertension represents a number of different disease states and associations.
There are only a few drugs that help severe pulmonary hypertension. Most mild cases do not require treatment. Losing weight is always a good idea with heart or vascular problems.
Question about Cor Pulmonale
Q: This may sound a silly question, but is cor pulmonale a serious condition? It seems from what I’ve read right heart enlargement (accompanied by feet and ankle edema) secondary to severe COPD is not a life–threatening problem.
Yet my mother’s respiratory nurse tells me that my mother’s heart could give out at any time. My mother has no problems with her left ventricle that we know of.
Could you explain more about heart problems secondary to COPD? Thanks.
A: Dear Sue, Cor Pulmonale is indeed a serious condition. It literally means, "the heart of the lung". The right pumping chamber, known as the right ventricle, pumps the blood that returns from the tissues of the body through the lungs to take on fresh oxygen.
When the lungs vessels are narrowed, as in COPD, and other states, there is increased resistance to flow through the lungs. Thus the right heart has to work harder and in doing so, enlarges.
But the right heart is not designed to deal with high pressures, like the left heart is. When the right heart fails and fluid builds up in the legs and abdomen, this is an indication of the right heart failing to meet its work requirements.
Oxygen is very helpful if COPD is the cause. There are some other medications that are used in Cor Pulmonale that is not related to COPD. Have your mother see a pulmonologist about starting oxygen at home, if this has not already been advised.
Q: What is “thickening of the lungs?”
A: Dear Margaret, This probably refers to scarring of the delicate alveolar membrane, which is the air-blood interface. Many things including drug reactions, environmental exposure and other unrelated causes of lung inflammation and scarring cause it.
Q: I have had pains in my ribs, chest and shoulders for about a month now, accompanied by flu recently and I have coughed up some blood in my phlegm. My GP has ruled out chest infection and diagnosed Tietze syndrome and sent me for a chest x ray. I am very worried it’s more serious, what do you think? I am a smoker aged 33.
A: Dear Sue, Tietze syndrome is a painful area in the ribs in the front, where the bone and cartilage meet. It is usually localized to a single point or two. It is not associated with coughing up blood. Your doctor will have to look further to make a diagnosis.
Q: Dr. Tom, I have read some promising items on the web about a lung valve. What is its status with the FDA and might it be available soon?
A: Dear Antje,
You are probably referring to valves that can be placed in the air passages to restrict the flow of air into the lungs, but still allow the lung segment involved to empty. This is a noninvasive way of reducing the size of areas of the lung that are not functioning well, in order to make more room for the surrounding lung. It is similar to a surgical procedure known as lung volume reduction. It holds promise, but has not yet been adequately evaluated and still awaits FDA approval.
Lung Damage from smoking
Q: Dr. Tom,
I am a 27 year -old male with a 7 pack-year cigarette smoking history. In addition I also smoked marijuana relatively heavily during the time I smoked cigarettes.
I have now quit both for nearly two years and exercise regularly.
Although I feel much better, I am concerned that I may develop COPD with normal aging after the damage I have already done, especially since my grandfather who smoked (piped tobacco) for only 2-3 years was diagnosed with moderately severe chronic bronchitis many years after quitting.
I am still able to exercise quite vigorously, although I feel I may get more short of breath than the average person when doing so.
My question is how much lung function can I now expect to lose with normal aging? Is it possible that the combination of this loss with the previous damage I have done may lead to COPD even after quitting smoking? Thanks for your advice and time.
A: Dear Mike, You wisely stopped smoking all materials. You probably do not have much damage, and your lung function will not drop faster than other nonsmokers with the same lung function as you have.
Why not get spirometry to reassure you? This will tell you if you have had any damage thus far. This is important since you grandfather had chronic bronchitis from only a small amount of smoking.