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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

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

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).

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

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

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

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

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

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

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

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

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

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

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

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

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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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

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

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

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

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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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

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

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

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

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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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

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

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

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

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

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

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

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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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

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

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