Peak Flow Meters and COPD
Q. I am wondering if performing a peak expiratory flow on a handheld flow meter in patients with emphysema is contraindicated in the emergency room for those experiencing an acute exacerbation? I've always been taught that peak flows (a device that is used at home to monitor your expiratory airflow) are paramount in asthmatics, however, can be detrimental for emphysematics, especially in the ER. I'd really appreciate your feedback. Thanks!
A. Dear Karen, Doing peak flow in emphysema in the emergency room is not dangerous, but it won't tell you much about the degree of airflow obstruction in emphysema. FEV1 is much better, and should be done to know something about the severity of airflow obstruction. This can be done with a simple hand held spirometer, not much larger than a peak flow device, but it gives far more information. Spirometry should be available in all emergency rooms.
Questions about Fibrosis Diseases of the Lungs
Q. Dr. Tom, If inflammation causes the air sacs to be damaged isn't it a good idea to have one every once in a while to see if you have some. I was recently diagnosed with Interstitial Pneumonitis (group of disorders characterized by inflammation and eventually scarring of the deep lung tissues, leading to shortness of breath) and possible early stages of Pulmonary Fibrosis in my lower lungs.
I was put on Prednisone that took away a lot of the bad symptoms. It is a horrible drug through as far as the side effects. What scares me is that if I don't take the Prednisone, the inflammation will be working on my lungs.
Neither one of my doctors think I need another x-ray right now. Are there doctors that specialize in IPF (Idiopathic Pulmonary Fibrosis)?
I am 67 years old, and this has hit me like a ton of bricks. I was so healthy and active before. Now I think I am going to die soon. If you could answer my questions I sure would appreciate it. Thanks.
A. Dear Betty, Interstitial fibrosis and emphysema are two quite different diseases and are not related. You need to see a pulmonologist who understands the full spectrum of interstitial fibrosis and its various patterns and responses to therapy. Some pulmonologists do specialize in the interstitial diseases, and will be most able to help you with your problem.
Q. How is Dr. Tom these days?
A. Dear John, Doing fairly well and working most days. I did get a week of fishing in Montana two weeks ago. Thanks for asking.
Any Ideas for a Good List Serve for a Pulmonologist?
Q. I am associated with a young pulmonologist in a rural area that could benefit from a list serve to post questions. Would you have a good contact?
A. Dear Paul, Sorry, I do not know all that is available for this purpose. I try to answer as many questions as I can each week.
Should I be Concerned About Sleep Study Results?
Q. Sleep study results revealed a pulse oximeter (a machine that measures your oxygenation) average of 92%. This was not during an apneic (absences of breathing) episode. I'm overweight, 38 and am not experiencing SOB (shortness of breath) or any other symptoms. Should I be concerned?
A. Dear Gina, No. Not on the basis of this information alone. Try to get more exercise to help with your weight.
Can Smoker’s Have a 100% Oxygen Saturations?
Q. 100% Oxygen Saturation Reading for Smokers?
I have been told that if a cigarette smoker is monitored for SPO2 with a pulse oximeter (a machine that measures your oxygenation), they will almost always demonstrate a 100% saturation reading. It was explained to me that because a pulse oximeter measures saturated hemoglobin, and the CO (carbon monoxide) from tobacco smoke combines readily with hemoglobin, the smoker oxygen saturations will show 100% even though he may actually be hypoxic. Is this correct?
A. Dear Gary, Partly, CO makes the pulse oximetry results unreliable, but will not make the saturation read 100% all the time.
Buteyko Method for Treatment of Asthma and Allergies
Q. I have achieved fantastic results with practicing the Buteyko Method for my asthma and allergies. I no longer have symptoms so do not need to use medications. Buteyko is a safe, simple, and natural solution to many breathing difficulties. More people should be aware that such a viable option exists.
Why isn't this breath re-training routinely offered as a complementary treatment when it is so effective at minimizing drug expense and side effects?
Carol RRT, CBP
A. Dear Carol RRT, CBP, Breathing training is taught to most asthmatics and patients with COPD. I never heard of the Buteyko method.
Does Chest Physical Therapy (CPT) cause Lung Cancer to Spread?
Q. I am a staff therapist in an acute care hospital. When I started my current job here 7 yrs ago, my fellow therapists told me that we do not do CPT (Chest physical therapy includes postural drainage, chest percussion, chest vibration, turning, deep breathing exercises, and coughing) on patients with active lung CA as it can cause it to spread.
Is there any validity to this? I had never heard this before. We had very specific criteria for CPT at my last facility and lung CA was not mentioned. Thank you in advance for your response.
A. Dear Deborah, Chest PT does not cause lung cancer to spread. I wonder where this wrong information got started.
Bronchitis or COPD?
Q. Dr. Tom, I have posted before you might remember me.
I am 36, male, and gave up smoking 20 months ago. I never really smoked that much, only at the weekend with a few beers.
I was troubled with asthma and rhinitis much as a child and in my teens and twenties had mild asthma.
FEV1 is 107%
FVC is 112%,
FVC/FEV1 is 77
I have had many tests over the last twelve months including a Bronchoscopy that was negative for Bronchitis, a Normal HRCT (High Resolution CT Scan) and a Methacoline challenge (a test that can identify people with “sensitive” airways, often used to diagnosis asthma), which was negative for asthma. My DCLO (lungs diffusing capacity) was 118%. My lung volumes are apparently normal as well.
I have been on Spiriva and Symbicort for 6 months now and they make no difference to my PFT's apart from giving me a 7 or 8% increase in FVC. I do not cough or have as much sputum while on Spiriva.
Thing is, I still feel like I am in the middle of a chest infection and my chest is wheezy and I suffer with chest pain. I have a spasmodic cough at times and when I laugh this is apparent. I do not have that much phlegm and when I do it is clear.
I also notice that my stomach and diaphragm are sore like my lungs are pushing down. I am short of breath more than usual and I cannot get a deep breath when I want one. I also am suffering with GERD a lot in the last 6 weeks and am taking an acid inhibitor, which by the way I have previously taken two courses of.
I am a private patient and I have spent a lot of money so far trying to get to the bottom of this. I have seen two excellent Pulmonologist; one said I was normal and stop the inhalers. The other agreed I had some chronic symptoms and prescribed an empiric trial of Spiriva. My primary doctor who is well up on lung conditions is pretty confused also.
What do you think regarding all this, should I just accept I have a bronchitis / form of COPD that is undiagnosed or keep seeking opinions until I get a label for my condition?
Thanks you Dr. Tom for your wonderful site.
A. Dear Conn, You do not have COPD. You could have some mild asthma, and can benefit from treatment of asthma symptoms. I think you should find one doctor that you like and trust and follow his or her advice.
Living with Severe COPD
Q. Dr. Tom, I've read your answers to some about the use of High Flow 02. Here is what I am using:
- Using an oximeter, with exertion my O2 saturations fall to the high 70's-low 80's even on 12 liters of 02.
- Resting, I need 8 liters of 02.
- In Pulmonary Rehab, I use a non-rebreather mask with 10-12 liters of 02 to keep my saturations above 90.
- I use a Caire High Flow portable, and, at home, have 2 liquid reservoirs Used together to give me the amount of 02 I need.
My Pulmonologist has approved all this for my COPD/Emphysema. I'm also on 20 mgs of Prednisone, and have trouble using less than that.
I have been evaluated for Transtracheal Oxygen (a method to deliver oxygen to the lungs via a small tube inserted into the lower neck) but, since I also have chronic bronchitis, that procedure is on hold.
In addition, I have lost my sense of taste/smell completely. The ENT, after running various tests including brain CT to rule out a tumor, says it's from a virus from my sinus to the brain centers that control these senses, and is permanent.
My thought is--couldn't the amount of 02 flowing through my nose affect my sense of taste/smell? I really miss tasting my food!
Even with severe COPD, I stay as active as I can.
There's a wonderful web site at http://www.portableoxygen.org/ I think it will help many of your readers understand the various 02 choices, including High Flow 02.
Your comments would be appreciated.
A. Dear Susan, You need more oxygen than most COPD patients. The web site that you cite is excellent. I doubt if the high flow oxygen is the cause for you loss of taste, but it is a possibility.
Can Medicine lose it Effectiveness?
Q. Is it normal for medicines to lose their effectiveness? I was on Prilosec for years, then I got severe stomach pain related to the medicine, today I cannot tolerate any prezole type drug.
A hiatial hernia repair helped a lot but now I am on Zantac and that effectiveness is waning. I was also on Detrol-LA but that has lost its effectiveness. What do I need to do?
A. Dear Leo, It is true that some responses to medication can wane. I think you need a gastroenterologist, working with a pulmonologist to help sort this out.
CO2 Retainers and the Respiratory Drive
Q. For CO2 retainers, can you avoid knocking out the respiratory drive by giving supplemental O2 to keep saturations 85-90%???
A. Dear Gene, The old idea that giving oxygen will knock out the respiratory drive, even in those patients with chronic CO2 retention is wrong. Just go ahead and give the oxygen at a flow to bring the oxygen sat to >90% and this will have no effect on the CO2, it will stay the same.
COPD and Higher Altitudes
Q. I've been told I have COPD. I've lived at sea level all my life. We're thinking of locating to Denver CO the mile high City. Do you think the thinner air would be detrimental to me? My condition has been diagnosed as minimal.
A. Dear Art, Probably it will make no difference. Denver is only at 5200 feet, the same as Salt Lake, Albuquerque, and El Paso, Texas. Just 13% less oxygen per breath. Come and enjoy the high, dry climate.
Different Activities Cause Shortness of Breath
Q. I swim 15 laps every day in an Olympic pool, 50 METER LAPS and when I get out of the pool I'm hardly breathing, however when I climb a flight of stairs carrying a bag of groceries I have to sit down to catch my breath. Any ideas?
A. Dear Art, Various activities may have different effects on you sensation of breathlessness. Often the high humidity in the air where you are swimming is soothing to the sensation of breathing. Shortness of breath just means you are working hard to breathe. It is uncomfortable, but not dangerous.
Drug Toxicity and Bleomycin
Q. Bleomycin (a drug that is used to treat several types of cancer) apparently is more toxic to lung tissue when exposed to oxygen. What O2 concentration is considered relatively safe to administer to these patients without increasing toxicity?
A. Dear Diego, This is very important. Almost any level of oxygen above normal can bring out Bleomycin toxicity, even if the Bleomycin was given in the past. If oxygen is required, it should be delivered at the lowest possible concentration.
Side Effects from Drug Used to Tuberculosis
Q. I am taking isoniazid (a drug that is used to treat tuberculosis (TB) and to prevent it in people who have had contact with tuberculosis bacteria) because I had a positive skin TB test.
My chest rays showed that I have no sign of the disease. I am a student and since I have been taking the medicine, I feel very tired, and dizzy. It is affecting my academic schedule. What should I do?
My Doctor is insisting that I keep taking the medicine, but I think it's interfering with my academic life. What should I do?
A. Dear Nancy, If you were my patient, I would have you stop the isoniazid, which can cause just the symptoms you report. If your doctor is really concerned about "latent tuberculosis", he could prescribe rifampin.
Just because you have a positive TBC skin test does not mean you will get the disease. Your risk without any treatment is small.
Question about a Thallium Stress
Q. Dr.Tom, I saw a Spring copy of the COPD Digest magazine in my husband's Dr's office and read about you. I sure wish I could take my husband to see you, you really impressed me with what you had to say, but I will have to settle for emails. GA is a long way away from you for us.
My question is, if you had a patient with emphysema and COPD, would you give them a thallium stress test (a test used to evaluate how well your heart is supplied with blood, at rest as compared with activity) using adenosine medication injection (drug increases blood flow to the heart and thus "mimics" an exercise test)?
I look forward to hearing from you.
A. Dear Glenda, It depends on the level of suspicion concerning the possibility of coronary artery disease. I think either test is possible, even with COPD unless exercise is just not possible.
Gastroesophageal Reflux Disease (GERD) and Pulmonary Fibrosis
Q. Dr. Tom: Are GERD and Pulmonary Fibrosis linked together? If so, I need to get some info on this subject. Thank you.
A. Dear Frank, There is no solid data on this. Repeated aspiration of gastrointestinal contents has been linked in some older studies to lower lobe fibrosis.
Connection between Spontaneous Pneumothoracies and COPD?
Q. Dr. Tom, In the mid 60's I had quite a few episodes of spontaneous pneumothoracies (lung collapse occurs where there is no clear cause) I was told by a doctor at the hospital in the Philippines that I would probably have problems later on.
I now have COPD and I am trying to get the VA to connect it to my collapsed lungs. There have been many cases where doctors have proven at least a minor connection but I have been unable to convince them. I know this is a controversial subject but maybe you could direct me to a pulmonary specialist that could help me. If I can prove at least a casual connection then that might help.
Jim, U.S. Navy
A. Dear Jim, Spontaneous pneumothorax, is commonly linked to small congenital blebs "blisters" of the top of the lungs. This condition is not related to the development of generalized emphysema later in life.
Q. Do you have any studies on nebulizing morphine to patients?
A. Dear Kim RRT (Registered Respiratory Therapist), I have not done any such studies. Several investigators, including Dr. Richard Light, have done nebulized Morphine studies.
Short of Breath but no Change in Pulmonary Function Test
Q. To start, I have Alpha-1-Antitrypsin Deficiency (Alpha 1), diagnosed in 1985. I started Prolastin therapy (medicine to treat
Alpha 1 and is given by IV, intravenous) in Feb 89.
My PFT was in the 50% range back in 1990. In November of 1990 I was diagnosed with non-hodgkins lymphoma stage IV and received Promace - MOPP chemotherapy and completed the first line chemo in June 1991. The lymph nodes and bone marrow were clear.
In November 1991 I under went high dose chemo/BEAC, autologous bone marrow transplant and stem cell replacement. After the treatment my PFT (Pulmonary Function Test) was still in the 50% range but I was drastically short of breath with exertion, such as climbing a flight of steps.
The pulmonary doc's say the lungs were not damaged. I had a stress echo performed and my heart is good. What could be damaged from the chemo & bone marrow transplant that could cause such a drastic change in my breathing?
A. Dear Tom, You could still have some lung fibrosis, even though your overall pulmonary function remains in the same range. Fibrosis can have a different effect on lung function than the emphysema from alpha one deficiency.
If you have some drug related fibrosis, this can change your lungs mechanical function and can be the reason that you now have shortness of breath.
MDI’s and Nebulizers
Q. Are MDIs more effective than nebulized medication?
A. Dear Lynda, No. The responses are about the same. You actually get more medication from nebulizers, because of the differences in dose, but the responses in the lungs are similar.
Questions about Pulmonary Hypertension
Q. Hello, I am 26 years old and was diagnosed with Pulmonary Hypertension (PH) 2 years ago. At my first Echo my PAP (pulmonary artery pressure) was 66, since then it has gone down to 50.
I have a history of Scleroderma (a rare, progressive disease that leads to hardening and tightening of the skin and connective tissues), but because I am overweight the doctors cannot seem to decide whether I have Primary or Secondary Pulmonary Hypertension.
The only medicines I am on currently are Norvasc and Atenolol, they had to cut them down because my BP was too low.
I have a few questions:
- I'd like to know if there is a cure for PH at all?
- How serious is this disease?
- Will I be able to breathe regularly again?
- Are there any questions I should be asking?
Thank you for your time.
A. Dear Charis, Pulmonary hypertension is a group of diseases. PH may be related to scleroderma, or other lung diseases. Or it can be so called primary pulmonary hypertension. There are a number of new drugs for PH. You need to consult a pulmonologist who is involved in the treatment of PH.
It is good that your pulmonary pressures are less than before.
Q. Dr. Tom, I was wondering what treatments are available for Tracheomalacia (is a weakening of the supporting structure of the trachea, cartilage)? This child has a severe case and requires the use of oxygen to sleep, and is exerting her energy to breath during the day, what would you suggest?
A. Dear Angie, There are surgical treatment of tracheomalacia, including the use of stents. Get a good consultation with a thoracic surgeon who does work in this area. Very important.
Related Tracheomalacia Question from the Archives:
70 yr. woman with Tracheomalacia
Q. I am a 70 yr. old woman who has moderate emphysema but just recently my pulmonologist did do a bronchoscope and found that I had Tracheomalacia (usually found in babies.) He sent me to a specialist who seems to be stalling as he told me to go to a gastroenterologist, which I did and he did an endoscopy. Everything was fine. This specialist wants to do another bronchoscopy so he can see for himself how far down the Tracheomalacia goes. All I want is for him to put a stent in to keep the trach open so I can breathe. It is quite difficult to breathe when I shower, dress or exert myself. I have oxygen but that does not help as much as my nebulizer containing Albuterol and Ipratropium. I think the Albuterol relaxes the Trach. Is it possible for you to tell me more about Tracheomalacia in adults and what should be done and if the specialist won’t put a stent in, where can I go to have someone correct this problem. I’m getting close to being housebound. Thank you for whatever information you can give me.
A. Dear Thelma, Tracheomalacia is a weakening of the supporting structure of the trachea (cartilage). It comes from inflammation and forceful coughing in some people with COPD. Stenting is the treatment. You need to find a pulmonologist who is experienced in stenting. Ask your pulmonologist to refer you to a doctor, pulmonologist or thoracic surgeon who is experienced in placing stents.
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.
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.