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Archive: Dr. Tom 84
Posted November 6, 2006

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

 

 

Complications from Too Much Oxygen
Q. What are the complications of delivering too much oxygen, and also how can I evaluate the effectiveness of oxygen therapy?

George

A. Dear George, There are few, if any complications from excessive oxygen flows, except drying of the nose and air passages.
You can monitor your oxygen liter flows at rest, exercise and while traveling by using a simple pulse oximeter, that costs about $300 or less. An oximeter should be prescribed by your doctor for reimbursement purposes.

Dr. Tom

Oxygen Saturation Drops Quickly During Exercise, Should Exercise be Stopped?
Q. If a patient has severe COPD (stage IV) and is obtaining a SaO2 of 92% with oxygen but quickly drops down to 80% Sa02 when walking on the lowest level of a treadmill for three-4 minutes. What is an acceptable drop in Sa02, when exercising and what level of desaturation should the exercise be stopped? 

Lessly

A. Dear Lessly, There is no clear-cut limit, but 80% would be reasonable, if the heart rate is not about 120. Be sure to have your patient use pursed lips exhalation, as in whistling to help improve oxygenation.

Dr. Tom

What are Pulmonic Regurgitation and Ejection Fraction?
Q. Chest X-Ray shows mild pleural thickening and mild pulmonic regurgitation, ejection fraction 65% on echo. What does it mean?

Donna

A. Dear Donna, Pleural thickening means a scar from old inflammation. Not much significance.
A chest x-ray cannot tell about pulmononic regurgitation, which is a backward leakage of the valve before the pulmonary artery to the lung begins, and ejection fraction is that percent of emptying that the left ventricle does. Normal is greater than 50%. These later values are determined by echo cardiography.

Dr. Tom                             

Spacers and Meter Dose Inhalers
Q. If I am using a fluorocarbon free MDI like Proventil HFA, should I use a spacer?

Ben

A. Dear Ben, No. I do not believe that spacers have much value, if you breathe with an open mouth and hold the device a couple of inches in front of the lips.

Dr. Tom

Grandmother has Lung Cancer, Should She See a Lung Specialist?
My grandmother was recently diagnosed with stage 4 NSCLC (Non-Small Cell Lung Cancer). It has spread to the brain resulting in two tumors, one about three inches in diameter. She recently completed radiation to the brain. She is very weak, too weak to travel.
Should we push for her to see a lung specialist? Should she be as weak as she is (it is hard for her to move around because she doesn't have the strength)? She is on steroids to prevent swelling in the brain, she was off the steroids for a couple of days and the swelling returned. The steroids are causing her pain; we are told that they may be breaking down her muscles in her legs.

TY

A. Dear TY, Your grandmother should see an oncologist if you are seeking more treatment. You may have done this already. There are some improvements is lung cancer chemotherapy that could possibly be helpful.

Dr. Tom

My Mother is in ICU With Pneumonia, What Should I Ask My Doctor?
Q.  My mother developed severe pneumonia and has been admitted to the ICU.  The pneumonia came on very suddenly, only two days from the onset of symptoms until she was admitted to the ICU.  Her blood pressure was very low the first day and has come back up some but is still in the low range of normal.  Her oxygen saturation is fluctuating anywhere between 83 and 93.  What kind of questions can I ask her doctor to learn more about what is happening to her?

J

A. Dear J., I assume your mother is not receiving mechanical ventilation. If she is the questions are different.
I would ask what organism is believed to be involved, what antibiotics are being used and your doctor's estimate about her prognosis. Also ask if she has some underlying disease that predisposes to pneumonia such as COPD, or diabetes.

Dr. Tom

Inspiratory Muscle Training and COPD
Q. Hi Dr. Tom, I have heard and read about the benefits of inspiratory muscle training, but I don't understand why it isn't being recommended more often. What do you think of rigorous IMT to improve the quality of living for those with COPD or people with asthma?

Dan

A. Dear Dan, Inspiratory muscle training is very helpful to many with advanced respiratory disorders. There are a variety of techniques for this.

Dr. Tom

Instilling Mucomyst Directly Down the Endotracheal Tube
Q. I know you can instill Mucomyst directly down an endotracheal tube (a breathing a tube placed in the airways, through the mouth or nose, to keep the airway open  and this tube can be connected to mechanical ventilators for the purpose of delivering air and/or gases into the lungs) instead of nebulizing it but I can't find the backup documentation. Can you help...Mucomyst gums up the ventilator exhalation valve system and that's why we do not like to nebulize it.

Regina

A. Dear Regina, I don't use the stuff myself. I do not know of any comparison literature.

Dr. Tom

Avoiding Further Damage to the Lungs
Q.
Dr Tom I am a 36 year-old male with mild emphysema (found after X-ray and CT scan). My FEV1 (Forced Expiratory Volume in 1 second) is still good at 101%. I have quit smoking.
I am wondering how quickly my lungs will decline with this horrible emphysema. I've heard that if someone with mild emphysema stops smoking, their lung function can improve for the first year and then it declines at a rate similar to that of healthy individuals for about five years.
But my question is what happens after the five years? In other words what happens in the long run to the lung function of someone with mild emphysema and a normal FEV1, who stops smoking, follows the treatment and generally looks after themselves?
Does the lung function continue to decline at a rate similar to that of healthy individuals?

Daniel

Dear Daniel, You are correct. You have done the most important thing to prevent the development of advanced emphysema. Avoid all environmental smoke and eat plenty of fruits and vegetables for their antioxidants. You will likely remain healthy. Enjoy life!

Dr. Tom

Worried About the Quality of Care My Mother is Receiving at New Hospital
Q. My mom has COPD, sleep apnea, paralyzed diaphragm on the left side and she is over weight.  About three weeks ago we took her to the ER because she was talking out of her head.  They said that CO2 had built up in her lungs and O2 level was at 48. 
They ended up putting her on a vent. She came off after a couple of days and then the CO2 went right back up so she had to go back on the vent.  They had to put in a trach since she had been on the vent so long.
Then they transferred her to a specialty place to help her get off the vent.  They have changed her medications around which seems to be having an adverse reaction with her.  She has many allergies and is allergic to several meds. 
When we voiced our concerns we were put off like it was nothing.  In this place she is in the ICU only has four beds. They are supposed to be able to watch her closely but in the last three days she has fallen out of bed, pulled her feeding tube out about five times, and pulled the vent off numerous times. 
We spoke with the nurse supervisor and she just said well I will look into it but she didn’t sound like we should make a big deal out of it.  To us it is a very big deal. I guess the nurse has to not get involved personally but it seems like these matters should be looked into. 
We are very unhappy with the care she is receiving there and would like to move her somewhere else but they say we can’t. How do they have the right to tell us where she can or can't be? Also I am trying to find another place for her but having a hard time locating one. We live in Kentucky.
Do you have any suggestions on finding a place for her? She is beginning to breathe on her own. Yesterday she did it for seven hours by herself.  But they are keeping her upset all the time and not trying to calm her down at all.  At one point her heart rate was up to 141.  I know if they don’t keep her calm she can go into cardiac arrest.  Any suggestions for that as well?

Elizabeth

A. Dear Elizabeth, Find another hospital that will give your mother proper care. See if there is a Kindred hospital that specializes in weaning patients from mechanical ventilation. In general, These hospitals offer excellent care for patients such as your mother. Take charge!

Dr. Tom

Are Chest Tubes a Contraindication for Chest Physiotherapy (CPT)?
Q. Dr. Tom, I am a nurse in a cardiac surgery ICU. Our patient population requires frequent chest PT and most all of them have chest tubes. Several of our respiratory therapists have come to me saying that patients with chest tubes should not receive CPT because it is contraindicated. Is there any truth in this statement? Do you know of any research I can bring back to them to support or not support this issue.

Melissa

A. Dear Melissa, No, presence of chest tubes is not a contraindiction to chest physiogherapy. I know of no research that can cite from memory.

Dr. Tom

Statistical Information on Ventilator Beds
Q. Hi Dr. Tom, I am doing research on ventilator beds throughout the country.  Is there a source where I can get information on vent beds and programs across all states?

Lloyd

A. Dear Lloyd, Dear Loyd, I have no idea. You better go on line and search for the literature you are seeking.

Dr. Tom

Will Sterile Water for Tracheostomy Care Cause Pseudomonas?
Q. Will using sterile water for trach care, cause pseudomonas?

Edwardean

A. Dear Edwardean,  No, Why should it? It is sterile.

Dr. Tom                       

Could Coughing Up Blood be a Sign of Lung Cancer Reoccurrence?
Q. My husband had lung cancer two years ago and has been in remission since his lower lobe was removed and he went through chemo. He was Stage 3A. 
He is now coughing up blood and I am worried the cancer is back, is this a possibility? 
Also two years ago they found 1 nodule in my left lung, now I have four nodules (two in each lung) but there are too small to do anything about.  I am very scared about this and it is always on my mind.  Please help

A. Dear Ruth,Coughing blood is indeed a sign of lung cancer and should be checked for this. Your nodules should be followed up in six months, according to most experts.

Dr. Tom

Have Spot on Lung and Worry that it Might Be Lung Cancer or Sarcoidosis

Q. This past January, after being hospitalized, my Dr. told me they saw a spot on my lung.  I am 54 with COPD, and I have about 24% of my lung capacity left. They have done three CT Scans on my lungs and still have not determined if it's cancer.
I am a past smoker. I want the Dr. to do a biopsy to see if it is cancer, but he keeps telling me he wants to wait.  Why wait?  Someone told me that if they did the biopsy and it was cancer, the cancer would spread quickly, is this true? 
Also, could this possibly be due to sarcoidosis?  I was diagnosed with sarcoid at a very young age, but was never treated for it.  They did a biopsy of my lung at that time and said it was nothing but sarcoid. Six months after the diagnosis, the sarcoid was gone and never re-occurred again. 

Thanks Mary

A. Dear Mary, It is unlikely that a new nodule is sarcoidosis, but this is not a certainty. Most small cancers do not spread rapidly. Your doctor is looking for any sign of growth of your nodules, to decide the likelihood of their being malignant. Follow your doctor's advice.

Dr. Tom

Diffusion Capacity has Dropped 17% in 14 Months, Is this Due To Mixed Connective Disease
Q. I am 40 years old and work as a RN in a MICU.  I have always been very physically fit, working out five to six days a week.  In late 2004 I started having SOB with stairs.  It progressed to the point where I would need to sit down after taking 15-20 stairs.  I have never smoked. 
PFT's in 4-05
DLCO of 92%
FVC 103%
FEV1 97%,
FEV1/FVC 79
FEV25-75 78%
TLC108% 
I was treated for asthma with no improvement and later told by two pulmonary doctors that I don't have asthma.  I have never gotten back to my previous level of activity.  I get SOB with any activity. 

PFT's in 3-06
DLCO at 83%
FVC 105%
FEV1 95%
FEV1/FVC 92%
FEF 25-75 68%,

I had a RHC and PH was ruled out.  At this time I was diagnosed with MCTD (Mixed Connective Tissue Disease). 
I started treatment with prednisone and Plaquenil.  I started to feel better on the prednisone, but then it seemed to lose it's effectiveness.  After five months of treatment for my MCTD I had repeat PFT's
DLCO is now 81%
FVC 91%
FEV1 83%
FEV1/FVC 74%
FEF25-75 59%
TLC 113%,

They said I have mild COPD at the small airway level with no response to bronchodilators.  I did have a HRCT in 3-06 that didn't show anything really. 
My MCTD is now evolving more into scleroderma even with increased treatment of methotrexate.  I will be seen in November at The Cleveland Clinic to see about a more aggressive treatment plan.  My Rheumatologist feels that the connective tissue disease is causing damage to my lungs.
What are your opinions on my DLCO.  I know it's still normal at 81%, but is a drop of 11% in 17 months with treatment a concern? Any other ideas you have would be helpful.

Laura

A. Dear Laura, It could be scleroderma developing. There are serologic test for this. Keep following your lung function and consult a pulmonologist for his further opinion.

Dr. Tom

Lung Disease and Have Heart Disease Symptoms; Could There be a Connection?
Q. Dr. Tom: I am a 49-year-old female. I have never smoked and was previously diagnosed with allergic asthma.
I was injured in a chemical exposure by Freon and Phosgene in 2002, which resulted in chemical burns and chemical pneumonitis. I was never hospitalized or put on forced ventilator treatment for the pneumonitis.
I have recurring respiratory infections about every four to six weeks that are treated with Ceftin, Tequin, or Levaquin. After a few years of recovery using a nebulizer, Advair, Albuterol, and Singulair, I have reduced RV, and a diagnosis of restrictive lung disease.
My chronic symptoms are dyspnea, chest pain, and increasing sinus tachycardia that was verified with a Holter monitor.
At a recent PFT/treadmill test, the arterial blood gas test came back with “acute respiratory alkalosis with normal oxygenation.” The chest CT w/contrast from June of 2006 results came back with the finding of bibasilar dependent atelectasis.
What is your opinion of the relation of these two findings to the chronic symptoms?
I am having a difficult time finding a pulmonologist and cardiologist who will work together on these issues. Do you have any suggestions?

Faye

A. Dear Faye, You may have some scarring at the base of your lungs, that gives you restricted breathing. The acute respiratory alkalosis just mean that you breathed more than necessary during the test, and transiently lowered you carbon dioxide.   
You do need a pulmonologist who can work with your cardiologist. You will have to inquire in your local area, about the possibilities of a referral. If you lived in Denver, I could recommend such a pulmonologist easily.

Dr. Tom

Medication Choices for Person with Borderline Osteoporosis
Q. My asthma has been controlled for five years with Flovent.  My bone density shows borderline osteoporosis.  My physician recommended stopping the Flovent and trying Spiriva.  Do you agree with this?  I do not have COPD.

Eileen

A. Dear Eileen, In general yes. Flovent, an inhaled steroid can contribute to osteopenia/osteoporosis. Spiriva is a good bronchodilator for either COPD or asthma. It will not contribute to bone loss.

Dr. Tom

Any Suggestions on What Questions to Ask Doctor about CT Scan results?
Q. My father is 66 years old. He has smoked for as long as I can remember. He went in for a routine physical the other day. He had been coughing & has had history of bronchitis and pneumonia in the past.
The Dr. did a chest x-ray. It came back abnormal. My dad told me his chest x-rays have always been abnormal due to a severe case of pneumonia in the past and heart damage. They did a CT scan a day or two later. He got the results today and a nodule was found on the right lung.
I am very frightened and beside myself. He has been referred to a Pulmonary Doctor, but doesn't know the appointment date. I want to know answers, but first I want to find questions that can be easily answered. I don't know if I should be thankful that only one nodule was found? He didn't ask the size or they didn't tell him. He knows how worried I am and when I call, my mom tells me not to upset him.
I don't want to upset him, I just want to make sure he is being aggressive on this and I want the best doctors in on it.
Any suggestions for questions to ask the pulmonary doctor? Also, do I have a right to go with them to this appointment? Thank you and I am anxiously awaiting your reply.

Concerned Child

A. Dear Concerned Child, By all means you have every right to accompany your dad and ask questions. Ask about size, calcifications, and whether or not the border is sharp or "ragged". A pulmonologist will know the significance of his nodule and the importance of these questions. About 90% of small non calcified nodules are benign. Almost all calcified nodules are benign.

Dr. Tom

Could Heavy Exposure to Asbestos Cause Pleural Thickening and Small Lung Nodule?
Q. I had a one time, heavy exposure to asbestos during home remodeling about ten years ago. Recently my X-rays and CT showed thickening of the pleura and a small nodule.
I've had shortness of breath for some time and my doctor is baffled. Could this one time exposure to asbestos cause asbestosis or mesothelioma?

E.R.

A. Dear E.R., Yes, the pleural thickening is most likely benign, but can be due to asbestosis, as can the nodule. Also there is a lung cancer risk here. Be sure to see a pulmonologist for this problem.

Dr. Tom

What are Granulomas and Hamartomas?
Q. Dear Dr. Tom, I have been having fatigue and shortness of breath for quite some time. I recently had a chest x-ray completed and the report said there was an atypical granuloma or hamartoma of 12mm semilunate appearance.
The doctor did not seem too concerned but I want to know what this means. Also, my aunt has hereditary emphysema and my sister has severe asthma. Is it even a possibility that I could have inherited this?

Stacie

A. Dear Stacie, Both granulomas and hamartomas are benign. They are not inherited. Asthma can be.

Dr. Tom

Could Walking Be Damaging my Heart?
Q. I live at 5000 ft and was concerned about O2 sats and exercising-my rest O2 is 92-94 and when I walk steadily my O2 sats drop to 85-88 but when I stop the sats go back to low 90's within a few seconds.
I have lived at 5000 ft for 10+years and I walk two to four miles five times a week and was told I might be damaging my heart (enlarging right side) was told to ask you by COPD RRT Mark Mangus <great guy>.
Was told by my doctor I did not need O2-others say need it when exercising—my doctor is a four-minute wonder office visit.
Hope you can give me some encouragement as if I must give up walking in the mountains-not sure I want that type of life. I am 68 year old and fit except for COPD. I thank you in advance for your time and expertise.

George

A. Dear George, Your oxygen level is normal for 5000 feet. Keep walking and forget about any doctor who will only spend four minutes with you. Stay well.

Dr. Tom

Lung Pain and Decreased Lung Capacity After Seizure Event
Q. Dr. Tom, I had deep brain stimulation August 9 for Parkinson's. A few hours after surgery I had a seizure that lasted about 12 minutes. After receiving anti-seizure meds I spent the night in ICU having very shallow breathing and suspected atelectisis.
I was put on a three day anti-biotic as prevention to pneumonia. Since that time, I continue to have what I call lung pain with a decreased lung capacity. The pain seems to migrate around my diaphragm, sometimes back, sometimes front. Any thoughts?

Jay

Dear Jay, Sorry, no. I suspect these symptoms will subside if they were due to the electrical stimulation.

Dr. Tom

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