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Archive: Dr. Tom 59
Posted April 25th, 2006

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

Can You Tell Me, In Plain Words, What My X-Ray Results Mean?
Q. I received some resulted from n radiology report that read as follows:

  • There is mild hyperinflation, with biapical pleural parenchymal scarring.
  • The heart is upper limits of normal in size. 
  • There is thoracic spine degenerative change, without focal consolidation, effusion or pneumothorax.

Can you please tell me in third grade terms what this means?

Cera

A. Dear Cera, You were able to take a big breath.  Your lungs look normal. However, normal lungs may still not function well and that is when you need measurements from simple spirometry (National Lung Health Education Program, NLHEP; http://www.nlhep.org/).

There may be some scar at the top of both lungs, from infections in the past, or this may be normal. Your heart is slightly big and you have the beginnings of a “bad back.”

Dr. Tom

 

What Should I Ask the Doctor?
Q. I had a routine chest X-ray and a 8-cm nodule was found on my right lung. They did a CT scan to make sure it wasn’t just an overlying flap of skin and ruled it wasn't. The change in CT scan they say was not significant. 

They then ordered a PET scan (Positron Emission Tomography is a test often used to detect cancer), which they said it was negative. 

Do they mean it is negative for cancer?  I have a follow up appointment with a lung specialist and would like to know what questions or follow up procedures may be medically necessary to rule out cancer totally if the PET scan does not. 

Sue

A. Dear Sue, Was it 8 centimeters or 8 millimeters. Makes a huge difference. PET scans usually indicate malignancy, but they may be positive in active infections. Ask about the size to be sure, and whether he thinks the nodule is malignant.

Dr. Tom

Additional Resources

Questions to Ask Your Doctors
This site contains lists of questions to help the patient or loved one receive the most information possible. These are question to ask your pulmonologist, thoracic surgeon, radiologist, or oncologist.

In order to find the document:

  • On the home page click on “Cancer 101
  • Locate “Treatment (fourth from the bottom) and select “Treatment”
  • Locate “Questions to Ask” on the ‘Treatment menu) and select it.

Talking With the Doctor

 

Do Granulomas Cause Pain?
Q. My pulmonologist told me that I have a small granuloma in my left lung. He told me that granulomas do not need treatment and they occur due to an increase in calcium deposits.

That was a year and a half ago. However, during the course of that time, I have been having pain when I breathe deeply, particularly when I exercise. I have been diagnosed with mild asthma by the same pulmonologist four years ago and have been taking Advair and Albuterol on a regular basis.

Well, the pain is once again coming back in that same area, on and off. He told me that granulomas should not cause pain, so what could be the cause of it? And what are some possible solutions? I would appreciate any advice.

Niki

A. Dear Niki, Your doctor is right. Granulomas in the lungs do not cause pain. He will have to explain you symptoms. He knows much more about you that I do, from your brief description. DR Tom

 

How Can I Help My Brother to Live a Healthier Life?
Q. My brother was diagnosed with diabetes a couple years ago.  He was never one to want to see a doctor and didn’t take good care of himself. A few weeks ago he was admitted into the hospital because he couldn't breathe and they drained 450cc of fluid from his lung.  He has pulmonary edema. 

He had some tests done and they found 2-3 spots on his lungs at which time they did a biopsy.  We're awaiting the results.  How likely that something like this could be cancer?  He used to be a heavy smoker and up until recently was a heavy drinker.  My grandmother died of cancer.  We're very worried about him and don't know what to do to help him.  How do you help someone who doesn't want to be helped?

Marie

A. Dear Marie, You can’t help someone who does not want your assistance. Wait for the biopsy results, and then they can tell you if the nodule is cancer.

Dr. Tom

 

Follow-Up Question about Carbon Dioxide (CO2) Retention and COPD
Q. Thank you for your response to my question regarding CO2 retention and the COPD patient.

I need to know what, if any, problems to expect when the O2 flow rates required are above the 1 to 3 lpm (liters per minute) you refer to as not being a problem even when the PO2s went above normal. Does the same apply?

Can I just start telling my fellow respiratory therapists and MDs that we do not ever need to worry about CO2 retention period, in reference to treating the hypoxia? How do I explain the respiratory drive no longer being an issue with CO2 retention?

Linda

A. Dear Linda, CO2 retention is rarely a result of the liter flow. There is a complex mechanism of CO2 retention when 100% oxygen is breathed with a tight fitting mask. Here the nitrogen is washed out of all lung units and those with low ventilation/perfusion may close and thus the CO2 goes up. This has nothing to do with the drive to breath.

If patients need more than the usual 1-3 liters per minute to achieve a Saturation of 90-95%, there is no reason for the CO2 to go up. CO2 does rise when the patient is in exacerbation and develops respiratory muscle fatigue, but this has nothing to do with the drive to breath.

Dr. Tom

Read Linda’s previous question.

 

Pre-Surgical Chest X-Ray showed a Shadow
Q. I am 40 years old and I have COPD. I was admitted to the hospital for a hysterectomy but the operation was refused as I had shadows on the bottom of my left lung and blood in my sputum. I have also been diagnosed with fibromyalgia low iron Can you help?

Linda

A. Dear Linda, These diagnoses do not fit together. You need a doctor to sort this all out. Blood in sputum needs explanation. You may need a bronchoscopy (a diagnostic procedure in which your doctor uses a scope, with a camera on the end, to take a look at the inside of the airways and lungs.) by a pulmonologist.

Dr. Tom              

 

Worried about Lymph Nodes Found in CT Scan
Q. I had a CT scan of the chest on 2/20/06. It showed:

  • A noncalcified mass in the left upper lobe about 4-mm in size. 
  • There are subpleural infiltrates seen about the lower lung fields bilaterally. 
  • There was some linear scarring or atelectasis the inferior lung bases.
  • There are abnormal mediastinal adenopathy present with multiple lymph nodes seen in the pretracheal space and subcarinal region. 
  • There are borderline to slightly enlarged hilar lymph nodes present bilaterally. 

I had a CT Scan of the abdomen and pelvis one week later and scans through the lung did not show evidence of pleural effusion or basilar infiltrate.

I then went to a pulmonologist and he had me take a blood test to rule out sarcoidosis and fungus and pneumonia.  That came back normal. 

I then went to see an oncologist and he recommended that I take another CT scan of the chest in one month to see if the lymph nodes are any larger and if the 4-mm noncalcified granuloma has gotten any larger. He said if they did, I would have to have a mediastoscopy.

I do have a tightness in my chest now. I don't know if it's from all this stress or from cancer.

Do you think the oncologist is correct to wait a month for CT scan?  Would you suggest some other tests in the meantime?

My mother died of small cell lung cancer at 69 and my sister died of small cell lung cancer at 43.  At this point, I am getting really edgy.  I am a 56 year-old female .

Kathy

A. Dear Kathy, You are definitely at risk of lung cancer, even if you did not smoke. The oncologist and pulmonologist should work together to follow you. You may need a bronchoscopy or mediastinoscopy (a procedure in which a lighted instrument, mediastinoscope, is inserted through a neck incision to visually examine the structures in the top of the chest cavity). If the nodule grows in three months, it should be removed.

Dr. Tom

 

Worried about Using Oxygen after Polyp Surgery
Q. I am 73 years old.  I have had adult-onset asthma since I was 63.  In December 2005, I contracted viral pneumonia and have been on two liters of oxygen since that time. 

I also have difficulty breathing since I also have nasal polyps.  I hope to be able to receive an operation to remove the polyps to possibly reduce my chronic cough, which I feel may be the result of a sinus drip. How will I be able to breathe following the procedure?   I understand that my nostrils will be filled with cotton to control the bleeding for up to two weeks.

Rose

A. Dear Rose, You can use a mask for oxygen delivery during the time your nasal passages are obstructed.

Dr. Tom

 

Granulomas in Lungs and Now In Both Eyes
Q. I am sure you have heard of granulomas in the lungs.  Now, can you say you have heard of having such and being told then, that they are of no significance, later developing them inside both eyes, and still being of no significance, nor of relativity?

Jackie

A. Dear Jackie, This sounds like a disease called sarcoidosis, which is a disease of granulomas of multiple organs, including the lungs and eyes. You need to see an experienced pulmonologist about this. Eye involvement with sarcoidosis, requires treatment. Some lung manifestations do not.

Dr. Tom

                                         

Methacholine Reaction that Last Several Days
Q. I recently had a methacholine challenge test.  As soon as the test was completed I went into convulsions and they lasted off and on for two more days. 

Is the chemical used for the methacholine test similar to carbon dioxide?  Could this have been a severe allergic reaction or something similar to carbon monoxide poisoning? 

I have a history of epilepsy so do not know if either the chemical triggered something or if the breathing constrictions could have done something to trigger the spells? 

Pat

A. Dear Pat, Methacholine does not cause convulsions. It is not carbon monoxide. You should see the doctor who manages your epilepsy, for possible adjustment of your medications.

Dr. Tom

 

Been Coughing Since this Past December
Q. I have been having chest pains for over a year now and my doctor cannot find out the reason.  All tests (echo and stress) have been normal.  I do have a pericardial cyst but have been told that it is nothing to be worried about.  Sometimes the pain has been so severe that it causes me to double over.

I have also had chest x-rays and CT scans done and they show lung shadows and small scattered densities in my right upper lung cell and in the right middle lobe laterally.  I have also had a PET scan and it didn’t show anything abnormal. 

I am concerned because I was diagnosed with pneumonia in December 2005 but am over it now, yet it seems like I can’t get rid of the cough at times I can cough up phlegm but a lot of times I can’t cough up anything. Just when I think I'm better, I start coughing again. 

What would you recommend?

Myra

A. Dear Myra, See a pulmonologist, if you have not consulted one already. You need an explanation for the continued cough. You did not mention smoking. Stop if you are.

Dr. Tom

 

Need Advice on How To Help Patient Understand the Benefits of Home Oxygen (O2)
Q. I work in pulmonary rehabilitation/pulmonary function.  I have one particular patient who went through Phase II several years ago, and has recently returned for Phase III.  Great guy, but here’s the problem: at room his resting O2 saturation is 92% and with exercise, he requires 3-4 lpm with an O2Saturation of 88-91%. 

This information was sent to the attending physician several times.  Physician orders home oxygen, patient adamantly refuses.  We have all counseled this patient on the benefits of wearing oxygen, to no avail. 

My question is:  Do you feel that much good is accomplished from allowing this patient to continue with Phase III when he refuses the home oxygen? We have copies of your book in rehab, and have offered it to him in hopes of his consideration. Any other ideas? Thanks in advance for your response.

Melissa

A. Dear Melissa, It is probably in his best interest to try to move ahead with pulmonary rehabilitation. We do not yet have the science to support the of use oxygen in exercise, when normal saturation is present at rest. This question will be addressed by very large study, which is now just starting, and supported by the National Heart Lung and Blood Institute. Conclusions will not be available for years. In the meantime, it does make sense to use oxygen for exercise in desaturations.

Dr. Tom

 

How Long Can Methicillin-Resistant Staphylococcus Aureus (MRSA) Affect Your Health?
Q. I contracted MRSA (a type of bacteria that is resistant to certain antibiotics). Is this a disease that will totally leave my system or does it lie dormant. 

Mary

A. Dear Mary, It does not lie dormant in the tissues. It can be carried in the nose and throat mucus, without causing infection. This most commonly occurs in patients who have received a lot of antibiotics.

Dr. Tom

 

Pain When Breathing Deep
Q. I am a 33 year old woman and have begun to experience a great pain on my mid right side of my back. This pain only comes when I breathe in deep.  What could it possibly be?   

A. Dear Mariah, This is probably pleurisy. It has many causes. You should see a pulmonologist, or an interest who has lots of experience with pleurisy.

Dr. Tom

 

Has Had Persistent Headache after Being Exposed to Gas and Exhaust Fumes
Q. I was exposed to gas and exhaust fumes for 2 1/2 hours on Friday, 02-24-06 and for 45 minutes the following Friday, 03-03-06. I had an excruciating headache and on Saturday 03-04-06 and the headache has stayed and will not go away.

I was hospitalized for it and am on my 31+ days with headaches and nausea. Will I ever get relief?

Ginny

A. Dear Ginny, I do not believe your headaches are from the material you inhaled in the past. You need a diagnosis for your headaches. You may need to see a neurologist.

Dr. Tom

 

How Severe is My COPD?
Q. My FEV1 number is .75. Can someone tell me how severe my COPD is?

Julie

A. Dear Julie, If this is 75% of what is normal for your age and sex, it is mild COPD. If you smoke, stop it immediately.

Dr. Tom

 

How do ‘Spots’ on the Lung Appear on a Chest X-Ray?
Q. My husband just had a chest x-ray done for a physical. They have called him back to do two more as he has a "clear" spot about the size of a silver dollar on his lung. What could this mean? I was under the impression that cancer and emphysema showed up black on chest x-rays. Should we be worried?

Jennifer

A. Dear Jennifer, You need an explanation for the spot. I do not know what you mean by a “clear spot” or a “black spot.”

Dr. Tom

 

Purpose of Spiriva
Q. I had a doctor in Dallas, Texas who, for several reasons, made me feel that she was not quite adequate. I do have emphysema and was put on Spiriva. I am in a fairly early stage of noticing shortness of breath and after taking Spiriva for about six weeks I have not noticed a difference.

My question: Is taking it going to help prolong deterioration of the lungs and help maintain my current capability or is it just to enhance current breathing? I called my doctor a couple of times and never got an answer to this question and therefore, I quit taking it.

If it is of a long-term benefit, I want to go back on it immediately. Or, do I wait until I really feel the need? Thank you.

Also, if you can, I would like the name of a good pulmonologist in Dallas worthy of your recommendation.

Joy

A. Dear Joy, Spiriva, is a long-acting medication, and it does slow lung deterioration, for at least one year. It is a very safe medication. There are many good pulmonologists in Dallas. I do not know one personally.  Be sure you see one who is board certified. You can ask the American Board of Internal Medicine, about qualifications.

Dr. Tom    

For more information see:
Ask the American Board of Medical Specialties®
Answers to frequently asked questions about doctors. Questions such as: how to find out if your doctor has had a malpractice or complaints, how to register a complaint, what does it mean for my doctor to be board certified, etc. No registration is required to view the questions and answers.

Check Doctor Specialties with the American Board of Medical Specialties®
Check to see if your physician is board certified. Registration is required and you are limited to 5 searches in 24 hours.

 

Ventilator Smells ‘Fishy’ After Cleaning
Q. I clean respiratory equipment. I have noticed a fishy smell after cleaning some infant ventilators, any ideas?

Charles

A. Dear Charles, I have no idea what causes this odor.

Dr. Tom

 

Worries That Symptoms Could be Something Other than Diagnosed Bronchitis
Q. I have been to the doctor and have been told chronic bronchitis. Yuck. I have been a pack a day smoker since early teens and am now 50. Both my parents died from lung cancer. Mom was 62 and dad was 66.

I have finally quit smoking (just two weeks ago) but am concerned the diagnosis of bronchitis is not correct. I have a lot of pain in my right upper shoulder and feel very uncomfortable in the right part of my bronchus. I keep loosing my voice on and off during the day and am trying to clear (not my throat) but below my throat, down in the bronchial tubes. My throat is red and a bit swollen.

Most things I've read say that bronchitis causes a wet cough. I am not getting mucus out of my lungs or throat, sometimes just the tiniest bit, but that gives great relief. My right side bronchials feel stiff, swollen and miserable. On top of all this I am so tired.

My doctor said is could take a while to feel better. I am inhaling Advair two times a day and just finished a Z pack antibiotic. I had a chest x-ray about a year ago and it was okay then.

Do you think I need to give myself more time to feel better and does this sound like bronchitis to you?

Macy

A. Dear Macy, You should feel better soon. You should have spirometry to measure your lung function. With your family history, you should have a CT scan which is much more sensitive in the diagnosis of lung cancer, than a chest x-ray.

Dr. Tom

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