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Archive: Dr. Tom 123
Posted April 20, 2008

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

 

 

Biopsy of Nodule Difficult Due to Position of Nodule
Q. Dr. Tom, I had an abdominal CT scan and by chance they found a 9 mm noncalcified pulmonary nodule within the lateral aspect of the lower left lobe adjacent to the left diaphragmatic leaflet. They said percutaneous biopsy (tissue sample is obtained by insertion of needle) of this nodule would be technically difficult due to proximity to the diaphragmatic leaflet.

I just turned 39 years old three days ago. I have never smoked. However my father just passed away from Idiopathic Pulmonary Fibrosis, he was 75 years old and never smoked. I can't stop fearing the worse. Every time I look at my children I cry. Please advise me. Thank you so much,

Bethann

A. Dear Bethann, Your chances of having lung cancer are so small that they should be of no concern. The nodule is almost certainly a healed granuloma. You may seek the reassurance of a follow up CT is six months or so. Stay well and enjoy your children.

Dr. Tom

Tracheostomy Humidification 
Q. Are there studies for non-ventilated adults with a tracheostomy to use Heat Moisture Exchanger (HME). Pediatrics seems to use HME vs. aerosol mist.

Reppert

A. Dear Reppert, I am sure there are some studies on this. I suggest consulting the literature.

Dr. Tom

Changing Medications
Q. Dr. Tom - I am presently taking Advair 250/50 Diskus, for Emphysema. Since I don’t have insurance, I am going to switch to Symbicort. I am going to have my doctor write a prescription for me, but I wanted to look online at Canadian sites to get prices. Could you please tell me what the equivalent dosage with Symbicort is? I also take Spiriva handihaler 1X day, which I will be staying on.

Joanne

A. Dear Joanne, I do not know about the exact equivalent doses between Advair and Symbicort. Most pulmonologists prescribe 160/4.5mg, which are budesonide and formotorol, respectively.

Dr. Tom

Something in My Apartment is Irritating My Lungs and Skin
Q.
Dr. Tom, I brought home some wet laundry months ago and when I hung them up it irritated my throat and made my skin itch severely. I bled from the scratching.

I now have to wear a mask at home because the air is so heavy. Question 1) How can I identify what is in the air and how can I get this “stuff” out of my apartment? Opening windows simply stirs up the air and makes it harder to breathe.

Joe

A. Dear Joe, There are air samplers used by OSHA (Occupational Safety and Health Administration http://www.osha.gov/ ) and EPA (Enviromental Protection Agency http://www.epa.gov/ ). I do not know of any air test for inhaled antigens.

You may be dealing with molds, as a guess. Dr. Tom

How Much Is Too Much Radiation?
Q.
I recently had two CT Scans done for shortness of breath and chest pressure. I am now having pain in upper back, neck and head.  I would like to see a chiropractor but I will probably need an x-ray. 

I am concerned about the amount of radiation I have been exposed to.  Is it safe to have an x-ray done since I've already had two CT Scans?

Mary Jane

A. Dear Mary Jane, The amount of irradiation from a simple chest x-ray is tiny compared with a CT. I wonder what the two CTs were for.

Dr. Tom

Treatment for Pulmonary Fibrosis
Q.
Dear Dr. Tom, I am very worried about my mom, now 79. She has pulmonary fibrosis with honeycombing and had an acute exacerbation a couple of months ago.

They have prescribed prednisone but I have read that it does not do a lot to stop the disease.  Do you know of any new drugs for IPF that will soon help people suffering from this?

If so what drug looks like it holds promise to help stop this disease from getting worse.

Tim Whitehouse

A. Dear Tim, There is no established treatment for this form of advanced IPF. I suggest consulting with an institution that is involved in testing new drugs. Denver’s National Jewish Medical and Research Center would be an excellent choice.

There are drugs used for various serious diseases that have a rationale in IPF, and sometimes they are effective on an anecdotal basis.

Dr. Tom

Dusty Desert or Warm Humid Location?
Q.
  I have recently quite smoking after 37 years. I have emphysema and asthma. Our home is in Las Vegas, however, we are living on Maui, HI for a year possibly two for my Husband’s work.

My breathing is a struggle here, is it the high level of humidity. Which is worse for me the dry dusty desert or the warm humid climate?

Lori

A. Dear Lori, You can tell which is worse for you, by how you feel on a daily basis.

Dr. Tom

Does Recording Wrong Smoking History Effect Spirometry Results
Q.
I had one PFT performed in 2003 when I was 36 years old and another in 2007.  They were done in different labs.  On the first test, the report indicated that the technician used .5 for the number of packs per day (which was accurate).  For the second test, it seems the technician put in one pack per day for some reason.  Does this affect the predicted values for the test, i.e. are the results incomparable because of this and other changes in predicted values? 

My results are below.  If you could, please comment on the change in the results as well.  Thank you for all you do.

2003  
FVC  117% predicted
FEV1  110% predicted
FEV1/FVC 72 94%predicted
FVC 102% predicted
FEV1 89% predicted
FEV1/FVC 72 87%predicted - predicted 82%

Dave

A. Dear Dave, Only the fact of smoking history is recorded, and does effect prediction for normal values. Your tests are normal. Stay well.

Dr Tom

Priority of Monitoring Chest Tubes
Q.
Dr. Tom, My patient is a 25-year old male with a chest tube is complaining of shortness of breath. What should be my first priority; check the chest tube or obtain a set of vital signs and oxygen saturation.

Kate

A. Dear Kate, It depends on the purpose of the chest tube. That is, is it draining blood, air, or just there for long-term treatment of a residual space. It should be checked along with vital signs and oxygen saturations.

Dr. Tom

Are there Dental Side Effects to Spiriva?
Q.
I have been using Spiriva inhaler for about a year now.  Nothing else has changed in my medications or in my diet.  However, my teeth are decaying like crazy and I need several thousand dollars worth of work done on them.  They are TOTALLY decaying everywhere, which was never the case before.  I've had regular dental care since I was age four, and I am now 65.

My teeth were excellent before the Spiriva treatment for COPD.  What are your thoughts about this?

Leona

A. Dear Leona, I am not aware of dental problems from Spiriva.

Dr. Tom

Can Drinking Water Raise Your Blood Pressure?
Q.
I attend pulmonary rehab at a North Florida lung transplant facility. Each session blood pressure, heart rate and 02 saturation are recorded at the beginning of the session (after a brief rest), during the peak effort on a treadmill, and recovery.

On this particular day my blood pressure was a little lower than average but nothing to get alarmed about. My recovery blood pressure was a little lower than the beginning reading.

The RRT ask me to drink some water to bring my blood pressure back up. I promptly walked about 20 feet and drank about 2 to 2.5 oz. of chilled water and walked the 20 feet back to my seat. The RRT checked my blood pressure and it had gone up but not that much if it had been low enough to cause any concern to begin with. My question is, did my drinking any amount of water raise my blood pressure? What if any is the relationship between drinking water and ones blood pressure?

Thank you for your time and consideration.

Rusty, EFFORTS member (Emphysema Foundation for Our Right to Survive http://www.emphysema.net/ )

A. Dear Rusty, There is no relationship between drinking ordinary amounts of water and blood pressure. In states of severe dehydration, rehydration with water and electrolytes would help raise blood pressure.

Dr. Tom

Signs and Symptoms at the End of Life
Q.
My husband has severe COPD. He was on two liters of O2 as of today he turned it up to three liters. He just started having a constant cough that is somewhat wet and coughing up white stuff.

His O2 drops down to 70% when he gets up and goes 10 steps to the bathroom, I also noticed his urine is now reddish brown and cloudy and stinks. He slept somewhat is a upright position so he wouldn’t cough so much. His legs never hang down, he keeps them up and sort of under him at all times and they are so white in color. His face is most of the time red, and sometimes he looks blue.

Is this what I can expect for the closing of his life with me. He has 30 percent of the lungs left over three years ago. He still smokes seven cigarettes daily and won’t give them up.

With everything I’ve told you is he getting closer to death? I know you are not a predictor, but please tell me what to be looking for. I would like to have my two sons here with me when it happens if possible.

A. Dear Debbie, It is hard to predict the time of death in advanced COPD.

It is clear that your husband has very advanced disease and not long to live. He will most likely die in his sleep. Death from COPD is rarely uncomfortable for the patient or the prepared family. 

Dr. Tom

Does Nebulized Lidocaine Help Bronchospasms?
Q.
Dr. Tom, I have severe asthma and I was wondering if there was any research on nebulized lidocaine to relieve severe bronchospasm in the Emergency Room. How safe is it, for children as well?

Derrick

A. Dear Derrick, Nebulized lidocaine has been used in very dilute concentrations to combat serious bronchospasms. I do not recommend it in children.

You would have to consult the literature to find out the preparations that have been studied. It is certainly not in common use.

Dr. Tom

Diaphragm Paralysis and Treatment
Q.
Dear Dr. Tom I am a 62 year-old female with small airway disease. I’ve been evaluated for lung transplant and am on hold right now because my PFT numbers have stayed fairly stable for three years.

My concern is that I have a right diaphragm that is paralyzed. My left lung functions at 30% and the right at 60%. My question is, once a diaphragm is paralyzed is there any hope of improvement to that diaphragm?

There has been some talk in my medical group about tacking down that diaphragm to help my breathing but that there hasn't been a lot done in this area with adults. There is a surgeon here that has done this on children with positive results. Have you heard of this being done on adults and what would be the risk? Thank you for your kindness.

Marylin

A. Dear Marilyn, The cause of the diagphragmatic paralysis is a factor in its future evolution. Sometimes it is reversible. There are operative techniques to fix the diaphragm in a lower position. You would have to ask your surgeon about this. You can get along well with only one functioning diaphragm.

Dr. Tom

Twenty One Years Old and have Breathing Trouble
Q.
Hello Dr. Tom. I am a healthy 21 year-old male. I weigh 145, I exercise often, and I have never had any serious illnesses.

I spent a year in Iraq driving a tank for 13 hours at a time. I quit drinking two and half months ago to get ready for Ranger school. I currently dip and don't smoke. However, I have been having trouble breathing lately.

It’s an odd feeling to tell you the truth. I don't have any trouble while exercising but after feel short of breath. When I’m in class I feel either anxious or like I’m going to quit breathing. My arms and legs have been falling asleep on occasion while sleeping and sometimes when I’m sleeping it feels like either my heart sputters or I quit breathing for a second and wake up freaking out.

This happens like once or twice a week but my lungs feel heavy all the time. I’m a college student and I don’t have much money. Can you give me some advice sir?

Casey

A. Dear Casey, You may have sleep apnea, which should be considered by your doctor. Also the fact that your shortness of breath follows exercise suggests the possibility of asthma. You need spirometry before and after exercise and probably a sleep study. Maybe you can get this when you are enrolled in ranger school.

Find a way to get an evaluation, because you should not have to live with these uncomfortable symptoms. You probably can get control with simple medications.

Dr. Tom

Quit Smoking but Worried about Lungs
Q.
I am a 30-year-old female. I smoked moderately for about 10 years (17-27); at the height of my smoking years, I smoked one pack a day, age 19-22.  I completely quit smoking when I became pregnant in 2006.

I work out regularly. When I do an intense cardio workout, I notice my lungs will crackle at the early part of the workout. I am worried about this, since I am a former smoker. What could this be? How concerned should I be?

Amanda

A. Dear Amanda, No concern. You probably have a bit of mucus that you notice as you start exercising. Stay well and enjoy life.

Dr. Tom

Chest Pain When Breathing Deeply
Q.
I’m 28 years old, male, I quit smoking two months ago, was a smoker for ten years. I’ve been experiencing pains in my chest when breathing deeply, and during shallow breathing, lasts for a few minutes before passing.

Alex

A. Dear Alex, Pain on deep breathing has many causes, particularly in older people. If you are concerned, I suggest seeing a pulmonologist, but at your young age, I doubt if there is anything serious behind these transient symptoms.

Dr. Tom

Mother has Hospice Care and Pain is Not Under Control
Q.
My mother is in the end stage of COPD we have hospice in but her pain level is not under control.

What we need to know is she has very dark urine and her out put has slowed way down, as well as having a major head ache for the last two days. To me it feels as though she is swelled up in the base of her skull going up into her head and now she is swelling throughout her body at a rapid rate if you have any ideas please let us know.

Ty

A. Dear Ty, No person should suffer undue pain. Morphine by mouth is safe and will control most pain.

I do not know the reason for the dark and scanty urine volume. One would consider dehydration, but with the swelling, this is most likely from fluid retention.

Push for pain relief with enough narcotics, and do not try to figure out the details of her urine color and volume. You mother is near the end of life, and in a hospice where comfort is the highest priority.

Dr. Tom

 

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