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Archive: Dr. Tom 24
Posted June 21st, 2005

Unusual Feelings in Chest is Causing Concern
Q. Hello Doctor, I have been living with mild COPD for three years now, my main component is persistent asthma with mild chronic bronchitis. However, I have been having periodic trouble with chest and back pains. The pains seem to vary and are vague, they also manifest as lower rib pain, pain in the upper centre of my back, a clicking sensation in my upper chest at the front. I have had a heavy feeling in my lungs also.

Is this pain part of COPD, I had a HRCT (high resolution computed tomography) 3 months ago and it was negative.

Dick

A. Dear Dick, No. These sensations of pain are not part of COPD or asthma. Your CT does not show any emphysema, which is good. I assume you do not smoke. 

Dr Tom

 

Needs Relief from Hacking Cough and Mucus
Q. Hi Dr. Tom, I smoked for years and I have been diagnosed with Chronic Bronchitis. It did not show up on a bronchoscopy with tissue biopsy where they took 4 samples and my Spirometry report was “very” normal.

Despite an aggressive regime over the last 6 months with Symbicort, I still have a hacking cough and sputum most days.

I have tried GERD (Gastrointestinal Esophageal Reflux Disease) meds and a steroid nasal spray with no joy. Can you suggest anything else? I am at my wits end with this.

George

A. Dear George, This is a tough one. Have you had sinus x-rays? You could still have a sinus infection, even with no response to inhaled steroids. Have you tried an anticholinergic bronchodilator, like Atrovent? It may be worth a short course to see if you respond.

Dr Tom

                

Worried About Mom’s Pain in Chest and Shortness of Breath
Q. Dear Dr. Tom, My mom has been having pains in her chest and she thinks that it is her lungs. The pain is in the upper chest all the way across the body and in the same place on the back. I am wondering what the problem might be.

She had an x- ray and they didn't find anything. Also she has been losing her breath for no reason. The doctor gave her an inhaler. They are not sure what it is.

Let me know if you need more information or if this is a common problem.

Rocco

A. Dear Rocco, Your mom needs a diagnosis. She needs a spirometry to tell about airflow, and also a consideration that these pains are heart related. Chronic lung disease does not commonly cause pain.

Dr. Tom

 

Are There Less Invasive Tests Rather Than a Mediastinotomy?
Q. My most recent chest X-ray showed “differences” from my last one (I have COPD) so I had a CT scan, followed with a bronchoscopy.  My pulmonary doctor found no signs of cancer but I do have enlarged lymph nodes. Now, he wants me to have a mediastinotomy (a procedure in which the doctor inserts a tube into the chest to obtain biopsy sample/s of the lymph nodes in the chest). 

I would like to know if this is common procedure just because I have enlarged lymph nodes? Particularly since there was no sign of cancer where the other enlarged lymph nodes were, which were in my lungs and lower right esophagus. 

Aren't there other, less invasive, tests that could be performed first?

Shelley

A. Dear Shelley, Yes, a PET scan will help tell if there is the likelihood of malignancy. If negative, this is pretty reassuring. If positive, you need a biopsy by mediastinoscopy.

Dr. Tom

 

How to Check Endotracheal Tube (ET-Tube) Placement  
Q. Is there a best practice for verification of ET-Tube (a tube that is placed in the trachea to keep airway open) position?  I assume an x-ray is the most accurate, but we often have anesthesiologists that use capnography (measures exhaled CO2) or other means of verification.

Steve

A. Dear Steve, Capnography only tells you that the ET tube is in a major airway. It measures CO2, even if the tube is in a mainstem bronchus.

X-ray positioning is more accurate for determining the tracheal position.

Dr. Tom

 

High Oxygen Flows for Those with COPD
Q. Last week you answered a question relating to a person on 8lpm (liters per minute) of a nasal cannula. 

The person was also asking about it being too high a flow for a person with COPD.  We were taught that higher than 5lpm on a nasal cannula was detrimental to the nasal mucosa and also was unnecessary because the reservoir was already full at 5 lpm. 

Can you tell me what I can read to update myself that high levels of O2 like 8 lpm, is no longer a concern for people with COPD? Thanks.

Pamela, RN, RRT

A. Dear Pamela, I do not know of a readily available reference to answer your question. Most people who feel that they need a high liter flow for COPD do not have a deficit in oxygen, when monitored by oximetry.

Oxygen does little to relieve shortness of breath. This is because the work of breathing is the main cause of shortness of breath.

Dr. Tom

See the question from last week.

Increasing Need for More Oxygen and Poor Reimbursement for Oxygen in Nursing Homes
Q. My father is on 8 liters per minute by nasal cannula for COPD. Often times, he feels this is not enough so the nursing home staff turns up the concentrator to 9 or 10L/min.

I have heard this can be very detrimental because at some point the brain “forgets” to make the body breathe.  At what point can this happen? 

What is the next step if 8L/min is not sufficient?  He has a phobia about using a mask and I'm not sure he'll consider that option. 

Is liquid oxygen a better option? What do you do when he maxes out at 10 liters per minute? The durable medical equipment company doesn't have machines that go higher than 10. 

Last, why is it that Medicare will not cover 80 percent of the oxygen cost when a patient is in an intermediate care facility?  If he were at home, in assisted living, or in skilled nursing, Medicare covers that cost. It's an abomination.

L.M.

A. Dear L.M., Forget about the old notion that high liter flow will shut off the brain to breathe. This is not correct. But higher flow than 8 liters for COPD is highly unusual.

Few people with COPD require more than three liters per minute. I doubt if this much is really needed, if monitored by his oxygen saturation with a pulse oximeter.

Oxygen does not relieve shortness of breath, as many people believe. The shortness of breath comes mostly from the work involved in the act of breathing. People may feel relief because of the flow of air around their face. Try to put a fan by his bedside. It can give great relief.

I have a simple comment about what Medicare will and will not pay for. At times it is an arbitrary decision, and without reason. It is very hard to change Medicare.

Dr. Tom 

Can Theophylline Improve Response to Steroids?
Q. Hi Dr. Tom, I smoked and have chronic asthmatic bronchitis with no airflow obstruction (FEV1 110%). I cough and have mucus all the time and my steroid meds do not help that much with this, but the breathlessness is not as bad.

I found this article on the Web titled: Why Smokers Lung is Resistant to Steroid Treatment?

Its about a breakthrough in COPD research and how treating with theophylline can switch on some gene that makes steroid meds more effective in reversing the underlying inflammation / process.

Do you think it is worth talking to my pulmonologist about a trial of a low dose theophylline + my existing steroid med, Advair or Spiriva.

I am at my wits end with the chronic cough, mucus and chest discomfort. Your advice is appreciated.

Con

A. Dear Con, Yes, this is a good idea. You only need low dose theophylline to achieve this effect. You do not need blood level monitoring.

Dr. Tom

*** For those who would like to read more about this topic, please read the complete abstract.

 

Daughter is Worried About Father’s Resistance to Treatment
Q. My father (age 63) had a quadruple bypass in the beginning of February 2005. At that time he was told he had severe COPD and possibly, lung cancer. He has been a smoker for many years average of 3-5 packs a day and an alcoholic, 12 beers or more a day.

Since he's been home he's back to his old habits and I noticed he's no longer doing his breathing treatments. The Dr's told him if he continues this way of life he wouldn't live another 6 months.

I was hoping you could give me some basic info like what signs I should be looking out for? What is the average life expectancy in this case, so to speak? I don't even believe he's going to the doctor anymore. All he says is he's, over 21 and there's nothing they can do. 

April

A. Dear April, There is no simple answer to your question. Self-destructive behavior is hard to combat. Your father needs all the help he can get, including your love. Maybe a psychiatrist is in order.

Dr. Tom

       

How Long Does it Take to Feel the Effects of Smoking?
Q. Dr. Tom, I am a RT and I have been smoking for 5 years. I am definitely trying to quit.

Have there been studies that determine how long it takes to feel the effects of smoking, or when do the lungs start losing elasticity? 

Tom

A. Dear Tom, Fortunately 80% of smokers get no lung disease, but 50% die prematurely of one of the smoking related disorders. Do not play “Russian Roulette” with your health. Stop smoking immediately.

Dr. Tom

 

Got an Idea!
Q. Just wanted to say hi.  We met in Denver when we were introducing the Cryo2 liquid oxygen system back in the late 70’s. 

Went on to co-develop the first demand oxygen controller.  Got an idea....What would you think about a controller that was co-controlled by oximetry?

Dave

A. Dear Dave, Good question. I just met a doctor from Germany, at the 48th Aspen Lung Conference, held last week. He said he had a patent for such a device. I am going to find out more about this.

Dr. Tom

 

How Can I Find Out Why I Feel the Way I Do?
Q. I am 79 years old and have been on oxygen for the past five years. Every day is a little harder to get through; but my pulmonologist tells me that everything is the same as the year before.

My heart rate is very fast and the cardiologist put me on Cardizem (medication for heart) and I am still not feeling better. How can I find out how bad my condition is?

Henrietta

A. Dear Henrietta, I need more information to be able to come up with an answer. Some days, people feel bad and others feel good, for no apparent reason.

Dr. Tom

                

Are There Benefits of Pulmonary Function Tests (PFT) When Patients are Acutely Ill?
Q. I was wondering about the reason for ordering a PFT on the acutely ill hospital inpatient.

I always thought it to be better once their acute disease state has resolved.  Are there situations where a PFT on an acutely ill respiratory patient would be of any benefit with their course of treatment?

Roger

A. Dear Roger, Of course, but remember that an abnormality, may resolve as the patient receives treatment. Simple bedside spirometry is very underused. No need to go to a PFT laboratory.

Dr. Tom

 

Need Surgeries but has Lung and Heart Trouble
Q. Hi Dr. Tom, I have a bad mitral valve in my heart that the doctors don't want to operate on because of my bad lungs.  The lung doctors do not want to operate on the bulle in my lungs, because of my heart problems. 

What's the answer?  I am on multiple meds and 24/7 O2 at 2L normally, and 4L when exerting.  Thank you!

LuLu

A. Dear LuLu, I need more information. In general, I would do the heart first and see what benefit you get.

Dr. Tom

 

Worried About Husband’s Lung Symptoms
Q. My husband was taken to the ER on the 11th (June) for shortness of breath, chest pain, and cough. They checked his oxygen level with an oximeter and it was at 90. Over the next three hours it went down to 86 so they admitted him and put him on 3 liters of oxygen. After a day in the hospital they decided to let him come home with 2 liters of oxygen. 

Now, if he does anything, which includes taking 20 steps without the oxygen he is severely short of breath and starts coughing. In the last 5 days or so he has complained of severe pain in the calf area of his leg - deep pain.

The doctors were going to run a test on his lungs for a blood clot but didn't figure he had one, so they decided against running it.

Now my husband is so tired of going to ER’s, doctors, etc. and not finding anything out that he said he will wait until he can see his pulmonologist on the 27th of this month. 

Is it possible that he does have a blood clot in his lung and maybe his leg? He can hardly walk because of the pain in his right calf. The only way that his oxygen levels stay up is to be on the 2 liters of oxygen 24/7.

Also he has asthma and has had several attacks in the last year. Several years ago he was told that he had restrictive lung disease.

He was in a car wreck about 7 years ago and punctured the lower lobes on both lungs and they were not re-inflated. Now has scar tissue on both of them. He uses inhalers and meds for allergies and asthma. Thanks.

Nancy

A. Dear Nancy, Get your doctors to do a CT of his chest now, to rule out a lung clot. It is not wise to wait for the next clot, if this is really the problem.

Dr. Tom

 

Does My Friend Have Lung Cancer?
Q. Dr. Tom, My best friend found out he has scar tissue on the lung. Does this mean cancer? Thank you.

Theresa

A. Dear Theresa, Probably not. But a follow up chest x-ray or a CT should be done.

Dr. Tom

 

Worried that Husband May Have COPD
Q. Hi Doctor Tom, My husband (a former smoker) has recently had some Pulmonary Function Tests, his FEV1 (103%) only goes up 2% after bronchodilator but his FVC increased by 16.8% on his previous score which was already 108% of predicted.

He is complaining about being short of breath and is taking his asthma medication a lot more than usual. 

What could this be? His pulmonologist says asthma is not likely, and wants to see him in 6 months to see if there has been a change!

We are worried he may have COPD.

Ruth

A. Dear Ruth, He does not have COPD with these normal spirometry results. I agree that it is fine to wait for 6 months to see his doctor again. I doubt that inhalers are necessary.

Dr. Tom

                

Is Thick Mucus a Major Side Effect of Vistaril?
Q. Dr Tom, My primary doctor gave me Hydroxyzine Pamoate (Vistaril) for panic attacks, when I have severe SOB. I read that the drug could cause thickening of the mucus in the lungs. Should I use this drug? 

Thank you for your valued information.

Shelby

A. Dear Shelby, Vistaril may dry the secretions from the lungs some. You and your doctor need to decide if the benefits outweigh this possible side effect. Other drugs such as Xanax are probably better for panic attacks.

Dr. Tom

 

Can You Have a Normal FEV1 and Have COPD?
Q. Hello, I smoked for 10 years and now feel unwell with a chronic cough and sputum. I feel my lungs are expanding in my chest to the point that my lower ribs are sore and I have upper back pains.

I have had a chest X-ray and a PFT (pulmonary function test). My doctor says everything is normal. My results are FEV1 103% and FVC 110%.

Is it possible to have the hyperinflation part of COPD with a normal FEV1?

Jean Luc

A. Dear Jean, Yes, but if so, it is very mild. You probably have simple chronic bronchitis, which is chronic cough from smoking, but without airflow obstruction. I assume you have stopped smoking. If so, the chronic cough will probably go away in a few months. It takes that long in some patients.

Dr. Tom

 

 

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