Drs. Karpick, Yeager & Petty Q&A




 Ronald J. Karpick, M. D.
EFFORTS Rally 2001,
Washington, DC

Dr. Tom Petty, M.D.,
F.A.C.P., F.C.C.P.

EFFORTS wishes to thank Drs. Ron Karpick and Petty for devoting their time and EFFORTS in providing answers
for our members to some of our most important questions. 

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Disclaimer:  The information provided herein, is not intended to be of a diagnostic nature or to question treatment by your own physicians.  It is meant strictly as information and education based on what is disclosed in the questions submitted by our membership.  Any response by  is based solely on his training and knowledge and of course might be subject to correction or difference of opinion.  In the event you feel a mistake has been made,  would be interested in hearing from you. 
 

Is There Pain with Emphysema?

Q. My Mother, has emphysema. She was just put on oxygen 2 months ago, but recently has been experiencing SEVERE PAIN, in a ring around her ribs and upper back. We 1st thought it might be pleurisy but her pulmonary Dr. says no! She has had 2 rounds of prednisone and a Z-pack but nothing helps. They just say, oh well you have bad lungs! She has had several chest x-rays, and a lung scan and nothing! They now have her on pain patches($168.00) but I feel this is just masking some other problem. Is there continuous SEVERE PAIN with emphysema? I can't find anything about this in any literature. She is afraid of lung cancer! Please help! Thank you, Cherie

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A. There should not be severe pain from emphysema by itself. It is overwhelmingly likely that the lady must have something else going on. Since the pain comes around the chest on both sides, have her doctors considered a vertebral fracture (secondary to hard coughing and presence of osteoporosis) been considered? That type of fracture can make a COPD patient miserable. I would think that, if it is possible, the lady should have a more thorough investigation than we are being told about. Stronger pain meds in patches (or however administered) can depress respiratory drive and are a little scary to use in pts with COPD unless there is a very specific need for them. On the other hand, there might be a very good reason for them. But just plain emphysema is not a sufficient reason in my book, unless there is something else going on. Hope this will help. Henry Yeager, MD

Tracheomalacia

Q. I was diagnosed with Emphysema in 1999. I have been treated for that and during the years a lung infection, and last Aug. 2003 I had Bronchitis, so they thought and it continued on and off for a year. About 8 months ago the cough sounded different (like a frog), exertion took my breath away and I could not bring up any phlegm so the Dr. decided to do a Bronchoscopy. What he found was Tracheomalacia. Now I have read online that only babies have this problem. Well, let me tell you, that's not true. I'm 70 and it started about 8 months ago. I have been sent to a Pulmonologist at Fairfax Hospital in VA, hoping he would put a stent in the Trach. As far as I'm concerned, he is stalling. It took 6 weeks to get in to see him, he wanted me to go to a Gastroenterologist and have an Endoscopy, which I did, nothing was found, wanted me to have a spirometry test, which my Dr. does every time I go to him which is about every month, since the knowledge of the Tracheomalacia and everything was given to this Dr. I even took him the picture of my Tracheomalacia but he wants to do his own Bronchoscopy. It's getting to the point where I am going to become housebound as I cannot breathe if I exert myself by washing, dressing or sometimes just walking. My next appointment with this particular Dr. is 11/2 after a 6 minute walk, which I'm doubtful I will be able to do. Now that winter is coming, I am getting very worried, I might not make it through the winter if something isn't done soon. Sorry to bore you, but thought you should know my problem. Thelma

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A. Tracheomalacia in an adult with COPD is quite uncommon, but probably could, as the patient says, be specifically treated, if that is the valid diagnosis. It seems that there are only a few recent reports on it listed in Pub Med from the National Library of Medicine. A recent references on the topic is: CD Wright. Tracheomalacia. Chest Surg Clin N Amer 2003;13 (2):349-357. If the patient feels he cannot wait for his appointment, there must be other "invasive" pulmonologists or thoracic surgeons in his area, even at that hospital, who could see him earlier. He should not give up on the medical profession quite so easily if he is having problems with one of us! Henry Yeager, MD

Bacterial vs Viral Infection

Q. I know that the only way you can tell if you have pneumonia is to have a chest x-ray, but how can a doctor tell if you have a bacterial vs a viral infection? I went to my PCP Monday (trying to get rehab approved) but also because I was starting to feel bad. I've had this disease for some years now and know when a dreaded infection is starting. It scares me a lot since I am on oxygen 24/7 3-4L and have a low fev1 (22%)and was told that each time I have an infection more damage it done and the harder it will be to get over the next time.

The reason for this posting is that I was in the hospital Christmas 2003 and New Years 2004 with pneumonia. I had been fighting an infection since October. The doctor would give me an antibiotic, I would take it all, feel better, but about two days after stopping the antibiotic ... here we went again. Each time the doctor would give me another kind of antibiotic and we would go through the same routine .... like being on a roller coaster...until I ended up in the hospital. I am hoping I can get over this without visiting the hospital. On Monday after looking quickly in my ear, my mouth and a quick listen to my lungs .. said I had a bacterial infection and they gave me a shot and put me on Cefzil. Friday came and I was still not better, still SOB, sore throat now and right ear hurting, coughing up thick ugly mucus, stopped up nose, but lots of drainage in my throat, just general feeling like "you know". Called doctor who said to come in which I did. He gave a quick listen to my lungs, never looked in mouth at my really sore throat and gave me another shot and put me on a burst of prednisone. I'll be calling back tomorrow, as I am not better which I would think with two shots, antibiotics and prednisone I would be just a "little" better. I don't know why my PCP did not just tell me to go to my pulmo. On my insurance (I'm on SSD/medicare) my PCP has to "refer" me. I will be suggesting that. In the mean time ... my question ... how does a doctor tell which kind of infection you have so he can give you the correct medicine to fight it??

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A. It is very hard to tell clinically whether an infectious flare-up in COPD is bacterial or viral in origin. As she and most of your readers probably already know, in COPD a virally caused bronchitis is often followed by bacterial secondary infection. As far as viral flare-ups, beside taking the flu vaccine each fall (not the new intranasal one), and avoiding large crowds during the "flu season", there is not much we can do the big majority of the time in viral infections. However, many, if not most COPD patients are chronically infected with bacteria, and rather liberal use of antibiotics that hit common respiratory pathogens (although controversial because of the danger of encouraging development of antibiotic resistance, and expense) is probably wise in COPD patients with chronically colored sputum. There can be an advantage in use of certain antibiotics (sometimes more expensive, unfortunately) that have anti-inflammatory action as well as inhibiting or killing respiratory germs. Something perhaps as important, or more important, in COPD is keeping the airways as clear as possible, with bronchodilators, taking generous amounts of liquids, and effective coughing. If patients cannot bring out secretions without it, sometimes it can be helpful to take guaifenesin in adequate dosage to loosen up secretions. Finally, some people get benefit through use one of the devices available today to assist in evacuating the mucus. Postural drainage can still occasionally be helpful if there are some parts of the lung that won't drain any other way. A couple of additional thoughts for the lady, which may be possible. If she could find a pulmonologist who also does some primary care, it might be easier for her - however this is a lot harder to do these days the way health care insurance is setup than it was years ago when I first started. Finally, if she wants to get some additional evaluation from specialists, there must be people in San Antonio at the Medical School, or at one of the Clinics in Austin, who could at least go over her program and see if they make any further recommendations that would be helpful to her. Henry Yeager, MD (I'm from North Texas, and still a Texan at heart).

Is O2 Ever Not Beneficial?

Q. In reading posts from other members, it seems they might be on lots of meds but not on any supplemental O2. Obviously there are those on O2 + meds part time, and those on it 24/7 at different levels, etc.

Then I read the other day a study that was done about 30 years ago, and seems from all I can momentarily locate, the data still stands. Those who were on O2 24/7 outlived those who were on O2 on a more limited basis. Does anyone know of more recent data links, studies, etc. that might help to clarify this as still factual? ie - 24/7 vs part time O2 = lifespan prospect?

Gosh I hope that makes sense to others. I'm not trying to start any controversy, but I know the use of O2 is the lifeline for many with COPD. Are there situations where using O2 is not beneficial for those with COPD? Thanks ever so much for understanding what I am trying to ask."Joy

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A. The authorities still believe supplemental oxygen prolongs survival in persons with arterial pO2 lower than 60, but there are a couple of studies out more recently that suggest no survival benefit if the pO2 is 60 or higher. There may be some beneficial effects, however, on some aspects of quality of life, and on pulmonary hypertension, in COPD patients without such bad blood gases (JAMA 290:2301, 2003.) The article in that reference seems like a pretty good summary of the current state of therapies for COPD.

There is interesting new work, but not confirmed yet as far as I know, suggesting that even if a COPD patient's blood oxygen levels are OK, oxygen supplementation may be of value in the exercise one does in a rehabilitation program. This is from UCLA, and is in Am J Resp Crit Care Med, 168:1021, 2003. There is an accompanying editorial as well.

People have toyed with this idea for a long time, but there has never seemed to be very good evidence before. Maybe this will help some! Best regards, Henry Yeager

Measuring Heart Rate

Q. Let me preface my question by stating that I do not use my Oximeter constantly but when I feel "under the weather" I do check it. Have also had it checked against the one in my doctor's office and it is quite accurate.

Over the past few weeks I've noticed that I will feel slightly dizzy, maybe even a slight headache, and if I check the oximeter I will find my 02 levels will have dropped to a not quite acceptable level, but what is concerning me is that my pulse rate will have dropped to the very low 50s. It tends to jump around but has gone as low as 46 today and then will bounce back up to l00 or so.

The normal for me for many years in the Pulse Rate dept. has been 90+ at all times. Have been told after two different Heart Caths that it was due to a hardening of the heart muscle from a bad virus I had 17 years ago and didn't quite take care of myself. Kept working, etc. etc. Heart doctors referred to it as typical "joggers heart." Whatever that means. Would appreciate your comments.

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A. This not an easy question to answer. Could be that you oximeter is just not registering all the beats. Or is could be an irregular heart rate. Your oximeter averages several beat before giving an indication of rate. There are some causes of serious rhythm disturbances such as complete heart block, where the rate is very slow and regular, e.g., 40 consistently. Then there is the "tachy-brady" syndrome, which means that you run fast and slow due to a sinus node that gets sick, The sinus node is the main rate controller in normal situations. "Sick sinus syndrome" is the name applied. This requires careful EKG monitoring over time such as for 24 hours with a Holter Monitor. Hope this helps. Dr. Ron Petty

Pulmonary Fibrosis

Q. I wonder how many on the list have pulmonary fibrosis.  My PCP and pulmo doc have recently started writing E and pulmonary fibrosis as a diagnosis on my paperwork, although they have always said I had a lot of scar tissue in my lungs.  They both think it is a result of several pneumonias and acid reflux.    I presume there is no treatment for it - other than what we have for COPD.  I wonder if Dr. Yeager or Dr. Karpick would care to address this?
Also I wonder what the long term outlook is for it.  Thanks Barbara C - TX

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A. The term "lung fibrosis" is a descriptive term that can cover a number of different entities. A significant percentage of COPD patients may have a little or sometimes a fair amount of scarring in their lungs as seen on x-rays or CT scan. This can be the result of old episodes of pneumonia, or old earlier, healed TB, oro nontuberculous mycobacterial disease, or exposure to industrial dust, or perhaps aspiration from GERD, or whatever. If the GERD is significant, & one's pulmonologist and/or GI doc will have to make this determination, putting the patient on a GERD regimen (antacids,
proton-pump meds, propping up head of bed, having an early, light meal before reclining, etc., can be quite beneficial, and can act to prevent
further scarring.

There is a condition called IPF, or idipathic pulmonary fibrosis, which is distinct and has its own findings, course, and is very difficult to treat.
It is typically distinct and different from COPD. It is usually progressive over several years, & steroids & immunosuppressives have seemed to help in a
few cases, but very few. There are several new treatments now that have some promise, but are not causing any miracles. Sometimes transplants have been
done in severe cses when possible. Also, there are a number of rarer diseases that can be associated with lung fibrosis, but that is enough for
now. H Yeager, M.D.

 

MAC

Q. I was recently released from the hospital and told that I have something known as MAC.  I was told it was in the TB line but not contagious.  I also was told that the meds can effect my liver.  Do you know anything about this?  Thanks Mary Ellen-GA

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A. MAC (Mycobacterium avium complex) (or MAI) is a cousin of TB. It is one of the commonest of the environmental mycobacteria, to which we all are probably exposed a lot of the time. The huge majority of time they cause no
problems, but they can cause lung infections. Occasionally they appear in sputum cultures that are taken for TB. Unless they show up repeatedly in cultures, or are found in tissue biopsies, etc, a doctor really needs to be sure that the MAC is causing problems. Until 15 or so years ago, it was thought that MAC infection almost always was in somebody with prevous lung disease, such as COPD or silicosis or old TB, or unless a person were profoundly immunosuppressed. Now we know that Caucasian and Asian women, especially, when they get older, with no underlying lung disease, may get
lung infections with these germs that may be stubborn and hard to treat. The medication regimen usually includes clarithromycin or azithromycin, which can cause various GI upsets, but liver function abnormalities are not
common. Usually MAC is treated with one or two other companion drugs, such as rifampin and ethambutol. People are usually recommended to take treatment for one year after their sputum becomes negative. Incidentally, a lot of the
work on early work on MAC disease came from the Battey State Hospital in Georgia, and MAC skin test sensitivity is commonest in the Southeast part of the US. H. Yeager, MD

Abdominal Surgery and Lung Capacity

Q. Is it true that having abdominal surgery will almost always leave a Lunger with less lung capacity than pre operation
because breathing deeply causes so much pain, the patient won't do it? Sharon

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A. It is true that one will have a temporary loss of lung function after upper abdominal surgery, for several reasons. Pain usually plays a role; there also commonly is reflex impairment of diaphragm function for a while after surgery, hence trouble taking deep breaths, etc.Obviously, need for optimal resp. care for a period of time after surgery. Without it one may have retained secretions, sometimes infection (bronchopneumonia), and even at times respiratory failure. However, there is no reason I know of why one's lung function should not eventually get back to where it was before surgery
after one recovers. H Yeager, MD

Antibiotics and the Skin

Q. I am using a daily dose of antibiotics and I cannot go into the sun without skin problem. I knew this by experience. But since a week my skin is very sensitive and is very scaly. There is skin coming off the whole day. Does anyone have an advice? The antibiotic I use is based on doxycycline. Trudy

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A. Sensitivity to sunlight is well known with doxycycline, and to other drugs of the tetracylcine family as well.  Don't know any way to get away from this, except to wear hats and long sleeves and pants when one must be in the sun when on these meds. Patient should check with their MD to see if they really need to be on continuous antibiotics.  If
"yes", then talk to MD about using other ones, or rotating from time to time. But keep in mind that all meds will have some side effects in some patients. There is interest in Japan and elsewhere to some extent in the use of macrolide antibiotics, such as erythromycin and clarithromycin (even in low, non-bacteria-killing dosage in some programs) for
their anti-inflammatory effect in various chronic bronchial inflammatory diseases.  There is one condition seen mostly in Japan, panbronchiololitis, for which this is a standard treatment. H. Yeager, MD

Chronic Bronchitis/Emphysema

Q. Hi, This question is for Mark or DR Ron or anyone else that can answer it. I would like to know if you can develop Chronic Bronchitis as a result of having Emphysema . I have always had very little congestion during the day except when I had a cold or infection . Now I am more congested than I have been before , is this the progression of Emphysema or could it be the onset of Chronic Bronchitis ? Bill NY

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A. You ask an interesting question. As you recall, chronic bronchitis is inflammation of the bronchial tubes, the airways. The inflammation is characterized by cough and sputum production. The cells in the airways is usually pus or polymorphonuclear cells, unless the process represents an allergic response then the cells are another type of white cells called eosinophiles. This disease is separate from emphysema where the alveoli are broken down, the septal walls are destroyed and not rebuilt, leaving holes in the lung tissue. The two diseases are separate, but cigarette smoking can cause them both. Since you did not have cough and sputum before, you should ask your physician what has happened. Are you inhaling more irritants from cigarette smoke, or other substances? Have you developed asthma? Let us know. Thanks for your question. Dr. Ron

Fingers Bluish

Q. My fingers are a bluish color, up to just before the knuckle. Would that be a problem with my oxygen being too low or maybe a heart problem? Thank you Mari

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A. Dear Mari, You are correct to be concerned. Blue fingers are called "peripheral cyanosis." The cause is deoxygenated blood which is more purple or blue than oxygenated blood. This could be secondary to not enough oxygen getting into the blood due to lung disease or as you state, slow perfusion of blood in the fingers due to slow perfusion due to a low output of blood from the heart. This low output could be due to the heart muscle being too weak to push the blood forward or the valves preventing the forward flow of blood. Your physician should be able to help determine what is the cause and the appropriate treatment. Please keep me advised as to what you learn. Dr. Ron

Continuous Prednisone

Q. Hi everyone! Just had a small question for the group. I noticed a few people are continuously taking prednisone daily. Can anyone explain why they are on it long term? Just curious...Thanks

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A. Dear John, Daily Prednisone or corticosteroid usage should be used only for a disease state that requires it. There are some illnesses produced by inflammation of the blood vessels (arteritis) and I am sure others where the disease is not controlled by intermittent or discontinuous Prednisone. With regard to the chronic obstructive lung diseases, usually the acute exacerbation is treated with daily Prednisone for 10-14 days and then stopped. There are some people whose disease is not controlled by intermittent cortisone use and have to be on it daily. Even in those situations the physician should try to decrease the steroid dose to every other day or at least try to get to the lowest effective dose. If the disease process is controlled, Prednisone can be weaned, but if an individual has been on the steroid for a long time the dose may be able to be decreased by 1 mg. every 30-60 days, to allow their own adrenal glands to resume functioning. It may take 6-12 months for the adrenal gland to work normally. Your physician can do a cortrosyn stimulation test which means taking a baseline blood cortisone level, injecting the cortrosyn in your muscle, and then drawing cortisone blood levels at 30 or 60 minutes. The lab analyzes the blood and several days later you get the result. Your cortisone level should double or go above a level of 15 or so. Before the test, if you are on a low dose of Prednisone, like 1-2 mg., your physician may ask you to stop Prednisone and switch to dexamethasone at an equivalent dose. The blood tests will not distinguish between Prednisone and your own adrenal output, but does not detect dexamethasone. If your cortisol level does increase normally, then it is felt that your adrenal glands are functioning normally, if the level does not increase normally, you may have to wait more time or try to decrease the Prednisone further if your disease process allows it. Thank you for your question. Dr. Ron

Whooping Cough

Q. I heard on the news last night that whooping cough is starting to really increase in Missouri. Now, my question is, if we have had it before, what are the chances of us getting it again and is there anything we should do to protect ourselves? Pat

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A. Whooping cough is caused by the organisms Bordetella pertussis and parapertussis. This bacteria is transmitted by airborne droplets from individuals with the disease. Epidemics occur about every 3-5 years, but isolated cases can occur anytime. Where the organism resides when it is not causing disease is not known, at least by me. There does not seem to be an animal reservoir. The disease is usually a childhood one, but with the Pertussis vaccine, children are protected. The effect of the vaccine lasts about 12 years. I do not think it has been studied to see if adults with chronic lung disease would benefit by being revaccinated. After an individual inhales the infected droplet from a sick person, the incubation period is from a few days to three weeks before the first symptoms appear. The initial phase is called the catarrhal phase as it is characterized by a drippy nose, tearing, reddened eyes, a little fever and being tired. These are pretty nonspecific symptoms; just like a head cold. After a few days to a week, the next phase occurs; the paroxysmal phase. This is a dry nonproductive cough (although this is the infectious phase). There may be a sore throat. The cough is one with several expiratory coughs followed by an inspiratory gasp or wheeze; the whoop. Only about a third of infected adults will show this kind of cough which gave the disease its name. The word pertussis means "violent cough" and the Chinese name for the disease is "a cough of 100 days." These paroxysms of coughing may be as frequent as 30 per day and are worse when lying down, when inhaling cold air or pungent perfumes or odors. The cough can produce thick clear mucus with plugs. The cough can be so violent that it ends in vomiting. The cough slowly decreases in intensity and frequency and eventually goes away. Unfortunately, some individuals will get a pneumonia, middle ear infection, altered mental state and even seizures. Individuals do die with this infection. The difficulty in making the diagnosis is that the organism is most readily detected by nasal swabs early in the disease, and as the disease progresses it is more difficult to isolate the bug. There is a fluorescent antibody stain that can be used on the nasal swab, and there are some other fancy blood tests, but they are not sensitive and specific enough to be of use. Obviously, if there is a cluster of people with the above symptoms, whooping cough should be considered. The CBC will show an elevated white blood cell count (WBC) with a predominance of lymphocytes, not polymorpholeukocytes (PMN's) which usually are elevated by a bacterial infection. If you are exposed to an individual with whooping cough, the use of the antibiotic Erythromycin Ethylsuccinate (EES) is protective. If you are the one with the disease, the antibiotic may not change the course of the disease! Other antibiotics which may be useful include Trimethoprim-sulfamethoxazole, Azithromycin and Clarithromycin. So if you are exposed to an individual with whooping cough, get your physician to prescribe EES. If you get the disease, you have to take the antibiotic for at least 14 days in the hope you will not get sicker. If you have a cough for longer than 2 weeks, talk with your physician, whooping cough may be the cause, but there is a long list of other things that can cause a persistent cough. I know that is a longer answer than anyone wanted, but it is an interesting problem for which we do not have a really good answer. Dr. Ron

 

Odors/Perfumes as Irritants?

Q. Any time I use anything other than a few unscented things I've found and baking soda and vinegar (not together) I get very sick.  It usually starts with headache, dizzyness, SOB, and mental confusion.  Sometimes I can stop it there but more often it goes to coughing and sneezing and post nasal drip.  Maybe it's the exertion for you; for me it's the smelly stuff.  And I don't suppose it "causes an infection" but the effect is the same if it breaks down your resistance and you catch whatever is passing by. Polly

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A. Any strong odors or perfumes can be irritating to the nose and respiratory tract. You do not have to be allergic to the substance; it is an irritant. Once the mucosa or surface of the respiratory tract is exposed, it responds by swelling, putting out more mucus and making the airways even more sensitive. You cough, wheeze and become short of breath. The best treatment is avoidance of the odors and chemicals. Use of albuterol and ipratropium inhalers is helpful. Dr. Ron

Rib Pain

Q. Also having pain in my rib cage. My doctor said it was pressure from my inflated lungs, putting pressure on my spine. I do know that in the afternoon, my sob increases, with tightness.  Very little sob until about noon.  Does anyone have this problem. If so, what should I do to prevent this. Gets really bad until bed time. I do pursed lip breathing but it doesn't help much. Hannah

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A. You have an intriguing problem. I am not aware that the lungs become more hyperinflated as the day goes, and deflate during the night. I wonder if you have "bloat." This is the enlargement of the abdomen due to gas in the stomach and intestines which occurs when an individual swallows air into the intestinal tract. This happens if false teeth are loose, if we drink though a straw, drink liquids by sucking the surface of a glass of milk or other beverage (as opposed to drinking with the surface of the beverage above the upper lip, giving one a beverage mustache but not inhaling as much air as the usual way of drinking) or eating, drinking and talking at the same time, inhaling air between bites. We also get gas into our stomach by eating gas producing foods such as cabbage, broccoli and of course carbonated beverages. This gas in the stomach, distends it, pushes the diaphragm up and interferes with our ability to take a deeper breath. When we sleep, the gas travels through the intestinal tract and out the bottom, so when we awake in the morning our abdomen is flat and our diaphragm in its usual position.

The treatment is to change one's eating and drinking habits to minimize the amount of gas swallowed. Do not use charcoal to absorb the gas. Charcoal absorbs lots of medications preventing them from getting into your blood stream where they need to be to work as your physician prescribed.  Let me know if this is helpful or if you have other ideas.   Dr. Ron

 

Tessalon Perles, Serum Carbonate

Q. Went to my doc today.He gave me a new prescription, as he heard me coughing.  But also gave me something for the cough called Tessalan Pearls, it looks like.  Do you know anything about it, or have any experience with it.  Don't want it to suppress, when I really have something down there, that needs to come up, which I do sometimes though not often.

Also, when I got home, I looked at my copy of the lab report he gave me and noticed for the first time that it said CO2   29.  I'm assuming that is what is in my blood, as if it would be taken in those tests I have seen recently being talked about, that I never had.  Is that number okay?  He did not mention it, and all the rest on there was good. Thank you, Betty

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A. Tessalon Perles will not interfere with coughing up mucus.  With regard to the serum bicarbonate, it is high and may be due to a metabolic cause such as low potassium or magnesium in your blood and body. Unfortunately, the serum potassium is only about 2 per cent of the bodies potassium, so the blood potassium may be normal, whereas the total body may be deficient in the ion. The bicarbonate may reflect the kidneys compensation for an elevated arterial pCO2. Although having an arterial blood gas performed may not be the most pleasant experience, the pCO2 and pH of that arterial sample will help your physician and your pulmonary physician ascertain the true cause of your elevated bicarbonate level. Dr. Ron

 

Anemia

Q. I was told yesterday I was also anemic. I had never been before so it is a first. I had pancreitis and some think this is the cause, but my absorption of iron to the blood is only 4 percent they call it by coincidence saturation. So my question is could this be a coincidence all these down anemic or is there some sort of connection. Ie, medicines, diet, vitamins or prescription drugs. Let me know anybody what meds you are on or vitamins etc maybe there is a common thread to this. Lee

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 A.Anemia refers to a low red blood count. If this is related to blood loss like from a stomach ulcer, a bleeding colon tumor, the red blood cells are frequently small and contain little hemoglobin. It is called a microcytic hypochromic anemia. The serum iron tests would show low iron, high iron binding capacity and thus a low saturation which is the fraction of iron divided by the iron binding capacity. Another iron carrying protein called ferritin would be high. The treatment consists of finding why you are losing blood and then treating the ulcer, etc., and giving you iron tablets to replenish your iron stores in your bone marrow, where the red blood cells are produced. There are drugs like non-steroidal anti-inflammatory drugs (aspirin, motrin, celebrex, etc.), steroids (prednisone), fosamax, alcohol, and others which can irritate the digestive tract, causing blood loss. Thanks for your question. Dr. Ron

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Anxiety

Q. I have been debating whether to ask my doctor for meds for anxiety.  I seem to be able to handle panic attacks yet, but I get very stressed when I am going places, especially in the hotter weather when I am more apt to get more sob. I seem to have been talking myself out of going, so I don't have to go thru the stress.  I cause myself to get very sob just anticipating going.  I still drive, and this is getting harder and harder. My question, is there something low dose I can take? Is there one that will not suppress the Lungs? And thirdly I am a recovering Alcoholic for 36 years and still afraid of some drugs.  I love being able to discuss these things with people who have faced similar circumstances. Thanks.......Esther

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A.Thank you for your question. Panic or panic-like symptoms are common in folks who cannot breath. You do need to get some help, as you note that you are restricting your activities as a consequence of the way you feel. I have found psychologists and social workers are very helpful in helping you develop ways to cope with your feelings and to get on with living. Psychiatrists are not that helpful, usually. There are medications such as Buspar and Wellbutrin which can help with panic attacks and are not addicting.  With your history, it may be better to avoid the drugs such as Ativan, but this is where a psychiatrist would be helpful.

Please do something. Do talk with your physician about it, start with non medical approaches and if these do not help, then consider medication. Good luck, and let us know what happens. You are not alone in your feelings.  Dr. Ron

Oximeters

Q. Yesterday, I had my last series of tests within my participation in the Tiotropium (Spiriva) trial in the Montreal Chest Institute. While I did the bicycle "ride" (controlled by the sophisticated computer), they monitor many things: among them, heart electro-cardiogram, blood tension, and oxygen content with a sensor clipped to the ear.....an oxymeter... The inhalotherapist testing me....said that this type of oximeter was more relevant than a model clipped to fingers (like the Nonin). She added that the idea behind the reason for using this type of oximeter on the ear, was to measure the O2 content near the brain and not on hands.... Does this make sense to any of you? Yves

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 A. The oximeter measures the difference in the color of oxyhemoglobin and hemoglobin without oxygen. In your finger, there is the chance that the blood flow may be decreased by arteriosclerosis in the aorta or the arteries going to the finger. This would decrease the accuracy of the finger oximeter reading. There are people who get white fingers when the hand gets cold, they have a process called Raynaud's phenomena so again the finger test is not accurate. Also the finger test while you are working on the bicycle or treadmill may be inaccurate due to movement of the finger and oximeter. However, in the normal individual, the readings should be the same. Dr. Ron

Blood Gas Results

Q. I just had a blood gas test and my actions caused the bad results. I have to turn the concentrator up to 3lpm from 2.5 lpm to shower but for just around the house my sat stays over 90 % with the 2.5. Yesterday I turned it up at about 9:30 AM and today went to turn it up and found I had failed to turn it down. I had the ABG done at 11 this morn and the PCO2 was 64.8. This is about 20 points high and was a result of the high O2 flow for about 24 hours. I' m sure everyone else won't be this careless but a word to the wiser and more careful. Jim

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A. Dear Jim, Before anyone can comment about your blood gas results, we would need to know the pH, pCO2 and pO2 of the ABG's.  There is a growing controversy about the concept that too much oxygen in people with COPD and carbon dioxide retention (pCO2 above 50) can be detrimental. Other things such as potassium, magnesium, kidney function, Prednisone dose and a whole list of things can change the pCO2. So please get back to us with all of the numbers and we will see what we all can learn. Dr. Ron

Prone Position Helps Breathing?

Q.Thank you for your description of why the so-called "emphysema tripod" position helps us to breathe.  I know too well that it works but never understood why.  I'm still a bit confused, though.  Members keep advising everyone to pile up the pillows or sleep in a recliner or somehow to raise the head when sleeping.  I have never found this helpful.  All it does is give me a backache.  I sleep on my side in the fetal position. There is no way I can sleep on my back, or even lie on my back.  For this reason, also, I can't use a C-PAP or Bi-PAP.  I also find that the pressure on my abdomen when I lie prone and propped up on my elbows helps me to breathe.   If I lean over the back of a chair and tilt it towards me, I feel that the pressure on my chest helps me to breathe.  In both cases, it is inhaling against pressure that actually helps.  I have no idea why.  I do feel, though, that it is also resting the upper body that helps.  I think I read recently that hospitals are experimenting with putting lung patients on their stomachs.  Have you heard anything about that? Ethel

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 A.I have not heard of putting COPD patients on their abdomen. However, what ever works for you is correct. In the Intensive Care Unit (ICU), there is a growing body of data that says patients with Adult Respiratory Distress Syndrome (ARDS) do benefit from the prone position, that is belly down. This causes the blood to pool in the dependent portion of the chest which alters the relationship of ventilation and perfusion. Perhaps, your emphysema is more in the upper and posterior lungs, so that when you lie down more blood goes to your more normal lower and anterior lungs. The results of a High Resolution CAT scan may be helpful here. Please check with your Pulmonary Specialist. Thank you for your question.  Dr. Ron

Increased Energy or Stamina for COPD Patients?

Q. I joined EFFORTS on behalf of my father, Doyle Moore.  He has been suffering from emphysema and COPD for several years.  He has to spend most of his time lying flat on his back - it is the only way he can breathe.  He does not have the strength to sit up for more than a few minutes at a time.  The slightest exertion, such as standing by the bed or sitting on a bedside toilet will cause him to desaturate and he has to lie still for several minutes before he can talk.  He is on constant O2 at 2 liters/min and he turns it up to 3 while sitting up, etc.  As long as he lies still he can breathe just fine and frequently takes off his cannula in an attempt to keep his lungs from needing too much O2 all the time.  My father is under the care of a pulmonary specialist, but he has not been seen since he was in the hospital in December and March.  A physical therapist came to his house for a few weeks after his last hospitalization, but he has not yet received much benefit from it.  He is unable to make the trip to the doctor. I have two questions I would like to ask: 1)  Is it OK for him to remove his cannula for a while as long as he does not feel any ill effects from it?  His baseline oxygen saturation in March was 91%; 2)  Can you suggest anything that might give him a little more energy or stamina?  He has no interest in walking around the mall, he just wants to be able to sit up and play with his  grandchildren. He is on the following medications: Albuterol sulfate and ipratropium bromide in a 1:1 mixture in the nebulizer. four times daily. Prednisone 25 mg/day; Bumetanide 1 mg/day (twice if swelling); Inhaler each night:  2 puffs of serevent; Pravachol 20 mg/day; Aspirin 81 mg/day; Saw palmetto daily for prostrate; Vitamins C, E and multivitamin; Any thoughts or information will be greatly appreciated. Ray

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A. Dear Ray,  Thank you for your questions regarding your Father, Doyle. If your Father's saturation breathing room air was 91%, it would not hurt to take off the cannula for a while, but it may not be helping him either. The body responds to low oxygen by constricting the airways to those alveoli ventilated by low oxygen and this can put a bigger pressure on the right side of your Father's heart, predisposing to more edema.

Your Father is taking some medications which could make him weak. Prednisone at 25 mg a day is a moderate dose, but it can cause muscle weakness and loss of bone support  osteoporosis). The diuretic butamide (Bumex) can cause a low body potassium which will make muscles weak. Pravachol can inflame muscles and thus make them weak. It is of interest that your Father feels best lying down. Usually people with COPD like to sit up, either propped up on their arms or lying over a table. This puts the diaphragm lower and allows the lungs to expand a little more. When you are lying down, the belly pushes the diaphragm into the chest cage, making the lungs smaller. Does he have any other disease like cirrhosis or something that might shunt blood when he is sitting up and not when he is lying down?

Your Father should get to see his physician. You would have to alert the Doctor how ill he is and prepare him to consider doing arterial blood gases to check on the O2 and CO2 but also on the pH. The latter could help ascertain if he is low in Potassium, Magnesium or Chloride. Electrolytes, a Complete Blood Count (CBC) and maybe a chest x-ray may be warranted. If your Dad is ill enough, you might arrange to have the physician meet him in the Emergency Room if you need to transport him by ambulance. If you Father is this ill, maybe he does not need the cholesterol lowering drug, Pravachol. However, if he has significant coronary artery disease and angina, perhaps it should not be stopped as some think the cessation can precipitate a heart attack. Ah, if medicine could be straight forward. Good luck with your Father, let us know what you learn.  Dr. Ron

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Altitude

Q. As a person with Emphysema, I know I have extensive damage to the alveoli. I Iive at 500' altitude. I believe that because my body is constantly deprived of normal levels of  O2 the the increase in blood supply has taken place as though I were at a higher altitude. I assume  that this is correct as indicated by my resting pulse rate in the high 80's and low 90's. Two years ago when I visited the rim of the Grand Canyon (7,400 feet) I needed O2 at increased levels just to walk very slowly. It would seem that there is a permanent benefit in living at low altitude for those of us who are breathing impaired.... the body should increase the amount of hemoglobin to max its ability to carry O2 ....then increase pulse rates to process O2 .....and lastly  increase blood pressure in the lungs to process O2. (leading to cor pulmonale). I measure myself against my healthy wife (same age- 71 and exerciser) whose resting pulse is 65-66.   Please correct my misconceptions. George

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 A. Your understanding is correct up to the point of the development of cor pulmonale. The blood pressure in your pulmonary artery is increased because of the loss of capillary blood vessels so that the blood has less space to fill. In addition, the low oxygen level in the alveoli you do have causes the blood vessels surrounding the alveoli to constrict. These two factors make a higher resistance to blood flow though the lung. Your heart compensates by trying to squeeze harder, but since it is a thin muscled right ventricle that pushes blood through the lung it fails. This allows blood to back up in the liver and legs, i.e., heart failure secondary to lung disease, cor pulmonale. Thank you for your thoughts. Dr. Ron

Crackling Lungs

Q. I really appreciated receiving your reply to my letter questioning lung problems.  According to my pulmo (and he is supposedly good...head of the department in his hospital) I do have idiopathic pulmonary fibrosis.  He said tests confirmed that.  I did check the site you gave me, but the more I read, frankly the more terrified I become.  I've already checked everywhere else I could think of and also got a second, independent opinion...and it's always the same - prognosis is sour.  And the fact I also have emphysema of course, does not help the picture any.  I've been turned down several times for clinical trials (I never smoked, my age, need meds for hypertension) so there really is nowhere else to go.   I did ask the question because although my dr is competent, he does not volunteer much information. Unless I ask a specific question, I don't get anything.   The day he told me I had the crackling lungs, other things came up, so I forgot to challenge that.   He does not think much of support groups, does not want me to go for lung rehab, even told me to use the Pulmicort (that he gives me!) "if I feel like it".   I feel as though he knows there is no hope anyway, so why bother.

He did give me an Rx for Albuterol when I told him of the breathing problems I was having.  And he is from one of the better hospitals in Queens...to get another dr means my going into the city, which is too much of a trip...subway stairs kill me, and taxis are much too expensive.  I did make sure my next appointment is on a day when my husband is working, as I would like to ask very specific questions and I cannot do that unless I am alone there.  My husband has physical/emotional problems of his own and cannot deal with too much of this...he does try his best, but it's difficult.   And only for his sake, do I want to prolong my life as much as I can... there's just no way he can manage on his own.    Anida

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A. Dear Anida, I am a bit confused by your physician's attitude. It is true that Idiopathic Pulmonary Fibrosis has a poor prognosis, but that does not mean that there are treatments to try. If indeed your disease is idiopathic, meaning that there is no underlying disease producing it, some physicians would give you a trial of Prednisone or even immune modulators to see if you would respond. The use of the bronchodilators such as albuterol and atrovent could be used as a trial to see if you respond, even if your pulmonary function tests did not show a response in the FEV1 to bronchodilators. You say you have emphysema. Do you have two lung diseases, E and IPF?  You may want to ask for another opinion from some other pulmonologist in the hospital. It is not unusual for the heads of hospital departments to be on a rotational or political basis, not reflecting the physician's knowledge or intellectual capacity. Ask your doctor whom he would send his mother to see, and ask the American Lung Association of your area if they know of physicians interested in IPF. Let us know how your next visit works out. I would give your physician the IPF website and ask his opinion. If he is not familiar with the site or shows no interest, really get that second opinion quickly. Dr. Ron

 

A Breathing Question

Q. Last Sept I was hospitalized with pneumonia and when I came home I still had trouble breathing so they check my O2 with the finger oximeter, it dropped to 87 while walking so I was able to get home oxygen. Not realizing Medicare paid for oxygen, I sent the oxygen back but I felt like I was doing ok and I wouldn't need it... It didn't take long and I had a relapse so to speak and I went to ER where they put me back on prednisone, which seem to help my breathing a lot along with my nebulizer and inhaler (albuterol).

In April I got on Medicare and went straight to a Pulmonologist who took me off of Prednisone and put me on Pulmicort and also put me on Guaifenex LA 600MG to help me expel the mucus. I seem to be doing pretty good and almost felt normal but I started getting really weird bad headaches so 2 or 3 weeks ago, I took it upon myself and went off of Pulmicort and that weird headache left but I am now starting to feel what I refer to as 'breathing attacks'. I don't know if its because I went off of Pulmicort or if its from going into some high altitude over the weekend. I went with my daughter and her husband to NM and CO, I did fine until they tried to go over a small mountain and I literally had a major breathing problem.  They quickly descended and we drove back to Kansas but I have been having one breathing attack after another.

When I refer to the breathing attacks, I mean they feel like something warm starts moving up inside my chest and my air feels like it starts cutting off, its hard to explain, its like someone puts their fingers over my nose and mouth.  My heart starts going a hundred miles an hour and I stop in my tracks, trying to breath, I usually have to start telling my brain to calm down, than try to get the inhaler, take it, grab the nebulizer and start slowly breathing into it.  I feel like I am needing oxygen really bad. These attacks come on when I walk or try to do anything. I noticed it starts in the evening (chest feeling heavy) and when I wake in the morning, the first thing I have to do is grab the inhaler and turn the nebulizer on as I feel I can't breath... around 11 A.M. I start feeling ok until evening comes and it starts all over again...

The next day after returning home from the weekend trip, I called my doctors office and my doctor was still on vacation and the doctor filling in for him refused to see me until the next day (& yes I had explained I couldn't breath and felt like I needed oxygen) so since I couldn't get in and the breathing attacks were really bad I had my brother bring over one of his oxygen cylinders. Well, the oxygen was blissful heaven, the difference between nite and day!!!  I used it off and on until noon the next day and went to the doctor appointment.

At the doctors afternoon appointment, she wouldn't let me finish explaining to her what I was doing or how I was feeling, she would cut me off and just kept saying I was just experiencing trapped air, nothing to do, just breathe!  I told her I was doing pursed breathing and it didn't help, these attacks felt like I was being choked off of air but she wouldn't listen. I told her how much the oxygen help and she said I probably needed it and she had the nurse check my O2 with the finger oximeter.  Keep in mind by the time I got to the appointment, I just finished taking my 5th breathing treatment and had oxygen all morning and it was the mid afternoon when I usually feel the best anyway... Well needless to say my O2 stayed at 95.   She then told me to come back when I felt I needed to check it again but I could not have oxygen unless I drop below 90... thats it, she did not check me out, no test, no x-rays, no nothing, she didn't want to help me figure out what to do when I had those attacks to find out what they were or what was causing them or what to do when I had them or explain...I went back yesterday around noon when my chest was still feeling heavy and they walked me with the finger oximeter again and I had 2 breathing attacks with my heart racing like a race horse, the nurse gave me some oxygen but said my O2 still stayed at 95... Then this new doctor refuse to see or examine me, and had her nurse come in and tell me, Quote, "you do NOT have a COPD problem because my O2 did not drop while walking"!!! Unquote...  and when I question the nurse she told me the doctor could not treat me because she said in her opinion I did not have a copd problem!   Duh, Now this is news to me, since when are people diagnosed with COPD based on their finger oximeter O2 level readings???  I have had tons of test, pft, bronchoscope, xrays, c-scans, and have been told over and over I have COPD emphysema and each year when I have some test again I get told my lungs are getting worse... I have had several heart test and have been told my heart is good. I get bronchitis every year and deathly sick even with a cold.

My question is, I don't know what to do about these breathing attacks, if I go to the ER, they will call my doctors office and since my doctor is still out of town, the only one there is that new woman doctor who is now telling me I don't have copd... I don't understand and I can't sit in my chair forever or take one breathing treatment after another trying to keep me breathing every time I go to the bathroom or walk and etc... I am nausea and I think its because I am taking too many breathing treatments and using my inhaler too much trying to breath when I walk...  Is this woman correct when she is basing copd on someone's finger oximeter O2 level readings alone? I've never heard of that one before... I am really upset, confused and don't know how to get myself to breath without oxygen when these attacks keep happing over and over... like  I said, they seem to come on towards the evening and when I awake, I struggle to breath and have to quickly take a breathing treatment and use my inhaler before I can even get up... I don't know what is going on or how to correct it...Cee Cee

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A.You will need to schedule an appointment with the "old pulmonologist" for as soon as he returns to the office. Ask the secretary to give you two blocks of time so that you can discuss what you have told us. Even give him/her a copy of the e-mail you sent us. First you have to be sure that all of your prior records, i.e., the PFTs, bronchoscopies, cardiac studies and everything else are there and have been reviewed. Then you want to be examined, maybe get a chest x-ray, CBC to be sure you have not become anemic and an ABG breathing room air. If you can schedule the visit for the time of day you feel bad, so much the better. Then you have to discuss the attitude of the "new" physician. She doesn't have a lot of experience, but she should be able to treat you as a person with a problem. Perhaps your personal diagnosis is not correct, but you are not a physician. She is to figure out why you feel so bad. There has to be an explanation and hopefully a helpful intervention. In the absence of your "old" physician, she has to assume medical responsibility for your health. If possible take along a friend or spouse so that everything said will be heard. In the interim, if you continue to feel bad, do go to the ER and ask the doctors to exam you and do the tests before they call the new young physician.  Let us know how it works out for you. Dr. Ron

Air Movement in Lungs

Q. My pulmo dr tells me he hears "crackling sounds" in my lungs...can you explain what that is?  I did ask him, and he said it's normal for those, like me, that have lung fibrosis...but did not go into further detail.  What, exactly is happening? And is there anything you know of that can be done?  I did ask that, too, but he shrugged and said there was nothing he knew of, at this time.  Will I be around when someone finds out what to do?  Thanks....anida

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 A. Dear Anida, The crackles your physician hears with the stethoscope on your chest relates to sounds produced in the small airways as you inhale. In pulmonary fibrosis the sounds are like Velcro being opened. The exact cause of the sounds is not known. If one has COPD, crackles as well as wheezes can be heard, the crackles on inspiration or inhalation and the wheezes on exhalation. Again, these sounds are made by movement or air in the smaller airways. Air does not move in the air sacs except by diffusion, so no sounds are produced there.      If your pulmonary function tests show a reduced vital capacity, normal or above normal expiratory flow rates (FEV1/FVC above 70%), a low residual volume and a low diffusing capacity then you have data consistent with pulmonary fibrosis. There a number of causes of pulmonary fibrosis and these should be looked for as the treatment and prognosis may be different. There is a web site for idiopathic pulmonary fibrosis, I think it is <www.coalitionforpf.org>. Let us know more about your disease, it is your body and the physician should tell you what they think you have. Thanks for your question.  Dr. Ron

New and Confused About Diagnosis

Q. I am new here.  And I am confused.  I am female, 33, a lifelong nonsmoker and last month I was told there are cysts on my lungs.  I experience significant shortness of breath and have difficulty with most nearly all daily activities more strenuous than sitting in a chair.  I am also in a great deal of pain in my chest and ribs that does not go away no matter what.  This pain has been steadily getting worse over the last several weeks. I am confused because I have been told I have paraseptal emphysema which (I am told) produces no symptoms.  And yet I have ymptoms.  The other possibility is that I have lymphangioleiomyomatosis (LAM).

Here is what the radiologist said about my lungs: There is extensive predominantly subpleural bullous disease, most pronounced in the lower lobe and the region of the middle lobe.  Bullae have very thin but visible walls which are fairly uniform.  There is no significant fibrosis.  There is no pleural effusion or lymphadenopathy.  The mediastinal structures are otherwise unremarkable.  The chest wall appears intact. Impression:  paraseptal emphysema. I would appreciate the following:
- any information about paraseptal emphysema
- help in translating the above paragraph into plain English.  I can look up the words, but I don't understand what it *means*.
- is emphysema related to allergy history?  I have had severe tree allergies all my life and have had pneumonia, bronchitis, and asthma as a child.

I am currently following up with doctors to resolve the diagnostic confusion about paraseptal emphysema vs. LAM.  I understand LAM pretty well, as there is a lot of information about it.  I don't understand paraseptal emphysema all that well at all.  Any information on paraseptal emphysema would be appreciated. Thank you, Mary

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A. Thanks for your question. Paraseptal emphysema is also called periacinar emphysema. This type of emphysema is not associated with air flow obstruction, so pulmonary function tests like Spirometry would show that you have a normal rate of forced exhalation. The volume of air exhaled in the first second (FEV1) would be more than 70% of the total volume exhaled (FVC).

Anatomically the lung is like the roots of a tree. The airway in the windpipe or trachea is the largest, and as the air traverses down into the lung, the airways become narrower and narrower (bronchi) finally ending up in the airsacs or alveoli. The airsacs from one of the more terminal bronchi are called the acinus. The acinus is covered with a thin membrane called the septum. This is similar to the covering of the segments in an orange. Thus Paraseptal E is adjacent to the septum, periacinar E is around the periphery of the acinus. This is the same area in both descriptions. The only clinical significance of this form of E is that the small blebs can break causing air to escape from the lung into the chest cavity (pneumothorax) and can coalesce and become bigger looking like balloons (Bullae) which can squash the surrounding lung, potentially causing the vital capacity to be smaller. None of this should cause the shortness of breath and pain you are experiencing.  The radiologist report means that you have a fair amount of these balloons or bullae in your lung, but more in the lobes of the lungs closest to the diaphragm i.e., at the bottom of your lungs and in the middle lobe which is one of the three lobes in the right lung.     

Again the lung is divided by membranes or pleura covering the surfaces of the lung. The right lung has the upper lobe which contains the bronchi and alveoli coming off the upper lobe bronchus which is a major division of the trachea as that structure is divided into the right and left sides. The other lobes in the right lung are the middle and the lower lobes. The middle lobe sits closest to your heart on the right side and is at the bottom of the lung. The balloons have thin walls which would be expected from dilated airspaces adjacent to the surface of the acinus. He did not see scar tissue (fibrosis), fluid around the lung (this is pleural effusion and would be abnormal), and no enlargement of the tonsils or lymph node tissue which is a normal component of the lung. The mediastinum is the structure separating the right and left lungs, contains the trachea, nerves, lymph nodes, blood vessels and the heart. The chest wall is the ribs and muscles which you can see and touch yourself, surrounding and protecting the contents of the chest.

You may need a cardiac or heart evaluation to be sure your shortness of breath and pain are not related to heart dysfunction and that the Paraseptal E is just an incidental finding. If you have to have an invasive procedure to determine if the blebs are due to some other process like lymphangiomyomatosis (LAM), the physicians may recommend a procedure called "VATS" of video assisted thorascopic surgery which is less invasive that a thoracotomy where the surgeon makes a big incision (4-5 inches long) between the ribs to expose the lung.

Allergies and asthma do not lead to emphysema. They can cause air flow obstruction but do not break down alveolar wall producing emphysema. I do hope all works out for you.  Please let us know what is the cause of your symptoms.   Dr. Ron

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Petroleum Jelly

Q. The latest issue of Breathe Well magazine from BI has an article by Paul Ferris on living with oxygen.  He says that his doctor recommends a light coating of petroleum jelly inside his nostrils to keep them from getting crusty and bloody.  Claims that the petroleum jelly will not combust.  All well and good.  But, how about the stuff blowing down into our lungs?  Would this not be a cause of lipid pneumonia?  I would love to find out that I could use something like that in my nose. JJ

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A.  Dear Joan, You are correct in being concerned about petroleum jelly flowing into your lung and causing a petroleum pneumonia. If you just put a dab, a little bit of the Vaseline on the inside of your nose, I do not think this would be a problem. There is a Nasal gel I think produced by Ayr that can be purchased for this use also. Your oxygen delivering folks may get upset if you tell them you are doing this, so don't tell. Theoretically, if the oxygen and petroleum product got mixed and touched by a spark that you would get a flame. Just don't put matches or candles near your nose when you are inhaling supplemental oxygen! Dr. Ron

Harmonica and Lung Exercise

Q. I accidentally ran across this site http://www.hoerl.com/Music/harmon4.html about a physician prescribing playing a harmonica to help his asthma patients. I would like your oppinion on it like could it help or is there any actual danger in it. It sure would make the breathing exercises I do with the voldynn 5000 a litle more enjoyable.

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A. Using a harmonica sounds intriguing. I am sure it would help your diaphragm and breathing control, but I have not done any research to learn if it really helps from a scientific point of view. You could research it on PubMed on the National Library of Medicine site and put in Asthma and Harmonica to see what turns up. Please keep us posted.  Dr. Ron

What is a KENALOG Shot?

Q. My PFT from October 2001 says the following: Pulmonary Function Diagnosis: Severe Diffusion Defect-Pulmonary Vascular Minimal Neuromuscular Disease.

A few paragraphs above it says: following administration of bonchodilators, there is no significant response. It also says, The reduced MVV in the absence of significant airway obstruction suggests the presence of neuromuscular disease. The diffusion defect is consistent with a pulmonary vascular process. I don't see where asthma fits in here, but then again I'm not a Dr. Actually, I really don't understand any of it. Do you? If so, would you let me know? Much thanks, judy

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A. You ask about a Kenalog shot. Kenalog is the brand name of Triamcinolone. It is formulated to be a depot form or a slowly releasing preparation so that one injection slowly is released over the course of weeks. It however, does have all of the side effects of corticosteroids. Those being elevated blood sugar, hypertension, cataracts, glaucoma, osteoporosis, avascular necrosis and easily injured thin skin. I have heard of some physicians giving an individual with hay fever a shot at the beginning of the hay fever season with protection for the following 6-8 weeks. It is handy, but as mentioned, it has a lot of side effects. Dr. Ron

Post bronchodilator Spirometry lower than the Pre-bronchodilator study

Q. My dad's PFT Report lists 2 columns - one with a heading of "PRE-RX" and one with a heading of "POST-RX". From what I understand, the first column of values is the spirometry results prior to using a bronchodilator and the second column lists the spirometry results after using a bronchodilator. I assume in this case you use the word 'remarkable' to mean a noticeable improvement. My question is what, if anything, is indicated when the POST-RX values on the PFT Report are significantly lower? Thanks, Nancy

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A.The fact that the post bronchodilator Spirometry was lower than the pre-bronchodilator study usually means that your Dad became fatigued with the test procedure. As Gary Bain related, the post bronchodilator study is done after the inhalation of a bronchodilator such as albuterol and/or ipratropium. If the FVC or the FEV1 increase by more than 12% and more than 200 cc, this would indicate a positive response and an asthmatic component to the expiratory airflow limiting disease. Dr. Ron

Vertebroplasty

Q. Is there anyone who could tell me about a procedure called vertebroplasty? I understand plastic substance is inserted between the vertebrae. It is supposed to eliminate pain and hinder osteoporosis, brought on by the use of too many steroids. Anything on the success rate? Reecovery time? Any information would be appreciated. Thanks, Jim Bastien

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A. Vertebroplasty is a relatively new (3 years ). As you say it involves injecting a substance into the vertebra, not in the disc spaces to the best of my knowledge. However, this topic is not in the pulmonary realm, so please go to Google or to the National Library of Medicine for more definitive information. The material is squirted into the partially collapsed vertebra to make the vertebra more strong and not capable of collapsing further. It is usually used in people who are experiencing severe pain for more than a month after the collapse. Usually the pain goes away without any intervention, even though the bone remains collapsed. However, if the pain does not go away, vertebroplasty can be quite helpful. The procedure is usually done by an Interventional Radiologist using a fluoroscope or CAT scan to get the needle in the right place. I do not know all of the side effects, but the radiologist has to be careful not to inject the material into a vein as it can embolize into the lungs. I hope this helps. Dr. Ron

Spirometry & Longevity

Q. I went to my pulmo the other day. He gave me a spirometry test. I had one in June 2001 and my lung capacity was 26%. Now in March it dropped to 20%. I asked him how much time I had left and he said it was all up to God. Only he knows. When I pushed him further asking how long other patients lasted with 20%, he advised that I had about a 5% chance of lasting 5 more years? I am really afraid. I feel like I can go anytime. Can anyone help me with additional info on this? Irene

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A. Dear Irene, Please do not get hung up on numbers. Yes, there is some statistical relationship between the results of Spirometry and longevity, but recall statistics are numbers made up from a large number of individuals. Any one individual is not predicted by the values. You and I might die tonight or tomorrow, it has nothing to do with the results of our breathing tests. What is important is how we live each day. Just because you have one or more diseases does not mean that you cannot live each day and enjoy them. Do what you want to do, do it today and tomorrow, do not put it off as no one knows what the next day will give us. Make the use of every day. Your physician and you should devise a program of medication and exercise which maximizes your present health situation. Do not dwell on dying, live. Dr. Ron

Surgery Considerations

Q. Hi Friends, I'm being evaluated by several medical specialists (pulmo, cardio, neuro, endo, ...) to see how risky surgery for a blocked carotid artery would be. Well, I've learned so much from Efforts and web sites members have posted...the medical folk have raised eyebrows when they realize I actually understand what they are talking about...The language is mostly code...CT, P-Thall, Ejection Rate, Diffusion, ABG (what happened to c,d,e,f ?).... My pulmo wrote out recommendations for me to give to the surgeon...including B Blockers per Mangano protocol, periop pulmonary toilet teaching. He was amazed that I could define those terms... So, he said to relay his regards to Efforts....and I want to add my heartfelt thanks. All this information and shared experiences is helping me evaluate the risk of surgery and I am grateful to all of you. btw, my pulmo says nay, endo says yea, neuro says yea, vascular surgeon says yea,,,,I will see the cardio tomorrow to get his vote and then I will decide. The pulmo said I am managing my lungs and he would not subject them to the trauma of intubation unless an emergency situation exists...just sit here and wait for the stroke, I guess. Ok, quiz time. How many of you know what "pulmonary toilet" means... (Mark, I know you know.) Virginia

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A. Thank you for your kind words about EFFORTS. Gary Bain and the others who set up this web site did it especially to help educate everyone. It is neat that you are a good student. I am sorry that you have to use your knowledge on yourself, but the enlightened person can help themselves best. Please note that use of the Statin drugs and very low fat diets have been helpful in reversing atherosclerosis, which is the usual cause for carotid artery stenosis or blockage. There are newer medications such as aspirin, Plavix and some others that your neurologist will know that will help prevent more clotting at the strictured site. So there are options. As I have mentioned about others debating surgery on an organ outside of the chest, if you do not have a lot of secretions and if your lungs are as clean as you can get them before the general anesthesia, the more likely that you will not need to be on the ventilator longer than a patient without lung disease. You should get the surgeon who has done a lot of these procedures, and is good at it and fast. Your outcome will more likely be better than if done by someone with little experience or who works by the calendar rather than the clock! When people talk about "Pulmonary Toilet," did you know that Respiratory Therapists have a competition called the "Sputum Bowl"? Good luck on your examinations and your outcome. Dr. Ron

Colon Operation

Q. This is the first time that I seek information about myself, My question now is: I am going to be operated from a tumor in the colon about 0.3 cm. and I have a bullous emphysema, how risky it will be and how will be the procedure, will be with a general anesthesia, do I need to be intubated or not. I am going to need all the information you can give me please, I am a male 64 years old, and besides the emphysema and a high blood pressure I have had a very good health. Thank you for your time and help in this matter. Sincerely. Cesar

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A. Thank you for your question. This question should also be posed to your physicians, the Pulmonary, the Surgeon and the Anesthesiologist. Before your surgery you should be buffed and shined by your Internist and your Pulmonologist. If you daily produce sputum, it should be clear and easily expectorated. Your breathing should be as good as you can get it. You may be sure that you are using the inhalers properly and are on the proper dose of oral medications. The blood levels all in the correct range.The surgeon and anesthesiologist will tell you that you will be on a ventilator with an endotracheal tube as are all patients given general anesthesia. If your breathing is good, the endotracheal tube will be removed in the operating room or in the recovery room. If you do not have good lung function or produce a lot of secretions, the endotracheal tube may be left in for a longer time, possibly until you get into the Intensive Care Unit and all your physicians are comfortable that you are capable of breathing on your own and coughing up phlegm. Usually, the shorter the time you are intubated the easier it is for you. However, if you do require a longer intubation, it is only because your diseases demand it. You should ask about pain control after the operation. Sometimes an epidural catheter is inserted to give pain control, so that you are not sedated as you may be with oral or injected pain killers. You want to be up in a chair and walking as soon as possible in order to prevent collapse of your lung, collection of secretions in the lower airways and blood clots in your lung. Blood clots starting in the legs and floating into the lung causing Pulmonary Emboli are of concern. You should talk to your Pulmonologist and the Surgeon about putting you on blood thinners like Heparin or the newer Lovenox at the time of your operation and continuing them until you are walking regularly. I do hope all goes well. Please print out this note or at least write down the main points to discuss with your physicians. Dr. Ron

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What causes Respiratory Acidosis?

Q. I'm interested in knowing what causes Respiratory Acidosis, and how do you know that you have it? Are there any specific symptoms? Judy

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A. Dear Judy, Respiratory acidosis refers to the condition when the pCO2 increases at a rate faster than the kidney can produce and retain bicarbonate so that the blood pH goes from the normal of 7.4 to a more acid number such as 7.2. Carbon dioxide levels rise when we cannot exhale the gas which is a normal product of our bodies metabolism. In people with COPD, the lungs are injured by the disease process, so that when a burden such as a bronchial infection or pneumonia occurs the ability of the lung to excrete carbon dioxide is more compromised. Another way to get respiratory acidosis is with an overdose of sedatives or pain killers which suppress the respiratory center and decreasing breathing and thus decreasing excretion of carbon dioxide. Recognition of respiratory acidosis is somewhat difficult. The diagnosis is made by measuring the arterial blood gas, noting the pCO2 and pH. The individual with respiratory acidosis may show lethargy, confusion, lack of energy, warm fingers (due to the vasodilation properties of carbon dioxide), and a shaking or flapping of the outstretched hands. I hope this gives you a better understanding, if not, please get back to me. Dr. Ron

Can't tolerate oxygen concentrator

Q. I have a problem that I have never seen discussed in the short time I have been on efforts. I was brought an oxygen concentrator in Jan. to use for exertion and sleep. I used it for exertion but not for sleep. Shortly after that I started pulmonary rehab. On the treadmill I could hold my O2 sat to about 87, 88% without supplemental oxygen. All subsequent sessions were done on O2. I was in general functioning OK without oxygen but desaturating with exertion such as making up the bed. After only a short time using the oxygen I was desaturating to between 80 - 84% just walking from one room to another in the house. The concentrator I was brought had not been serviced since last May so I assumed that the dirty filters were the problem. I requested new filters. They brought me a different concentrator (saying it was brand new with clean filters but the hours on it were 6284 and the filters were a little dirty. I think the filters should always be changed in going from one house to another because one house might have mold or fungus, etc.) I tried it that day and by nighttime my lungs were full of fluid. There is no external source of water on this. I have gone from being able to function carefully without oxygen to being in great need of it. The more I use it the more I need it. It is a real catch 22. I remembered that last year I spent a month in Santa Barbara, CA and then returned to Los Alamos, NM at 7300 feet. Even athletes find that their breathing is worse at high altitude for a period of several weeks after coming from sea level. So I needed oxygen. In less than a month my O2 sat on oxygen was 63% (I quickly retired and moved to Santa Barbara.) So maybe there is something about concentrators that I simply cannot tolerate. I don't know what to do. I went to my pulmonary doctor on Wednesday and he would not hear my problem. I explained it over and over and he ignored it and said that my breathing was very bad and I must be on oxygen. He would not acknowledge that I had a problem. My lungs can't afford another bad experiment with concentrators. I know this all sounds strange and perhaps improbable but it is very real to me. I would appreciate any thoughts you might have. Wild guesses would even be OK. Pointing me to relevant information would be great. Help, Kay

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A. Oxygen concentrators filter room air (20.9% oxygen). The filters remove nitrogen which constitutes 79% of the air. The efficiency of removing the nitrogen is such that at 2 liters of gas flow the concentration of oxygen is about 97%, whereas at 5 liter flow, the concentration is about 95% oxygen. Theoretically, the oxygen coming from the concentrator is the same as that coming from a pressurized cylinder or from a liquid canister. The latter is essentially 100% oxygen, but usually that is not significant when we are inhaling by way of the nasal cannula. It is perplexing as to why you are desaturating more after using oxygen. I wonder if your disease is progressing and you are not stable or that there is some other disease going on. Do press your physician to make a correct diagnosis and to be sure you are stable and do not need some additional therapy to correct the cause of desaturation. The physician should listen to you. If the doctor does not listen, seek another physicians help. Good luck. Thank you for your questions. Dr. Ron

Testosterone for Men

Q. I have been very curious about the message Frank of Nevada posted here a few days ago regarding Testosterone, repeated below. I have not yet had an opportunity to ask my doctor about this, but somehow it seems to make some sense, especially if the lungs are considered something of a muscle? I note in one of your responses to someone's query about something else you referred to "respiratory muscles". If we have respiratory muscles then it would seem that Testosterone could be of some help to us with COPD. When I searched the Internet, I learned that to be purchased legally, Testosterone is a prescription drug, and probably so because of the athletes using or overusing the anabolic steroids and causing damage to their bodies. For us with COPD, it would seem that even if we were to overuse Testosterone we are at a sufficient age that such overuse would not catch up with us during our lifespan in any event. I guess to sum up my question, if their any justification in looking into this any further? I for one am willing to take some risk if there is a chance of benefit. Thanks. Bob of Ohio


Testosterone Leads to Improvements in Lean Mass for Men with Pulmonary Disease

By Cameron Johnston Special to DG News BERLIN, GERMANY -- September 25, 2001
-- Testosterone injections, coupled with a well-planned exercise program, can help men with chronic obstructive pulmonary disease add significantly to their lean muscle mass, and overall body mass. The injections also increase men's weight and contribute to a general improvement in their quality of life, according to Dr. R. Casaburi, of the department of respiratory medicine, Harbor-University of California - Los Angeles Research and Education Institute, in Torrance, California, who presented a study on testosterone injections yesterday (September 24) at the annual meeting of the European Respiratory Society, in Berlin, Germany. Read the rest of the article at
<http://www.docguide.com/news/content.nsf/news/E64654B752EA753885256AD2004C52>43

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A. Dear Bob, Testosterone and the other anabolic steroids do seem to be intriguing for men with COPD. The study shows that muscle is increased and that probably is good. You are right in that the diaphragm and the inspiratory and expiratory muscles are striated muscles and should respond to testosterone and exercise. What I would like to have seen would be that the Spirometry or a measure of inspiratory force would be increased by the combination of anabolic steroid and exercise. I do not know of an active study, but maybe you can get your local pulmonologist to start one or talk to the drug company producing testosterone or other anabolic steroids to see is anyone is working on a study. Obviously, the downside would be stimulation of prostatic cancer, so men would have to be screened before they embarked on the study. Let us know if you find out more. As you may know, much research needs to be done to help people with COPD. You may be a spark. Dr. Ron

Bronchospasms and Theophylline

Q. What are the specific causes of bronchospasms? Also, why is Theophylline prescribed to some emphysema patients and not others? Would be very appreciative if I could get answer. Thank you. Judy

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A. Dear Judy, Great questions. Bronchospasm is the contraction of the smooth muscle surrounding the bronchial tubes. The muscles contract due to a number of stimuli. Some of these are (1) allergens like cat protein and ragweed pollen, (2) nonspecific irritants like ozone and cigarette smoke, (3) emotions like laughing and crying, (4) exercise, (5) medications like beta blockers, (6) infections like influenza or sinusitis. Theophylline and Aminophylline are both old drugs call phosphodiesterase inhibitors. It has not been shown how they work exactly. They do have properties of relaxing contracted bronchial muscles, making the diaphragm and other respiratory muscles stronger, facilitating clearance of phlegm and mucus, and maybe immunologically protecting the airways. Unfortunately, they also have side effects such as tremors, heart palpitations, nausea, vomiting, gas and seizures. The therapeutic range of the medication in the blood stream used to be 10-20 mg%, but that has been reduced to 5-15 mg%. The higher levels are associated with the more likelihood of side effects. The blood level is heightened by some medications such as erythromycin and disease states like congestive heart failure. Other things like cigarette smoking reduces the blood lever. In the past the drug had to be taken four times a day, but with the new sustained release technology, brands such as Uniphyll can be taken once a day. The drug has had its rejecters and proponents over the years. I have found that the younger physicians have a tendency not to use, while us older physicians do use it. I personally think it is helpful and especially if an individual is on all the other medications and still not doing well. Blood levels do need to be monitored to be sure the level is in the therapeutic range; I usually try to get around 12 mg%. Drug companies have stopped making the drug not because it is not effective, but because it has become infrequently prescribed. The drug is still available for use. Dr. Ron

Swelling and Fluid

Q. John has a lot of swelling in ankles, face, hands, neck and stomach. He has been refused oxygen but they have not tested him after exercise. If he does exercise, he ends up with more swelling. He takes lasix but no potassium and now his doctor has told him to limit his fluid intake -- quite difficult in our climate. He also stops breathing when he is sleeping at times. Should he ask his doctor for a test of O2 levels after exercise as well as a sleep test? Does a specialist have to do the sleep test? We live in rural Australia -- not many specialists. Sorry for all the questions but the postings have given us a lot to think about. Kerry

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A. The first item of business is to get a diagnosis. Your local physician should be able to get pulmonary function tests and arterial blood gas tests done in the local or nearby hospital. The sleep study has to be interpreted by a specialist, but the recording can be done either at home or in a special sleep lab. Based on that data the physician can prescribe the appropriate therapy, whether it be medications, oxygen or a BiPAP or CPAP machine. I hope it goes well. Dr. Ron

Low O2 Levels

Q. Hoping I can get some benefit from the experience of you all --- I've only been on 02 for 2 1/2 weeks, so am still learning. I'm scheduled to go to rehab and am really eager to get started on some exercise ---I've always been a walker. I tried this morning to go and walk at the mall (my usual place) with my 02 in the handy-dandy little "golf cart". I also have an oximeter, so was able to monitor myself, and I just could not keep my 02 up to 90 ---unless I was standing still. I set the 02up to 3 litres, but I seemed to remember from one of your postings that 4 litres should be avoided. I finally gave up and went home ----where of course the same thing holds true ---if I do anything the least strenuous, my 02 level is down in the 80's and even 70's. Is this OK? I mean, is it OK to operate on low 02 level for a little while exercising??? Would appreciate any comments or advice. I truly hate to JUST SIT !!! Helen

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A. It is better for your entire body to exercise with your sats above 90%. Remember we live on oxygen. Sure people climb to the top of Everest without supplemental oxygen, but that is not best for their brain or body. Your muscles will improve by exercising with oxygen. Have a good time in rehab, start slow and advance as your body gets stronger. Dr. Ron

How Do We Plot Spirometry Test Result Changes?

Q. After the opening diagnostic X-Ray, we had a professionally administered Spirometry test and came out with 58% lung capacity and 39% for the one second capacity. According to our doctor, this qualifies as "severe" emphysema. He said that the 50% life expectancy for this kind of test result was 10 years. We will be re-doing the test in six months and then yearly. This brings up a number of questions.

- At what test level do you go on supplementary oxygen?
- At what level does "quality of life" suffer.
- We may be found to be qualified for the Lung Reduction Surgery. Is the operational risk worth the life prolongation likely to be experienced.
- What is your life expectancy experience for a 58%/39% Spirometry result? Female, 60 years old, 5'-6", 190 lbs, distended stomach, taking High Blood Pressure controlling medications.
- Statistically, how precise are the test results? Is a 1% or 2% change in subsequent tests statistically significant?
- Do the test results go up and down over time, or is there a consistent down-trend in all cases?
- Lots of questions. Looking for some answers. Really appreciate your opinions. Sandra

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A. Your questions are great, but answers are not easy because of the vagaries of the diseases. The numbers from the spirometry do show airflow limitation. You did not say if a test was done after inhaling albuterol and/or ipratropium. This would tell you if there was a reversible component to the disease. You did not mention if ABG's were done. There is no on-to-one correlation between the spirometry and feeling short of breath except that once the FEV1 is less than one liter many people will experience shortness of breath with activity. Pulmonary function usually declines in everyone over time. The rate of decline is usually steeper (worse) if one continues to smoke. There is variability in the PFT results, so a few percentage points are not meaningful. What is meaningful is the trend over time. The PFT's do not predict when one needs oxygen. That is where pulse oximetry at rest and exercise come in. If one desaturates below 90%, then an arterial blood gas (ABG) would be done to confirm the low partial pressure of oxygen (paO2) in the blood. If the oxygen level is below 55 mm. of Mercury pressure oxygen is prescribed. The idea that one can predict the duration of an individuals life if fraught with errors. Yes, there are studies that follow a population of people with COPD and the averages of life span. However, for any one individual it is difficult and perhaps foolish to predict. I have worked with the Hospice program and it has been very difficult to determine criteria that shows when an individual with COPD has only 6 months to live. People with COPD are a tenacious group and hang in there for long times. Unfortunately, the quality of life may not be what one wants, but the brain and the smiles can still be working well right up to the time of death. I usually try to tell people that they have a new diagnosis and that we can work together to slow the progression of the disease and to improve the quality of life. No smoking, flu shots, Pneumococcal vaccine, pulmonary rehabilitation and a good support group all make ones life better. Live each day, do not wait for the end to come. You will know when that is around the corner, usually before the physician. Thanks for your questions. Dr. Ron

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Confusion about Steroid Inhalers

Q. Hello Everyone. I am so confused over what medications are best for treatment of E and chronic bronchitis. I am on Advair and combivent. I really don't think that the Advair does much for me. The combivent does and I seem to live from one dose to the next. Has anyone here had that experience. I go for a checkup in early March and would like a change in medicine. What medicine's seem to work best for everyone here? I thought Advair was supposed to be the best that is available at this time??????

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A. Advair is a combination of Flovent and Serevent. Combivent is a combination of Atrovent and Albuterol. Combivent is the best for chronic bronchitis and emphysema, and Serevent is very useful. Serevent is slower in onset of action but does help to keep the bronchial tubes open for 12 hours. It is still unknown and somewhat debatable as to the role of inhaled steroids in COPD. The data so far show that there is no change in breathing tests over time, but that those inhaling corticosteroids (Flovent is one) have fewer acute exacerbations, fewer hospitalizations and a better quality of life. Albuterol is a beta adrenergic receptor stimulant. It is very useful in asthma. Atrovent (Ipratropium) is an anticholinergic drug which has some benefit in asthma, but is most beneficial in people with chronic bronchitis. It helps for 4-6 hours. There is no significant side effects by using it 2-4 puffs every four hours. If you use albuterol that often you may get shaky hands, cramps, rapid heart rate and you may notice loss of effectiveness. That is why many physicians suggest using it only as needed, not regularly. So consider asking your physician for a sample of Atrovent to use more frequently, use the Albuterol as needed and continue the Advair. Let us know what happens. Thanks for your questions. Dr. Ron

Recovery from Serious Illnesses

Q. I need some help from the experts I'll have to start almost at the beginning. Had to go by ambulance to hospital Jan 1st No temperature just rattling and all of the normal sounds, I have A B and E. I wasn't coughing up much green just coughing- I started on antibiotics the week before for "security" so thought it "would away".

They said it was pneumonia, 11 days in the hospital. with not enough strength to go to the bathroom. I had to have help with the bedside commode. On predisone and everything else. He finally said I could go home if I could walk around the room, cheated and done it. I got out about 11 and the morning meds hadn't been given, I had a prescription but Roy was going back later to get it.He didn't go until I got settled .one thing stooping all at once does. Your whole body hurts and you can't tell if it is bones or muscles. it hurts worse than anything I have had. About 15 minutes after I took the pill it eased off. I remember the Dr.doing that to Mother and we had no idea at the time. He just put her on more pain pills Had a Dr appointment last week and he told me to stop the Preside- I ask all at once- he said yes and I told him what it did to me, He wrote it in my chart and going to do research. This one isn't the pulmonary Dr. I am taking 5mg every other day but can't tell and difference in the way I Feel. I am not getting any strength back. I fall, legs just give away. Hands are shaky and I know you will say this is normal but my thinking gets lost on the way to my mouth . (I forgot who said they had to hold onto walls to walk) I have tried doing nothing, taking it easy and doing more,I still can't feel better.How do I get to feeling better. I quit smoking on the 1st and with the preside and have lost 32 lb.. Come on Dr. tell me I'm normal. Take care. luv Juania

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A. Dear Juania, You are normal. Now you have heard it, but lets try to understand what is happening. You have underlying lung disease and then you get a significant pneumonia that takes you to the hospital. Your body is weak from all of that process. The corticosteroids are great for inflammation and helping you get your lung function back, but usually they do not have to be continued beyond two weeks. The corticosteroids (Prednisone) do make your muscles weak and may make you feel either elated or sad. Lets see what your pulmonary physician has to say. The 5 mg of Prednisone every other day should not slow your recovery. Try to do a little exercise every day, but then give your body a chance to rest and recuperate from a serious illness. Dr. Ron

More on Oxygen & Proper Rates

Q. Short summary: Smoked for 30 years. Had portion of R lung removed for benign growth 4 years ago. COPD became a problem after that. I am on every conceivable medication for emphysema and use O2 24/7 but tend to just hang it around my neck alot of the time without even knowing I'm doing it which tells me I use more than I need. I DO, however, have to use it at night as testing shows I go down to low 60s when I fall asleep. (Is that really bad? The doc freaked out when he saw that.) Lately, I have been waking with paralyzing chest pain. I, immediately turn up the O2 - of course. Now I get that it should be the opposite. I should turn it off for awhile. By the way, this last exacerbation brought me from a normal of 2L to 3L. When the chest pain comes, I go to 4L!!!!!! Correct me if I'm wrong - with chest pain in the morning, turn down the O2. With headaches, turn up the O2 because it is neurological and is probably oxygen deprivation. When I was told by Er doc at Kaiser a couple weeks ago, I was told I had had two heart attacks,at least. I was given an ABG test and told that I do retain CO2 but not to worry about it because my body seems to compensate fine for it.?!? He said to stay as low as I can on the O2. During the day, I tend to be lightheaded and weak and can't walk without holding onto walls or tables or something. This is new for me. I haven't addressed this issue at all, i just manage to get around. Now it is time to fix it. Any suggestions? The doc put me on Prednisone a couple years ago (10mgs/day) and two weeks ago, raised me to 40mgs TID. Last weeks I was so swollen and crazy that I couldn't stand it so I just stopped taking it and am now better and will start again at 10mgs when I feel more stable. I know you shouldn't stop abruptly like that but I just couldn't take one more pill!!!!! I am now using only the regular nebulizer stuff. I also take Flovent,SSKI,theophylline,Singulair,Norco Q4h (he doesn't know this but I never take it. It makes me too sleepy just like the prednisone.) Actually, I am not sure what it is for. I have very little pain anymore although it does seem to open up my airways a bit. But not enough to make it worth taking a narcotic! Any help you can offer would be appreciated, Ron

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A. I presume you mean the the pulse oximeter readings fall to about 60% when you sleep. That is low in that normal is around 92% and above. It makes me wonder if you have more than desaturation due to your lung disease. Have you ever had a sleep study monitoring your brain waves, movement of your chest and abdomen and legs to ascertain if you have sleep apnea?

Without knowing your arterial blood gas values, it is difficult to say about your extent of carbon dioxide retention. If you can learn the results of the test, that would be helpful. When we breath less, the carbon dioxide is not excreted from our body by the lungs, so the carbon dioxide (pCO2) level rises. This would cause your blood to become acid if it were not for the compensation done by the kidneys in producing more bicarbonate and retaining it to bring the blood acid level back to more normal (pH 7.35-7.45). This process is called compensation. You are correct that high doses of Prednisone can cause you to become mentally unstable. Some people become very manic, others very depressed. You should have discussed the problem with your physician. I do not understand why we allow Kaiser physicians not to be responsible to their patients. They are physicians and should render excellent care. They should be available for telephone calls from there patients. You should not stop Prednisone abruptly when you have been taking it for more than a few weeks. Your own adrenal glands are suppressed from making their own Prednisone by the Prednisone you ingest. It takes weeks to months for them to begin producing Prednisone, so you have to taper off the Prednisone tablets slowly and under the direction of the physician so that you do not get sick from too little Prednisone or cortisone in your body. Since you are taking SSKI or supersaturated potassium iodide as a mucus thinner, you might ask your physician to check your thyroid activity with a blood test called TSH or thyroid stimulating hormone level. If the iodine blocks the production of thyroid hormone, you could become hypothyroid. This slows down your breathing and metabolism and should be treated to make you normal again. Thanks for you question. Dr. Ron

Oxygen - Proper Rates

Q. I was disappointed to hear someone on this list describe how he / she was using 4 liters of oxygen and couldn't get the bottled gas to last very long. My pulmo. has emphatically warned me to NOT EXCEED 3 liters delivery under ANY circumstances. He described how the brain begins to shut down our breathing because it thinks its getting a poisonous too much oxygen. This causes an elevation of CO2 and an insaitable desire FOR EVEN MORE oxygen putting us in a bad spiral of breathlessness. And whats even worse this effect can last up to A WEEK. So please use oxygen in strict accordance with your physican's instructions. You'll use Less and enjoy it More.

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A. Oxygen is a medication to be used as prescribed. It is also part of our natural environment. We get addicted to inhaling oxygen at birth when the umbilical cord is cut. Oxygen is necessary for life. If our lungs do not get enough oxygen, the pulmonary capillaries constrict and over time we develop pulmonary hypertension, that is high blood pressure in the lungs and the right side of the heart. This can weaken the right side of the heart allowing fluid to back up in the liver and the legs. It is called cor pulmonale. If our brains and other tissues do not get enough oxygen, cell metabolism is affected. Cells do not work as well. The brain gets fuzzy in thinking and the muscles do not work. Your brain does not sense oxygen as poisonous. It does sense if you are getting too much oxygen and may slow your respiratory rate, that is the number of breaths taken each minute. That is not a problem unless you already are not breathing effectively to rid your body of carbon dioxide. If your arterial carbon dioxide (pCO2) is elevated above 50 mm of mercury, you are considered a CO2 retainer and if you breath less, the carbon dioxide level will rise. This can also make your brain fuzzy and even go into a coma. So do not use more oxygen than prescribed, but you should get enough oxygen while at rest, exercising and sleeping to keep your oxygen level above 55 mm of mercury or a saturation of 90%. If you don't then right heart failure can occur with decreased mentation and earlier muscle fatigue. I do not know if your physician is a Pulmonary specialist, but if he isn't, you might want to see one for a consultation regarding your oxygen requirements. Dr. Ron

Pneumonia without yellow or green phlegm?

Q. Can you have pneumonia without bringing up yellow or green phlem? Just normal clear or white?

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A. Yes, you can have a pneumonia without yellow or green sputum. Frequently the pneumonia is caused by Mycoplasma, viruses and unusual organisms. Pneumonias caused by the Pneumococcus and Staphyloccocus and those caused by gram negative bacteria do produce colored phlegm. Excellent question. Dr. Ron

Hydration, Good and Bad Days

Q. I think many of us are the same in that we experience both good and bad days. On the good days, we go about our business and are almost unaware of our illness. On the bad days, it is a struggle to get out the door and just the act of breathing seems almost impossible. I have tried, over the years, to figure this out because it seems, that with extensive lung damage, we would feel sick all the time. I know, there is no correlation for me anyway, with an oncoming infection, pollution, stress. The only factor I have been able to isolate is dehydration. I KNOW if I get dehydrated, my breathing will get worse. What do you think? F.Y.I., I am diagnosed as severe but not on oxygen and am still able to work, shop etc. on my own. My oximeter readings with exercise stay between 91 and 95 (my pulse goes up though). I am on advair 50/100, combivent and clariton. Thanks. Karen

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A. Thank you for your comments and observations. Yes, people with COPD and Asthma do have good and bad days. Heat-cold, dry-moist, high-low atmospheric pressure, morning-afternoon and others have been noted to make breathing difficult. It is good that you have made your observations and thus can act to keep yourself well hydrated. Water is still the best hydration product, and most of the time water from your water spigot is fine. Fruit juices may have extra calories, Energy drinks may have more calories and electrolytes, so water is fine. Coffee and caffeinated drinks and alcoholic drinks act as diuretics, depleting your body of water so are best avoided. Usually if your urine is clear, pale yellow or clear that means you are well hydrated. If you are on vitamins, your urine may be a brilliant yellow, but as long as it is pale and clear, that means you have enough fluid in your system. Dr. Ron

A Question about Infections HELP

Q. In 1996 I had a lung collapse from a bleb that popped, I am 67 now, I was in the hospital for 2 weeks waiting for it to seal which it did not, it was fixed with micro surgery, they took out about 10% of the top of the right lung and sealed it to my chest wall. I was home for 24 hours and had sub dural emphysema, back to the hospital for another 24 hours and then home again. About 4 days later I got up one morning and could hardly walk or keep my balance felt very weak, cold and rapid hart beat, back to the ER lung infection 3 days in the hospital with IV antibiotics and home again. Since that time I have been getting recurring lung infections all the time it started right after the operation and were about 3 months apart but they keep getting closer and closer together all the time so now it is barley 2-3 weeks between infections. They have done sputum samples and there seem to be about 3 different types of infections so I get anything from Cipro to penicillin type drugs along with the pred. bursts. They have taken high density CAT scans and all kinds of tests but do not see a local infection. I do have LOTS of blebs on my lungs with on large 11cm. one in my right lung which they are afraid to do anything about. I guess when it pops I will know it. lol This is taking it's toll on me as it takes longer to recover each time and my breathing seems less and less after each bout. I am on O2 at night only and use Azamacort, Combivent and Serivent when I do not have a infection. Other than this problem my health is fine I do exercise and am active, I just keep pushing my self but it looks to me like soon I will be on antibiotics and prednsone all the time. Anyone else have anything like this?? Sorry for the long history.

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A. The material we spit into a sputum sample cup may be simply juices from our mouth (saliva), secretions from the back of the throat and throat or from the bronchial tubes. The bacteriology lab can look at the sample under the microscope to see if it has epithelial cells from the mouth indicating saliva or if it has no epithelial cells but does contain white blood cells suggesting infection deeper in the airways. Unfortunately, whereas people without lung disease have a sterile upper airway, that is trachea and bronchi, people with COPD do have bacteria normally in the upper airway. These do not necessarily reflect the bacteria which may be causing disease in the smaller bronchi and bronchioles. Fiberoptic bronchoscopy with selective culturing of the small airways is the best way of ascertaining what is causing an infection out there. Bronchoscopy would also check the tubes to be sure there are no foreign bodies like peanuts or lettuce that one can inadvertently inhale or polyps or tumors which would could masquerade as infection. With regard your blebs and bullae, I think you should seek the opinion of a good thoracic surgeon to see if they can be electively removed. If the blebs break, you will get severely short of breath and potentially could die if help was not rendered quickly. Being at altitude in an airplane could allow the blebs to expand and break. There may not be a thoracic surgeon on the plane. Depending on your other health conditions you should be able to do well through surgery and actually breathe better after the large balloons are removed from your lung. Your physicians would do some additional studies to see if the large bullae are compressing more normal lung. If so you would be expected to feel better. If not, then the surgery would be more like lung reduction surgery and still should give you some relief, although it may not be as long lasting. Please talk with your physicians and seek the opinion of well trained and experienced thoracic surgeons. You may need to go to a national medical center for this. Dr. Ron

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Vertility/Deficit

Q. My PFT history is as follows (in a nutshell). In March of 1999 I had a PFT done and I had one done in January, 2000. In January of 2000 my FEV1 was 27% of predicted and I had lost 700cc of lung function since March of 1999. The doctor also wrote the remark, "Very severe vertility defecit" (I have no earthly idea what a vertility defecit is and probably don't want to know, either). In November of 2001 I had another PFT done and the same remark about the vertility defecit was there, but I lost an additional 500cc of FEV1 since the PFT done in January. My FEV1 level was now 15%. I have lost 12% from January of 2000 to November 2001. Nowhere on any of these forms does it say that I may not benefit from continued bronhcodialator therapy. My doctor does not use the term "end stage" because, as he puts it, there are too many different definitions of the phrase. One definition might be interpreted as meaning that doctors have given up on you and that you're going to die where another definition might be interpreted as meaning that you are at the end stage for what medications are available now. That last interpretation does not mean that you are hopeless or that you will not continue to benefit from the medications you are now on. I have an appointment with my pulmo on the 26th of next month and maybe I will get a clearer definition of the phrase, "severe vertility defecit." My pulmo has sent all of my paperwork to the Lung Transplant Division of the Pulmonary Department of the University of Alabama at Birmingham Hospital. I will probably go down there for a conference with some doctors later this week and will possibly have to make the choice about a lung transplant then.

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A. "Vertility deficit" probably stands for "ventilatory deficit," simply meaning that the movement of air or ventilation as measured by the PFT'S as the FEV1 is down. You are losing pulmonary function at a rapid rate. I presume you do not smoke cigarettes. You may ask you physician if a trial of oral Prednisone at a dose of 40 mg each morning for two weeks, checking your PFT'S to see if there is any reversible component. Good luck. Dr. Ron

Coffee

Q. I realize we all try to seek our pleasure where we may. Coffee may be a determent rather than a pleasure. When ever I drink over a few ozs I become SOB. I miss my 3 or 4 cups in the AM but the SOB is not worth the short lived enjoyment of coffee. I now have a cup on a Sunday AM, not every Sunday, but when I do have that 1 cup it is a real treat and pleasure. My liquid intake pre E was 3 0r 4 coffees in the AM. Many numerous glasses of Iced tea. The waitresses where I ate lunch would tell the new girls to take me the pitcher and save the legs. In the afternoon I would drink numerous Pepsis. For happy hour and the evening I had numerous glasses of H20 intake mixed with Crown. This is merely to illustrate that pre E I am not a person that a couple cups of coffee would affect in an adverse nature. I urge all to notice alterations in breathing after coffee drinking. Try cutting back until you reach a point that does not affect your breathing. If it should be at the point of no coffee then you have the decision to make. Is the coffee worth the change in breathing?

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A. Your observations about your coffee and caffeine ingestion and worsening of breathing is interesting. Caffeine containing beverages usually contain Theobromine which is a weaker version of Theophylline, a bronchodilator. I wonder if the volume of water you drank pushed up your diaphragm and thus made you short of breath. Coffee and tea are diuretics so you could get dehydrated, but that still does not help me explain your worsening shortness of breath. Alcohol also is a diuretic. It has no specific effect on your breathing. It does affect your gag reflex and your ability to fight off infection so alcoholics get more aspiration pneumonia than non alcoholics. One or two alcoholic drinks a day should not adversely affect your breathing. However, keep up the exercises and rehab! Dr. Ron

Coffee and Theophylline (Theodur)

Q. I was a coffee addict until I stopped smoking. At that point I slowed down by almost 50% and as time passes I have slowed more. I was on Theodur and had to keep the amount down since with or without coffee I would get the shakes any time they had me on enough to get the blood level into the recommended range. We are now trying to do without the Theo to see if it makes a difference.
[Comment - This is the major problem with Coffee and Theodur or Theophylline of any type. It adds to the effect of Theophylline and of course if you are already in the therapeutic range, can cause it to escalate and cause the uncomfortable heart pounding and shaking that so many of us have. This, particularly in heart patients can be a very serious problem. Gary]

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A. I concur with your thoughts, Gary. Of import is that the therapeutic level of Theophylline is no longer felt to be 10-20 mg%. Levels of 5-12 mg% are now the therapeutic range, so people on Theophylline need to know their numbers and to know that higher than 12 mg% but below 20 mg% are too high and associated with more side effects as you described. Levels from 5-12 mg% do open the airways, do increase the strength of the diaphragm and respiratory muscles and may have some anti-inflammatory effects. Any beverage containing theobromine such as coffee and tea can increase Theophylline blood levels. Dr. Ron

Holes in the Lung?

Q. When I had a triple-by-pass this past June. A day after the operation, I was told my lungs were full of holes. (blebs had burst.) Which also resulted in my lung collapsing. They had to put a tube into my lung to help get the air that was escaping from my lung out because it was going under my skin and blowing me up like a dough boy. If you touched me I went "snap, crackle & pop." Well, I was just told that all COPD people have holes in their lungs all the time. Is that true? I also was put on a ventilator for 3 days. Is it the anesthesia that causes us to have problems? I hope this is not a stupid question? I've just been very curious.

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A. People with COPD have inflamed bronchial tubes (bronchitis) and some have enlarged, distended air sacs (emphysema). No one has holes in the lung which allow air to flow from the bronchi to the pleural space and chest wall. Somehow the surface of your lung, the visceral pleura, was torn so that the air was not contained in the lung as is the normal. This could have happened due to an assistants hand, a device holding your breast bone apart, or a bony snag. If you do have bullous emphysema, in which there a lot of distended air sacs on the surface of the lung, tearing would be easier. I do not think the anesthetic gases would cause the lungs to leak. Great question, Dr. Ron

CPAP, BiPAP, NIPPV

Q. I am wondering about the mechanics of the BiPAP system and just how it works to rid my lungs of CO2. I thought Dr. Karpik would be able to answer in language that my feeble brain could register.

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A. The theory about using CPAP and BiPAP or any form on Non invasive Positive Pressure Ventilation (NIPPV) is that the airways collapse during exhalation in people with COPD and CO2 retention. The air being blown into the airways is supposed to hold open the airways on expiration in the same way as pursed lip breathing is supposed to. With the airways held open air can escape easier so carbon dioxide can be breathed out. Additionally, the positive pressure may take some of the work of breathing away from the respiratory muscles, letting them rest and recuperate. Studies seem to show that people who use NIPPV have more energy and feel better. I have not kept up with the literature to know if an individuals carbon dioxide level is really lowered with this therapy at home. Dr. Ron

Medications

Q. I had asked if taking nearly 100 plus pills a week was average for COPD patients and the reply from Efforts clients were to give you a list..it seemed to most everyone I am over medicated..here is my list, I take Guiaifenesin,4x day , accolate 2xday,claritin 1x, volmax 2x,theophylline 4x, wellbutrin 2x,furosemide 1x,ambien1x, foradil 2x, zantax 3 x, combivent 1 x, prilosec 1 x, plus 7 vitamins and minerals..of course not all is for COPD but most are..100 pills are COPD related...It is too much? My pulmonary Doctor was ask, by my husband if I need all these and he answer was yes..and now I am on blood pressure meds..some of the people with efforts says, they are just on one or two pills daily...I sure would like to take less..I don't enjoy taking all these pills plus the expense of medications..Please reply...thanks, Paula

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A. As Gary points out it is difficult to make a lot of comments about your medications without knowing more about your health problems. However, I will make some general comments. 1) Volmax is a beta 2 adrenergic drug so it is similar to albuterol and Serevent. Since it is a pill that is absorbed through your stomach, it has more side effects than inhaled Serevent. Its side effects are nervousness, shakiness, poor sleep. So you might ask to try Serevent or Formoterol and stop Volmax. 2) There is no drug named Xantax. Are you taking Xanax for anxiety and nervousness? If so, stopping Volmax. may allow you to take less Xanax. If you are taking Zantac for stomach acid, it could be discontinued since you are taking Prilosec. 3) You are on Theophylline four times a day. There are sustained release forms like Theodur, Theophylline SR or Uniphyll which can be taken once or twice a day. Recall Theophylline can cause gastroesophageal reflux and gastrointestinal upset, so if you blood level is above 12 mg%, you may be able to take less Theophylline and maybe your stomach will feel better.

Is your physician a specialist in Pulmonary Medicine? If not you might want to see one to see if these medications are all needed or if some of them can be changed to a different schedule. Good luck and thanks for the question. Dr. Ron

Too Much Albuterol/Atrovent ?

Discussion:   You are NOT taking too much IB (Atrovent) at the doses you say your doctor has you taking. While we DO know that one can get too much Albuterol and depending upon how much to much, for how long, can result in overdose symptoms of cardiac arrhythmias and even cardiac arrest and death - - - the same is NOT true for IB! The reason is that each of those drugs acts through a different pathway - - - Albuterol's being a parasympathetic nervous system pathway and IB's being a chemical pathway at the nerve/muscle synapse - - - the parasympathetic being in the same 'circuitry' as that which influences the heart and the nervous/muscle synapse NOT being related to, or in the same 'circuitry'.

[Folks can actually take tremendous amounts of Atrovent without toxic affects (more than 175 consecutive-breath actuations, in a few studies). The side effects of so much would be dry mouth, and other mucus membranes - - - but that would require much higher doses than any of you are taking. I am NOT encouraging ANYONE to take more Atrovent, or more than they need, just to educate you that the risks and concerns of getting 'too much' are profoundly different between the two drugs. Regards, Mark]

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Added Comments:  I certainly agree that ipratropium (Atrovent) is an effective bronchodilator which is safe at doses above those that are usually recommended. Ipratropium is a bronchodilator which works by way of the parasympathomimetic pathway, it is an anticholinergic drug. Albuterol (Proventil, Ventolin) is a short acting beta 2 adrenergic agonist or stimulator. It works by way of the sympathetic nervous pathway. Its effects are more like epinephrine or adrenaline which is the parent molecule. It can cause a rapid heart beat, irregular heart beat and a low serum potassium blood level. Thus it is best used as directed by your physician, usually as an as needed medication to relieve acute shortness of breath.

Salmeterol (Serevent) and Formoterol (Foradil) are both long acting beta 2 adrenergic agonists or stimulators. They should only be used twice a day as their effects are at least 12 hours of bronchodilation. For acute attacks between these 12 hours it is appropriate to use a short acting beta 2 adrenergic drug (Albuterol/Ventolin) and the anticholinergic drug Ipratropium.

From what I have been reading it is probably very appropriate for all people with significant COPD and Asthma to be given a trial on a long acting drug like Salmeterol or Formoterol to provide long lasting bronchodilation and perhaps some control of the inflammation associated with each of those diseases. There is a growing body of data that suggests that when one is on a long acting beta 2 adrenergic bronchodilator that the short acting drugs are better used only as needed as opposed to a regular schedule. Thus if you are on a regular schedule of albuterol and a long acting drug such as Serevent/Foradil you may want to ask your pulmonary physician if you could try using Albuterol irregularly, not four times a day unless needed. You may find that the albuterol is more effective when you get acutely short of breath. Have a good day? Dr. Ron

Transplant and Lupus?

Q.  I have a question for Dr. Ron. I've never been told that I'm bad enough for LVRS or a lung transplant, thank God. But my question is: do you think I would be eligible for either since I also have lupus? I have SLE, which used to really worry me until l was told I have emphysema. I don't want to bring the subject up with my doctor personally yet. Thanks.  Carol Anne

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A. You mention that you have SLE, that is, systemic lupus erythematosis. That disease does not have a definite cause, it is part of the auto immune diseases. It has affects on many parts of the body, usually the blood vessels and the kidneys. It can affect the lungs, but it does not produce emphysema which is a destruction of the air sacs, the alveoli. I wonder how the diagnosis of emphysema was made. Recall the diagnosis can be made by looking at the Pulmonary Function tests which show a large residual volume and a reduced diffusing capacity. A high resolution CAT scan of the lungs can visualize the enlarged air spaces which result from the destroyed air sacs.

I suspect that you may not be a candidate for a lung transplant due to having SLE, but review of the Inova hospital system transplant site (www.inova.com) does not delineate the excluding diagnoses. Perhaps you have access to a transplant program locally and can talk to them in general terms. Let me know what you learn.  Thank you.  Dr. Ron

Problems with Edema

Q.  I have tremendous problems with edema, doc has me on furosemide and klor-con (potassium) up to 80 mg a day when edema won't be controlled with 40 mg. 3 mos ago legs started turning red approximately 4 in above ankles with ensuing blisters, resembles bad sunburn, red coloration remains but blisters come and go with severity of edema. Now redness has creeped up to midcalf of leg, blisters have remained lower leg. Now feet stay puffed most of time and very tender where even floppy slippers cause slight pain like touching a sore bruised area. Muscles in legs and feet very tender. Hurts to touch legs.x CHF,PH,Pulm Fibrosis, COPD, plus many other dx. On 12 different meds, bipap, nebs, 02-24/7, 2L up to 3L.

My primary doesn't seem to know what is taking place other then the edema, dermatologist said scaly skin coming from edema, which he saw me for a cancer mole removal months before the severity of legs came about.  Would appreciate any information anyone could give me. Am beginning to get very concerned for I surely don't want to lose my legs or feet.  No diabeties showing up even tho runs in my family so that is possibly ruled out.  Shelbyloo

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A.Thank you for your question. It will be of interest if other people have experienced your problem. The redness and blisters are of concern in that they may indicate a cellulitis or infection of the skin. If the redness goes away with elevation of your feet for an hour, then the redness may simply be due to blood pooling in your legs. If the redness does not go away then I am concerned with the possibility of infection and antibiotics may be needed.

Of more concern is why you have the swelling. Have venous blood clots been ruled out by doing a venous doppler study? If not, you may want to suggest it to your physicians. If the veins are clotted, diuretics will not easily reduce the swelling. Then one may benefit from elastic hose to gently squeeze the legs to reduce the accumulation of that salt water. Do not wrap your legs with an ACE bandage, as these bunch and wrinkle actually predisposing you to get blood clots in the leg. If you are not on a salt or sodium restricted diet you may want to discuss that with your physician also.  Let us know what happens.  Dr. Ron

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Bad Breathing

Q.  Been having a hard time breathing. I'm on 3 liters 24/7 and take albuterol/atrovent 4 times a day, sometimes more. I have an oxymeter, and it stays around 99-100. Why can't I breathe well? Going to the pulmo doc thurs., but don't expect any real answers. What's the deal? Any ideas Sandy, Tenn

[From Gary Bain Sounds like you might be retaining a little bit. Practicep pursed lip breathing as much as you can to get that fullness feeling down, you should feel better. You also could be getting a little infection, that usually bounds me up pretty good. Also, be careful not to take more of your meds than what your doctor has prescribed. If you take it too often, it won't help as much.  Gary]

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A. Thank you for your question. Shortness of breath is a complex symptom. You don't tell us your diagnosis or your PFT'S, so I will presume you have some form of COPD.   As Gary has pointed out, pursed lip breathing can be helpful. The major factor is slowing down your breathing so you can get the old stale air out and give room for the fresh clean air you inhale. Are you exercising regularly? If not, we all have to, we all lose muscular strength as we get older and restrict our activities because of our lung disease or just not being active as we were when we were twenty years old. Are other things going on? Do you have more phlegm, discolored phlegm, fever, chest pain? These could indicate infection. Have you been losing blood in your bowel movements causing anemia? Have you been having chest pains, fluttering of your heart or swelling of your legs which possibly could indicate heart problems? Check the rest of your body and tell everything to your physician. If it is ascertained that your lungs are worse, perhaps your physician will add theophylline, salmeterol (Serevent) or even a trial of prednisone. Please keep in touch. Dr. Ron

Eyes and Oxygen

Q.  Hi; I was wondering if anyone out there on oxygen has this problem? About 6 months ago the whites of my eyes became very red and I went to the family Dr. he felt I had pink eye. Told me to buy a eye wash and use hot compresses on them. That didn't clear them up so I started to use an antibiotic eye/ear drop. It seemed to help somewhat, but they were still oozing muck. Then the family Dr. sent me to my Eye Specialist and I am on two different eye drops to control Glaucoma. He thought that maybe I was allergic to the eye drops ( I have been on them for years) and took me off of them for a week. Went back and they were still itchy and weeping and sore. He had also told me not to use the antibiotic eye drops because they would raise the pressure in the eyes. So, he put me back on the drops and suggested a different eye wash.  But he also said that I have this eye condition and to put hot compresses on my eyes and use the other eye wash.

As I was walking out he said "It could be your oxygen" I have been on oxygen going on 7 years that does not make sense. I said to him "What if they don't do the trick?" His reply was "Well then you'll have to come back" The eye wash was useless and back to the family Dr. I went and asked him to make me an appointment in Calgary with another Eye Specialist. His verdict was I don't have this eye disease , that I just have dry eyes and to put hot compresses on the eyes 5 times a day and use "Refresh Plus" 6 times a day for one week and he would guarantee my eyes would clear up. After 3 days of this procedure my eyes were so red and sore that I had to phone him and his comments were.......Well its obvious that your allergic to the Refresh. Stop it immediately. I said , What do I do now and his answer was go back to treating them as best you can and maybe you will have to come back and see else we can come up with. Needless to say I don't have much confidence in either Dr. and was hoping someone out there has had the same problem and has an answer for it Needless to say I have been using the medication I am not supposed to use when they get so bad and using hot compresses. I don't know what else to do. Thanks June

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A. Thank you for your question. I do not think oxygen is the cause of your problem. As you related you have been using oxygen before the problem and I have not seen this during my years working with patients. Glaucoma should be easily diagnosed by measuring your intraocular pressure. If it is above 19 then the pressure is high and glaucoma is one of the causes. You may want to check on the credentials of the ophthalmologists you have seen.

If they are not Board certified you may want to go to one who is. Perhaps you can get names of other good ophthalmologists from your friends or perhaps there is a medical school nearby with a good ophthalmology dept.

Do not give up, there has to be an answer to your eye problem. Please let us know the outcome. Dr. Ron

SOB EVEN WITH HIGH 02 SAT

Q.  I am having sob even though my 02 SAT is 96 and pulse is 123. I am reducing my intake of Prednisone every 5 days (was 40mg..now 30mg/day)..coming off a congestion episode lasting 30 days. I am wondering if my reduction rate is too aggressive. Input will be appreciated. I am using 4 lpm 02 from LOX in home and 4 lpm pulse dose when out and about.
Moderate SOB when I move about. ???? Why??  Bill

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A.  Dear Bill, Thank you for your question. Without knowing more about your disease it is difficult to give you a specific answer. Shortness of breath or dyspnea is a complex sensation. It is not only desaturation, but also is related to the work of breathing. In obstructive lung diseases the airways are narrowed, so it requires more effort to move air through the tubes.

Resistance to air flow is inversely related to the radius of the tube to the fourth power, that is if the tubes radius is decreased by 1/2 the resistance increases by a factor of 16! Shortness of breath is also related to the strength of the breathing muscles, that is the diaphragm and the chest wall muscles. Prednisone is a double edged sword. It helps reduce the inflammation of the airways, but also decreases muscle strength. Reducing Prednisone by 5 mg every week is not too fast as long as the original cause of the problem is under control. If the process is still ongoing, you may need to be on Prednisone longer. Your physician may want to check your pulmonary function tests and/or your sputum to be sure the acute process is resolving. If you can resume your exercise program, starting slowly, that will help your muscles get stronger again.  Please let me know if you have further questions.  Dr. Ron

Phlegm problem

Q.  I use a medicine called Vi-Q-Tuss (which is generic for Hy-Q-Tuss) for phlegm control. It is a liquid and I drink a pint of it each month. It has both guaffenesin (sic) and hydrocodone in it so it gives relief from pain as well as reduces phlegm. It tastes terrible but is effective. We are all different but it works well for me. Bob in Utah

I go to talk to someone and I can hardly get a word out because of phlegm.  It is very embarrassing because I'm not expecting it to happen. Does anyone have that problem? Any remedies. Thanks Love June

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A. Phlegm is a real problem. Some folks with COPD produce a lot of it, making it difficult to breath, to talk and causing the need for tiresome coughing. Hycotuss is a brand name for the combination of hydrocodone (a narcotic cough suppressant and pain killer) and guaifenesin (a common name is Robitussin plain). Unfortunately, the hydrocodone is a narcotic and can become addictive. If it is used intermittently, it is very effective.

Guaifenesin is an expectorant which may help loosen phlegm. It does seem to be effective in bigger doses than on the label. I have suggested 2-3 tablespoons four times a day of the plain Robitussin or generic, not the narcotic containing ones! Use the narcotic combination as prescribed by your physician.

Other people have found that hot tea or hot lemon flavored water also help to break up phlegm. Phlegm is an area which needs much further research. Dr. Ron

Emphysema and Asbestosis

Q.  My Name is Wayne, I have Emphysema and Asbestosis....I am also taking 2.5 litters of Oxygen ...I am on a Nebuliser IPRATOPIUM BROMIDE & COMBIVENT I have Depression and and Back Pain....I am also on 1mg of XANAZ, 40 MG. of PAXIL.....And a pain pill VICOPROFIN 250 Mg. I have been taking this for 3 Yrs. now and Find my self very Sedentary....I sleep a lot ....and live alone....I am 62 years old and hardly leave the house....I have a Caregiver 4 Hrs. a day 5 days a week.I`m concerned if this is the right meds. for me ? My Dr. is a nurse Practioner since I live in a small town in Montana..I hope some one out there can give me some Help Via the internet....Thank You and GOD bless You......Wayne....

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A.  Dear Wayne, Thank you for submitting your questions. For your information, Combivent is a mixture of Ipatropium and Albuterol. Xanax (alprazolam) is used for anxiety, but it can be depressing and can be addictive. Paxil (paroxetine) is an excellent antidepressant and frequently will help anxiety. You may ask your Nurse Practitioner to consider weaning you off the Xanax, but this has to be done slowly. You could go to 0.5 mg. for several weeks, then go to 0.25 mg. a day for several more weeks and finally stop it. Vicoprofen is a combination of Hydrocodone (Vicodin) and Ibuprofen (Motrin). Hydrocodone is a narcotic which is an excellent pain killer but usually it is not needed for three years. Back pain has a cause, and usually you can treat it with exercise and massage. However, if the pain is due to narrowing of the spinal canal or pinched nerves or collapse of the bones, alternative therapies may need to be considered. Since hydrocodone is a narcotic, it does produce depression and does depress breathing. You may want to discuss reducing and finally stopping this drug. If the cause of your back pain is not known, you may need some x-rays or a Magnetic Resonance Imaging (MRI). Have you gone through a Pulmonary Rehabilitation program or participate in a regular walking and weight lifting program? You may laugh, but most people with lung disease can benefit from an exercise program. You start out slow but slowly increase your activity. It does wonders for your body and brain. Is it possible to see a pulmonary specialist to review your situation? If so you might be able to better tailor your program and get to feel better. Please keep in touch. Thank you. Dr. Ron

Blood thinners

Q. Do your KNOW prednisone is a blood thinner? I was told that pred. made the small veins become brittle and that the thin (almost non-existant) skin does not protect these brittle veins (this makes one wonder about the very small veins in the brain) --but not that it was a blood thinner. Because of my prostate cancer (the big C). I have weekly blood tests, kalium, natrium, keatinen and PSA. Every time the nurse asks me if I use blood thinners and I say"no". Also 5 weeks ago when I broke my collar bone and 7 assorted ribs the Otho. asked if I used blood thinners and I said no. If pred. is a blood thinner --?  Cheers, KenR, Klundert, No. Brabant, Netherlands

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A. Aspirin is commonly called a blood thinner, but it does not act like heparin or warfarin. Aspirin prevents platelets from being sticky and closing off holes in blood vessels. When you scratch your skin you break capillaries and venules, that is, small blood vessels. The first line of defense to stop the flow of blood is the nondescript clump of material floating in the blood called a platelet. The platelet originates from cells called megakaryocytes located in the bone marrow. The platelet has no nucleus (neither does the mature red blood cell). The platelet sticks to the edges of the torn blood vessel and then it releases material to cause a blood clot to form. Aspirin inhibits this process though not 100%. It has recently been learned that if you take aspirin and ibuprofen together, the antiplatelet effect of aspirin is significantly reduced, so take Aspirin for your heart and brain several hours before you take the other nonsteroidal anti inflammatory drugs.

There are other drugs like Plavix (clopidrogel), anagrelide (Agrylin) and cilostazol (Pletal) which also interfere with platelet function. Thus the bruising you get from aspirin and these other drugs is due to breaking capillaries and venules from minor injury like hitting the door frame or the oven shelves and then bleeding into the skin because the platelets do not stop the bleeding.

Prednisone does not affect the platelets. Prednisone makes your skin thinner and more susceptible to bruising from minor injuries. Note that the bruises are on the hands, forearms and lower legs. They rarely occur on the chest or abdomen. There is no internal bruising, but Prednisone has been associated with stomach and intestinal bleeding as has aspirin.  I hope this helps.  Dr. Ron

Augmentin

Q.  What is the name of the drug which is a combination of amoxicillin and clavulanic acid as per the following report? Group, The letter from Schey et al., in which they commented that few cases of liver damage in association with the combination of amoxicillin and clavulanic acid have been reported is surprising. Hepatic dysfunction in association with amoxicillin/clavulanate is well recognized, and there have been scores of case reports on such dysfunction. Amoxicillin/clavulanate is the second most common suspected cause of hepatotoxicity reported to the Australian Adverse Drug Reactions Advisory Committee, which has now received almost 500 spontaneous reports of the association...http://www.pharmacistlinx.com/thearts.cfm?artid=275246&specid=24

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A.  The combination of amoxicillin and clavulanate is called Augmentin in the USA and Clavulin in Canada. The article is alarming in that the relationship with hepatitis is known, but is felt to be rare/infrequent. As the article relates, an incidence of 1.7 cases per 10,000 prescriptions. It is an excellent antibiotic combination in that amoxicillin is a penicillin like drug which kills bacteria, and the clavulanate inhibits the enzyme produced by bacteria to breakdown amoxicillin. It has been very useful for the treatment of acute on chronic bronchitis. I have not heard of any recalls or advisories to avoid the use of this antibiotic. I would not feel uncomfortable in using it. As you are well aware, everything has a good and a bad side. So far, I think Augmentin has been without significant risks. I do not know if the Australians have a different version of the medication or if there is some complicating factor in its use there. Has anyone in the group had a liver reaction to Augmentin? Dr. Ron

Exercise and CHF

Q.  Thanks for the encouragement to exercise. I do get a lot of exercise in the warm weather in the pool. I "walk" around and around fast enough to make a whirlpool. I do my best in water because of my weight. I guess I'll have to hang the portable on the walker and start walking up and down the driveway the best I can until the weather warms up. That won't be long here in Houston, and we usually heat the pool.  Lil

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A.  Dear Lil, Thanks for your conviction to exercise! Walking is great, but you do need to add some upper body exercise to your program. You could start by doing a modified push up at the kitchen sink. Stand an arms length away from the counter, put your hands on the edge of the counter, then lean into the counter bending your elbows. Depending on your strength, you can put your chest onto the counter and then push with your hands, straightening the elbows, pushing your body away from the counter. Your feet stay planted in one spot. You can work up to 50 at one time.

Mark has another exercise in which you use a chair with arms. You sit down, but then use your arms to push up, pulling your bottom off the chair.  When you get stronger you slowly lower your body back into the chair only by the strength of your arms. You can slowly build up to 50 of these also.  Keep the spirit, you will feel better.  Dr. Ron

Humidifiers

Q.  Being a new addition to the large family of COPD people I have a problem that needs to be resolved; are humidifiers recommend , some of talked to say yes, others say no.  Any input appreciated. Roy -Al

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A. Usually air humidified to 35-40% relative humidity is more comfortable to breath. In my area of northern VA, during the cold winter we have to use a humidifier to achieve that level. Putting water on the stove or on the hot water radiators does not work. I recommend a commercial humidifier such as Sears Roebuck (I do not own stock in this company that I know of.) The spinning top humidifiers sold in drug stores and usually reserved for infants with the croup spit out too much water and get the walls and floor wet. The Sears Roebuck type the water is picked up on a belt and blown into the air by a fan. Since the water can get infected with bacteria and fungus a special preservative is added to the water. I do not know that the powder that settles out from the humidifier is harmful to your health. You might want to check the magazine Consumer Reports to learn their findings. Dr. Ron

Colored or bloody sputum

Q.  On occasion I have spit up are when I was throwing up pink are red blood? Is this just part of this lung condition COPD. I have wondered because on a couple of clinical studies I did it seemed normal to them because most of the questionnaires I filled out during the studies would ask When you spit up was it red/ pink / clear Anyway thanks in advance .  Phyllis

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A. Discolored sputum is not normal. Sometimes after using a nebulizer with a bronchodilator such as Bronkosol and maybe others, the phlegm becomes pink due to the medication. Bloody sputum is never normal. It usually is due to bronchitis, but could be a sign of cancer. Your physician should be notified. Dr. Ron

Exercise and Cor Pulmonale

Q.  I'd like to hear Dr. Ron's ideas on this, cause I've heard that exercise goals are different with cor pulmonale. It's not supposed to be good to push too hard. Mild exercise is good but it's easy to overdo it and that just makes the condition worse. Or so I've heard. I had to quit pulmonary rehab when I developed cor pulmonale. It would take me two days to recover from one session of exercise.  Lil/Houston

Q.  Jean I have Cor Pulmonale or Pulmonary Hypertension whichever you want to call it and I walk on my treadmill every day 1/2 hour in the morning and 1/2 hour in the evening, sometimes longer. In the begining my heart rate used to really go high but now it increases, but not as much as in the begining. To be perfectly honest I think that we all get SOB on the treadmill but our sats will stay OK as long as we adjust our O2 to prevent them from going below 90.

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A. Exercise is good for you. We all lose muscle mass and endurance as we grow older. Our activities are not as strenuous or as prolonged as when we were younger. This happens to us all. Once you develop a disease that takes your breath away with exertion, you naturally exert less so you do not become short of breath. In rehabilitation terms, this is the downward spiral of dyspnea. The less you do because of shortness of breath, the less you are capable of doing. Cor pulmonale or heart disease secondary to lung disease is helped by exercising, however, since part of the cause of cor pulmonale is hypoxia or low oxygen, it is important to maintain good oxygenation during exercise. As Sharon pointed out, keep the pulse oximetry readings above 90%. Even if your pCO2 is elevated, with your physicians direction, turn up the oxygen while you are exercising and then be sure to turn it back to your resting level when you stop exercising. Hopefully you can enroll in a rehabilitation program so you have the benefit of the therapists knowledge to start your exercise program. They will have you start slow and slowly advance as your muscles and joints get accustomed to the various machines you will use. They will monitor your heart rate, the EKG, Blood pressure and your oximetry. Once you have gone through a program, they will give you a program to continue at home. It is really important to continue exercising even though you won't have the enthusiastic therapist urging you on. Listen to that little voice that says to exercise, it really is good for you. Yes, you will become short of breath, but you will also see that you can walk further, row harder, cycle longer than when you started the program. Unfortunately, if you stop exercise, the loss of function will recur. Do not feel bad that you cannot keep up with the Cardiac Rehab folks. They have a different disease which does not prevent them from achieving higher levels of exercise due to shortness of breath. Exercise and enjoy, though it is work! Dr. Ron

Exercise and Congestive Heart Failure.  (Also see above)

Q.  Can anyone with copd/emphysema and chf say for sure that exercise has made them feel better. I was at the hospital today and walking around that place made me sob and flat wore me out.  Lou

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A. I think that Bob gave you an excellent answer. There is a growing body of scientific data to show that exercise is beneficial for people with congestive heart failure. As Bob pointed out, your cardiac physician has to be involved. You should have a stress test before you start the rehab program. This would define the type and duration of exercise that would be safe for you. During the rehab program you should have your electrocardiogram and blood pressure monitored, so that the exercise is safe for you. This may sound elaborate and maybe scary, but it is done every day for people who have had heart attacks or cardiac surgery. Although exercise is difficult to start, you will benefit from it over the course of weeks and months.  Have fun and enjoy, but work with your cardiologist.  Dr. Ron

Various questions regarding terminology between COPD, Emphysema and Chronic Bronchitis and degree's...

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A.  Dear Lou, Sandi and Ethel, All of you have posted questions about COPD and emphysema. COPD is an umbrella term meaning Chronic (not transient) Obstructive (the FEV1/FVC ratio is less than 70%) Lung Disease. This general term includes chronic bronchitis and emphysema and in my mind chronic asthma. Chronic bronchitis relates to cough and sputum production with the findings of enlarged mucus glands, increased muscle and scarring in the bronchial tubes. Pulmonary Function tests may be normal and the diagnosis is "simple bronchitis," or show a reduced FEV1/FVC ratio with a normal residual volume (RV) and a near normal diffusing capacity for carbon monoxide (DLCO). The chest x-ray and chest CAT scan are normal. Emphysema alone has only shortness of breath as a symptom. Pulmonary function tests show a reduced FEV1/FVC ratio, a residual volume increased beyond 120% and a Diffusing capacity reduced, reflecting the loss of capillary-alveolar surface interface. The Chest x-ray shows big lungs, with a low depressed diaphragm, and may show areas of blebs or bullae which are large areas of destroyed air sacs. The CAT scan, especially the high resolution type actually can show the areas in which the air sacs are destroyed. The most common form of emphysema affects the upper lobes earlier and more severe than the lower lobes. Other forms of emphysema affect the lungs more diffusely. It is felt that the most common cause of both these obstructive diseases is cigarette smoking. It is not known why one smoker will get chronic bronchitis, another get emphysema and another get both. Once a cigarette smoker stops smoking, the cough and sputum production improve over the course of 2-4 weeks. The air flow limitation may improve, but if it was severe when first measured usually will not return to normal due to the scarring of the bronchial tubes. The rate of decline in the FEV1 is reduced so that air flow limitation gets worse much more slowly than if smoking had continued. An individuals disability is not well correlated with the results of the PFT'S. An individuals quality of life is significantly improved by Pulmonary Rehabilitation and a continued exercise program. For additional information, please check out the American College of Chest Physicians site www.chestnet.org  > looking at Patient Education on the left margin. Another site is the American Lung Association www.lungusa.org  clicking on the left column "Diseases A-Z," I hope this helps. Dr. Ron

Please return to top of page

Emphysema vs Chronic Bronchitis Diagnosis

A.  Dear All, The term COPD is an umbrella term and only tells one that the Spirometry shows air flow limitation. As Mark has said, some physicians use this general term instead of being specific. These physicians can be described as "lumpers" whereas the physician who states a specific diagnosis based on the data I wrote earlier would be a "splitter." The "lumper" is saying that the therapy is the same and that the differences that the "splitter" is concerned about are not important. So it comes down to philosophy. I am a splitter as I see different pathophysiologies, but do acknowledge that the therapy for both is frequently the same. I feel if we do not acknowledge the differences in these diseases that we will not learn more about them. Another difficulty is that many patients do have both diseases and thus it is easier to use the term "COPD" I hope all of the words written help everyone understand this problem. Dr. Ron

Migraines, Chest Pain, Dropsies, Concentrating

Q.  A couple of months ago I started getting the following symptoms on a daily basis: bad headache (migraine), chest pains, dropping things, falling, SOB, troubles concentrating on anything, troubles seeing things clearly, fatigue, leg pains even when I first get up in the morning that last all day, major arthritis pains.

I went to my PCP who checked my blood pressure which has been controlled by medication for the last 9 years, my blood pressure was back up at 190/110, non medicated I will have blood pressure of 210/190. He changed my medications to 2mg of Cardura, 25 mg of HCTZ, and 40 mg of Vasotec. This did bring my blood pressure down to 140/90. I was still having all of the symptoms so he sent me to a cardiologist. The cardiologist tested me with the nuclear scan and I do not have the results back yet, but the cardiologist said that based from the EKG part of the test that my heart and arteries are fine and that I should not worry about my symptoms as they are not life threatening This cardiologist is supposed to be one of the best in this part of the country.

I go back to my PCP on the 18th and I think all he is going to do is tell me to learn to live with it. I had a bout of this about 3 years ago and that was just about all that was ever done at that time, except the PCP did give me a prescription for Abuterol after I insisted.

I have had a 6 minute walk 2 years ago but that didn't show anything wrong .......oxygen meter read 92% before the walk and 98% after the walk. I was diagnosed with moderate E and chronic bronchitis in 1997, the diagnosis was made from an X-ray. My last FEV (which was done at a mall where they were doing asthma screening) was 80% so I don't think I am too bad off as far as my lungs go.

I just don't think I should feel this badly unless something is wrong someplace but the doctors seem to think otherwise. Am I just over reacting or can some one suggest something that I could bring to their attention? I am only 54 and I am not looking forward to feeling like this for the rest of my life. I am on an HMO so I do not have the luxury of choosing another doctor. Again, I apologize for holding my own little pity party here.  Jerry

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A.  Dear Jerry, Sorry to hear of your symptoms. First I wonder how much lung disease you have. You cannot diagnosis Emphysema from a chest x-ray unless very large blebs are seen. If the lungs look big, that doesn't make a diagnosis.

At the very least, you should have Spirometry to see if you have any air flow obstruction, that is, is the FEV 1/FVC ratio below 70%, and if so, what is the FEV1 per cent of predicted? The diagnosis of emphysema would require additional testing, looking at your Residual Volume and your Diffusing capacity.

Your symptoms could represent high blood pressure, but I wonder if the physicians should be looking at the blood supply of your brain and also to be sure you do not have a vascular aneurysm in the brain or some other process.  Let us know what they find. I would not just "live with it."  Dr. Ron

 

Difference in Nerve Pills

Q. I need advice on nerve pills, seems the xanax 12.5 I take off and on for my Tinnitis, that was originally given to me for SOB panic attacks, which I haven't had yet, is a contributor to Tinnitis, the pulmo today said I could try Lorizipam instead, has anyone taken this, I don't want to be on anything all the time, I just take the xanax when the tinnitis gets really REALLY bad like right now. Do you have to take Lorizipam constantly for it to do any good, or can I just take one when needed. I can't be sleepy or tired all the time from them, as with the 2 mothers, I have to be ready for anything all the time. Thanks for any help, By the way if anyone is interested, had a full PFT and same or 1-2 % better than last year. 40%FEV1 and 30% DLCO. Sat while walking the hall, after a treatment was 87% mine does not go down while walking, but after I stop it drops. LOIS Do all you can and then a little more LOIS, RRT, CPFT (ret)

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A. Xanax (alprazolam) is a benzodiazepine like Valium, and acts as a sedative. Loraxepam (Ativan) is also a benzodiazepine and may function by enhancing gamma-aminobutyric acid (GABA) activity in the brain. Both drugs last about the same time in the body. You can certainly use either drug on as needed basis, and they probably work better that way. You could try loraxepam at a low initial dose like 0.5-1.0 mg to see how it works. The lower the dose, the less sedation expected.  Congratulations on the stability of your PFT'S.

Right Side Heart Failure (Cor Pulmonale)

Q. I have cor pulmonale brought on by my lung disease and have been taking 80 mg of Lasix q am and 40 mg q PM, and diamox 500 mg to fight pulmonary edema.

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A. As Mark has pointed out, your recent blood tests show worsening of your kidney function. You do not need to restrict your water intake, but you do need to restrict your salt or sodium intake. Please check the archives of my monthly column, I think it may be in September, on cor pulmonale.  You may want to discuss with your physician the possibility of taking all of your Lasix each morning. This would allow your body to re-equilibrate the fluid inside your blood vessels and that in your tissues.  Diamox can be useful in treating a metabolic alkalosis if this is accompanying your respiratory acidosis, due to your lung disease. This would be manifested by an arterial blood gas showing an alkaline pH, with an elevated pCO2. Your blood potassium could also be low. Some people feel it is better to take Diamox not on a daily basis because the kidney gets used to its presence and the drug may not work as desired. It also causes your kidneys to excrete potassium, so one has to be sure to take adequate potassium chloride replacement. You might want to talk with your physician about stopping Diamox for a while, and if it is needed, to use it Mon, Wed, Fri, not daily.  Thank you for the question. Be sure to get that followup blood work in a week or two. Dr. Ron

Understanding PFT's

Q.  I had a pulmonary function test and here are the results, can you explain them?

Pulmonary Function Diagnosis:  Minimal Obstructive airways disease Mild Restriction- Parenchymal and Severe diffusion defect.  I'd appreciate if you could explain to me. Thank you in advance. Pup

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A. Both of your questions relate to the interpretation of Pulmonary Function Tests. You may want to review the EFFORTS main web site, under "medical information," scroll down to Testing for COPD/Emphysema and check out "Basic Pulmonary Function Testing and Reading." There is a lot of information here.

BJ, there is not enough information in what you have written for me to make any meaningful comment. If you have a copy of the PFT'S, the web site should clarify what you have. If not, get back to me.

Pup, "minimal obstructive disease" indicates that the ratio of the Forced Expiratory Volume in the first second (FEV1) over the Forced Vital Capacity (FVC), is less than 70% and the FEV1 as a percent of the predicted (based on your height, age, race and sex) is greater than 80%.

"mild restriction" indicates that the FVC is less than 80% of predicted and that the Residual Volume (RV) is greater than 120% of predicted.

"severe diffusion defect" means that the diffusing capacity for carbon monoxide (DLCO) is less than 50% of predicted.

This last test result seems to be at variance with the other test results you reported. This could be a real result or could be a lab error.

Your physician can help you understand this result, as it does relate to interstitial lung disease (that is on the EFFORTS website under "more PFTS" just the next line under "Basic Pul.Func. Testing and Results." If you have unanswered questions, please get back to me. Thank you both for the questions. Dr. Ron

Ventilation, need information

Q.  Recently, an anesthesiologist told me that if I were ever to be put on a ventilator that I would probably always be on one. This was news to me! I am now very concerned about surviving major surgery (for whatever reason).

To be hooked on a ventilator is not an appealing way to spend ones life. For this reason, I am asking those of you who have had ventilation during or after surgery to tell me about your experiences and what you know about ventilation.  I think if I have more information (particularly from someone with personal experience who has COPD)..  I can rest easier because I know more about what my options might be down the road.  Please share your experiences with us as I imagine others share the same concerns as I. Thanks. Bill

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A. It is wise to plan ahead even when the alternatives are not that exciting. Your pulmonary physician is better suited to tell you about your prognosis regarding coming off a ventilator. In reality, that is not an easy question to answer. First, it depends on why you need to go on a ventilator in the first place. It does make a difference if it is after a hip operation or a gall bladder operation or removal of a portion of your lung. Each of those represents a more difficult situation.

You may be aware of a "Living Will." This is a good time to develop one as you are thinking about the future. You should discuss with your significant other, i.e., wife, child, what your wishes are regarding terminal life support. Specifically, you can discuss your ideas about the use of a ventilator, and if used for how long before it should be withdrawn if the situation looks hopeless and you are not capable of making a decision at that time. You could also think about use of surgery, antibiotics, feeding tubes, intravenous feeding and other things I may have missed.

Life on a ventilator is not the same as breathing on your own. You have a hole in your neck, called a tracheostomy, into which a tube is placed and this is connected to the ventilator. The tube is below your vocal cords, so you cannot talk unless a special valve or tracheostomy tube is in place. The ventilator requires electricity so in the hospital, the machine is usually fairly large and the distance you can move is dependent on the length of the electrical cord. At a specialized nursing home or sometimes at your own home, the ventilator is smaller and can be powered by a battery, allowing you more mobility. I was the medical director of the ventilator unit at a local nursing home. Some of the people were able to be comfortable and lead a restricted but rather full life, taking trips outside of the home and participating in the activities in the facility. Mark Mangus, the EFFORTS Respiratory Therapist, tells me that they have a number of people on ventilators at home. We were not able to do that because of the need for 24 hour help, and usually one's wife and/daughter gets tired after a short while. Trying to keep a staff of nurses and respiratory therapists at the bedside 24/7 is expensive and difficult with illnesses, vacation, time off, etc.

I hope this perspective helps. It will be interesting to hear from people who have been on ventilators. Remember the ventilator is usually a temporary crutch, to get over the insult until the body is able to carry on by itself. So there should be lots of people who have been on a ventilator for hours or days who could share their observations. Dr. Ron

Prednisone "Bursts"

Q.  I have been taking prednisone that way over the years but never heard the term 'Pred Burst'. I keep anti-biotics and pred. on hand in case of cold symptoms. I then take a declining dose of prednisone: 40 mg for 4 days, 30 mg for 4 days, etc. 20 mg, 10 mg, done.  I'm surprised it would be given without tapering off after hearing the trouble some members have getting off. I guess that's after very long term use.  Ron Ersin - Troy

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A. Your question about Prednisone or corticosteroid bursts is a good one. Your physicians are correct. If you take Prednisone for a brief time such as 7-14 days you do not need to taper. This is because your own adrenal gland has not stopped producing corticosteroids completely in that short time. So when you stop the burst, your own adrenal gland starts making its own cortisone without hesitation. I do not know if there is definitive data as to when your own adrenal glands stop doing their job, but usually one tapers after a 3-4 week or longer course. If you needed emergency surgery or were in a severe accident within 6 months of stopping a burst, your treating physician may treat you with supplemental corticosteroids, just to be sure that you have enough corticosteroids in your system to cover the stress of the situation, but even that dose would be stopped after a few days and the immediate stress has subsided. Dr. Ron

Prednisone Bursts when on Maintenance dosage.   Dose Advair or inhaled steroid help?

Q. My new Pulmonary Specialist has me start at 40, then 35, 30, 25, 20, 15, 10, down to 5 where I stay.   I only get antibiotics for a bacterial infection [fever, colored sputum, tests to show clearly it is a bacterial inflection] and I get nothing for viral infection [have one now. Clear sputum, tired, very low fever, cough]. I finished 10 days of Levaquin several day ago for cellulitis of the finger.

My question is: I am on 5 mg. Can I try to stop my Pred completely [again] without danger and just use my Advair Diskus 500/50 and emergency inhalers?  Previously I would get 'sick' when I tried. I would like to try again.

Pulmonary Specialist said it is up to me, he doesn't know if I am 'steroid dependent' as he is a new doc I am using. [nobody ever tested me, just said I was]. I remain on 5 because it helps a back problem I have [a little bit].  I also get extremely tired and achy the first few days when I stop. Don't remember if I got sick with an infection or not. I have a history of Atelectasis and have to be careful.  Thank you.  Sheila

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A.  The answer regarding discontinuing prednisone after a taper in part depends on how long you have been on Prednisone and as you comment if you are steroid dependent. Even though you have a new physician, your old records should be available to the new doctor. If the old doctor is still available perhaps you can ask him/her. Taking Prednisone for your back is not a good idea in the long run. Prednisone is a great anti-inflammatory drug, but it also causes loss of calcium from your bones, so osteoporosis could make your back condition worse. Nonsteroidal anti-inflammatory drugs like acetaminophen, aspirin, and ibuprofen are good alternatives, but check with your physician if there are any reasons not to take them.

The symptoms you experience after stopping prednisone are steroid withdrawal symptoms. These can be minimized by decreasing the prednisone dose by 1 mg every week or two. If you have been on prednisone daily for several months, you may be able to reduce the dose from 5 to 4 to 3 to 2 to 1 to 0 mg only at monthly intervals, allowing your own adrenal glands to produce the full supply of cortisone.

If your pulmonary disease is such that it flares with cessation of oral prednisone, then you may need to be maintained on oral prednisone, perhaps every other day may suppress the disease. Inhaled corticosteroids may prevent the flare of your disease and allow you to discontinue oral prednisone altogether. However, you see you have to balance your weaning off of oral prednisone while your own adrenal glands return to full activity, the inhaled corticosteroid usually will not replace the bodies need for the full dose of the adrenal gland produced cortisone.

If your asthmatic or inflammatory component of your lung disease is controlled by steroids, the inhaled corticosteroids may do the job, unfortunately, they do not do the job for everyone.

I would try to learn if you have been shown to be a steroid responder by way of improved pulmonary function tests, try to learn if the time period that you have been on oral prednisone necessitates a slower taper off oral prednisone, that is one mg. a month and if inhaled steroids control your disease. Your physicians should be able to give you those answers or devise a plan of blood tests and pulmonary functions tests to give you those answers.  Dr. Ron

CT Scanning

Q.  Dr. I have a question on the CT scanning procedures now being advertised in my local papers. The cost of which will not be covered by my health insurance. Upper body (heart, chest, lungs) about $400.00 full body about twice at $800.00.I am a cancer survivor od a little over three years, having had my upper lobe removed from my right lung. I was lucky in that the cancer was found while still small (size of half-dollar). I have had no further problem and have X-rays taken about every six months.

1. Have you any feelings or knowledge of this procedure? If so, what are they.

2. Do you think the benefit would justify the cost? I can afford the cost if would be beneficial. www.ctscreening.com If you think others may profit by you answer, please post to list as well. Jack

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A. This new use of CAT scanning has caused a lot of people to wonder if this is what should be done. My personal opinion is that it is not. As you may know, there is not even consensus to use the chest x-ray to screen for lung cancer. The proponents for the use of the scan say that the scan will detect abnormalities early, before symptoms occur, thus allowing for earlier treatment and possibly a cure. Thus if they saw calcium in the coronary arteries, they would know that there was significant atherosclerosis which precedes a heart attack. If they saw a dilation of a large blood vessel like an aortic aneurysm that could be surgically repaired before it got bigger or burst. If a mass or tumor was seen it could be removed. The difficulty, as I see it, is that these sound good, but have not been tested. Calcified arteries around the heart does mean that there is significant hardening of the arteries (arteriosclerosis), but it does not mean there is an impending heart attack, and non-calcified areas of arteriosclerosis which would not be detected may be the cause of more myocardial infarctions. If an abdominal aortic aneurysm is detected, it is not likely to burst until it gets to be about 5 centimeters or 2 inches in diameter. There has been no significant proof that finding lung cancer earlier allows a greater likelihood of curing it. To be helpful the CAT scan looking for metastases of tumor or cancer usually should be done with both intravenous and oral contrast. This would allow metastases in the liver and spleen to be more readily seen and if lymph nodes were involved, they could be distinguished from the adjacent loops of intestine.

The hypothesis that the whole body CAT scan is useful has not been tested or proven, that is why the health insurance companies do not pay for the scan. The scan can also detect other spots which may not be real or may represent a benign process. The individual then has to undergo additional tests to ascertain if the finding is real and significant. The insurance company may pay for these follow up tests, but that drives up the cost of health insurance. If the CAT scan is negative, that does not mean you are free of disease. You could still have lung cancer (the spot has to be about 1 cm or a little less than 1/2 inch or bigger to be seen), you can have colon cancer, diabetes, or a whole host of diseases not seen by the CAT scan. In addition, you get a big dose of radiation with the study.

If you have had lung cancer, your oncologist may ask for specific blood and x-rays dependent on your symptoms and physical exam.  I have not had a screening CAT scan, even though the company frequently gives physicians the test for free.

There was an article in the Washington Post newspaper Health section (F), Tuesday, November 13, 2001, entitled "Looking for Trouble." The website is www.washingtonpost.com .Dr. Ron

FEV1

Q.  Doctor, I had a FEV1 Pred77% and Meas  87% %+ 10 I have several # just wondering , What is M V V severely reduced , and on another pft::: Severe Diffusion defect and Mild restriction ----Parenchymal.  Doctor, can you please tell me what all of it is. Thank you in advance Pup

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A. Although you did not give me all of the data, it sounds as if you have a restrictive process with impairment of the alveolar-capillary surface area. What this means is that your vital capacity, the deepest breath you can take, is small due to some process that is making your lungs small. Your residual volume, the volume of air left in your lungs at the end of a complete exhalation, should have been measured as small also, due to the same process. Your low MVV (maximal voluntary ventilation) is simply saying that you cannot huff and puff as you did as well in the past. It is related to the same process that is making your lungs smaller.

You and your physician have the task of finding out why your lungs are getting smaller and why the alveolar capillary surface area (diffusing capacity) is diminishing. This could be related to a process like Rheumatoid arthritis, a side effect of a medication or an unknown process (idiopathic pulmonary fibrosis). You may have to undergo some blood tests, a high resolution CAT scan of the lungs and maybe even a lung biopsy to get the diagnosis. It is important to learn why this is occurring to you so that the process can be halted and hopefully reversed.

Please keep us posted as you learn more and if you have additional questions. Dr. Ron

Medication for daytime sleepiness in Sleep Apnea Patients?

Q.  I went to my doc today and asked about Provigil for daytime sleepiness. He told me he was not familiar with it but would do some research and let me know. Wonder if Dr. Ron would have an opinion on this med? Barbara

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A. The drug Provigil or the generic name modafinil (moe-dah-fin-il) has been on the market for about 3 years now. It binds to certain receptor sites in the brain, causing an increase in the alpha activity and decreasing delta, theta and beta activity of the brain. This effectively reduces daytime sleepiness (as long as it is taken in the morning!). It is used in treating sleep disorders such as narcolepsy. This diagnosis is made by a sleep study utilizing EEG or brain wave measurements. The usual dose is 100-200 mg. Side effects include dry mouth, dry eyes, sweating, headache, dizziness, hot flushes, anxiety, bad temper high blood pressure, weight gain and sexual hyperactivity. So depending on your sleep disturbance diagnosis this drug may be useful for you. I would start with a dose of 100 mg and increase the dose to 200 mg depending on the effects and side effects. Thanks for your question. Dr. Ron

How Much Water?

Q.  Now that I have right sided heart failure to go with my COPD how do I reconcile my water intake? I was drinking almost my 8 glasses a day. Now, with fluid retention around the heart and in my legs I'm not sure what to do and the doctor seems not to be aware of it being a conflict. Thanks. Jean

Q.  Hi Jean, I've had CHF for several years and it is always a balancing act for me...too much fluid intake worsens the problem and leads to higher doses of diuretics and too little fluid intake, especially without a commensurate reduction in diuretics, leads to dehydration....I need a meter and alarm system....My cardio & pulmo doctors both told me to weigh every morning and assess the degree of edema and adjust my diuretics and fluid intake ........ well, that system is really a hit or miss for me.....Fortunately, my exercising during the last 4-5 months has resulted in steady improvement of my CHF and I've been able to reduce the diuretics and increase fluid intake if I want more... 

I don't know if any one has run across this problem before but I certainly hope so. I have been diagnosed with CHF and put on Lasix 20 mg as needed, with 20 mg potassium. Now here is the tricky part that has me stumped. I was told that if I gained three or more lbs over night to take the lasix. When I take it I have a tendency to dehydrate. In addition, normally with water retention the breathing would go down and peak flow would drop. Mine stays the same or slightly elevates. I am going to get a Drs. appointment next week but would be nice to have some ideas to take with me. Take care, Cecil

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A.  Dear Jean and Cecil,  Your questions about water intake and COPD are similar, so excuse me putting my response to you both in this one reply.

Right sided heart failure was discussed in my "Ask the Doctor" column in the August 1, 2001 newsletter. The problem starts with low oxygen in the lungs which in turn causes the blood vessels in the lungs, the pulmonary arterioles, to constrict, requiring an increased pressure to push blood through them. The right ventricle is a low pressure pump with thin muscular walls, it is designed to push large volumes of deoxygenated blood into the normally soft, compliant, wide open pulmonary arterioles and capillaries. It is not designed to develop a great deal of pressure. When it cannot push the blood forward into the lungs, the valve between the right atrium and right ventricle, the tricuspid valve, becomes incompetent, allowing blood to flow in the reverse direction so the liver and leg veins become swollen. This is seen as edema in your legs. In addition there are alterations in the chemicals of the blood and the blood flow though the kidneys so that salt or sodium is not excreted by the kidneys as normal, increasing the amount of fluid in the body, again showing up as swelling.

The treatment is oxygen to reduce the pulmonary arteriole constriction, and if that is not completely effective, then to reduce sodium/salt intake or take a diuretic to get rid of the extra salt water in your system. So you should not be concerned about the amount of water you drink, but the amount of salt/sodium you ingest. The less salt, bacon, prepared soups, etc., that you eat, the less sodium your kidneys have to excrete and thus less to show up as swelling.

Exercise is important as it increases the strength of your heart and increases the blood flow though your kidneys.

If your physician does give you diuretics to cause your kidney to excrete more salt water, please have your blood checked to be sure you do not lose too much potassium as this will make you feel weak.

Please talk this topic over with your Pulmonologist, so life can be made more simple for you. Dr. Ron

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Flu Shot?

Q. My daughter and I each had our Flu shots from the town on 10/30. Mine didn't really bother me, but PJ's arm hurt from the get-go and was sore for about two days. The whole arm! Must be something in the vaccine. JJ

Mr. B and I got our shots at UKROPS Grocery last Tuesday and my arm was just a tiny bit sore, but Mr. B's arm was swollen and red and hurt for 2 days???  Joan

Also, speaking of the best time to get the shots...my previous doctor told me definitely to get it in October in order to be best protected. Wonder who's right? Maybe Dr. Ron has some info on this subject.

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A. The Centers for Disease Control (CDC) recommends the influenza vaccine be given from October through November. It can be given as late as December, as most of the influenza activity in the past few years has been late December and early March. Peak antibody levels occur about 2 weeks after the vaccine and slowly subside thereafter.  One does not want to get the influenza vaccine in September as the antibody levels will be too low by the time the flu actually gets into the community.

Influenza vaccination causes fever, tiredness and soreness at the injection site in 10-64% of individuals and this may last for 1-2 days. Some people can become allergic to the preservative, thiomerosol, which could be the reason for the swollen arms. You should report this reaction to your physician so that this can be added to your record. If you get a swollen arm with the next flu vaccine then you may have to avoid getting subsequent flu shots or any vaccination with thiomerosol preservative in it. An allergist may be able to do a skin test to ascertain if the thiomerosol is the culprit. I would expect that the swelling will subside with a few more days. The application of hot soaks or cold may help it go down faster.  Dr. Ron

Taking Aspirin

Q.  Hi, Dr. Ron, I'm in a world of deep doo-doo down here with my doctors for a variety of reasons. Won't ask you to solve all my problems, just need some advice on one situation.

I cannot take Aspirin, any way, shape or form! I make a point of letting doctors, nurses, whatever, know this fact. Having taken me off my current pain med, my newest PCP recommended such meds as Advil or Motrin for me, for pain. My book on "Drugs, etc." says No. My Pharmacist says No. The doctor says yes.  Then I'm asked "Who are you going to believe - your pharmacist or your doctor?" Considering that this PCP does not know me and had not yet gotten my old records from my previous doctor, guess what I answered!

Bad choice on my part. It was flippantly remarked that I should get a new doctor. (This was done all over the phone. I've not seen anyone from the office, yet.) This IS a new doctor - and I can't even get an appt. with him for 6 weeks! And my HMO only allows you to change "on the month". There is no easy solution for me, but how would you handle the above question?  Claire - Sunny Florida - Today, at least~!

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A. The answer to your question relates to the reaction you had when you did take aspirin.  Aspirin (ASA) is the common name for the drug Acetylsalicylic acid. Reactions to ASA include acid indigestion, bleeding from the stomach or the duodenum (the first part of the small intestine after the stomach), bleeding into the skin, impairment of kidney function and allergic reactions such as asthma, nasal polyps and sinusitis, severe dripping nose.  Individuals with true allergy to ASA should not take any aspirin containing products and should not take the nonsteroidal analgesics such as Ibuprofen (Motrin, Advil, etc.), naproxen (Naprosyn) and all the others. The new COX-2 inhibitors are labeled not to be used by individuals allergic to ASA, but there are studies that show Vioxx is probably safe.

So depending on your reaction you will get different responses. If you just had heart burn it would be safe to take the other medications, if you had a severe asthma attack, you should not take them.

You may need to discuss your reaction to aspirin in the past and why you avoid it now. This new doctor is indeed new and just needs to learn about you. Thank you for the question.  Dr. Ron

Information on Respirators

Q. Hi!  My husband has end-stage emphysema and COPD and he is presently in the hospital with pneumonia.  They want to put him on a respirator.  Can anyone provide information on this.  Thank you.

Ray was totally mobile before the pneumonia. He is not able to work and such but he takes our five year old daughter to school and runs errands and such. Through some miracle the pneumonia is letting up and he is getting better. I knew someone on line once who I have lost contact with whose husband was on a ventilator and Mike went to the doctors and such but other than that was confined to a chair and/or bed. However, he was mentally alert and such. Doctors have told Ray that they are not sure they will be able to remove him from the respirator if they do eventually put him on one.

He only has 15% lung capacity. He is presently awaiting a lung transplant through Temple University but we are at the beginning stages. He just completed the numerous tests. I know that his heart is in very good shape because when we met with the heart doctor he said that he had never seen a transplant patient with such a healthy heart and he meets with all the lung transplant patients. Ray has only been disabled since 2001. He was a truck driver and was no longer able to do the work. We finally gave in after he lost four jobs when he had never been fired before.

I need information on the quality of life after being placed on a ventilator. I mean could he come home and be homebound but still watch TV and read to our daughter and give her a little more time with her daddy or would he be comotose? The pulmonary doctor the other day told me that he had a clear path I should let him take it.

However, I have heard over and over again that doctors hand out life expectancy's too easily. This doctor told us that Ray has like six months to a year left.  I have heard quite a bit recently about heavy doses of vitamin C and antioxidants and such. I am going to look into this and load him up on them. What do we have to lose, we are staring death in the face now. Thank you for your help.  Cheryl

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A. I am sorry to hear of your husbands poor health and of the predicament you both are in. Have you and your husband discussed this possibility or has he given you any inkling of what he wants to do in this situation?

You say he has end stage COPD, but that is not a well defined point. How well was he functioning before this pneumonia? Has he been on a ventilator before? If he was bed bound and not able to do the usual activities of daily living or if he was on a ventilator before, then you may not want to put him on a ventilator now. However, if he did get around and seemed to enjoy his life and if he has never been on a respirator before, then perhaps you should give it a trial. You could discuss a limited trial of the ventilator like 10-14 days to see if the pneumonia can be controlled and if your husband can get strong enough to come off the ventilator. If, at the end of the trial, he cannot be weaned off the respirator, then he can be made comfortable with morphine and Valium or similar medication as the ventilator and the endotracheal tube are removed. Sometimes, to our surprise, the individual does not die immediately, but at least they are no longer on the breathing machine. Your physician should agree to keep your husband comfortable.

If he does survive this episode, please talk about a living will and discuss some of the scenarios such as ventilators, feeding tubes, cardiac resuscitation and surgery so that both of you will know what he wants in the future. You should also tell him what you would want in those situations also, for although one thinks he will die first, one never knows. Then let your family and physicians know both of your thoughts. The written living will is helpful if there is any concern about an individuals intentions, but is only necessary if there is some disagreement as to those perceived wishes.

Please talk with your husband, his physician and anyone else like a chaplain or your own religious person for help in understanding your husbands wishes and options. Thanks for your question, I hope it works out well for you both. Remember, we are here for you. Dr. Ron

Prednisone Taper and Pulmicort

Q.  This question came up when I was reading your answer regarding tapering off prednisone.  I have been using Pulmicort for two years. One puff twice a day. In that period of time I have grown cataracts in both eyes and am now being told by my internist that I most likely have developed osteoporosis also. Because I see my eye doctor every year and the cataract problem popped up very quickly (I am having the second eye operated on Tuesday) and because my internist says that he had not seen evidence of osteo before ( I see him yearly also) I have to wonder if it is because of the Pulmicort. I am 57 and there is no history of osteo in my family. ( was tested for osteo 2 years ago and it was negative).

My question is this - if I also use Foradil twice a day and combivent when needed, how important is the use of Pulmicort. When I began the Pulmicort I was under the impression that it did not have the same side effects as oral steroids, but that does not seem to be the case for me. I also have a large component of Asthma along with E. I guess I am just wondering if I could get off the stuff and would I have to taper also.  Thank you for your help.  Pam

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A. Pulmicort is an inhaled corticosteroid, budesonide. At one inhalation twice a day, you are receiving a relatively low dose. About 35% of the drug is inhaled into the lung and does get into your blood stream. Thus it is potentially capable of having effects on the rest of your body, but it is a low probability. Foradil is a long acting bronchodilator, a beta agonist, without any corticosteroid in it. It would be reasonable to ask your ophthalmologist if the cataracts are located in the posterior subcapsular area, where corticosteroids usually produce cataracts. You might also ask the ophthalmologist if they think the corticosteroids are the cause of your cataracts, as there are multiple causes. Osteoporosis is similar, in that the dose of budesonide you take is low. Again you should ask your physician what they think is the cause of your process. As you say you have an asthmatic component to your lung disease, the inhaled corticosteroids are the best anti-inflammatory drug we have. You may want to talk with your pulmonary physician if you can reduce Pulmicort to one inhalation a day and/or if you would benefit from a trial of an anti-leukotriene drug such as Singulair. This drug is not as potent as the inhaled corticosteroid but can be additive to its effect without affecting your eyes or bones. It would be interesting to learn to what your physicians attribute the cataracts and osteoporosis. Thank you for your question. Dr. Ron

Steady Cough

Q.  For the last two months, I have been cursed with a steady cough. In the morning I feel fine but within 30 minutes I start coughing.  At first I cough up some green mucous and then smaller amounts of same after which I cough up small amounts of clear mucous all day. After coughing up anything, my chest feels clear but only for a few moments. My GP gave me Prednisone and Biaxin, but this didn't help. A second GP gave me Atrovent nasal spray and Combivent inhaler, 2 puffs three times daily. This didn't help. A pulmonologist gave me Flonase nasal spray and increased the Combivent to 3 puffs, 4 times daily. He also gave me Guaifinesin, 1200 units twice daily. This has not helped either except that the coughs are now more productive. At this point, I am coughing up more mucous than before and a lot more of it is green. I have mild empysema but I am functional. I walk a few miles every day including some very steep hills. Only strong exertion leaves me SOB. The inhalers have helped in this regard. I am wondering if I could have an infection of some kind that the Biaxin didn't cure. What is puzzling to me is that aside from this terrible cough, I feel OK. No fever or anything. Does anyone have any ideas?  This cough is making my life nightmarish. Any suggestions as to how to stop this mucous  will be much appreciated. Joseph

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A. You have simple chronic bronchitis. The green phlegm you coughed up first thing in the morning may not have been due to a bacterial infection. Sputum which has inflammatory cells, like polymorphonuclear leukocytes, in it, if allowed to sit in a sputum cup or overnight in your bronchial tubes will break down allowing green enzymes to be liberated. So initially, you may not have had a bacterial infection, so an antibiotic would not help. Now that the green sputum is persisting thorough the day, it is more likely that you now have a bacterial infection. Your physician may want to give you a course of ampicillin (if you are not allergic to penicillin) or trimethoprim sulfa or doxycycline or maybe do a culture of your discolored phlegm to learn the name of the organism and its sensitivity to particular antibiotics. There are lots of antibiotics your physician may want to try, but please take it for at least 10 to 14 days to eradicate the bug. Great question. Dr. Ron

Asthma Diagnosis vs Emphysema

Q.  I just returned from Temple Univ. Hospital where I went for a second opinion for my E! The doctor seemed unsure that what I have is just E.  He said that my last three year PFT's were contradictory. He has me coming back in three weeks to get advanced PFT's, and a cat scan.

He would not say what he is looking for but indicated possibly asthma.  My question to you Mark is this.  Can asthma mask itself as the big E?  He said that my chest x-rays show him nothing but hyper inflation, I thought that was Emphysema.  Please enlighten me!! Thanks, Sue

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A. Your consultant is correct. Asthma and Emphysema both make the lungs larger or appear hyperinflated on the chest x-ray. Asthma is a disease of the bronchi with reversible bronchoconstriction whereas Emphysema is a disease of the alveoli or air sacs, with destruction of the walls and blood vessels, it is not reversible. Pulmonary function tests looking at the expiratory flow rates, that is, the FEV1 before and after inhalation of a bronchodilator, the residual volume and the diffusing capacity should be able to distinguish between the diseases.  A high resolution CAT scan of the chest can show the holes produced by emphysema, whereas the lung in asthma is normal. I am glad that this second physician is being thorough. Thanks for the question. Dr. Ron

Prednisone

Q.  How long does it take to get prednisone out of the system?

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A.I hope your e-mail address means you finally got that coveted Corvette. Your question is a straightforward one, which in reality is complex.  If I were to take one 5 mg. Prednisone tablet today, the drug would be out of my system within a day.  If I took that tablet every day for 2 weeks, I might have an increased appetite and feel more euphoric, but once I stopped, again, the body would not know that I stopped. If I took that one pill a day for three months, my own adrenal gland would be suppressed from producing corticosteroids, and it would take up to 6 months for my adrenal gland to be fully operative again. If I needed surgery during that 6 months, my physicians would give me supplemental corticosteroids to be sure I had enough during the stressful period of the surgery and recuperation.  If you are asking how long before the side effects of Prednisone disappear, again, it depends on how much and how long you took the medication. If you got elevated blood pressure or diabetes as a consequence of the corticosteroids those usually resolve within a month or two after stopping. If you got a cataract or osteoporosis, that does not go away even after you stop the medication. I hope this answers your question, if not, please let me know. Dr. Ron

Dark Spot

Q.  Please guys, I would appreciate some urgent comments on this e-mail that I received from a very dear friend living in the UK. For some reason I could never persuade him to join Efforts. He always maintains that he is an ex South African and preferred corresponding with me. As if I am in any position to dish out medical advice! From previous letters I know that Colin is a very worried person. Hannes (South Africa)

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A. Thank you for forwarding the message from your UK friend. You are correct he should join EFFORTS just to be aware of what other people are experiencing. Remind him that there are no dues and to the best of my knowledge no "cookies" are inserted into your computer.  Regarding the questions:

1) No, it is not possible to say with 100% certainty that a dark spot is simply a scar. If you had prior x-rays which showed the scar there 3 years ago with no interval change, then you comfortably be assured that it is just a scar. If one had a pneumonia seen on x-ray before and the scar is in the same area, then it would be likely to be a scar, but again one cannot be completely sure. There is an entity called "scar cancer."  2 & 3)  I presume that you do not have old x-rays showing the scar, then a followup CAT scan would be reasonable, in the USA we usually do that in 3 months, that would be in December. March would be 6 months. Since cancer can develop in a scar it is appropriate to have the followup exam. 4 & 5) Since you have not seen the same physician more than once, makes it difficult to answer what they are thinking. It would be helpful to clarify your thoughts about surgery. Obviously, if you do not want any surgery for any reason, followup is not so important. However, if you would undertake surgery, either LVRS or a cancer surgery, you have to make that known to the physicians. The high resolution CAT scan of the lung can tell the physicians about the severity and location of emphysema. It has recently been learned that people with diffuse emphysema do poorly with LVRS, and thus the procedure is now only being offered to people with disease localized to the upper lobes and who show evidence of hyperinflation with low flat diaphragms. Perhaps you should see Dr. Williams at the Halton Hospital, and you could notify his office that you want to talk about your x-rays and your diagnoses and prognosis. This might insure that he would get your x-rays and review your folder before the visit.  Let us know if you have other questions and how this works out. Thanks for the questions.   Dr. Ron

Pseudononas

Q.  I periodically have this condition.. am put on antibiotics.. it clears then I get it a few months later. is there anyway of avoiding it and must I have treatment each time.? Marie in Singapore

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A.Pseudomonas is a bacteria which is not usually a cause of infection in folks with COPD with the exception of people with Cystic Fibrosis. The latter diagnosis can be made with a sweat test, and this diagnosis would be important to make as the treatment is a great deal different from the usual program of people with COPD.  

Pseudomonas can also be seen in people with bronchiectasis. Bronchial hygiene like postural drainage and chest vibration can help in this situation. Most of the time, Pseudomonas is the last organism cultured after an individual with purulent bronchitis has been treated with either multiple sequential antibiotics or after a course of a strong broad spectrum antibiotic. If the individual is doing well though the sputum is thick and green, one may take the approach of encouraging drinking of water to keep the secretions thin and no more antibiotics, allowing normal bacteria to grow back into the trachea and bronchial tubes, displacing the Pseudomonas. If the individual is sick with the Pseudomonas organism, treatment with Cipro or other anti-Pseudomonas antibiotic would be appropriate. Thanks for your question.  Dr. Ron

How Much Trouble Are We In?

Q.  My husband is in the hospital for the 3rd time this year,  He has never really recovered from the first time when he was in there with pneumonia in Jan.  He would get to feeling better and would try to get back to rehab would get ill again and go back on antibiotics, get to feeling better and back to rehab and on and on.  About a month ago he got a severe pain in his back.  The Dr. sent him to have a CT scan and a type of x-ray where they injected dye.  Still they said nothing was found.  Went to a heart specialist and he said nothing was wrong with his heart.  He would  desat with any activity.

Finally the hospital Pulmo looked at the x-ray and had a test run on the sputum and said he had an infection in the right lower lobe and ordered major antibiotic IVs, breathing treatment and percussion treatments on the lower right side.  I believe we are on the right track finally.  I also believe this has been the trouble for a very long time. My  question is:  Just how much trouble are we in??

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A.  I am sorry that you and your husband are having such a difficult time. It is difficult to say how much trouble you are in. From what you have written, I cannot tell if the CAT scan was of the back or of the lung. If it was done of the lung entities such as pneumonia and bronchiectasis should have been seen. If there is recurrent infection in the right lower lung, the physicians may want to look at sputum cytology to see if there are any malignant cells from a tumor in the bronchus predisposing to the recurrent infections. Another way is to do a bronchoscopy to look into the bronchial tubes to determine if there is a tumor or something else that could be partially blocking the bronchial tubes of the right lower lobe. The physicians may also want to look at your husbands blood for the concentration of immunoglobulins IgA, M and G. Sometimes we can become deficient in them and thus lose the ability to fight off infection. Please share these ideas with your husbands physicians and please let us know what happens. Thanks for your question. Dr. Ron

CMV Virus

Q.  Have a patient waiting for transplant. What is this kind of virus is CMV?

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A.  CMV stands for the Cytomegalovirus. It is a common virus with the incidence of infection increasing with age. It is transmitted sexually, by blood products, transplantation of bone marrow and organs and can be picked up from people at day care centers. It usually asymptomatic but can produce a disease similar to Mononucleosis which is caused by the EB virus (Epstein-Barr). One gets fever, fatigue, muscle and joint discomfort. Blood tests show a predominance of a particular white cell (the Monocyte) and abnormal liver function tests. This resolves spontaneously in the normal person. Unfortunately, people with immune systems compromised by infection with the HIV virus or by medicines to prevent rejection of bone marrow, solid organ transplants like lung, heart, kidney, one may require treatment with hyperimmune globulin intravenously or medications like ganciclovir and foscarnet. The compromised individual cannot control the spread of the virus which goes on to cause infection and inflammation of the surface of the brain (meningitis), pneumonia, hepatitis and the retina. The infection can cause the person to die.  The individuals physician would be best prepared to tell why they are testing the individual. Dr. Ron

Just want to ask opinion on this...

Q. Diagnosed in 1997 with Severe COPD - acute bronchitis...Doctor said I could only breath 35% of  what normal people could breath. Stopped smoking in 1996 and CONSTANT cough stopped at the same time.  pneumonia/bronchitis (never found out which) and respiratory failure in 2000.  I do not have a cough.. I do not have mucus.. How could I have been diagnosed with acute bronchitis??  Thought this meant coughing, mucus, etc..Thanks.. Marie

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A. I agree bronchitis is cough and mucus production so it is hard to ascertain why you were given that diagnosis. Maybe your physician can explain. Thanks for the question. Dr. Ron

Making COPD Worse

Q.  I realize that the damage I've done to my lungs from over 50 years of smoking is done, and isn't going to be reversed.  My question is, what is going to make the COPD worse?  If I avoid infections, avoid pollutants (already quit smoking in June), could I then have a REASONABLE expectation of not getting any worse?  Or is old age gonna do me in with the disease?  Shari

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A. Do not smoke, avoid folks who are smoking around you, do not dwell on your disease. It sounds as if you are doing well. Exercise, good nutrition and good sleep habits are already in your agenda, so you are doing all the good things. Get your influenza vaccination before the end of November, be sure you have had a pneumococcal vaccination. Unfortunately, all of us lose lung function normally, after the age of 18 yrs. People who are active cigarette smokers with COPD lose breathing capacity at an accelerated rate, but this rate slows down after stopping smoking. The cessation of smoking reduces the inflammation in the bronchi so that cough and sputum production decrease markedly after about two weeks. The cilia and the bronchi heal over the course of the year. Any destruction of lung sacs is not repairable. The likelihood of developing lung cancer decreases over the course of 10-20 years. You should enjoy your life. I would not worry about your Mother. My philosophy has been to tell my loved ones of any ailments and conditions early so they do not worry. If one talks about the health problems usually it is easier to communicate. If you try to hide your health concerns Mother may already be aware and be concerned. She might be comforted that you are taking care of your health. It depends on your relationship with your Mother.Thanks for your question. Dr. Ron

Maximum Dose/Flovent

Q.  Hello my friends - My Doctor, in response to me telling him I've been more sob, has prescribed FloVent, Diskus, 250 u.g. 2 puffs 2 x day instead of FloVent Inhaler, same dosage. Also, am on Salbutamol and Atrovent, 2 puffs every 6 hours. He said the FloVent Diskus should help me cut down on the usage of Salbutamol and Atrovent. Is the FloVent Diskus any better than the Inhaler? It's just in powder rather than liquid isn't it?

What is maximum allowable doseages of Salbutamol and Atrovent? I was starting to take them about every 3 to 4 hours instead of every 6 hours. Is that too much?

My emphysema is quite bad - on oxygen 27/4: 3 at rest, 4 light activity, and 5 or 6 for heavy activity. At night I sometimes use 4 lpm. Some nights I seem to wake feeling 3 is not enough. Joyce

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A.  Dear Joyce, Thank you for your question. It has several layers. Atrovent does not seem to have any upper limit of use, so using 4 separate inhalations from the metered dose inhaler (MDI) four times a day should not be a problem.

Regarding Salbuterol, the official dose is 2 separate inhalations four times a day from a MDI. If you take too much, your heart rate may become fast, you may get muscle cramps. Frequently, the addition of Salmeterol MDI two puffs twice a day helps by prolonging the effect of the beta agonist bronchodilator Salbuterol.

Regarding Flovent, the amount you get from the MDI and from the Diskus should be about the same. In reality, each activation of the MDI dispenses

220 mcg. of Flovent into the mouth. A great deal of this is squirted onto the back of the throat and is swallowed, surprisingly, only 10% or thereabouts gets into the airways. The Diskus dispenses 235 mcg. is the inhalation rate is 60 liters/minute. The idea is that since it is breathe activated, most of the powder goes into the lung and less into the stomach.

I have not seen data to say how much goes into the lung. The conversion from the MDI to the Diskus would be worth a try to see if you do better after a month. There is a larger question here, since you say your diagnosis is emphysema, does the inhaled steroid do anything for you. Corticosteroids reduce inflammation produced by eosinophiles in the disease of asthma, but do not do much for the neutrophilic granulocyte inflammation seen in chronic bronchitis. For an acute exacerbation of Chronic Bronchitis, a high dose (40 mg) of Prednisone for ten days appears to be helpful, but extending that course does not seem to help breathing or pulmonary function. So you may want to discuss with your physician if the inhaled steroid is doing anything for you. One way to ascertain if you do respond to corticosteroids, is to do a Spirometry, take 40 mg. of Prednisone for 2 weeks and then repeat the Spirometry while on the Prednisone to see if there is any significant improvement. If there is then your physician will want to reduce the Prednisone to the lowest effective dose. Some of Prednisone sensitive individuals will be able to be switched to inhaled steroids with preservation of the improved Spirometry. If the 40 mg. of Prednisone trial does not change your Spirometry, the Prednisone should be discontinued and you would not benefit from the inhaled steroid.

With regard to your oxygen requirements, you might want to see if your pulse oximetry drops at night when you are on 3 liters of O2. Have you considered the use of Transtracheal Oxygen (TTO). This type of oxygen administration can result in less oxygen use and frequently improves the quality of life. I believe the main site of EFFORTS has information on this technique.

Please feel free to share these thoughts with your physician.  Dr. Ron

Flu Shot Booster?

Q.  I was at the pulmonary DR Thursday, he asked if I wanted my flu shot. I asked wasn't it too early he said no that I took them every year so I had an immunity build up so this was like a booster shot. If I wanted to I could get another one the end of Dec. or Jan it would not hurt to get two but I did not need it. I trusted what he told me & got it. Do you here at EFFORTS think that was right what he told me? Maxine

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A. Each year the influenza vaccine is designed to protect against the influenza viruses that the Center For Disease Control (CDC) feels are going to most prevalent that year. Each years vaccine is usually different from the last, so companies have to manufacture a new batch each year. Thus your doctor saying that the vaccine is a booster is not wholly correct. The vaccine causes your body to produce new antibodies to the substances in the vaccine. If there is overlap with last years vaccine then the low level of antibodies still present from last year would be enhanced or boosted. It takes about 2 weeks after a vaccination to see significant levels of antibodies in your blood. The CDC suggests that the vaccine be administered between October-November or later if the vaccine is not available as was the case last year. Giving the vaccine in September is usually a little early, as our usual influenza season typically is late December to February.

However, the CDC says that if it is unlikely that an individual would not be able to get the vaccine in the Oct-Nov. time period, it can be given earlier. The CDC does not make any recommendation about a second flu shot later in the season. I do not think Medicare pays for more than one flu vaccination per season. So consider yourself vaccinated for this year as I presume you received the new vaccine and not vaccine carried over from last year, though you might want to ask to be sure. In future years I would wait until October-November to get your shot. Thank you for your question. Dr. Ron

Breathlessness and FEV1

Q.  I was wondering if you could answer a question about FEV 1's. Mine is not bad and only at well between 50% and 60% depending on whether I am sick or not. Then I see other peoples that are so much lower than mine and they can do more than me. I have always been a very busy person so I don't lay around and I do exercise. I have also been to rehab twice. What makes it so hard for one person to breath when there FEV 1 is not that low. Just curious because sometimes it just doesn't seem like numbers match up to how breathless we each are. Kathy

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A.  The relationship between the FEV1 (%of predicted) and FEV1/FVC ratio and the symptom of shortness of breath or dyspnea in not a clear one. There are people like you who have a reasonable FEV1, but are more short of breath with less exercise tolerance than someone with a lower number. Some explanations suggest that the addition of the diffusing capacity which is a measure of the air-blood interface in the lung called the alveolar-capillary membrane is lower in the more symptomatic people. Others talk about physical fitness, the couch potato not having the strength and endurance of the active person. Some others talk of psychological factors or other health problems like heart failure. There is no easy answer to your astute question. I think that it is important that you remain active and follow up those exercises you learned in Rehab. You may want to ask your physician if there are any complicating factors which may be contributing to your shortness of breath like systolic or diastolic heart dysfunction, hypo- or hyper-thyroidism, or electrolyte imbalance. Sorry that I cannot not be more definitive than that.   Dr. Ron

Increased Weakness After Exercise

Q.  This is complicated so bear with me, please. I have had an increasing weakness in my lower body for two or three months. Exercise seems to increase weakness not improve my muscle mass as before. Went to the DR last month and was told that she could find a very weak pulse in my right leg and intermittent and weak in my left. Now my question, I have noticed in the past week or so that after I complete one of my exercises and take an oxymeter reading it is not consistent, at times. For example, after 15 reps of chair aerobics my SATs showed 97%, pulse 103, for about two seconds and then the pulse jumped to 131 and the SATs dropped to 89% in a split second. With pursed lip breathing it then started coming back up gradually. I Have replaced the battery in my oxymeter and Checked my pulse reading against my blood pressure cuff (digital). My daughter is a nurse at a nursing home and I borrowed one of their finger oxymeters, mine checked out exactly. I am scheduled for vascular study next month but I can't even find anything on the web like this. Any suggestions, other than need mental evaluation, LOL. Take care, Cecil

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A. The fact that your lower body feels weaker with exercise, together with the finding that you have decreased peripheral pulses in your legs, suggests that perhaps you have vascular disease involving the arteries to your legs and lower body. Your physician may ask you to get a Doppler study of your legs to see if the blood flow can be quantified by way of a simple sound wave test which does not require anything other than a probe on your legs and blood pressure measurements at several levels on your legs. If this test is suggestive, the next step would be to do an angiogram, that is, injecting a substance which is seen on x-ray as white. This could be injected into the artery by way of a catheter put into the artery by way of a small cut in your groin. The same catheter can be used to dilate narrow sections of the artery to increase the blood flow at the same time of the substance injection. The medical term is doing an angiogram and percutaneous angioplasty.

I do not think you lung is producing this problem. I do not have a good explanation for the drop in the pulse oximetry unless the flow from the legs is so slow that the desaturated blood from your exercising leg muscles takes a longer time to get to your fingertip. That is more theoretical than something I have seen. Let us know what you learn. Thank you for your question.  Dr. Ron

Can Exercise Improve Diffusion

Q.  I had PFT done last week after receiving report from PET scan of a suspicious nodule in right lung. My doc wanted to do a needle biopsy but after conferring with surgeon, radiologist, etc. they decided, because of its location and size (1cm) they could not do it. I will have another scan in a few months to see if it has grown any but my doc is very pessimistic about the whole thing. Thinks surgery would be too dangerous due to past experience with surgery. My FEV1 is down to 55 from 59 but diffusion is 35. The diffusion seems to be what he is basing his reluctance on. My question is - is there any way to improve diffusion with exercise or anything else? I am on 02 pretty much 24/7. Thanks for any input! Barbara

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A. Thank you for your question. I agree with Mark that there is nothing you can do to increase your diffusing capacity. What is important, is why is your diffusing capacity reduced?  As Mark has related, the FEV1 of 59 falling to 56% (presumably of predicted) suggests that your disease is not obstructive, i.e., not simple chronic bronchitis or emphysema. However, without seeing your complete PFT'S I cannot render a diagnosis. If you do have a restrictive lung disease, some of these are associated with the development of both benign and malignant nodules. If this 1 cm. nodule is deep within your lung tissue, inserting a needle through the lung and into the nodule would be associated with a high likelihood of developing a collapsed lung due to air leaking out of the lung and producing a pneumothorax. Depending on the size of the air leak, you could get into trouble breathing perhaps even requiring the insertion of a tube into the air space, a chest tube. Depending on your pulmonary diagnosis and your other health situation, watchful waiting may be the best approach. However, it is your body and you should ask your pulmonary physician if the concern relates to your experience with prior surgery or his experience with people similar to you. If you do not feel comfortable with the discussion, you should seek another opinion.  Please let us know what happens. Thank You.

Do I Have Bronchiectasis

Q.  Hi Online gang;  Been going thru lots of tests lately and also started qualifying rehab again.. this time for transplant and not NETT.  I'm going to write in the latest on my testing at Henry Ford Hospital in a few days when I'm done.  But first I have to mention something strange for you to think about.  I am testing at Henry Ford because U of Michigan disqualified me due to age.  I am 63 and Ford will do Medicare lung transplants until 65.  The doctor at Ford said that I should have a double transplant due to my bronchiectasis.  Ford has done 56 transplants from 1988 to 2000.  I then talked to Pittsburgh and they told me that they would not do a double past age 60 do to extreme risk.....they have done 468 transplants during the same time frame. They also mentioned that some of their referred patients who were advised that they had bronchiectasis, were reexamined at Pittsburgh and no sign of bronchiectasis could be found. I only have my heart catherizations to go through yet...both left and right.  I'm really vacillating on my next move.  I have time to think it over due to the long wait ahead.  any suggestions from experienced members.  Will let you know more as it occurs.  Larry

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A.  The question asked by Mr. Hempsall is a difficult one. Each center seems to have its own criteria for lung transplant surgery. The first question is does he have bronchiectasis? This could be a diagnosis made by bronchography or by high resolution CAT scan, or some other means. I think if he has a suppurative disease of both lungs that he would be treated like a person with cystic fibrosis. I don't think one would do well postoperatively with immunosuppression and persistent infection in the unoperated lung. The other question relates to his choice of hospitals. Personally I would want an institution who does a lot of them and has good statistics. How does one find out? I just put lung transplants into my CompuServe site and came up with 5000 sites! I looked at a few.   www.hcfa.gov/medicare/lunglist.htm  is a list of the Medicare approved transplant programs.  www.patients.unos.org looked like a good site with one area entitled "transplant 101" which was a general information area, it looked helpful. < www.webcrawler.com/health/procedures  > was the Gale Encyclopedia of Medicine. I am not aware of this encyclopedia, but its general information sounded appropriate. < http://medhlp.netusa.net > was a self help site. It looked as if it should be explored. Thanks, Dr. Ron

Secondary Erythrocytosis

Q.  This is one side effect of lung disease that we have never discussed on this list that I am aware of.  I was wondering if you would ask Dr. K about it and if it possibly is the cause of our leg cramps that seem so common to those of us with emphysema. (Secondary Polycythemia) http://www.merck.com/pubs/mmanual/section11/chapter130/130b.htm

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A.  Thank you for your question about leg cramps and polycythemia. To the best of my knowledge, the two are unrelated. The Merck Manual article on polycythemia is well written. The etiology of leg cramps is not really known. I know that the beta agonists, like albuterol, stimulate the beta receptors in striated muscles also, causing finger, hand and possibly leg cramps.  Theophylline can cause leg cramps. Usually these medication induced side effects decrease over time or with a reduction of dosage. People have used Vit. E, quinine water and stretches of the calf muscles to reduce these painful cramps which usually occur at rest and even when going to sleep. If the leg cramps occur with walking or running, one has to be concerned about arterial insufficiency of the legs. There are noninvasive tests as well as arteriographs which can make this diagnosis.  Dr. Ron

Reducing Prednisone and SOB

Q.  I have been trying time and again since March last year to reduce intake of prednisone as the possible negative side effects of this medication are frightening. Every time I got down to 15 mg or under, I had to drastically increase after a while as SOB was becoming unbearable. Having conquered one addiction (three years today!) I seem to have developed a new one. It appears as if I'm doing much better this time round as I've been on 7.5 mg per day now for over a month and it really seems that I'm holding surprisingly well. I plan on reducing to 5 mg pd from 1 September.  Problem is I'm also using Flixotide 500, (Flovent), a corticosteroid presented in what is locally described as an Accuhaler (discus?) - 2 inhalations per day. As 500 is the upper concentration available, I am now uncertain what my daily intake of prednisone really is. Shouldn't inhaled prednisone also feature in the equation when formulating a weaning program?  My pulmo didn't mention this. Hannes (South Africa)

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A.  Regarding your question about weaning from Prednisone, there are several points. Your body is dependent on Prednisone. Your own adrenal glands make about 5-7.5 mg each day. At the higher levels of oral Prednisone your body becomes physiologically dependent on it. Your own adrenal glands do not produce Prednisone as they see plenty floating around. This is different from the addiction people experience with alcohol, opiates or cocaine. Alcohol and the others are a brain disorder, the brain is different as a consequence of using the drug. This does not happen with Prednisone.

If your lung disease is controlled, you can slowly reduce Prednisone, but when you get below 10 mg a day, you may have to reduce by 1 mg every 1-2 months while your own adrenal gland awakens and slowly resumes producing Prednisone. If your lung disease is not stable, you may not be able to reduce the dose and may actually need to increase it.

The inhaled Flovent is certainly a steroid and some of it does get into your blood stream either from that which is swallowed into the stomach, or that which is absorbed from the lung. This dose is variable and at this stage of your weaning you should not try to calculate it into your total daily Prednisone dose.

Please do this weaning with the guidance of your physician, who may want to check your Pulmonary Function Tests. If you are doing well, you may be converted to dexamethasone a corticosteroid which is not detected in blood cortisone tests so that a blood cortisone test would reflect your own adrenal function. Dr. Ron

Pain on Left Side of Chest

Q.  I have severe pain off and on on the left side of my chest and I would like to know if anyone else experiences this. I also have it on the right side but not as bad. Oh yes and I just had an angiogram so it is not my heart.  Maybe the good doctor could give us some input. My doctors and most others say there is no pain in the lungs. They have said some of it is from scar tissue but I wouldn't think that could cause so much pain. Anyway any input would sure help. This time it kept me down for 2 days and then I am drained from lack of sleep. I know I should go to the doctor but I kind of get tired of bothering them.  I do take 500 mg of Hydrocodone(spelling)as needed usually about 4 a day. Kathy

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A.  I agree with your physician, the lungs do not have pain fibers. However, you are having pain, there has to be an explanation. Pain can come from the pleura which lines the inner side of the ribs, from the nerves in the chest wall itself and if pinched by the spine. You may want to see a specialist in pain management, or a physical medicine specialist. The first task would be to find out why you have pain. The character of the pain would help narrow down the possibilities. Did you have shingles and this is left over pain, do you have a collagen vascular disease with pleurisy, do you have a tumor of the pleura, do you have any spine abnormalities which could pinch the nerves? There are a lot of possibilities, so I would continue to learn the cause and then treat the cause. Please let us know what happens. Thank you for your question. Dr. Ron

Body Cramps

Q.  I've been having severe, at least hourly, hand, foot, leg, rib, jaw cramps. I tried all the good suggestions made and none worked. (Heat helped a little but not when I was out of the house or busy.) Then I realized I had been 24 hours without a cramp. The only "new" thing seemed to be a serving of seaweed that I had had the day before. That was last Thursday and I have had only minor spasms, starting late Monday, since. Assuming it was the seaweed: Is it the Iodine? Or is it the thyroid function? I have been very hypothyroid years back but currently the docs tell me I don't need supplementation. Do I, because I'm 20 years postmenopausal, need more thyroid function (or more iodine) because of the lack of estrogen? If it's albuterol that's causing the cramps I/we can't get away from it, so does it mean that thyroid/iodine can counteract some of its side effects? And if so, would more seaweed make albuterol less effective?

Hope this makes sense. For  specifically: is this scenario scientifically credible? And, are there dangers in trying to increase dietary iodine or are there better ways to take advantage of its possible benefits? Polly

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A.  Your question about cramps is intriguing. There was something metabolic going on. My first concern was an imbalance of calcium. Seaweed does have iodine, but I believe it has a number of other elements in it also. It would be hard to get an overdose of iodine by eating foods, and as you know, most commercial salt has iodine in it to prevent low thyroid function. I am pleased that you are better, but I would suggest you see your physician and asking for a metabolic profile to check on your calcium, magnesium and phosphorus. I do not think that your thyroid could recover in 24 hours after eating the seaweed, but the thyroid blood tests are readily available. Let us know what you learn. Dr. Ron

Frequency of ABGs/Chest Xrays

Q.  Should ABGs and chest xrays be done at least once a year?  I can't even remember the last time I had either of these.

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A.  The frequency with which chest x-rays and ABG's should be done is not set in any rule book. It all depends on your lung disease. If you have asthma that is under good control and you are leading a normal life, you would have no need for these tests. You should get Spirometry done every 6 to 12 months to be sure that you are not losing function silently. If you have COPD but your Spirometry shows your FEV1 is well above one liter, there is no need for follow-up ABG's. If you have severe COPD and are on long term oxygen therapy, I believe an ABG should be done annually, but again there is no ruling written anywhere. There is no criteria for Chest x-rays. I think an annual one for an ex or present cigarette smoker is helpful, but this can be disputed. Some might say that individual should have a screening spiral CAT scan, but again that is debatable. If you have any concerns, just ask your pulmonary physician for a recommendation. Dr. Ron

Edema/Dehydration

Q. (1)  I seem to have this up-and-down problem with edema and would like to get some views on it.  When the edema was very severe, my pulmo increased and even mixed diuretics.  At one stage I was taking 4 Lasix 40 mg pd as well as up to 6 Plenish K (potassium for cramps) 600 mg pd. I eventually seemed to get the swelling down and reduced drastically. In my latest fight against edema I have been on 1 X 10 mg Unat plus 3 X 25 mg Aldazide tablets pd, no potassium. I now find that although the swelling again subsided and I reduced the Aldazide to one tablet pd, I seem to have dried out and now face possible dehydration! It seems a no-win situation, if the edema doesn't get you, the dehydration will.

Q. (2)  How do I establish whether I'm tending toward dehydration? What are the symptoms? Must I stop diuretics completely when I do become aware of drying out? When and in what quantities must I take diuretics when the swelling starts again? How can I maintain an acceptable balance with this?  In view of water retention, what liquids and in what quantities are recommended during these peak and valley periods? Hannes (South Africa)

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A. With regard to the 8/17 question by Hannes, it is another example of a great question, with no easy answer. Edema in patients with COPD is most likely related to Pulmonary Hypertension and right heart failure, but it could be due to left heart failure, kidney disease, liver cirrhosis or protein deficiencies (hypoalbuminemia). The edema represents sodium which pulls water into space outside the blood vessels (extravascular compartment) as opposed to fluid in the blood vessels (Intravascular compartment). It is possible to be dehydrated: not enough fluid in the intravascular compartment, so that the heart, kidneys and brain do not get sufficient fluid, the blood pressure could be low, the urine dark and concentrated yet there could still be edema of the legs!

I am not aware of Unat, it must be a brand name in Africa. Aldazide is probably a combination of Spironolactone which is a potassium retaining diuretic, and hydrochlorothiazide a regular diuretic which causes the kidney to lose sodium, potassium and water. The spironolactone usually allows one not to have to take additional potassium supplements.

My feeling is that a little edema is OK. To ascertain if one is too dry or dehydrated, blood tests like measuring the serum sodium, chloride, bicarbonate, Blood urea nitrogen and creatinine. One would also measure the serum potassium to be sure that it is in the normal range, though you can be total body low in potassium and have a normal serum potassium. The serum chloride and bicarbonate can suggest if total body potassium is low. While on diuretics, the physician should check the serum magnesium and phosphorus periodically.

The only thing that Hannes should do is not eat a lot of sodium, i.e., potato chips, bacon, canned soups, TV dinners. You have to read the labels.  The sodium is responsible for the edema, so the less sodium you eat, the less your kidney has to get rid of. His physician should be able to give him some guidelines regarding what to do when the edema is gone or if he feels dehydrated. Thanks for the question. Dr. Ron

Fighting the Respirator

Q.  When my late husband was in the hospital in 1995, he went into cardiac arrest and was rushed into CCU and put on a respirator. I was told I could not see him until they got him settled down as he was 'fighting' the respirator. It was a long time before I got to see him, hours at least. What does that mean when they are fighting the respirator?

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A.  "Fighting the Respirator" What this usually means is that there is lack of coordination between the respirator trying to push air into your husband's lungs and your husbands own breathing pattern. There are multiple potential reasons for this lack of coordination and it is up to the physicians in the Critical Care Unit to ascertain why this is occurring. The physician has to assess if the machine has any leaks, if the speed with which the air is being blown into his lungs is too fast or slow, or if the volume of air being blown in is too large or small. They have to assess if the cause of the cardiopulmonary arrest is interfering with ventilation. This takes time and effort. Until your husband and the ventilator are working well together, he might look uncomfortable and the multiple alarms may be making a lot of noise. Thus it is better to get your husband comfortable before you get to see him. Thanks for your question. Dr. Ron

Desating with Exercise

Q.  My husband is on the road to recovery after battling pneumonia since Jan. He is back in monitored rehab and is staying above 90% oxygen on 3L while exercising.  Long story short: Sitting with 2L he maintains 95 to 97% moving across the room he desats to upper 80s even if we up the oxygen to 3L to 3ŻL before he moves. This only occurs when he walks. He has been in rehab for 2 weeks.  What are we doing wrong. Very frustrated!

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A.  Regarding "desating." As you recall, pulse oximetry measures the percentage of oxygenated hemoglobin, usually at the finger tip. Saturation is related to the pH or hydrogen ion content of the blood; if the blood is more acid, the saturation is lower even though the partial pressure of oxygen is the same. Saturation is also affected by the temperature, the higher the temperature, the lower the saturation, at the same partial pressure of oxygen. Another confounding factor is blood flow, if the blood is not getting to the finger probe, the saturation will go down. This can occur with vascular spastic diseases like Raynauds or with congestive heart failure with poor pumping to the organs or tissue.  Thus there are a number of factors to be considered when looking at that one number, the saturation by pulse oximetry.      

If the heart is pumping well and is able to pump more blood when doing exercise, the normal response to exercise is a slight increase or stability of the pulse oximetry reading. If there is heart failure, the oximetry value will fall with exercise. If the individual only has lung disease, the problem is one of getting oxygen into the blood. With the obstructive lung diseases, there is difficulty of getting the oxygen rich air into the alveoli with good capillary circulation to pick up the oxygen onto the hemoglobin molecule. There is what is called ventilation-perfusion (exchanges of gases within the lungs-pumping of blood through organs or tissue) mismatch.

For clarity, think what would happen if all of your air went into the right lung, none into the left one, and all of your blood went into the left lung and none into the right. There could be no transfer of oxygen into the blood because they would not be coming together. You would not be able to live in that scenario. In normal lungs there is also some normal mismatch. Standing upright, more air goes into the top of the lungs and more blood goes into the base of the lungs. That is why our pulse oximeter never is 100% breathing room air. With the obstructive lung diseases there is more mismatch which is worse when we exercise, so the oximetry reading goes down. Increasing the amount of inspired oxygen, by turning up the inspired oxygen, does not change the mismatch, it just supplies more oxygen to the alveoli which do have some blood flow. 

While we are talking about oxygen therapy, the question has been raised if too much oxygen could cause an individual with COPD who has a resting carbon dioxide level of 55 mm Hg to slow down their breathing so that the carbon dioxide level would rise to dangerous levels. Recall that the normal resting partial pressure of carbon dioxide (PaCO2) is between 35 and 45 mm Hg. Note that the small "a" after the P represents artery. When I was in my training I was taught that too much oxygen could cause a dangerous buildup of carbon dioxide in patients with baseline hypercapnia (elevated PaCO2). The data is not all in, but this can occur in a small number of people who are acutely ill. Thus the need for low flow, controlled supplemental oxygen. However, if the individual is stable and not acutely ill, the increase of oxygen by an additional 1/2 or 1 liter/minute will probably not do any harm. This is important when an individual with COPD sleeps and exercises as the blood oxygen level can fall, increasing the pressure in the right side of the heart causing pulmonary hypertension and injuring the right side of the heart. Please recall my earlier article on cor pulmonale/right sided heart failure. If desaturation is noted to occur in sleep or with exercise, it would seem prudent to increase the amount of inspired oxygen to achieve saturation's of 90%. As long as you are not acutely ill, this should not cause you to retain significant amounts of carbon dioxide. If you are acutely ill, the amount of inspired oxygen would have to be monitored with the measurement of the PaCO2 which can be done only reliably with an arterial blood gas (ABG) measurement. Thanks for the excellent question. Dr. Ron

Lung Disease and Birds

Q. I have a question concerning my COPD I have had since May 1997; I have three cockatiels and one pocket parrot, these are my babies. A representative of Family Medical my oxygen supplier that I should mention having the birds to my Pulmonologist. I pray you will tell me that the birds are o.k. for me to have as pets.

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A.  With regard to the birds, unfortunately, we can become allergic to the proteins in the feces of the birds, contributing to hypersensitivity pneumonia which can become chronic.   Your physician, who hopefully is a well informed pulmonologist, should be able to tell you if your clinical/x-ray picture would make him worried about the birds. I recall a church friend whose auto license plate was "sneezy" was seeing my partner about her asthma. She said he never asked her about having pets. She had 3 cats. One has to be ever vigilant. Ron

Q.  What is Cor Pulmonale / Pulmonary Hypertension.  Right Side Heart Failure?

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A.  This is a long explanation, and to make this list simpler, we have shown it on another page at http://www.emphysema.net/hyper.html

Q.  Many of us have a problem with runny noses upon exertion.  Can you explain this?

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A.  The medical term is rhinorrhea. I do not profess to be an expert in this arena.  Sometimes this is due to the cholinergic nervous system and will respond to nasal ipatropium (Atrovent). It is commercially available as 0.03% and 0.06%. It is used about 15 minutes before going outside or whenever the drippy nose is anticipated. Ask your physician for a sample to see if it works. There is no overdose or side-effects to be concerned about.

Q.  What do you think about the use of Oximeters by the patient?

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A.  The question of oximeters is a good one. I did not suggest that all of my patients get one. I have been concerned that they will get concerned with little changes. There is about a 4% error in any one reading. If the saturation dips for 1-2 minutes, that may not be significant from a physiological point of view. If the saturation stays down for 10 or more minutes. that may be significant. If the saturation drops for long periods of time while sleeping, that could explain the new development of right sided heart failure. When I was interested in learning more about the patients saturation history, I would let them borrow the office pulse oximeter or get one of the better oxygen supply companies to do an overnight study for us. If you have more information on the utility of pulse oximeters, I would appreciate the sharing of ideas. FEEDBACK:  Added by : The letters you sent about the use of pulse oximeters were excellent. Feedback is useful. I do not know if I have seen an article in print about the patients perspective and the usefulness of the instrument. I am glad that everyone seems to use them to tell them when to stop or slow down but then return to the activity. People with COPD frequently are de-conditioned so I am glad to hear that the low SPO2 does not put a permanent cessation to the exercise program. With regard to turning up the oxygen level, I have found people with elevated pCO2 forget to turn the O2 down once they finish the activity and thus expose themselves to the problem of further CO2 retention.  Dr. Ron

Q.  I am having Surgery (Hip Replacement) and have COPD.  What should I be concerned about?

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A.  A patient should: 1) Notify his pulmonary physician and get checked over before anesthesia is given. His ABG's might need to be checked. 2) Be sure the orthopedist is planning on some form of deep venous thrombosis/pulmonary embolism prophylaxis with heparin and/warfarin. He does not want or need blood clots form in his legs and float into his lungs further interfering with their function. 3) Plan to get out of bed as soon as the surgeon allows and get moving to keep up his respiratory reserve. 4) Take a list of all his medications into the hospital and monitor that they are continued, or if not, that they are discontinued for a valid reason.

Q.  Can Asthma be misdiagnosed when the patient actually has irreversible COPD?

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A.  I think the biggest difference in the therapy of asthma is that one uses anti-inflammatory drugs early. This could be cromolyn sodium or more likely an inhaled corticosteroid. The pulmonary function studies should improve and if the disease is caught early enough, may become normal until the next attack. In COPD, the treatment may not include anti-inflammatory drugs. The type of inflammation in asthma is eosinophilic, whereas, in chronic bronchitis, it is more polymorphonuclear cells. The eosinophilic reaction responds nicely to corticosteroids, whereas that of PMN cells does not. So if anyone is simply diagnosed as having COPD, i.e., one set of PFT'S are done and a postbronchodilator study is not done, the reversible component would not be diagnosed and then not treated. As you know, short and long acting bronchodilators are used in both diseases.

Prozac/Xanax

Q.  My Dr. changed me over to Prozac the last time I went which was a week ago today, I was taking Paxil and I told him I could't see where it done much good so he said try Prozac.  So my question, do you think I should quit it and tell him? The one I liked the best and it seemed to work the best was Xanax, but he said and I thought too that they were real addictive, so do you think it would be o.k. to go back to Xanax, I know he would say it is all right, and I have a whole buch of them I got from Merck because they send a 3 months supply, and I only took a few.

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A.  Xanax is a benzodiazepam, a sedating tranquilizer. It is relatively short acting. This makes it more addicting, but that state is a relative one. It is used for treatment of anxiety and panic disorders. It is not an antidepressant as are Paxil and Prozac. These two are in the serotonin reuptake inhibitor class. They are very similar. As you said, it does take 1-2 months for these drugs to become effective. If the dose is too big, other symptoms can arise, thus the need to have a knowledgeable physician guide the treatment. Xanax has immediate effects, one of which is sedation, which would be serious in someone with COPD with high pCO2. Thus it needs to be used with discretion. If the fellow is diagnosed with the disease of depression, antidepressants drugs and counseling are warranted.

Pulmonologist and Questions

Q.  This morning I had an appointment with my pulmonologist and I am afraid I intimidated him. Asked him where I could be involved with a pulmonary exercise program and where was there a support group for COPD victims. Also asked about my breathing test scores and how do I interpret them. Was I mild, moderate or severe COPD. Also. like a fool, had to show him pulmonary testing info I pulled of the internet. That did it, he proclaimed that in all his years of practicing Pulmonary Medicine he never had a "patient" with so many questions. Ended up by saying a little information is a dangerous thing. I tried to tell him I was trying to work with him to help my condition, and he announced that there was no way my condition could improve. By now, he called his nurse to set up my next appointment in 2002 and pleasantly said, Good Bye.

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A.  I hope that the 2002 appointment is in January and not in July.   I hope the physician is not telling you that he prefers you not to be so informed. It is certainly in your best health interests to know as much as you can about your body, the physician should help you learn and become your partner. If the physician seems to be brushing you aside, give him another chance, and if the attitude persists, you will need to talk to him to find out what his concerns are and if you can work with him or if you need to see someone else.

Excessive Cough

Q.  I have this dry hacking cough that I have had for years (almost ever since I was diagnosed in 1990, but growing worse the last few years) and it is beginning to drive me bananas. After considerable hacking I can usually bring something up, but by that time I am worn to a frazzle. This goes on day and night, although it seems to slow down during the night. In fact, it slows down so much during the night I sometimes think it is all psychological. It doesn't seem to make any difference if I am on antibiotics or not .... the cough is always there. And it takes only one or two short coughs to make me SOB, and until I recover I can't talk or move. Sometimes I have a series of coughs which causes bronchial spasms, and this really does drain all my energy.

I use throat lozenges like they are going out of style (Fishermen's Friend is the best for me it seems), and the doctor has prescribed Guaifenison which I keep on hand, but no longer feel it does much good. It seems as though my heart functions properly... otherwise I think I would have had a heart attack by now. I am on oxygen 24/7 and go to Rehab twice a week.

This is stressful too, as I cough a great deal while I am exercising. There are others at Rehab who cough also, but by no stretch of the imagination do they as much as I do. My fellow Rehabbers ask me frequently about my cough, and this makes me wonder if I am not bothering them. I mention this to my doctors (pcp and pulmonologist) from time to time, but don't seem to get any answers there. By their silence are they telling me that this is just a part of the disease and I must learn to accept it? If anybody has any suggestion of any kind, toss them out as I am getting desperate.

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A.  Cough is a difficult symptom, but it is important. Coughing is important as a way to clear the tracheobronchial tree of irritants and phlegm. However, he has an irritating and exasperating cough. The usual causes of cough are: 1) cigarette smoking, 2) Postnasal drip, 3) Asthma, 4) gastroesophageal reflux. I hope #1 does not apply to him any more. Asthma should respond to acute bronchodilators such as albuterol and be detected by pulmonary function tests before and after a bronchodilator. Postnasal drip may not be obvious but his doctor may see mucus secretions in the back of this throat. This drip does not usually respond to the non-sedating antihistamines unless it is a definite allergy. Frequently one gives a trial of the old antihistamines such as Drixoral Cold and Allergy (a mixture of the antihistamine Dexbromphenerimine and the decongestant pseudoephedrine) may be helpful. The diagnosis of Gastroesophageal Reflux may be difficult, unless Bob tells us he has heartburn, burping or abdominal discomfort after eating. Rather than a lot of testing, a trial of proton pump inhibitors for at least one month (and maybe 3 months) may be in order. Prevacid and Prilosec are some of the more known brand names. Bronchoscopy may be needed to evaluate for an enlarged trachea, or a mass in the tracheobronchial tree. I would not say that the cough is part of his disease, unless he has bronchiectasis. If he does, use of postural drainage, flutter valve, larger doses of Glycerol Guiacolate and bigger doses of Ipatroprium may help. Some medications such as ACE inhibitors (angiotension converting enzyme inhibitors) used for treatment of hypertension, heart failure or nephropathy can cause a cough which will go away within four weeks of discontinuing that medication. There are alternative substitutes for this medication. A recent reference he may want his pulmonologist to review is "Assessment of the Patient with Chronic Cough" by Yu and Ryu in the Mayo Clinic Proceeding 1997;72:957-959. I would be interested if Bob could give us a follow-up of what he and his physicians learn. He should not just live with it.

Sleep Testing 

Q. The doctor said I woke up 12 times an hour, which apparently isn't bad but is clinically significant. What I don't understand is that it seems to say that the longest apnea was 2 minutes and 55 seconds. That sounds like almost enough to cause brain damage. Then it also says "lowest oxygen desaturation of 49% occurred at 05:33:58." Under comments, it says "significant oxygen desaturation occurred during sleep in association with obstructive sleep apnea, diagnostic of sleep apnea syndrome." I got a C-PAP after that but I couldn't sleep with it, and when I told the doctor, he said "Send it back." I did. No one ever suggested oxygen.

After the hospital test, my doctor (another one) got a letter saying "During NREM sleep typical apneas lasted 30 seconds and resulted in O2 desaturation to 84%. There was a suggestion that there could be more apnea in REM but there was so little REM during the night, this was unable to be quantified. These tests show that the patient has an Axis A diagnosis mild obstructive sleep apnea and periodic leg movements during sleep which end in arousal. In addition to any treatment of the obstructive apnea, the patient should be strongly advised to lose significant weight, as this may partially or completely relieve her propensity to apnea. In lieu of the above, treatments for periodic leg movements during sleep may be considered. These include use of Sinemet .. . or Neurontin. . . .Mirapax is another possible treatment. . . We would be happy to restudy this patients as you and she decided is necessary." My doctor told me to look the drugs up on the internet and decided whether I wanted to take them. I do not.

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A.  I have had no formal training in Sleep Medicine. I have not reviewed your sleep apnea site yet. She  may want to sit down with a Neurologist, certified in Sleep Medicine. If Restless legs is interfering in her ability to sleep, she needs to be checked to be sure she has no deficiency in Magnesium, Potassium, Iron and maybe Phosphate. If there is no metabolic reason or medication reason for the restless legs, then she may need to try a medication. I am disappointed that one physician told her to get the information from the Internet. All of the medications have side effects, what she needs to learn how frequently and serious are the side effects. Sometimes the physician can give her samples to try after explaining what the medicine is expected to do. With regard to the question of sleep apnea, again, a good sleep physician should be able to analyze the two studies she has had and make some meaningful observations. If indeed she has sleep apnea, there are several C-PAP and BI-PAP machines available to try. A good DME company should work with her to give her the best try of using the apparatus. It does take time and work on her part, she may have to be patient for a week or two. There are alternative therapies such as mouth pieces and others I do not have on the tip of my tongue, but that is where the specialist comes in. I would have a Neurologist Board Certified in Sleep Medicine look her over. I know it is another physician, but falling asleep all of the time is not good quality of life.

Q.  About Theophylline?

A.  Immediate release theophylline is absorbed equally well from an empty and a full stomach. There is no significant peak to trough difference or area under the curve of absorbed drug. Sustained release theophylline if taken with a very fatty meal (71 grams of fat!) will achieve a higher peak level due to more rapid absorption in the stomach. A meal containing 71 grams of fat is: 8 oz. of whole milk, 2 fried eggs, 2 strips of bacon, 2 oz. of hashed brown potatoes and two pieces of buttered toast! Most of us do not eat that breakfast any longer. If you eat more normal meals, it does not matter if you take sustained release (SR) or extended release (ER) theophylline before, after or during meals. In general, it is best to take the medication at the same time each day. This would allow your physician to measure your blood level to be sure it is in the therapeutic range of 5-15 mg/dl. If there is any question as to whether you are on an immediate release or sustained release theophylline just ask your pharmacist. Do not crush or chew the sustained release theophyllines, they are made to dissolve in a particular fashion as they travel through the intestinal tract. If they are chewed they act more like immediate release, thus you would get a spike and short life of the drug, not the sustained level you were supposed to get. Of more importance than food is the relationship of theophylline and other medications. Always ask your doctor and also your pharmacist if a new drug will affect your theophylline blood level. Specifically, cigarette smoking, phenytoin (Dilantin). Rifampin (an antibiotic used primarily against the tuberculosis bug, but can be used with certain Staphylococcal infections) as well as other less frequently prescribed drugs will cause the Theophylline level to decrease in your blood. Other drugs will increase the Theophylline level, possibly pushing into the toxic level: cimetadine (Tagamet for ulcers), erythromycin and clarithromycin (Biaxin), Cipro, Alcohol, estrogens, ticlopidine (Ticlid), methotrexate, tacrine and lots of others. So check with both the physician and the pharmacist so appropriate adjustments can be made in your dose, or provision to check your blood level. If you have any question, your physician could check your blood level after you have been on the new formulation about a week to be sure the blood levels are the same.

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The above questions are asked by members of EFFORTS on our EMail List.  If you wish to join EFFORTS, please go to http://www.emphysema.net and you will learn more about us.

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