Consequences of Inhaling a Patient's Nebulizer Treatment
Mist During the Patient's Exhalation
Q. My wife is a medical technologist. While drawing
blood the patient frequently is receiving a treatment
of aerosolized medication. There is no filter on
the exhalation side and she breathes in the patients'
exhalation that contains aerosolized medication
and possibly pathogens.
Have there been any studies indicating that inhaling
this aerosol can be a risk to those employees who
inhale it? Is the use of a filter on the exhalation
side of the nebulizer a common standard in the respiratory
A. Dear Tom, I assume you are tal king about the
exhalation port of a ventilator, used to support
ventilation. It is possible to put a filter on the
exhalation port, but it is not commonly done.
I know of no studies that show risk from the exhaled
medication to the technician working at the bedside
in these situations. There is always an infection
hazard whenever aerosols are produced by patients
as in coughing, sneezing or laughing, or from the
ventilator side in a patient with a dangerous infection.
Precautions are used for these possibilities, which
include isolation of the patient in contagious disease
Family History of Lung Disorders, Should
I be Concerned about My CT Scan?
Q. I recently had a CT scan done on my neck for
a lump I have back there that showed fine, just
lymph nodes. However during this scan they found
Minimal Biapical Pleural Parenchymal scarring of
my lungs. Could you please explain what this means.
I'm only 24 years old and a bit worried. My mother
has had her right upper lobe removed due to Nontuberculosis
Mycobacteria and my grandfather died of COPD last
year. Do I need further testing?
A. Dear Shannon, This x-ray finding does not have
any specific significance. It suggests some remote
inflammation in these areas, but this is not certain.
You should not smoke. You do not need any other
tests if your breathing is normal.
The Effect of Low Oxygen Levels On Other
Q. I monitor my O2 level and I worry when I am
at 86 or lower. What damage does the lack
of O2 do to my other organs especially my heart?
I do have an O2 concentrator for exercise and sleep.
Should I use O2 more; but as soon as I sit down
my level goes up to 92-94.
Thanks for this excellent informative column.
A. Dear Rose Ann, These oxygen levels are not low
enough to cause organ system damage in otherwise
healthy people. A saturation of 86% is normal at
altitudes of 10,000 feet, such as in Leadville,
Colorado. But your heart has to work harder to deliver
oxygen to the tissues. It is best if you can keep
your oxygen saturation above 90% at both rest and
exercise. DR Tom
Is There a Mechanism that will Mimic Incentive
Spirometry in Neonatal Patients?
Q. Is there anything that can be used besides a
positive pressure breath to mimic incentive spirometry
for a neonatal patient on high flow nasal cannula?
A. Dear Resp, Not that I know of. A baby takes
a deep breath to be able to cry, which helps to
Numbness of Arms and Legs, Could this be
a Reaction to Coumadin?
Q. In February I spent 8 days in the hospital with
right upper quad pain. An earlier CT scan showed
Portal vein thrombosis in 3 places, a cyst and hemangiomia
on liver (benign, non-cancerous, tumor consisting
of dilated blood vessels. When a hemangioma occurs
in the liver it is called a hepatic hemangioma).
In hospital MRI showed only right portal vein thrombosis.
Heparin was started, and Coumadin. One hour after
Coumadin my arms and legs went numb. Doctor in hospital
said it was in my head.
The next 2 nights the same thing happened, I insisted
on a reason and neurologist checked PDR said it
was a reaction, not in my head, and it went away
in about a week.
Ever since I left the hospital I have had sharp
tightness in lower ribs on both sides, sometimes
in my upper back and side higher on my chest it
comes and goes. My doctor said it's in my head!
I am also on Nexium 20 mg a day, along with the
Coumadin 7.5 mg/day.
I think I am having a reaction to Coumadin. It's
been 10 weeks now. I still exercise and weight train
and do regular work. This is really a problem at
times. I'm in great shape, so what's the problem?
A. Dear Chris, I do not believe that Coumadin is
the cause of these symptoms. They sound muscular
in origin. They should go away as you improve.
Is There a Lung Hazard by Breathing Indoor
Swimming Pool Chemicals?
Q. Could swimming in an indoor pool pose a respiratory
health risk to children? My son takes lessons
at our local YMCA and in only that 1/2 hour there,
I can feel the chemicals when I breathe for the
rest of the evening. I would like to get a
membership there, but could it pose a risk for my
4 year old son to breathe the chemicals in a few
days a week?
A. Dear Amanda, Chlorine vapor may be irritating.
Also some swimming pools have organisms that cause
inflammation of the lungs. You should ask the swimming
pool company about how they control for these possibilities.
Need Advice Regarding being Startled Awake
Gasping for Air
Q. My boyfriend has been startled awake in the
middle of the night 3 times this past week, and
is gasping for air, and is unable to breathe.
After a moment or two, he is able to regain regular
breathing pattern, but, when he is abruptly awoken,
he is panicked, as he can't seem to breathe, as
if his air passage is blocked.
What directions should we take with this, and what
could possibly be causing this problem? We are concerned
that perhaps his body will not wake him if this
continues to occur. Please advise as to options
we should do/review to stop this from occurring.
He does not snore or have any previous condition
to irregular sleep patterns or any other medical
condition at this time.
A. Dear Jen, This sounds like it could be obstructive
sleep apnea, even without snoring. Or it could be
some aspiration of stomach contents. Better see
a pulmonologist and see if a sleep study is needed.
Also studies for acid reflux can be considered.
Need a Clear Explanation on the Subject
of Alveolar-arterial Gradient (Aa gradient)
Q. I couldn't remember how to figure the Aa gradient.
I found the equation but I'm looking for a clear
explanation that explains the steps and why. Can
you please help me?
A. Dear Kay, The alveolar- arterial "gradient"
is really a difference. It is due to ventilation-perfusion
mismatching, or some abnormality of the alveolar
membrane. You can use the formula to calculate it,
or you can do an alveolar air sample, if you have
the sampling device and compare it with the measured
arterial oxygen tension. The factors are the FI02
(fraction of inspired oxygen, the percent concentration
of oxygen in the gas entering the lungs), RQ (Respiratory
Quotient measures the ratio of the volume of carbon),
and PACO2 (Carbon dioxide tension, i.e. pressure,
in arterial blood), but you can take the PaCO2 as
a surrogate for the alveolar number. Clear?
Metered Dose Inhaler (MDI) Protocols for
Use in Mechanical Ventilation
Q. Are there specific protocols for MDI use via
A. Dear Lee, Yes, Look in a respiratory care textbook.
Need Help for the Chronic Pain Following
Sixteen Spontaneous Pneumothrax
Q. I am writing to you in hopes that you will be
able to help me where others have failed.
My history is as follows:
5 diagnoses of Pericarditis (is a disorder caused
by inflammation of the pericardium, which is the
sac-like covering of the heart) in 2001
3 diagnoses of a Spontaneous Pneumothorax (Spontaneous
pneumothoracies - lung collapse occurs where there
is no clear cause)
1 chest tube
2 more Spontaneous Pneumothorax
Pleurodisis Procedure, (a procedure to prevent
recurring fluid build-up between the lung linings)
2 more Spontaneous Pneumothorax
Pleuradisis Procedure non orthoscopic
4 Spontaneous Pneumothorax, on Left Side
2 more Spontaneous Pneumothorax
Pleurodisis on Left Side
3 more Spontaneous Pneumothorax
ALL this in 4.5 years.
I now have chronic pain with both of my lungs having
been operated on. And I still deal with popping
blebs (an air- or fluid-filled sac in the lung,
a blister). I am on a regimen of painkillers
and ibuprofen. Have been for three years.
Now they want me on either Dilaudid or Methadone.
I want neither of these drugs and want this all
to stop. What can I do to stop getting sick
and dealing with pain and taking addictive narcotics?
Hope you can help.
A. Dear Chris, You need to tell me the underlying
diagnosis that explains all these spontaneous pneumothoraces.
It sounds like you have pleural pain from all these
procedures. I would consult an acupuncturist and
see if he or she has any ideas.
What is Your Opinion of Oxygen Conservers?
Q . I have been tested and am eligible to use an
"oxygen conserver." However, my physiotherapist
is opposed to it saying that the company just wants
to make money since I need to purchase it (not covered
by our health plan). I was anticipating greater
freedom and mobility with the conserver. What is
your opinion? Currently, I am on 2L 24 hours a day.
I am 73 years old.
A. Dear Rose, Oxygen conserving devices give you
more range from portable devices, i.e. bottles or
liquid oxygen. You get the best range from liquid
devices such as the Helios or Spirit. These have
built in conserving devices. Medicare pays for these,
but suppliers are slow to admit this. They make
more money from concentrators and e-cylinders, which
I assume you are using. If so, insist on changing
to liquid oxygen. Most Helios type systems will
give you 6-8 hours away from home. Insist on being
Update on Mother' Condition and a Few More
Q. Dear Dr. Tom, Thank you for answering my question
regarding my mother ( Worried and at a Loss about
How to Help Mother Chronic Lung Problems ) last
week. You have no idea how encouraging it
is to have a doctor respond to questions when someone
is ill. I am happy to say my mother is going
for a fifth opinion regarding her undiagnosed problems
with a pulmonologist next week.
I was wondering if you know of instances where
prednisone has helped sufferers of Vocal Cord Dysfunction
(VCD) thereby squashing claims that a diagnosis
of VCD could not be made if prednisone did help.
Also, do you have any thoughts or experience with
Empty Nose Syndrome occurring in patients that have
had sinus surgery? Is there any validity to this
syndrome as most of the symptoms match hers?
Thank you in advance for taking the time to respond.
A. Dear Christine, Prednisone does not help vocal
chord dysfunction at all. I am not familiar with
the "empty nose syndrome".
Have Had Both Upper Lung Lobes Removed,
What Should My Oxygen Level Be?
Q. I have had the upper left lobe 3 1/2 years ago,
and the upper right lobe removed 3 weeks ago. All
the cancer was removed from both lungs. I came home
last week on oxygen.
I'm feeling good but am wondering what my oxygen
level would be without oxygen. What is the
average amount of oxygen that I should read at all
times with this condition to function properly?
Should I have an oxygen meter at home? Thanks for
reviewing this. Looking forward to your answer.
A. Dear Guy, There is no way to guess what your
oxygen level will be with your remaining lung tissue.
You should get your doctor to order, prescribe,
a personal oximeter (a device that measures your
oxygenation) for your daily use. Insurance will
reimburse in many instances.
Nebulizers Versus Meter Dose Inhalers (MDI's)
Q. My hospital where I work is thinking about switching
from nebulizer treatments to MDI's. Could you tell
me if there is a benefit of one over the other or
is this just a productivity maneuver? Another hospital
in my area has already switch so I feel we won't
be to far behind
A. Dear Janie, The comparison trials show that
the same result is achieved by metered dose inhalers
as with powered nebulizers. This can be a great
saving in time and money.
Is Lupus Visible on a Chest X-Ray?
Q. I was very sick for about a week and
a half before going to an urgent care center.
I had started a really bad cough and the left lung
had a "twinge" in it.
The doctor ordered a chest x-ray and showed me
the results. She was very puzzled, as she
saw a very large mass in the right lower lobe.
It blocks the outline of the heart on the frontal
view x-ray. She immediately said it was lupus.
Is this possible to see and should she have ordered
a second x-ray?
A. Dear Johanna, Lupus can involve the lungs,
but it does not produce a large mass. It can cause
a localized accumulation of fluid, called an effusion.
Usually this is on both sides of the lungs.
Normal Breaths per Minute
Q. How many breaths do average persons breathe
in one minute at rest?
A. Dear Joseph, About 12 to 16.
Should I be Concerned about X-Ray Showing
Minimal Biapical Pleural Thickening?
Q. I recently had a chest x-ray and the results
said " Minimal Biapical Pleural Thickening." I looked
on the Internet to see what that means, but it is
very confusing. It sounds like I have the beginnings
of lung cancer. Is this true? My dad just died from
lung cancer in Oct. of 2005.
A. Dear Kim, We have had several similar questions
recently. These x-ray findings are not specific
for any diagnosis and may not mean anything. Sometimes
there is a residual of a remote inflammation.
Worried about Husband's Recovery from Lobectomy
Q. My husband found out that he had lung cancer
when he got a knot on the side of his neck that
would not go away. It was CT Scanned, his chest,
just because he was a smoker and found a 3cm.cancer
Stage I., upper left lobe.
A lobectomy was performed seven months. He has had
3 follow-up CT Scans. The last one showed a spot
in the left parotid gland, which was benign. But
now the knot on the side of his neck is back. He
is on Levaquin but if he is not better soon, he
has to go to an ENT.
Ever since surgery he has coughed more and coughed
up more stuff than he ever did. He still loses his
breath upon doing much at all.
He did have a second surgery the day after his lobectomy
because the bottom 1/2 lung had broken open, 30
stitches were required. So we are sure the healing
time will be more but he has good and bad days but
never has a day that he does not lose his breath
at least once. He is tired and coughs up so much
phlegm. He is back to work but so much worse than
before the surgery.
He did not appear sick at all at the time. Any Ideas?
A. Dear Phyllis, He may still be in the healing
phase from the lobectomy. He could also have
some underlying lung disease such as COPD,
which is common in lung cancer patients. The
"knot" in the neck needs explanation.
Electrical Lung Massager
Q. As part of my "homecare treatment" the physiotherapist
has recommended a "massage of the lungs...in particular
the lower lobes." As a result of the massage,
I am coughing a great deal, and although the
mucus amount that I am spitting up has increased,
it is not really significant. I am to have the massager
(electrical) twice a day for a period of about 10
to 15 minutes. What is your opinion of this lung
A. Dear Rose, This may help mobilize secretions
from the lungs. It is not usually necessary for
prolonged periods of time.