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Archive: Dr. Tom 113
Posted January 29, 2008

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

 

 

FEV1 Dropping After Quit Smoking
Q. Dear Dr. Tom Happy New Year. Hope you are well now.

Can I ask your expert opinion on my health problems? First, I am 59 year old male, diagnosed with COPD (emphysema) four years ago after an x-ray.

I had smoked all my life but when I was diagnosed I tried stopping. I have been totally smoke free since last May. Since stopping smoking, I exercise and have a good diet, but keep getting repeated chest infections, which are treated with various antibiotics, and prednisone.

 I am under the care of my family doctor and not a chest doctor, although I did see one but was well at the time. You will see by FEV’s figures that this has gone down and is worse since stopping smoking and the chest infections.

I take Spiriva, salmeterol, Ventolin, Qvar; I also take Adalat 30 for blood pressure problems. I also take other medicines for pain relief for spinal surgery some years ago.

I then later had a spirometer check.

My FEV’s are
Dec 2006
FEV 1            2.16
Lung   FVC      3.64 litre
peak flow        426
July 2007
FEV1            1.7
LUNG FVC    4.4 Litre
peak flow       420

One of the questions I would like to ask is why are my lungs getting worse after cessation of smoking and starting daily exercise and diet over 9 months ago (prior to this only smoked two a day for the last three years) gave up cold turkey style?

I have been diagnosed with diverticular recti and I have noticed that this is getting larger and my stomach expanding although I am limiting my calories and cannot get rid of my expanding waistline. I am still wheezing and SOB is getting worse. Also I have repeated infections. COPD in the UK does not get much attention can you please help me Dr. Tom?

Stuart

A. Dear Stuart, The apparent loss in FEV1 is most likely due to the infections. If so, you should recover most of the lost function. FEV1 does go down slowly and regularly as a function of aging. Keep on your medications and maintain a good exercise program. You should do well.

Dr. Tom

 

Small Densities found on CT Scan
Q. Hi Dr. Tom, My husband had a CT scan of abdomen. They saw a small density in his left lung. Had second CT said it looked like scarring, 1.2 by 2.3 cm, but to have biopsy. He’s a non-smoker. All else was clear. No mediastial adenopathy or pleural effusion, lungs were clear. What your opinion?

Stephanie

A. Dear Stephanie, The risk of this being cancer is small because he is a non-smoker. Smoking related cancer prevalence goes up with age and is also related to family or occupational risk.

 He should have a follow-up CT in about four months to see if the lesion is stable. It is not too small for a biopsy, which would tell you for sure what it is.

Dr. Tom

 

Do Lung Infections Always Show Up on Chest X-Rays
Q. Is it possible to have bacterial lung infection or other infection that does not show up on chest x-rays? I am desperate.

Mary

A. Dear Mary, Yes. Sometimes there can be a fairly extensive infection that only shows up on CT Scans.

Dr. Tom

 

Father is Short of Breath but They Will Not Prescribe Oxygen
Q. My Father had lung cancer that was removed along with a part of his right lung. Three years later we noticed that he had trouble breathing while walking or exerting himself. It has now progressed to not being able to go from chair to chair. They now say COPD. 

They do not prescribe oxygen because the problem is not breathing in but pushing the air out.  What stage is this and what can we expect.  He is a fighter and amazes us daily.

Leigh

A. Dear Leigh, Oxygen is very helpful in COPD when a deficit of oxygen is present. It improves both length and quality of life. Find a doctor who is more interested in improving quality of life, and that may well include oxygen.

Dr. Tom

 

How Can Patients with Respiratory Distress Have High Oxygen Pressures
Q. Dr. Tom, I'm in the RT program and am wondering from one of my case studies how PaO2 can be as high as 138 in a patient with respiratory distress. I also wanted to know if you would suggest some good books that I can learn from.

Kitty

A. Dear Kitty, There are many good books on respiratory are. I suggest Kacmarek and Pierson's text.

An oxygen tension can only  be high, i.e. 138 with supplemental oxygen or under hyperbaric conditions.

Dr. Tom

 

What are the Differences Between Obstructive Lung Disease and COPD?
Q. Dr. Tom, Recently my mother was told she has obstructive lung disease, but not COPD.  She is a nonsmoker.  What is the difference between the two?  Should she seek a more specific diagnosis?

Jennifer

A. Dear Jennifer, COPD is an obstructive lung disease. Also chronic asthma as it relates to COPD is an obstructive disease.

Dr. Tom

 

Parents Say Cough is Normal
Q. I had a severe cough. Last week my phlegm was green and I found it hard to breathe. I'm just 13 years old my mother and father said that my cough is just normal like that. But when I started to get up this morning I coughed so hard and it already kills me. I can't breathe well could you help me?

Elaine

A. Dear Elaine, You most likely have asthma, and should see a specialist.

Dr. Tom

 

 Short of Breath and Have a Positive D-Dimer Test:
Q. I am 37-year-old healthy non-smoking female, moderately overweight.  I have had persistent chest pressure and some mild shortness of breath for about two months.  Two months ago, my symptoms were more acute with chest pain and I went to emergency room. 

All cardiac testing was negative, but D-dimer  (a test that is ordered when ddep venous thrombosis, DVT, or pulmonary embolism, PE, are suspected) was positive, so I had chest X-ray and Q/V scan, which were negative.  PCP has been trying to help me figure out symptoms and we have explored GI causes without success.  She re-did a D-dimer this week which came back positive again (335). 

I am scheduled to go to pulmonologist at the end of the month, but I am very anxious about the positive D-dimer.  Am I safe to wait that long?  No other causes of positive D-dimer seem to apply to me, so I am worried about undiagnosed clotting and it has been two months since my scan so I am also concerned about walking about with an untreated pulmonary embolism.

Dawn

A. Dear Dawn, The positive D-dimer needs to be explained. You could be having clots. It is not dangerous to be active, however.

Dr. Tom

 

What Do You Think of Transtracheal Oxygen
Q. I just found your page and think it is great. I recently had to start using 02 all of the time. I have been going to rehab for four years with no 02 and have done well for as bad as my emphysema was but now I have the 02.

My question is "What do you know and think about transtrachael surgery to deliver the 02 that way? Since I have been using the cannula I have a constant allergy on my face from it {latex free). No help from the dermatologist, yet.

My rehab respiratory gal tells me that they used to do them quite a bit but she has not seen a lot lately. Do you feel this is a dangerous procedure and I do realize you have to be on continuous flow of 02 all the time.

 There is a site on the internet where this is talked about and I found it most interesting being I have this problem. Thank you so much for addressing this and I am learning from your great site.

Judy

A. Dear Judy, The transtracheal method of oxygen administration is excellent for selected patients. It avoids all the nasal canulae problems. It is a very safe procedure. It is not good for patients who are troubled with lots of mucus. Consult the Transtracheal Institute in Denver.

Dr. Tom

Could CT Scan Results Be From a Boxing Trauma
Q. Dear Dr. Tom, I recently had a CT Scan that found a 3mm micro focus of pleural thickening on the lower left lung base.  I went for a follow-up three months later, no change.  The report says that the lungs are clear and there is no evidence of any mass nodule or infiltrate.

The doctor says it's most likely from an old infection or trauma.  I was a boxer years ago. I was wondering if this can be from trauma?

Bob

A. Dear Bob, This is probably the explanation. It is so small and has shown no growth that I would forget about it.

Dr. Tom

 

Is It Safe to Go Climbing after a Having a Collapsed Lung?
Q. I am a 36 year fit and healthy male. I have a history of pneumothorax on one side. After three instances, this was corrected with pleurodisis about seven years ago with no recurrence.

I wish to travel at high altitude on holiday this year and wanted to know what the risk was likely to be of either pneumothorax or another complication. The holiday would involve trekking/hiking at 3500-5500m.

Ian

A. Dear Ian, There are no guarantees in medicine, but you should be fine trecking at high altitude. Have fun.

Dr. Tom

 

Had a Pulmonary Embolism and I Am Worried about CT Scan Reports
Q. My husband had multiple bilateral pulmonary embolisms three years ago.  Follow-up CT scan done eight months later read "spiral CT of the thorax was performed from the level of the lung apices to the adrenal glands during the bolus administration of intravenous contrast.  The heart is normal in size.  No pericardial effusion.  The visualized pulmonary vessels demonstrate no definite evidence for filling defect.  If there is persistent clinical concern for pulmonary embolism, further evaluation with VQ scan would be recommended.  There does not appear to be evidence for significant hilar or mediastinal adenopathy.  There are a few small nonenlarded lymph nodes present.  The thyroid gland appears normal in size.  No more than very minimal fibrolinear change at the right lung base which may be related to subsegmental atelectasis versus scar.  This appears slightly nodular at the very inferior aspect of the right lung.  No focal infiltrate or pleural effusion.  

Impression:  Minimal fibrolinear change at the right lung base which may be related to subsegmental atelectasis versus scar. 

He had a chest x-ray done January 2007, everything normal.  Had a CT scan done December 2007.  Report read:  "Axial CTA images are obtained through the thorax with intravenous contrast administration.  MIP multiplanar reformatted images were also obtained and reviewed.  There are small bilateral axillary nodes without frank lymphadenopathy.  The thyroid is normal in size and position.  Small mediastinal and hilar nodes without frank adenopathy.  The thoracic aorta is normal in course and caliber.  The heart is not enlarged.  There  is no pericardial effusion.  Small hiatal hernia.  Evaluation of the pulmonary arterial tree in multiple planes reveals no evidence of significant pulmonary embolism within the main pulmonary arteries, or first or second order branches.  The tracheobroncial tree is patent centrally.  There is a 5 mm lung nodule subpleurally within the superior segment of the right lower lobe best appreciated on series 4 image 14.  This is nonspecific but more likely postinflammatory in nature.  Six month follow-up chest CT recommended to document stability/resolution.  There is minimal scarring in both lung bases, right greater than left.  There is no parenchymal infiltrate or pleural effusion.  An evaluation of the osseous structures demonstrates no osteolytic or blastic process. 

What does all this mean?

He was a smoker and quit three and a half years ago.  Primary doctor believes it to be benign, sent us to thoracic surgeon for reassurance he too believes this is nothing but am to have a repeat CT scan without contrast end of March 2008 for stability. 

Is this 5mm nodule found in the second CT scan the same as the scar tissue that appears slightly nodular in the first cat scan?  What does not specific mean and what does post inflammatory mean?  My niece is a physician's assistant for pulmonary specialist she says it is trauma from PE's all that can be done for such a small nodule if wait until next CT Scan, she too believes this is 99.9% that it is nothing. 

Reporting seeing the lymph nodes, is anything wrong with them by the way the report reads, my niece says no just that they see the nodes, we all have them, is this correct that nothing is wrong with them? 

Barbara

A. Dear Barbara, Your dissertation contains multiple questions that would require several paragraphs to answer. This is beyond the scope of this site.

In essence, there is nothing wrong except some scar, probably from the old pulmonary and the small nodule of 5mm should have a CT follow-up as advised.

Dr. Tom

 

Wonder about Daughter’s Recurrent Pneumonia
Q. Hi there I am writing today about my four year old. She was hospitalized in June 07 following this x-ray. Here is the impression from the report:

The findings are compatible with small airways disease with atelectasis. A bronchopneumonia would be difficult to exclude. I would recommend short-term follow-up films to see if the findings resolve. There is apparent fullness of the hila but I believe this is related to the perihilar opacities.

She has pneumonia again. This is the impression from this x-ray from about a week ago: There is a right perihilar infiltrate.

I have said that since the first time she was sick she has not been right as far as breathing is concerned. I was wondering if you could give me your thoughts. I would really appreciate it.

Julie

A. Dear Julie, I am not a pediatrician, so I suggest you consult a pediatric pulmonologist.

There may be some correctable reason for the recurrent pneumonias. Perhaps there is an abnormality of her immune system, and I would ask your doctor about this.

Dr. Tom

 

Could Atelecasis Be Causing Pressure on My Portal Vein?
Dear Dr. Tom, I was recently diagnosed with Primary Biliary Cirrhosis. I am experiencing mild jaundice. I have been told that a liver transplant is likely in my future. I had an MRI and it said in the report that bibasilar atelectasis was present.

Do you think this could possibly be caused by pressure from the portal vein in my liver due to the PBC? Thank you so much.

Michelle

A. Dear Michelle, I doubt if this is the explanation, but it is possible.

Dr. Tom

 

Parenchymal Scarring
Q. What does parenchymal scarring of the base of the left lung mean?

Wendy

A. Dear Wendy, Essentially nothing of significance. It most likely is a result of an old inflammatory process, such as a pneumonia, which may not have been clinically evident. Nothing needs to be done about it.

Dr. Tom

 

Combination of Medications and “Stable” COPD
Q. Is it safe to use Spiriva and Symbicort together with albuterol inhaler for a rescue? Also could you define what stable COPD is? Thank-you very much

Teresa

A. Dear Teresa    These drugs and drug combinations are all compatible with each other. "Stable"  is in the eye of the beholder. It generally means free of exacerbations (flare-ups) and pulmonary function that is not declining more rapidly than the age related rate.

Dr. Tom   

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