Q: CT Scan showed mild emphysema. But recent a spirometry test showed normal lung function. I take Spiriva once daily and Seretide twice daily. Do I need to take medication?
A: Dear Anne, No a CT scan does not measure lung function. It is possible to have mild emphysema with no symptoms and good prognosis. Of course, avoid all smoking, even passive.
Q: My mother has a severe cough with lots of congestion in her lungs. Her x-ray was clear. This has been going on for about 2 months. She was given Tussionex by her doctor, but this doesn’t help the problem, it only makes her sleep.
What can I do to help her get rid of her cough? Doctor is of no use.
A: Dear Beth, Chronic cough is a problem that requires a diagnosis. Cough suppressants do not do much. The treatment of the cough is the treatment of the underlying disease, i.e., the cause.
Restrictive Lung Disease
Q: I have restrictive lung disease. I am in rehab. The nurse said it is worse than obstructive. Is this true?
A: Dear Betty, It all depends on what kind of restrictive disease you have. There are many causes. I need more information. Have you seen a pulmonologist to get information on the type of problem that you have?
Q: I have emphysema, with an asthma component, and would prefer to take as few meds as possible. In your experience would it be possible to treat severe COPD (fev1<20%) simply with short– and long–acting bronchodilators?
I am presently taking Xopenex, ipratropium, prednisone 10mg alternate days with bursts every couple of months x 2 years, Proventil HFA as rescue, theophylline 200mg, digoxin 25mg, pulmicort turbohaler. I do not like taking multiple medications, because of the associated side effects. Spiriva did not work for me.
Nothing helps dyspnea at this point. I am starting pulmonary rehab soon and am a candidate for Emphasys valve trial.
A: Dear CB, Most patients with severe COPD, meaning emphysema, with some bronchitic or asthmatic component benefit from some form of bronchodilator. Short–acting anticholinergics, as Atrovent and beta agonists, i.e., albuterol can help abort symptoms.
It is convenient to take them together as Combivent. Oral bronchodilators such as Xopenex have lots of side effects and are not more effective than inhaled agents, theophyllines help some patients. If Spiriva does not help, forget it, it is expensive. Have you tried Advair 50/250? Helps some patients reduce flare-ups.
The emphysema valve is experimental. May help. Good luck.
Multiple Lung Infections
Q: I had bronchitis June ‘04 and then again in October ’04. Recently I had pneumonia in right lung. I have been on 8 different antibiotics and 7 times on prednisone. As of December 04, I was diagnosed with pleurisy and walking pneumonia. I am back on Cipro for the second time.
What can be done to avoid all these chronic lung infections? I will be seeing my primary doctor in three days. What should I be asking him?
A: Dear Debbie, Have him do tests to see if your immune system is working. There may be a way to treat acquired immune deficiencies that are sometimes the reason for repeated bacterial infections.
Climate and COPD
Q: I have COPD with oxygen at 1 liter at night and for exertion. My son lives in Lake Havasu, AZ. The nurse said I should not live in Arizona where it is so hot, that it dries the lungs and makes it harder to breathe. Is this correct?
A: Dear Dee, Go to Lake Havasu. It may be hot and dry, but your nose will still humidify the air that enters your lungs. Enjoy the region, which is a very pleasant place to visit or live.
X-Ray and Emphysema
Q: Hello DR Tom I would like to know how emphysema is read on an x-ray? What are the technicians looking for? Thank you for your time. I am new to this site, pretty informative.
A: Dear Dell, Regular chest x-rays are not accurate in diagnosing emphysema unless it is very advanced. CT scans can show early emphysema. But no kind of x-ray tells about lung function.
Get a spirometry (a test to measure lung function that can be done in a doctors office) for this. ONLY two numbers, the volume (called forced vital capacity) and the flow (forced expiratory volume in one-second) are important. See how close these numbers are to normal for your age, sex, and height. Stay well.
Q: Are there any contraindications for mixing Racemic Epi and Albuterol/ Atrovent combo?
A: Dear Don. No, but racemic epi works somewhat like albuterol, so tremor or changes in your pulse rate may occur. Even palpitations.
Medication and Thrush
Q: I have COPD and was on Spiriva and Advair for about two or three months when I developed thrush and hoarseness. I used medications and the thrush is gone but I am still hoarse.
I have been off Advair for about 5 days. My concern is I’m still hoarse. How long should the hoarseness last? I am getting concerned.
Prior to the Advair and Spiriva, I was on Serevent, Aerobid and Atrovent. Now I am on Spiriva and Serevent. I notice I need my albuterol more often since stopping the Advair. Any suggestions would be appreciated.
A: Dear Rita, Better have a doctor look at your vocal cords, to see if there is an abnormality there. Your hoarseness should be gone, if due to the fluticasone (a corticosteroid) in Advair.
You will need more albuterol when off Advair and Serevent. These drugs have a long bronchodilator in them. The action is similar to albuterol, but albuterol lasts only 4 hours and the salmeterol, which is the bronchodilator in Advair and Serevent, lasts for 12 hours.
Q: My mother is 79 years old and was a heavy smoker for close to 30 years where she smoked 1.5 packs a day. It’s been 20 years since she has had a cigarette. She’s had a chronic cough for five years now and has seen a pulmonary doctor for the past three years.
I forget the exact terminology the doctor used about her condition (some chronic cough/infection), but he said there were nodules on her lungs and scar tissue. The doctor thought the scar tissue was from a previous case of pneumonia and since she was responding to antibiotics, he believes it’s nothing more serious. Additionally, the doctor said her condition hasn’t changed over the past three years and since he’s been doing CT scans there is no reason for concern.
He has prescribed the following:
I am really concerned about her and would like your thoughts on this diagnosis and if you could recommend a course of action.
A: Dear Randy, That’s a lot of medicine for a chronic cough. Your doctor may be correct that the problem is a result of previous infections. This suggests bronchiectasis (an abnormal destruction and dilation, widening, of the large airways).
Since he had done a CT scan, he should be able to tell if bronchiectasis is present. Sometimes some bacteria that are similar to tuberculosis, but NOT contagious, get into bronchiectasis patients.
Have him test her sputum for what doctors call MAI bacteria. He will know what this means. There is therapy for this problem if confirmed. Let me know.
Q: I am 73 yrs old and have mild/moderate emphysema. I have had six separate episodes of a “cold” in the past three months.
My MD gave me a 4mg dosepak of Methylprednisolone yesterday. I feel a bit stronger this morning but am concerned about taking Prednisone. Any suggestions or thoughts would be greatly appreciated.
A: Dear Marliese, Short courses of prednisone may abort flare-ups of COPD, which includes emphysema. Short courses have few side effects. See if you get relief. Beware of long-term prednisone, because of complications, but some COPD patients have to be on a small maintenance dose for control.
Q: I have emphysema (COPD) and have recently had many upper respiratory infections. I have recently purchased an air filter with ionizer, UV light and hepa filter with ozone option, as a preventive measure, but not have been told that an ionizer may be harmful with this diagnosis. Please advise.
A: Dear Barbara, I don’t think that home filters, with ionizers and UV light do much good or harm. They are expensive.
Q: I recently had a CT scan of the lungs first in Philadelphia and then a repeat in New Jersey to evaluate a 4mm nodule. On the second CT scan there was no nodule in the right upper lung, but now one in the left lower lung measured at 5mm. This one, I suppose, is new.
The report stated, suspicious. The doctor in New Jersey wants me to wait 3 months for another CT scan. I want to go back to Philadelphia and see if this new 5mm nodule was on the first cat. Should I be concerned? What further testing done right now? How should I proceed? Thanks so much!
A: Dear Ann, CT scans pick up a lot of nodules and about 90% are not cancer, i.e. benign, But the new ones and the ones that grow are likely to be early malignancies.
Chronic Lung Infections
Q: Hello Dr Tom, I am a 25 year-old female with severe brittle asthma and Common Variable Immunodeficiency (CVID) that was diagnosed after finding early signs of bronchiectasis on my CT scan.
Because I am dependent on high doses of oral steroids to stabilize my asthma, serious infections have been a severe problem in the past. I am on continuous antibiotics to try and limit the number of infections.
Additionally, I send sputum samples into the hospital once a month to try and detect bugs as soon as they start. Recently, all the samples were negative however, the lab results all record ’mucus and pus’.
Why would my sputum contain pus if there was not an infection? Does this mean that further damage is continuing?
A: Dear Hannah, The bacterial infections that you have had in the past result in an inflammatory process that often continues after the bacteria are killed.
This may be a slow smoldering inflammation. The steroids you take for your brittle asthma may help control this inflammation.
There are some other treatment approaches that are emerging for such situations, such as taking antibiotics in the class of macrolides, i.e. erythromycin or azithromycin (Zithromax) which is better tolerated. These antibiotics are taken continuously to combat inflammation through mechanisms quite separate from antibacterial effect. Consult your doctor about this possibility.
Q: It is my understanding that steroids are a fact of life, post transplant. Are there any other drug that can be used in place a steroid and be just as effective?
A: Dear Janet, There are a number of drugs used for control of rejection beyond steroids. Only experts in transplantation use these drugs, you should consult them.
Q: In some instances during a six-minute walk test the oxygen saturation drops below 88% then continues to drop after the individual has stopped walking. Why does this occur?
A: Dear Jean, The continued destaturation comes from blood returning mostly from the lower extremities that had their oxygen taken up during the exercise. This means that the tissues are not getting enough oxygen delivery during exercise. Oxygen delivery is a product of the heart and the content of oxygen (related to saturation) that is reaching the tissues.
Q: My mother was diagnosed with COPD in June 2004 and has progressively gone downhill. Her pulmonary doc says her lungs look better than last year, but she is on oxygen now and very short of breath. With her oxygen level dropping she can’t do anything physical.
They suspect a bleed somewhere but are unable to locate it thus far. I am at a loss as what area/specialist to pursue - blood, lungs, and heart. None of her doctors have a clear answer and she is just getting less and less active. Any ideas on where to go from here?
A: Dear Laurie, This complex situation requires a diagnosis. Reduced exercise capacity may be due to effort of breathing that relates to her pulmonary function. Also, if there is any failure of the heart to meet the exercise load, this may be a factor.
Anemia gives the blood less oxygen for the tissues and causes more demands for heart function. Finally, the acceptance of inactivity leads to a state of deconditioning, so this may be a complex matter.
Best to try to keep active with oxygen and see if more can be done for the heart or the diagnosis and the treatment of any accompanying anemia.
Cost of Medication
Q: My husband and I are both 72 and were diagnosed with COPD several years ago and have been using Qvar 40mcg inhalers ever since.
My problem is that we are retired living on our social security income and I have exhausted every avenue in pursuit of finding assistance is getting our inhalers at no cost to us as they are not covered by the Together Rx Card or Medicare. Can you please help us?
A: Dear Pattie, Inhaled corticosteroids such as Qvar may help to reduce the exacerbation of COPD and reduce hospitalizations. Their use in COPD remains controversial.
There are cheaper preparations of inhaled corticosteroids, such as Triamcinolone. Your doctor should be able to prescribe a more cost effective drug.
Q: My husband had back surgery 2 years ago. After surgery he had multiple blood clots pass through his lungs causing 50-60% damage to his lungs
He uses oxygen at home and lives in Florida it is very hot and humid making it hard for time breathing when he goes outside. It’s like he’s a hostage in the summer, and in Florida summer is 9 months long! I want him to have more freedom to go outside and not feel so bad.
I know the dusty desert or high elevation isn’t the answer, but there has to be someplace that would be better than where we are, I was wondering if you had any suggestions for the best area and climate for him to live in?
Thank you so much for making this site available, it’s very helpful to read the questions and answers.
A: Dear Tammy, He will be better in a milder climate, at a low altitude. The Gulf of Mexico may be a good place, but it still gets hot. There is no perfect climate for people who have oxygen–related needs and hate the humidity. Some do like the west coast of Florida or lower California, but it can be expensive.
COPD and Birds
Q: Dear Dr. Tom, My father has developed Emphysema in his lungs and suffers from a terrible case of sleep apnea. He has been in and out of the hospital the past six months. He has a trach tube now in his throat and depends on his oxygen tank to keep him breathing.
He is going through a great depression now. My father has always loved birds, for Christmas this year I wanted to get him some doves, but I am concerned that they may get him sick. Could having birds in his house harm him in anyway?
I believe that they could help with his depression.
A: Dear Veronica,
Birds may cause lung infections, rarely through the organisms they carry. Most often birds cause allergic inflammatory reactions in the lungs, known as hypersensitivity pneumonitis. Does he like fish? They are safe and can be very entertaining.
Q: Do you know of anyone who has Tracheomalacia and have had a stent put in? I want to know what they feel? Do they have trouble eating, cough or gag causing the stent to move?
A: I have had patients with stents and tracheal procedures known as tracheoplasty. Only very experienced surgeons should do these procedures. They may help some, not all persons with this rare disorder.
Q: Dr. Tom, I have had severe COPD since August 2000. Upon any exertion my lips get numb and my arms and face feel like pins are sticking into them. Could this be my oxygen level dropping?
A: Dear Pam, Probably not. You could have your doctor or his therapist check your oxygen level with an oxymeter while walking to see if you maintain your oxygen level.
COPD and Medications
Q: I have COPD, mostly asthma, and use the 250/50 Advair and albuterol when necessary. Are there side effects from using the Advair and would Spiriva be better choice with fewer side affects?
A: Dear Judith, All medications have potential side effects. Advair contains salmeterol, a beta agonist, is a long–acting version of albuterol, also a beta agonist. Alone or together they can cause muscle tremor and extra heartbeats, known as palpitations.
Spiriva, which is tiotropium, is in another class of drugs known as anticholinergics. The side effects are mostly dry mouth and blurred vision, but are rare. These drugs work through different mechanisms, and are often taken together.
Q: I have been diagnosed with pulmonary hypertension. What is the normal pressure and what is considered high? What is the recommended treatment?
A: Dear Jeri, Pulmonary hypertension is a group of disease states where the normal pressures in the lung's circulation increase. Normal pulmonary pressures are about 30/15.
Primary pulmonary hypertension, which sometimes runs in families, has much higher pressures when it is usually diagnosed, often 100/50 or more.
There are a number of other disease states associated with pulmonary hypertension including the arthritis group, COPD, interstitial lung diseases and liver diseases. Also pulmonary hypertension may be a complication of AIDS.
There are many treatments, but none are completely satisfactory. Certain drugs can lower very high pressures. Your physician will know what is most appropriate for your condition.
FYI: Other drugs are under development.
Shortness of Breath
Q: Dr Tom, My father has COPD and the disease is progressing. I do not understand why his blood oxygen levels are in the mid 90's, and he gets shortness of breath (SOB). Walking from one room to another exhausts him however, his blood oxygen levels remain high. Please advise.
A: Dear Jeff, This is a common question. A deficiency of oxygen is not usually the reason for shortness of breath. It is the increased effort from breathing due to obstructed air passages.
While giving oxygen is important to improve prognosis and it may improve exercise, it does not affect the effort in breathing. That is why shortness of breath continues in spite of oxygen.
Q: I have COPD/Emphysema and have been on prednisone, 10mg a day, for about a year. What could happen if I just stop taking it?
A: Dear Tom, If you stop it abruptly, you may feel weak, achy, and have a low blood pressure. It should be tapered down slowly, if your doctor thinks that you can do without it.
Q: I have asthma and COPD. Is there anything I can do to stop feeling so tired? Also where can a person get a concentrator that adjusts itself as you need more oxygen?
A: Dear Ina, Tiredness is common with both asthma and COPD. Some of the reason is poor sleep. Other causes are the energy used in moving air in and out of obstructed air passages, called the work of breathing.
There are some experimental oxygen concentrators that aim to adjust the oxygen flow to your needs. None are on the market.
Many people have their own oxymeters, to be able to measure oxygen levels at home and they can then change their liter flow to meet their needs under various situations in daily living.
Effects of Smoking
Q: Hi Dr Tom, I had childhood asthma. I started smoking about two packs a week (generally binge smoked when in bars) when I was 17 and stopped at 34.
I now have shortness of breath, a constant morning cough with no sputum, and chest pains. I have had a full work up and the pulmonologist says that all is normal.
Have you seen this before in people with childhood asthma who smoke? Will this improve over time?
A: Dear Dave, It may be that you are having asthma at times other when you are tested in your doctor’s office. Keep away from all smoking, such as in bars and restaurants. You should improve.