Weaning Guidelines to Follow for Mechanical Ventilator
Q. Is a weaning protocol (detailed guidelines used to safely remove patients from mechanical ventilators) used for a post-op cardiac patient that includes using Pressure Support Ventilation (PSV) outdated?
What are the national standards for Post-Op CABG (Coronary Artery Bypass Graft) patients?
A. Dear Kristi, No, not outdated, but I never did use pressure support. Weaning means separation. All the intermediate steps such as IMV (Intermittent Mandatory Ventilation breaths are delivered at a preset rate), PSV, etc are unnecessary if you can determine when a patient can breathe on their own. I think that protocols are useful for people new to the field, but not for the experienced.
I don't understand your question about CABG patients. Most patients can be simply extubated (removal of a breathing tube from a person’s airway) when they are awake, assuming no underlying pulmonary deficit.
Needs Help; Many Symptoms and No Answers
Q. Dr Tom, Hopefully you can help me. For the past three years I have been suffering from shortness of breath (constant), sinus problems and a post nasal drip. I have been to so many doctors and none have helped me. I also tend to yawn, as that helps me to breathe. I do not have a reflux. I have done all the required tests but still no diagnosis. Can you help me?
A. Dear Anton, I cannot guess what is wrong from what you tell me. A good pulmonologist should be able to make a diagnosis.
Questions about Croup or Mist Tents
Q. Have you read any studies recently with mist tents causing mucous plugs? Also, what about mist vs. aerosol set ups, or room humidifiers? Is one delivery system more efficient for the patient for humidification purposes?
A. Dear Mary, I know nothing new about mist tents. They are mainly used in pediatrics, and I am not a pediatrician.
Sexual Dysfunction and Insomnia
Q. I have sexual dysfunction and I also have insomnia. I have this kind of feverish feeling at night. What is my sickness, sir?
A. Dear Stanley, I have no idea. See a good doctor.
What Causes Blebs?
Q. I just had a recent CT Scan and was told I have some small blebs on the top of my lungs. I know what they are, but can you tell me how common they are in the general population and what causes them specifically?
A. Dear Linda, They are not rare. Probably 1-2% of the population have them. This is an estimate. No population studies have been done to determine their prevalence.
Dehydration and Excessive Sputum
Q. I am a Respiratory Therapist in a community with a high percentage of elderly COPD patients. These patients tend to have increased amount of sputum expectoration. Should I encourage these patients to swallow the secretions to ward off dehydration or should I encourage them to not swallow the sputum?
A. Dear Kennedy, It doesn't make much difference. Most people with this problem swallow.
When is it Safe to Fly after having a Pneumothorax
Q. My 17-year-old son has had two spontaneous pneumothoraxes (s a collection of air or gas in the lung linings and causing the lung to collapse) in his left lung and just underwent thoracic surgery this week to staple off a portion of the lung, to remove two sections of blebs that had not shown up on a CT Scan, and to affix the lung to the chest wall.
He is scheduled to fly in three weeks, on a two-hour trip in a pressurized plane and then an hour trip in an un-pressurized small plane. Is it OK to fly three weeks after surgery and are both pressurized and un-pressurized environments safe?
A. Dear Averill, He should be healed in three weeks. There are no guarantees that he will not leak again, but he has had the proper treatment. I suggest that he go ahead with his trip.
Why Can Boys Hold Their Breath Longer Than Girls?
Q. I did a science fair project on “who can hold their breath longer: boys or girls” and my results came out that boys held their breath longer than girls. Why can boys hold their breath longer than girls (these were 11- and 12-year-olds)? Thank you.
A. Dear Cassie, They probably try harder, just to “show off.” I know of no studies that show that sex determines breath-holding ability.
Conflicting Opinions about My Lungs, What Should I Do?
Q. I am a Kaiser patient. This December close to Christmas, I came down with influenza (forgot to get flu shot). It was bad and I had to be rehydrated in the E.R. on Christmas evening. I also had a bladder infection. I did not fully recover until the end of January. I was coughing up gunk until then.
While I still had the flu, I was diagnosed with COPD via a many-sided lung x-ray on January 4 and a spirometry test on January 19. The pulmonologist diagnosed as moderate COPD. My FEV1 was 65%.
I am confused because the radiologist and my new primary care physician said the special lung x-ray was normal, but my pulmonologist and the doctor who actually saw me and ordered the x-ray said I had hyper inflated lungs. Pulmonologist said that sometimes tall thin people have bigger lungs and that could be the case. I am lanky, but normal weight and only 5'6". I'm 50, next month, and female. They say I have emphysema from smoking on and off since I was 25 years old.
I am wondering about the x-ray interpretation and the accuracy of a spirometry test taken while I still had a little gunk, from flu, in my lungs.
I also am highly allergic to grass and dust since I was ten years old and was getting allergy shots until the flu hit. I have to start up again.
I bought a hand held spirometry meter and my lungs are 85% normal today at 7 p.m. I used Atrovent inhaler one spray in the morning about 10:30 A.M.
Should I have another PFT? Does influenza affect x-rays and PFT tests?
A. Dear Erica, Influenza can affect the chest x-ray if it causes pneumonia. It can also affect lung function as measured by spirometry. Chest x-rays are not accurate in diagnosing emphysema. They do not measure function.
The device you bought is probably a peak flow meter. This may not accurate reflect your FEV1. I suggest you get spirometry again for peace of mind, and never smoke again.
Idiopathic Pulmonary Fibrosis (IPF) Questions
Q. I was diagnosed with IPF (Idiopathic Pulmonary Fibrosis, a chronic lung disease that causes inflammation, scarring, and thickening of the lung’s tissues and the cause of this condition is not know) a little over two years ago.
Do you know much about this? I would like to know what the longevity is for this, and also if there are any genetic testing going on in my area? I live in South Carolina.
A. Dear Mary, There are a number of subclasses of interstitial fibrosis. The “idiopathic interstitial fibrosis” one has the worst prognosis, but this varies with patients. Hereditary factors do play a role in some families.
There may be genetic testing at the medical school in Charleston. Two of my former fellows, doctors Sahn and Heffner are there. You may want to contact either of them. If so, say “hi” for me.
CT Scan Shows Multiple Spots on Lungs, What Should I be Asking the Doctors?
Q. I went into a doctor with chest pains and had an x-ray. I changed doctors and explained to that doctor of the other x-ray and he ordered another chest x-ray since the first one showed a spot in the upper right lung.
Second x-ray also showed the spot on the right lung and another on the left lung. He then ordered another to see if there were any changes. After the third x-ray he ordered a CT Scan, which showed 6 spots on my lungs. He has asked me if I'm coughing up blood, which I said I was not.
I do have chest discomfort and am tired and really do not want to do much. This has been going on for two months.
He is now sending me to a pulmonary specialist. What can I expect, and what should I be asking this doctor when I see him? I do not have insurance and must pay out of my own pocket. I do not want to be a burden to my wife and drain what savings we have. I want the doctor to be honest and up front. Thanks for giving me your time.
A. Dear Laurel, These nodules require follow-up depending on their characteristics. The interval may be three month or six months, depending on size. Your doctor will be looking for growth of these in the interval. Ask him if he believes a PET scan is indicated. It is expensive, but helps to distinguish benign from malignant nodules. Most of these are benign, but you need a pulmonologist to help guide your decisions.
Q. I started taking Atenolol (medication to treat heart conditions) at age 22 for mitral valve prolapse (or high blood pressure and chest pain). At 27 I began taking Toprol xl (medication to treat heart conditions) instead for high blood pressure and Flomax for BHP (Benign Prostatic Hyperplasia, enlarged prostrate) with urninary problems. I was in an accident in November with blunt abdomen trauma and concussion. I am now told I have post concussive syndrome
I suffocated almost to death one day almost two months after the accident and was diagnosed with bronchial spasm in emergency and then asthma. I was prescribed albuterol inhaler.
I have not felt well with my head—on at least two days I thought I could die—I now appear to be doing better. Before that, I had pressure on my head and tightness bad for about a week—particularly bad for a day or two. Finally I was admitted in hospital after six emergency visits, and
the pressure improved or went away
I still have breathing trouble. I used to think I had perfect lungs. I swam for years. The medicines I take now are 25 mg of Toprol XL, reduced from 100 mg now that my blood pressure is not as bad, and .4 mg of Flomax and 17 g albuterol.
Are these combined medications good for me or do you see any problem with this combination? I took Albuterol with Toprol XL and had tightness and major trouble breathing—only within three hours of each other.
Flomax almost had a slightly similar reaction—less severe.
Are there any alternatives such as a natural or a drug substance that you could suggest so I could talk to my doctor or a new one with? Which type of doctor should I see?
A. Dear Jon, If you have bronchospasm, i.e. asthma, the Toprol may worsen this. Talk with your doctor about drug interactions.
Questions about Bleb that were Seen On CT Scan
Q. Just a question on CT results. The report states lung are hyperaerated with COPD changes. Small emphysematous blebs are seen mainly in the upper lobes. Granulomas (calcium growth) are seen throughout the lungs, largest in RL (right lower) base measuring 1.2 cm. I am not concerned with the granulomas as a pulmonologist cleared these previously.
Should I be concerned with these blebs and do they required follow up with a pulmonologist? And what exactly do these blebs mean?
A. Dear Anna, The blebs are localized “bubbles” on the surface of your lungs. Usually they are of no significance. Occasionally they leak and cause lung collapse, called pneumothorax. I suggest that these are not important. Your doctor, who knows more about you, can tell you more.