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Archive: Dr. Tom 81
Posted October 2, 2006

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

 

 

The Mixing of Lung Medications
Q. I read one of the questions on your site and the person was using Combivent with Spiriva, is there any danger in using both?  I have always relied on the Combivent but was told it hadn't been tested with Spiriva.  And, is there any reason to use Advair 500 with Spiriva?
Thanks; you are truly amazing to answer all our questions and to project such a caring attitude.  I do wish you were my "in person" doctor.

Karla

A. Dear Karla, Spiriva and Advair are perfectly compatible. The three drugs, tiotropium in Spiriva, and salmeterol and fluticasone in Advair work through different mechanisms that are compatible.
This has become a popular combination for COPD patients with moderate or advanced stages of disease. Spiriva can also be used with Combivent, but this is not common, and the ipratropium part of Combivent is similar to the tiotropium of Spiriva. Not dangerous, but also not recommended.

Dr. Tom

Federal Drug Administration (FDA) Dosage for Different Age Groups
Q. Is there a rigorous enforcement by the FDA in regards to dosage for age ranges for the use of respiratory care aerosol drugs?

Renee

A. Dear Renee, No. The FDA only makes recommendation. Dosing is the responsibility of the prescribing physician.

Dr. Tom

Son Does Not Have Insurance; Can He Afford to Wait to See the Doctor?
Q. Dear Dr Tom, What would you say if your son (stubborn 22 yr. old) has had a cough for two years, has been coughing up blood often, very SOB and has had elevated leucocytes in the past and now has them again?
Let me briefly explain, He went to the Dr about a year ago      (because I nagged him into it). I do not know what the Dr said other then the fact that he said something about fluid in the lung and he had the elevated cells. Son did not tell current Dr that he had elevated cells one-year prior that we never found out what the cause was. Dr gave son a few different drugs and cough never went away.
Bottom line is Son does not share with me what is really happening and he has not been back to Dr in six months or so because he lost his insurance and says he feels better. But he is still coughing all the time.
Sorry if this is lacking info but it is all I have and I am just grasping at straws trying to figure things out. Son is now willing to go back to Dr's and will share what outcome is but has to wait until Insurance kicks in, not sure how long.
I'm guessing it could be symptoms of a few different things, but wanted to ask.  I appreciate the service you provide. 

Christine

A. Dear Christine, A chronic persistent cough is never something to ignore. There are too many possibilities to be able to make any kind of diagnosis, based on the limited information you gave. Your son better make an investment in his future health. He is wasting money on other things, such as, possibly, smoking material that is causing the cough.

Dr. Tom

How to Improve SOB and Oximeter Reading
Q. What can I do to improve my pulse-ox reading and my shortness of breath?

Don

A. Dear Don, Try slow deep breathing with exhalation against pursed lips as in the act of whistling. This is known as pursed lips breathing. Take in a complete breath rather fast, and breath it out against pursed lips slowly and completely. Keep repeating this as you observe your oximeter.

Dr. Tom

 

Spirometry Results and is FEV1/SVC Important?
Q. I am a 35 yr old Irishman and former smoker. I wonder if you could comment on my recent spirometry results:
PRE:         POST:
FVC 105%      123%
FEVI 100%     122%
FEVI/FVC 74%   77% (ref 77%)
FEV1/SVC 63%   77% (ref 77%)
PEF 106%      116%
MVV 124%
VC  123%
TLC 101%
RV 35%
DLCO 115%
My doctor described the results as "nearly normal" but suggested there was evidence of "a slight obstructive component which was completely reversible" He bases this on the fact that the FEVI/SVC% is 63(REF 77%), but returns to 77% after medication. My FEVI and FVC also shot up to 122 and 123%; despite the fact that they were pretty good before medication.
Anyway my doctor seems to think I have mild asthma. My question is would you agree with this diagnosis? I’m kind of confused since I always thought that once the FVC, FEV1 and FEV1/FVC% were all normal- which they are in my case, you could pretty much rule out any abnormalities.
Is the FEV1/SVC% a more sensitive indicator of airway obstruction than the FEV1/FVC%? I’d also like to ask you Dr. Tom if you think there’s any evidence of COPD based on my spirometry results.
My doctor seems to think that my overall spirometry is good and that there’s no support for COPD because of complete reversibility. Would you agree with him? I would really appreciate your thoughts.

Sean

A. Dear Sean, Your lung function is normal. You do not have COPD. Forget all the tests except the FEV1, FVC and the ratio. The other tests are misleading in most cases.

Dr. Tom

Would Like to Stop Taking Advair
Hello. My son is ten years old, and recently diagnosed with hiatal hernia and acid reflux, and a mild case of asthma. They think the asthma is from the acid reflux.
He has been on Advair for two weeks, and having testicular pain, and throwing up. I would like to discontinue Advair. I'm wondering what your opinion is on Advair? Could he stop sudden, or does he need to wean off? Is there a safer inhaler?

Jeannie

A. Dear Jeannie Advair can be simply stopped. There are other inhalers for asthma.

Dr Tom                

Concerned about Advair Warning
Q. Dr Tom. Welcome back, and I hope you caught " the big one ". Come to Nothern Ontario Canada. Thanks for answering so many of my questions but this one is important. My doctor put me on Advair two puffs morning and two puffs evening.
I looked up the drug on the computer and I was shocked to find that this drug has killed people. Now not large numbers but 13 out of 13000 is not to turn a blind eye.
Advair makes me tired and shaky. I am now afraid to take this medication, as I have high blood pressure (under control), and it does affect the heart.
What would you substitute that would be as good. I am a member of your organization and EFFORTS (Emphysema Foundation for the Right to Survive: http://www.emphysema.net/) and I have been reading lately in efforts of a wonderful drug called Foradil.Is it similar to Advair?

Philip

A. Dear Philip, Foradil is similar to the salmeterol in Advair, which is blamed for some deaths on a statistical basis. The Advair also contains fluticasone, which can be taken separately. 

Dr. Tom

Lymph Node on CT Scan         
Q. I am a 31 yr. old female and I was at the emergency room tonight with tightness in the chest, I thought I might have a pneumonia because I had it two years ago that left so called scar tissue on my lung a couple months after.
Tonight they told me that I have bronchitis and they did a chest x-ray that showed a spot on my lung, so they ordered a CT scan. They said it was multiple lymph nodes in the AP window and in the hilar bilaterally. No pleural effusion, and no infiltrate or pulmonary mass.
They said those two things are good and that I should not worry about cancer, that everyone has tons on lymph nodes and that mine are just showing on an x-ray and that they must be inflamed. Should I be concerned that I have cancer of the lymph nodes?

Tracy

A. Dear Tracy, This is most likely a disease called sarcoidosis, which is not a cancer. It usually goes away. See a pulmonologist to confirm the diagnosis.

Dr. Tom

What Does a Severe Reduction in Diffusion Mean?
Q. Dr Tom, I'm rather confused about my X-Ray and PFT Results.
I am 50 year-old male, smoked cigarettes 28 pack years.
I quit three months ago after my x-ray results showed signs of
COPD: hyperinflation, air trapping, etc. six weeks later had a PFT test my results:

FVC  Actual 5.58         Pred. 5.38         %Pred 104
FEV1 Actual 4.42         Pred. 4.36         %Pred 101
FEV1/FVC % Actual 79     Pred. 81

RV Actual 2.68 Pred. 2.20 %Pred 122
TLC Actual 8.50 Pred. 7.57 %Pred 112

Diffusion
DLCO  Actual 17.73 Pred. 36.37 %Pred 49
DL/VA Actual 4.69 Pred. 4.81 %Pred 98
VA L  Actual 3.78 Pred. 7.57 %Pred 50
Pulmonologist findings normal lung volumes severe reduction on diffusion may be component of interstitial lung disease (IDL).
I have no SOB and exercise 1 to 1and a half hours each day. I walk between four and six miles each day; sometimes I run a mile or so with no SOB.
So what do you think COPD or ILD?

Rulie

A. Dear Rulie, Your diffusion test is normal, when corrected for the lung volume you have. You do NOT have ILD. Your pulmonoligist should know this.

Dr. Tom

With a FEV1 of 39%; Shouldn’t There be Some Sort of Picture on CT Scan that Shows COPD?
Q. Dear Dr Tom, Thank you so much for your time in providing this wonderful service to people like me who feel too much like a hypochondriac asking so many questions at my own pumonologist’s visit.
This is not really a question I would feel comfortable asking my pulmonologist. CT Scans diagnosed me, twice with pneumonia before I was sent to a specialist two years ago. I smoked a pack to 1 half a day for 28 years. I stopped smoking 13 years ago. I am a 52 year-old female.
I went to a pulmonologist that came highly recommend and I like him very much. My FEV1 came back at 39%.  Neither the radiologist (who happens to be a friend and am sure would tell me) nor my pulmonologist could see from the x-rays or CT Scans any sign of emphysema.
My pulmonologist sent me two hours away for a second opinion because he said I had him stumped. The second opinion pulmonologist also said she did not see signs of emphysema on either picture. She did, however, give me the diagnosis of significant emphysema.
After reading up on the disease I agree with her because looking back, everything points to it. I just had another lung infection and the radiologist did say that my lungs were hyperinflated due to the emphysema.
I have two questions.
1. Most importantly, do you think because my pulmonologist couldn’t make a diagnosis I should stay with him? He is very proactive now with me. As I said I like him very much but it concerns me because not only did he not see anything from the CT Scan and x-rays but even with my PFT numbers I had him baffled.
two. Do hyperinflated lungs go back to normal once the infection subsides?
Thank you for your opinion.

Ally

A. Dear Ally, Stay with your pulmonologist. Sometimes the CT does not show emphysema. Depends on the type of CT. Hyperinflation just means lots of air in the lungs. It can "go away" with a complete expiration in normal people. Emphysema patient have air trapping and the lungs will not empty normally. This is because of loss of elasticity of the lungs and obstruction of the small air passages.

Dr. Tom             

What Happens to a Patient who is Shunting and What Would Their Arterial Blood Gas Look Like?
Q. Explain to me a patient shunting, and what will their ABG’s (Arterial Blood Gases) look like.

Barry

A. Dear Barry, Shunting means that the blood from the tissues, which goes through, the right heart, is not in contact with fresh air in the alveoli of the lungs. A true shunt is due to an abnormal blood vessel or group of vessels in the lungs, or a defect in the heart. In a right to left shunt, there is an oxygen deficit that is not corrected by breathing supplemental oxygen.

Dr. Tom

Could all of My Nasal and Throat Symptoms be Caused by my Lungs?
Q. I have had trouble swallowing as well as constant throat clearing and a feeling of excessive phlegm in my throat. Thought it was perhaps reflux, but have had many endoscopies and barium swallows and all do not point to any conclusive evidence of reflux. Although I do have symptoms of reflux (occasional regurgitation of food. heart burn...) my physicians do not believe that reflux can account for my symptoms.
I feel that I do have a postnasal drip but a CT scan of sinuses is normal. I seem to hack up white, tenacious phlegm and wonder if it is coming from my lungs or sinuses. Infrequently, I cough up greenish phlegm and have some relief of my symptoms for several hours.
Could all my symptoms be related to my chest or lungs ...an area not yet investigated?? I have no breathing problems and a recent pulmonary function test (PFT) to check for asthma, it was normal.
I am very disturbed and uncomfortable with the feeling in my throat and the excessive phlegm that sits in what feels like my throat, esophagus. Food gets stuck in my throat and sometimes when I swallow I have to work at getting my food down. These symptoms have persisted for over a year.
Lastly, I have been examined by several ENT and they did not find anything special. Could this all be coming from my chest? Your advice would be appreciated.

Randy

A. Dear Randy, Your symptoms are not explained by all the tests you have had. I would suggest chronic sinusitis, but the CT of the sinuses should confirm this. Reflux also seems possible. Maybe it was missed. I suggest over night pH monitoring for acid from your stomach, to see if there is some missed nocturnal reflux. You will have to see a gastroenterologist to arrange for this test.

Dr. Tom

Was on a Ventilator after Last Surgery, Will this Mean that I will be on the Ventilator after this Surgery?
I have a history of asthma and sleep apnea. In 11/03 I had an anterior cervical discectomy and fusion (C4-5, C5-6, C6-7) and bone grafting.
Following the procedure, I required ICU and was on a ventilator, for several days then released to a regular room. 
Per the anesthesiologists report my post-op chest x-ray showed bibasilar atelectasis.
I am having another surgery in the next few months and need to know more about what this is (atelectasis) and why I had the complications. Is this a one-time freak incidence or is it something I might expect to happen again? 
The surgeon said I was put on the ventilator as a precautionary measure due to swelling. I am experiencing the fear the tube will not fit down my throat later if the swelling is still increased.

Nancy

A. Dear Nancy, Your anesthesiologist will have to access this. Using a tube in the windpipe is common with neck operations for the reasons your doctor used this precaution, along with the ventilator in the past. These issues can only be decided by your attending physicians.

Dr. Tom

Could X-Ray Diagnose Tuberculosis (TB)?
Q. Hello Dr. Tom: I'm 57 1/2 year-old female. I needed a pre-op for foot surgery and the chest x-rays were normal.
The last several months I have had a dry cough and when I breathe I had pain in my left side of chest.  My doctor took chest x-rays and EKG. The EKG was normal but the doctor called me in for another chest x-ray because the first (pre-op) one had white spots scattered on both lungs.
I went back last Friday, and the chest x-rays still showed white spots. I had a breast augmentation in 1990 and when I looked at the X-rays I saw bright white pinpoint dots near my breasts and a clouded area in my upper right lobe.  The doctor said that was what the radiologist was most concerned about. 
My doctor is a GP and he told me that after the radiologist looked at them he would call me with the diagnosis.  I asked him what he thought it might be and he said tuberculosis.
I have no symptoms of TB, only a dry cough and chronic sore throat for over two months now.  I smoked when I was in my teens through 25. I can't understand how a normal chest x-ray could become abnormal in just several months? 
I had pleurisy 20 years ago.  That was only in my left lung
Please help; I'm on pins and needles because I won't know anything until Monday or Tuesday. I do NOT have any symptoms of TB except for a dry cough.  I do NOT have night sweats or fever.  Any advice would help.

Joyce

A. Dear Joyce, Tuberculosis is not a common disease in this country, but with the description of your x-rays, it is a possibility. If it is confirmed, it is easy to treat. Tuberculosis may exist with no symptoms at all, or with the ones that you have. Be sure to get the diagnosis, for sure!

Dr. Tom

What is Subsegmental Atelectasis?
Q. I recently had some test done in the emergency Room (ER) and one of the test said I have a nominal subsegmental atelectasis in left lower lung but there is no free air or free fluid in the pleural space what does this mean?

Gary

A. Dear Gary, It means that just that a small portion of your lung is collapsed. This should clear, or else it needs further investigation.

Dr. Tom

Could My Bad Lungs Cause Circulation Problems in Hands?
Q. I have problems with circulation; hands turn white and feel like they are really stiff also at night and sleeping.
I had blood clots in lungs healed up now. I have gained a lot of weight but not on any steroid now but have taken some inhaled     Have test taken for heart all of them they are ok. Doctor said bad lungs.
Is this feeling of stiffness from my bad lungs? Also have it in other parts of body stiff to extreme stiffness. Thanks for your comments on this. You are a caring doctor, I can tell.

Carol

A. Dear Carol, There are diseases of the connective tissue that also involve the lungs. These are the so-called collagen diseases of which rheumatoid arthritis is one. I am only guessing here. Better see a pulmonologist to sort this out.

Dr. Tom 

When and If I should Get a Repeat Scan?
Q. I am a 47 year-old female former smoker. My CT scan of thorax reads as follows: 1.The study is essentially unremarkable. two. Lungs are somewhat hyperinflated. Minimal juxta pleural thickening posteriorly left upper lobe, most likely post inflammatory in nature. 3. Possibility of a very tiny nodule 1-2mm posteriorly right mid lung area four.No acute cardiopulmonary disease,
My chest x-ray is negative (no abnormalities) and I have no other symptoms. I have conflicting information on having repeat scan.
My question is when/if should CT scan be repeated? How likely is lung cancer? Very upset.

K

A. Dear K., The results of your study are not alarming. It is very unlikely that a small cancer is present. I suggest a follow up CT in six months, just to be sure.

Dr. Tom 

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