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Archive: Dr. Tom 62
Posted May 17th, 2006

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


Tracheoplasty
Q. I am going to Boston to have tracheoplasty (plastic surgery of the trachea) via thoracotomy surgery (incision of the chest wall).

Could you explain how this surgery is performed and what the recovery is like?

Carol

A. Dear Carol, A tracheoplasty is a repair of the main air passage in the neck and upper chest. By going through the chest, in your case, there must be damage or some other form of problem in the lower “windpipe,” just above where it divides in to the main air passage for each lung. I cannot speculate what the procedure is for. You need to discuss this with your surgeon.

Dr. Tom

Follow-Up Question about Continuing Symptoms

Please see a previous question from David.

Q. This question is a follow up to one I asked a couple months ago. I have been experiencing a constant mild wheeze, periodic cough, and mild SOB since early January and along with a short exposure to silica. I've had chest x-ray, complete PFT's, and examination by a pulmonologist at St. Luke's Medical Center, and everything comes back normal. He reviewed my x-rays and PFT's. My oxygen saturation was 98% in his office, and after a brisk walk around the testing area, it remained at 97 or 98% the whole time.
My SOB is super mild, and I don't have any trouble or any noticeable change in my breathing while exercising or being active. I'm a healthy (besides this crap) 28 year-old male who has never smoked, and is in moderate physical condition.
I'm growing tired of clearing my throat constantly, coughing, and wheezing on every breath. Same pattern of morning cough with very little sputum production (kind of a white/yellow in small little pieces), then mild cough and all day wheeze that seems to go away when I lay down at night. I'm It just feels like there's something constricting my breathing, albeit mildly.
I'm just hoping this goes away, but it's the same every day all day. It's lasted for four months now, so it doesn't appear to be going away on its own. I am going in for a metha-something challenge at my pulmonary doctor's office next week. Any thoughts for me on what this could be?

David

A . Dear David, With the symptoms you describe, this could well be mild asthma, with normal lung function and oxygenation.

The methacholine test is designed to provoke your air passages to constrict. The pulmonologist can measure airflow before and after the methacholine challenge, and determine if you have airway hyperreactivity, one the hallmarks of asthma. If positive, this test will help confirm asthma, and be the foundation for asthma treatment, which should end your symptoms. Let me know the results.

Dr. Tom



Normal FEV1 and a Low Diffusing Capacity (DLCO)
Q. I hope this finds you well, what a Godsend you are to us, you and Mary.

I wonder why - if the only numbers with meaning in a spirometry test are FEV1 and FEV - a person with a high FEV1, but low DLCO can't breathe without supplemental oxygen?

What does it mean when one's FEV1 stays the same, but the DLCO number plummets AND the patient's 'normal' blood/oxygen drops to 92, 93 and she has a tougher time breathing...?

Please take care of yourself.

Sharon

A. Dear Sharon, The FVC and the FEV1 are the key number from spirometry. The DCO is different, it measures the transfer of gasses across the lungs. Some of the scarring diseases of the lungs are characterized by oxygenation problems, but still normal lung “mechanics”, which is what spirometry measures.

Dr. Tom



Treatment for Bronchiectasis
Q. Could you please tell me if bronchiectasis should be treated the same as bronchitis or asthma?

John

A. Dear John, In general, yes. Both antibiotics and bronchodilators may be useful in chronic bronchitis and bronchiectasis, but in bronchiectasis there is more need for antibiotics and a greater spectrum of infectious bacteria.

Dr. Tom



Can Medications be Used Together?
Q. Can Foradil Aerolizer be used in conjunction with Combivent?

Howard

A. Dear Howard, Yes, but Foradil, is a long-acting bronchodilator in the Beta agonist class. The albuterol component of Combivent is a short-acting Beta agonist, so the side effects of the two drugs may be additive. The other component of Combivent is ipratropium; a different kind of bronchodilator, in the anticholinergic class and it is compatible with all Beta agonists.

Dr. Tom



Worrried about Hyperinflation and COPD
Q. I recently had a PFT to assess shortness of breath. Prior to today I had thought this was probably just mild and due to anxiety. However, being a former smoker I asked my doctor if I could have a PFT. I am a 28 year-old male, 5'9”, 130 lbs. I smoked a pack a day for about 7 years and also have a history of marijuana use. I quit all smoking 3 years ago and now exercise regularly. My results are as follows:

FVC: 6.54

FEV1: 5.64

FEV1/FVC (%): 86

Pulse Ox: 96% (I've seen mine range from 95-99%)

TLC: 8.93 (131% of predicted—5.09)

RV: 2.28 (152% of predicted—1.50)

DLCO 44.32 (135% of predicted—32.88)

The PFT report states: “The FVC, FEV1/FVC ratio and FEF25%75% are within normal limits. The airway resistance is normal. The TLC, FRC and RV are increased indicating over-inflation. The diffusing capacity is normal. However, the diffusing capacity was not corrected for the patient's hemoglobin (the last time I had it checked it was 47%). CONCLUSIONS: Over-inflation without concurrent obstruction is of uncertain significance.

The chest x-ray shows bilateral hyperinflation of lung fields.

My understanding is that hyperinflation is a sign of emphysema. And isn't this a very late sign and poor prognostic indicator? Is it ever possible to have hyperinflation without emphysema or other COPD diseases? Does my FEV1/FVC % mean I don't have COPD?

I am worried to death about this, and it's going to be weeks before I see my doctor. Please, pardon my desperate tone, but I don't think I'll even be able to sleep tonight. I realize you cannot answer all questions and are busy, but I'd be extremely grateful for your input.

Feel free to edit any of this if you wish to put the information on your website.

Mike

A. Dear Mike, You do NOT have emphysema. You are just able to take a very large breath. Your ability to empty your lungs is normal. Hyperinflation in your case does NOT mean emphysema. Your diffusion test is normal. Your doctor should not worry you so. Stay healthy and enjoy life!

Dr. Tom



Questions about CT Scan Results and Previous Lobectomy
Q. I'm a 58 year-old male who has never smoked. I was diagnosed with stage III colon cancer in 1996, which metastasized to my left lung in 2000. An upper left lobectomy was performed in June 2000.

A recent full body CT Scan revealed the following: Impression: Heart and mediastinal structures appear unremarkable. Mild COPD is seen with chronic lung changes with apical pleural thickening. No acute infiltrate seen. Mediastinal node is not enlarged. Scarring left upper lobe seen anteriorly and in the left lung base. Left upper lobe scarring more prominent compared to previous study. No discrete lung mass seen.

Because I do not have a cough, nor do I cough up sputum and I do ride a bicycle vigorously daily for 1.5 hours without shortness of breath so the radiologist's impression leaves me with the following concerns and questions

(1). What would be the origins of mild COPD if I never smoked? I did have unprotected exposure to asbestos from 1976 to 1981 on a fairly routine basis. I also had unprotected exposure to a polyurethane concrete crack sealer which contains trace amounts (according to the material safety data sheet for this product ) of Toluene Diisocyanate for two days in February 2006. Although the garage door and windows were open during this process, I did almost pass out at the wheel while driving shortly after using this crack sealer.

(2) Why does the radiologist make reference to the upper left lung lobe if it was surgically removed in 2000?

(3) Once a lobectomy is performed, what fills the space where the lobe resided?

Rick

A. Dear Rick, The lung changes following removal of the left upper lobe, should not be interpreted as emphysema. The lower lobe expands to fill up the space, and there may be some accumulation of fluid that leaves a scar. Spirometry would tell you about your lung function (see National Lung Health Education Program http://www.nlhep.org/ ). The chest x-ray does not tell about lung function.

Dr. Tom



Lost Mother to Lung Cancer and is Concerned about CT Scan Results
Q. I am a 34 year-old female with a smoking history of 22 years off and on. I lost my mother to lung cancer on Nov. 2, 2005. I have been sick since October with a horrible cough, fatigue all the time, chest pain I thought it was caused by all the coughing, weight loss, headaches. My doctor put me on an antibiotic for two weeks, which didn't help. New symptoms since Jan. 2006 include right shoulder/back/neck pain, numbness to my right arm leading all the way down to my fingers. (said it was a pulled muscle), and a weight of 25-30 lbs. since Oct. 2005. Upon my return visit I was then told it was allergies.

This all becoming a horrible nightmare for me. That's what my mom thought was wrong with her. I requested a chest x-ray. There was a left lower lobe mass that appeared on the chest x-ray; I was scheduled for a CT with IV contrast the very next day which clearly showed a tiny noncalcified nodule in the left upper lobe anteriorly which measures 5 x 4 mm in size, additionally in the right middle lobe there is a focal irregular soft tissue opacity which has the appearance of post inflammatory change. Additionally there is a tiny noncalcified nodule present in the right middle lobe, slightly inferior to this region measuring 3-4 mm in size. Of course the report said the noncalcified nodules that are present are indeterminate by CT criteria, and suggest a repeat CT scan in three months to document stability of these findings.

At my follow-up doctor visit I was told that there would be another CT scan in three months, and was sent home. I was called by the doctor's office the next day, which was a Saturday, telling me to come in for more blood work. They ran a TB test, a fungal test, an HIV test, and they were all normal. My CBC was sent to the Mayo Clinic a week ago today and the results are not yet in.

They also did a sputum culture that showed a heavy growth of Hemophilus Influenzae so now I am being treated for bacterial pneumonia, taking Sulfonamide. Can you shed some light on all of this?

Since I just lost my mother who had just turned 56 I am a little freaked out by all of this and I feel as if I am going crazy trying to analyze this report. Can these noncalcified nodules that have been found be a direct relation to the bacterial pneumonia? I can't find any direct studies on the internet that will back up the cause of noncalcified nodules being caused by this bacterial pneumonia.

Can you give me your opinion on what I should do next? Should I consult with a lung doctor. My repeat CT scan is scheduled for May 9 to determine if the nodules have grown. Should I skip the CT scan and request a PET scan? Your help and opinion is appreciated.

Mrs. McCarthy

A. Just get the follow-up CT. I would suggest waiting six months to give time for possible growth. Very small cancers grow slowly at first. Most small nodules are benign, i.e. about 90% of them. Some of these, or all could be mucus plugs associated with your hemophilus infection.

You are wise to follow up, but do not be frantic about this. Waiting will not be wasting time, and you will get more useful information.

Dr. Tom



Worried and at a Loss about How to Help Mother Chronic Lung Problems
Q. My mother, who is 63, has been having chronic lung problems for 10 years that cannot be diagnosed. She is chronically short of breath, coughs violently, has terrible sinus head aches, wheezes so loudly through her nose and what sounds like her throat, she wakes herself up, and is exhausted all of the time.

She has had the sinus surgery, countless chest, sinus and thoracic x-rays and CT scans all with unremarkable results. About six years ago she received a diagnosis of bronchiectasis, but all subsequent CT scans show no progression.

She has seen, and still sees, allergists, pulmonologists, general doctors. She has been prescribed inhalers, nebulizers, saline irrigators, etc. and the only drug that offers her any relief is prednisone-which she will not take for any length of time because of the side effects.

I suggested getting tested for Vocal Cord Dysfunction since she has similar symptoms, but her doctors say if that is what she has, the prednisone would not help her.

All of her doctors are at a complete loss. I have watched my mother go from a woman who was full of life with boundless energy, to a virtual shut-in who cannot work and is depressed because of her condition. She is open to alternative therapies, she's open to anything, but a lot of alternative medicine recommends licorice which can raise the blood pressure.

I purchased a pepper inhalant after reading about people with similar symptoms using it with great results, however her doctor recommended against it because he advised it could damage her sinus cavity and she did not want to risk it.

I understand you cannot diagnose someone you have never seen, but I am begging you for any suggestion so I have some hope of getting my mother back. Thank you in advance for any advise you are able to provide.

Christine

A. Dear Christine, Some doctor, most likely a pulmonologist, should be able to make a diagnosis. Insist in flow volume test to see if vocal cord dysfunction is present, a simple breathing test done by pulmonologists.

Has she been bronchoscoped (a diagnostic procedure in which your doctor uses a scope, a tube with a camera on the end, to take a look at the inside of the airways and lungs). Again this could be done by a pulmonologist. Do not have her inhale pepper. It is too irritating. Get an answer.

Dr. Tom



Inhaled Dry Clay, How Worried Should I Be?
Q. About six months ago I started taking a ceramic class using stoneware. On several occasions I heavily inhaled dry clay that was on my hands into my lungs and felt strong burning in my lungs. I have learned since to wash my hands after working with clay, but nevertheless I did have this happen at least six times. The final time I was coughing for over an hour.

I have learned that the clay has free silica, which is a carcinogen and the particles bury deep in the lungs. How worried should I be about the damage done to my lungs and is there anything that can be done about it, other than being careful from now on?

X .

A. Dear X., I doubt if you inhaled enough small particles to cause what is known as silicosis. The dry or wet clay on hour hands is made up of large particles. You should remain well. Dr. Tom



Non-Viral Pluerisy
Q. You may recall my previous letters to you: I have had normal spirometry for the last three years (I am male, 37 and 181cm my FVC varies between 5.42 and 6, My FEV1 can vary from 4.15 to 4.66 and my FEV1 / FVC is always constant at between 75-77). I have also had a host of other tests, all normal. I am a past smoker with childhood asthma but a host of symptoms including cough, SPB, sputum production, inability to get a deep breath and chest ache. I have also been worked up by a Rheumatologist.

I now have had a recent bout of Non Viral pleurisy (is an inflammation of the pleura, the lining of the lungs, causing pain) which really knocked me out for a few day. My PCP (Primary Care Physician) maintains it is from a deep breath I took while taking my Symbicort inhaler. This is not the first time this has happened. I have had two HRCT thorax, the last being a year ago.

Considering all my tests I am without diagnosis; however my breathing is without doubt compromised. Up until this incident I was agreeing with the doctors and telling myself I was normal however the non viral pleurisy does concern me, what do you think this could be? My Pulmonologist and PCP have told me in the past that they do not have all the answers.

Conn

A. Dear Conn, I do not recognize non viral pleurisy as a specific entity. It could not have been due to your inhaler. You could still have asthma, with your symptoms.

A bronchial provocation test could help establish this diagnosis. In this test, you inhale a drug aimed at provoking your airways into a spasm. Airflow is measured before and after the challenge, and again after a bronchodilator.

If asthma is the diagnosis, in spite of normal airflow when you are tested, this test can be confirmatory and forms the basis of maintenance asthma treatment.

Dr. Tom



What does Clinical Improvement Mean?
Q. In 2001 I was put on oxygen as my oxygen level went to 88%; since then I have quit smoking. In August 2005, I was taken off the oxygen after they gave me a lung test, and I was 97% at rest, and 94% on exercise. Since then I have been getting along fine without oxygen.

My current medication is Spiriva, and Albuterol inhaler for shortness of breath.

If I may I will give you the test results of the spirometry:

The FEV1 is mildly reduced and FVC is minimally decreased. The static lung volumes are significant for increased RV, which is suggestible for airtrapping. There is a mild reduction in DLCO (a test that measures the transfer of gasses across the lungs ). There is no significant reversibility after bronchodilators.

IMPRESSION: Mild obstructive airways disease with evidence of air trapping noted. Loss of alveolar capillary interface, which is evident by the decreased DLCO, could be to smoker lung damage. Underlying interstitial disease cannot be ruled out. The patients present study compared to a prior study dated 4/17/01, the FEV1 (bronchodilator) has improved from 1.25 liters in the prior study to 1.49 liters presently. The FVC remains unchanged. Presently, the DLCO also does not show any significant difference. Clinical correlation is recommended.

The doctor has written on my medical record that I have been clinically improved for a year. My question is what is that my medical record says that I have been clinically improved for one year, and I just got off the oxygen in August. Could you also tell me exactly what this test reads? The test was taken in 6-21-2005. Thank-you so much for taking the time to write me back. I really appreciate it.

Terri

A. Dear Terri, Your lung function is significantly improved. You will probably maintain this level of lung function with no more smoking, except for the slow decline related to age. Stay well.

Dr. Tom



Worried about Mother's Recovery; Following Lung Cancer Surgery
Q. I am very concerned about my mom, who has diagnosed for lung cancer. She went into surgery, removing two lobes from her right lung. This was exactly 5 weeks ago. Until today she has not fully recovered, feels weak, and has pain when she coughs, yawns, or sneezes. Is this normal and what an she do to feel better? How long will it take that she will fully recover?

We have given the biopsy to an oncologist and we are waiting to see what treatment will be.

Sandra

A. Dear Sandra, It may take longer for your mother to reach her maximum improvement following major lung surgery. A significant amount of lung tissue was removed. I do not know the status of her lung function prior to the surgery. She should have simple lung function measures by spirometry (see National Lung Health Education Program http://www.nlhep.org/ ) after about 3-6 months.

Dr. Tom



Conflicting Opinions about Side-Effects of Bronchodilators
Q. I was diagnosed with asthma a little over a year ago.

I have symptoms daily and take Advair 500 to help control it. My question is regarding albuterol; I tried an albuterol inhaler twice several months ago that resulted in worsening of my symptoms-I got more short of breath for 6 hours both times.

My doctor said that it was probably the propellant, so prescribed a nebulizer for me. The other day I tried albuterol via nebulizer and had the same effect; when I asked a nurse about it, she said that I maybe needed to take more, that is what they do in the hospital.

Are some people sensitive or allergic to albuterol or to short-acting bronchodilators in general? Is there an alternative I can try?

Angela

A. Dear Angela, Some people have worsening of their asthma, from short acting albuterol. You could try a fast acting but long lasting bronchodilator in the same class, formoterol, prescribed as Foradil.

Dr. Tom



Trouble Catching Her Breath after Quit Smoking
Q. I quit smoking two months ago after almost 30 years. Quitting was much easier than I expected and I have no desire to smoke again.

The only problem I'm having is breathing. When I was smoking breathing was never a problem but since I quit I'm having problems catching my breath. I've been on some sites that say it could take 3 to 6 months before breathing is normal. Is this correct? If so why, and is there anything I can do to get some relief in the meantime?

A. Stopping smoking should not cause shortness of breath. If you were short of breath from COPD related to smoking, the lung impairment will usually stabilize or slightly improve in a matter of months.

I suggest getting you lung function measured by simple spirometry (see National Lung Health Education Program http://www.nlhep.org/ ) to see what impairment you may have.

Dr. Tom



CT Scan Shows Atelectasis
Q. I am currently being treated with Levaquin (antibiotic) for a bronchitis which did not clear up after 10 days of Zthromycin (antibiotic) treatment. I was having pain in my lower left back upon breathing in and coughing and so went for a chest x-ray which seemed to indicated actelectisis ( collapse of the lung or part of the lung) or scarring in the lower lobe of the left lung. I had a CT Scan today which came back negative to tumors, pulmonary embolism, etc and seems to still indicate linear scarring or atelectisis.

The internist has advised me to follow up with an x-ray in 4 months and if it has cleared up then we will assume it was atelectisis, if it is unchanged we will assume it is linear scarring. He is checking in with me at the end of the week to see if my other symptoms are improved.

I am still coughing (although much less) and am very tired even though I have been resting for four days (normally work 10-12 hours a day/6 days per week.) I am also still experiencing sweats and chills periodically throughout the day and night. Granted this may clear up by the end of the week.

Should I be concerned about the CT results? Should I seek out a pulmonary specialist or does the course prescribed seem appropriate? I am a 42 year old female with a long history of bronchitis and bronchial asthma--as an adult I am likely to take an antibiotic once or twice per winter season along with albuterol. Otherwise, I am very fit and healthy.

Susan

A. Dear Susan, You should have responded to antibiotics by now, and also feel better, if your problem is a common infection. The linear atelectasis should not be a cause for concern right now. It may clear in time, if it was a result of a bronchial infection. You should see a pulmonologist if you are not better soon.

Dr. Tom

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