Q. Would you also expect people with a  FEV1 of less than 19% to be able to exercise to the extent mentioned? Once I'm able to do half an hour with no stop, should I pick up speed, or try to go longer?  I try to exercise each day, but some days can't do too much.  Thanks. Marie-CT

* * *

A. I recommend that *everyone* try equally hard to do the MOT they can, with regard to exercise and load.  I have no specific "expectations" for some very good reasons.   One of those reasons has to do with the very fact that when your FEV1 is 19 %, it takes a "boat load" of "intestinal fortitude" to put yourself into a situation of such extreme discomfort as exercise puts you in AND to trudge on within that discomfort for only a 'promise' that you'll feel and do better over time.   Each person has their limits of tolerance.   It is not my place to force anyone to ignore or be untrue to themselves and ignore their fears and discomforts for "my" sake or satisfaction.   You do what you do because YOU want to do it.   No one else can MAKE you WANT to do it.   The desire HAS to come from you.   As for me, it is my humble pleasure to be there to help those folks who DO come to the decision to "suck it up" and plow full speed ahead to at least TRY to get in better shape.
 
Your described approach is certainly adequate.   If you can, I'd recommend adding even more time - - up to 60 minutes, if you are currently going at less than 2.5 mph.   Be flexible and willing to adjust up and down on time and load so that you keep goinig in the generally upward direction on everything.   Remember, you will always have some days when everything is a struggle and you won't be able to do as much.  Just try to balance them with the good days, when they come along. Best wishes! Mark   <|{:>)

Q. I have a question I hope someone can help me with. I recently had new PFT done. They showed a very big decrease in lung function since May 2003. I was hospitalized in Nov. 2003 I was in the progressive care unit, on 2L O2. When I was moved to a regular room, they moved me in a wheelchair, and cylinder tank. While I was being moved from one floor to another, the nurses aide who was moving me stopped several times to talk to friends, and even got off the elevator on the wrong floor. I felt as if the O2 was to high, and when I questioned her, she didn't check it just said it's fine. My daughter caught up to us before I got to the new room, so I had her check the O2, and it was set at 10L. My question is, since I am a retainer, could this large flow amount have damaged my lungs more than they already were?? I was on 10L for approx. 15 minutes. Thanks for any info, Marilyn-NY

* * *

A. While there was most likely no reason to give you that much oxygen, the short time that you spent on it would not harm you in any way. Stories of inattentive healthcare workers such as this make me feel very sad. I see it as a symptom of one of the biggest problems in healthcare today which is lack of funding. When we offer low pay for difficult and frankly often
unpleasent work (such as nurses aides- now called Patient Care Techs here in Illinois)we often attract people who are "not as caring as they should be". However, I would say again that 15 minutes of high flow oxygen will not cause any long term damage to any adult. John A. Richter RRT

Q. Hi I got  a letter from SSI today. They want me to see a doctor of theirs for breathing test.  What's that and how do they do it? God Bless Debbie  Pa

* * *

A. The test involves breathing in very specific ways into a machine to measure how effectively you can mechanically move air in and out of your lungs.   One involves breathing in and out as rapidly and deeply as you can for about 15 seconds.  Another involves taking as deep a breath as possible and then blowing out as fast as you can while being "coached" by the technician.    It is the technician's job to  get the very best test you can perform, and they get very "into it."

They MAY give you a treatment after part of the test and then repeat part  of the test.  By looking at the pattern of your results, the physician can determine the details of your disorder, the severity of your condition, and how it responds to medication. Larry Conway, Registered Respiratory Therapist

Q. When it was first suggested that I go to rehab I believe it was a several week program for 4 days a week 2 hours each session.  I finally got to  walking a LOT more since getting on Spiriva and for the past two weeks I  have spend about 1 1/2 hours a day walking about 2 miles.  My question  is, once I have done the amount of time that the rehab would have required of  me, do I just stop?  If not what is recommended?  I hadn't really  given this any thought.  I can't keep spending 1 1/2 hours of my day  walking around in circles.  I have a business to run and evenings are spent  with domestic obligations.  Single parent and all of that kind of  stuff.  So could someone let me know what is recommended? Thanks, John

* * *

A. If you can't keep up the 1 1/2 hours per day, then do as much as you can as often as you can.  Try to get that 2 miles down to 40 minutes (which means get to walking faster).   Do NOT drop to less than 3 days per week, or you will lose most benefit you can gain.  If you DO decrease what you now do, without at least maintaining the distance covered, then expect to see a loss of the conditioning you now have gained..
 
Don't kid yourself - - - like so many folks I've dealt with have tried to do - - - and think that pulmonary rehab is the "ONLY" place you need to exercise, nor the "ONLY" amount of exercise you need.   Pulmonary rehab endeavors to "get you started" toward a more prolonged and intense exercise regimen AND so that you can be physically active in your life to a GREATER degree.   You most certainly CANNOT "do it all" at/in the rehab program.   This never was the case and never will be.
 
You lament that you haven't got time to do all that exercise because you have a business to run and a child to care for as a single parent.    I have to respond as I do to the many hundreds whom I have cared for that you cannot afford NOT to do as much as you can to keep yourself 'able' to meet those obligations.   If you let the life of the business and taking care of others detract from efforts to keep yourself ABLE to meet those obligations, the problem will soon take care of itself, when you find yourself too sick to do anybody any good, much less yourself.   Harsh words? ? ?    Yes! ! !     But, I know no more effective means to grasp one's attention than to be brutally blunt.   I've seen too many good folks over too many years who thought they could dictate their lives with pulmonary disease according to their preferences.   Nary a one succeeded. in dictating to the disease how it would progress and affect them.   They were all victims.   Even as smarty-britches as I might think I am when it comes to pulmonary disease treatment and living effectively with it, even I know that I couldn't outsmart the progression and live my life according to my preferences alone, were I faced with the same circumstances as you and our fellow listmates! ! !   The same goes for not using oxygen when the time comes that it is evident that it is needed.   We can refuse to use it.   But, we will get worse faster/sooner and harsher for the avoidance - - - so much so that we will make our remaining days much more miserable than they need be, even when we DO condescend to use it.

John, life is full of choices - - - as you well know.   you are doing great where you are now.  You have much room for improvement, too.  You are - - - understandably - - - looking for ways to cut down on the time consumed to manage your health needs.  Yet, you have not reached a point as yet where your health has been optimized with all the time you now spend.   What you need to do is determine how much health you need to be effective in the life you choose to lead.   Then, you must make your schedule.   Unfortunately, there are a finite number of hours in the day.   You must fit your needs within their confines.  In the end, it doesn't matter WHAT would be the time spent for the exercise accomplished in a pulmonary rehab program that has any bearing on you.  It is what YOU need to do that which you want/must do in your life. Best wishes and regards, as always, Mark  

Q. I think that this question may be wishful thinking on my part but I need to ask anyway. Is it possible to direct the air on inhalation to different ares of the lungs. I have been diligently practicing diaphragm breathing over the last 5 days and it feels almost as if the lower lobes are getting air (and I seem to calm down more rapidly) that was not happening before. During this same period I also switched from combivent (2 puffs x 4/day) to Spiriva and Albuterol. Thanks, Tom in CA

* * *

A. Years ago, when I was a baby respiratory therapist, my physical therapy counterparts taught me the theory behind and technique in how to administer "segmental breathing".   In this method, we would place our hands over an area of the patient's thorax, with the target segment of the lung in the upper most position and while we pushed and restricted the expansion of thier chest, we instructed them to take in a slow deep breath.   Of course, the idea was that if we compressed those segments around the "affected one" they would take in air and expand only the desired segment.   As with not just a 'few' techniques passed on from our physical therapy friends - - - and to be fair, many we concocted on our own, over the early years of respiratory medicine and respiratory care (1950's and 60's) - - -  this technique sounded good on paper but was completely BOGUS in performance.   With the advent of fluoroscopy, we were able to watch radio-labeled air enter the lungs during all manner of manipulations.   What we learned was the air goes by way of the path of least resistance, no matter what you try to do selectively to the external chest.   If you restrict chest movement, it is an "all or none" principle.   You cannot selectively ventilate any part of the lung without isolating it from the "inside", by using a tube to blow air into that part alone.  Since the airways conducting gas to the individual segments of the lungs are so small, it is not a practical (nor desirable) thing to do.
 
While segmental breathing may still be taught, where it is taught from the standpoint of "evidence-based" science, it is taught as a historical treatment, no longer considered within the realm of acceptable, or standard of care, much less state of the art! ! !    Lastly, insurances and Medicare have long ago removed it from any reimbursement category, since it was discredited as ineffective and bogus.
 
What you HAVE been experiencing is improved ventilation - - - probably attributable to BOTH the Spiriva AND concerted effort to control the muscular contribution of your abdomen to breathing.   Today, I like to call the technique "belly-breathing", since you want to concentrate on drawing air "DOWN" into your lungs (into the bottoms of them, figuratively speaking) using your lower abdominal muscles, and NOT your chest - - - especially NOT your upper chest.   Diaphragmatic breathing has also been discredited in the techniques many of us were taught, because the techniques themselves, lent to leading the user astray into paradoxical ventilatory movements.   ALSO, it has been noted by many, that no matter what, we ALWAYS use our diaphragm to breathe.  The 'problem' is that when we get into trouble - - - panic breathing - - - we recruit our "accessory muscles" of breathing - - - in the neck and upper chest - - - and force them to do too much of the work.   They cannot do more than a modest amount under the circumstances we demand their recruitment, so we get into trouble with panic, when they fail to do as much as we try to get them to do.    I have described belly breathing in earlier posts that should be easily found on our EFFORTS website, either under medical questions, or respiratory therapists pages.   Take a look there and read more about it. Best regards, Mark Mangus, RRT

Q. Hi all, just a question if you are a retainer of CO2. I know that the norm is 37 to 42. What if any are the treatments to lower it. Just curious. Mine was 40 in January. I asked my doctor today but he says you don't want to know. Also he said in the American Journal of Medicine which doctors get, he said there is a few more things they are coming out with soon in trials to help us along with the valve. Any reply will be welcome. Bill         

* * *                                    

A. The normal range for CO2 on an arterial blood gas is 35 - 45 mmHg.   Your 37 - 42 is a little on the tight sode and not the "standard".   If yours was 40, then you are at absolute perfect for CO2 and shouldn't be worrying about it!
 
There are no 'specific' treatments for elevated CO2, as the reasons it elevates are related to the "physical/structural" changes in the lungs as the result of advancing COPD.      Lung Volume reduction - - -by whatever means is possible and appropriate at the time one has it done - - - and/or transplant, are the only treatments that 'directly' correct CO2 eliminations problems.   There is no effective "pharmacologic" (medication) treatment that is currently available., nor is there one in the pipeline, or expected.   Personally, knowing gas exchange and physiology as I do, I'
d be very afraid of a "pill" that would be purposed to lower/correct my elevated CO2.   That's because the way our fascinating physiology works, to lower the CO2 by forced means, requires sending yet other components out of whack in the process.  AND, because the compensatory process is a "cascade" of actions, one or two medications wouldn't be able to affect change on the whole process in THIS case, to fully and safely correct the range of deranged parameters.   you can do that with the heart, and vascular system (heart beat regulating medications and blood pressure controlling medications).   But, the process of metabolic balance in relation to gas exchange is WAAAAAYYYY to elaborate and not conducive to similar controls.   Those treatments to which your doctor referred are likely some of the new drugs targeting relief of breathing difficulties, without necessarily altering the structure of the lungs, per se. Regards, Mark

Q. I am a recent member.  I have been lurking since about March. I am almost 65 years old and have been with oxygen almost 9 years (the big E). My question is I was told to use oxygen  2L at rest and up it to 5 for moving around and exercise, on the treadmill, so which should I use?  According to what has been written, the concentrator gives out less when you move it up to the higher numbers. Concentrator Or Liquid? Thanks for your help. Janette/Mo

* * *

A. There's a LOT more to choosing between LOX and gas oxygen systems than exercise oxygen.   If you are displease with the inconveniences of your gas system (concentrator and tanks), then certainly give LOX a try.   But, don't throw the baby out with the bath water simply because of oxygen needs during treadmill walking.
 
The change in concentration when turning your flow up to 5 shouldn't be tough to make you want to abandon it, especially if it has worked well for you until now.   If you have an oximeter and can follow what your saturation does during your walking periods AND is stays > 90 -92 %, then you need not worry about making any changes.   The concern expressed in the posts was when turning the flow PAST 5 liters, where it can be seen to go, but you don't know exactly what the flow is, nor the purity.   Another option you have without changing systems, is to get cylinders of compressed oxygen from your supplier and a regulator that will allow you to exceed 5 liters, if necessary, just during your treadmill walking times. Talk to your supplier and learn what your options are and what your specific concerns should be and what "they" can do for you. 
Best Regards, Mark

Q. I have read quite a few people saying, in regards to general anesthesia, "If I had surgery , they couldn't get me off the vent" It's been a while since I have been in surgery, does the anesthesiologist place patients on vents,while they are being operated on? Or do the people mean intubated/extubated?

If a patient goes into surgery, supplemental oxygen dependent, under a general anesthesia,O2 is being delivered to them while they are under, what factors contribute to the inability to extubate the patient and place them on their supplemental O2? the anesthesia itself? PO2 levels? What factors are involved in clearing the COPD patient for surgery..? Does the surgical team, inclusive of the pulmo doc, what do they look for in clearing a COPD patient for surgery? The lungs of course, but what actually determines clearance for surgery?
 
Also, I have been doing some light reading on  PFT"s, "body box" versus "no body box. Is the body box more accurate in obtaining results?  My last set of PFT's were done, no body box, the results were terrible, so bad that in fact , I thought maybe I should be placed in a body box, 6 foot under..maybe in the back yard..lol Thank you, Carol in Pa

* * *

A. The whole notion of "the person with advanced COPD getting 'stuck' on the ventilator" has to do with the all too common occurrence of the case where the person with COPD has to have surgery.   They get through the surgery and the anesthesia all right.  But, once they've recovered from the procedure, they become "unweanable" from the support of the mechanical ventilator.   Theory has it that folks with advanced COPD work hard to breathe every minute of their lives.   (That's no 'theory'!   Y'all can attest to that 'fact'!)   When they are put on mechanical ventilatory support, that work is all but taken over by the machine.   As a result, when it comes time to divorce machine from patient, the patient doesn't want to go back to doing all that hard work.   So they just kind of "vege out" and get stuck there for - - - well - - - a LONG time.   Attempts to wean the support off are met with no taking over of the work by the patient.  They become "unweanable", so to speak and are labeled/described as being "ventilator-dependent".  
 
While that explains the overall view of the phenomenon, in laymen's language and perception, the "science" behind the problem is anything but easy, obvious or incontrovertible.   Some have theorized that the muscles get weak from the vacation from having to work so hard.  That is supported by measurements that show decreased contractile strength and endurance of respiratory muscles.   But, that's not the whole story.   Some say nutrition plays a major role, a fact which has borne results in studies.   BUT, that too is not the whole story either.   Yet others say there are no significantly insurmountable obstacles besides the clinicians' unreasonable expectations.  They agree that yes; respiratory muscles ARE weakened.   But, they can still support the work to breath if 'required' to do so (a nice way of saying "if forced" to do so).   They agree nutrition is a problem, but not such that it prohibits weaning attempts.  They argue that expectations in "weaning parameters" are the main problem.  We want too high a result in strength test.  We want the patient to be able to maintain unrealistic values on their blood gases.   This can easily be a major obstacle, especially when the patient is a CO2 retainer and the clinician is looking for "normal" CO2 before deciding the patient is safely weaned.  Some say we expect them to have to do more than needed to maintain their own breathing in order to consider them able to liberate from the ventilator.  And there are yet more reasons beyond these.
 
At any rate, the problem is the physicians are afraid to "electively" put a patient 'at risk' for falling into that trap.   So they refuse to clear you for surgery.   Yet, they'll not often stand in the way if you need surgery for a life-threatening problem.   The anesthesiologists have a system that takes patient information and derives a anesthesia risk category, to which the patient is then assigned.  The categories are I - IV, IV being the most risky.   Most anyone with blood gas changes of COPD and/or a very low FEV-1 is a category IV anesthesia risk.   They will be treated VERY carefully and watched like a hawk during surgery to keep out of trouble or on top of trouble if it rears its ugly head in some way.   My experience/observation  is that the anesthesiologists 95 times out of 100 can get ANY bad COPD patient in and out of surgery in good shape.   Its what happens to them afterwards that determines their fate where the ventilator's concerned.   IMHO, much more than we can measure rides on the skill and confidence of the physician managing the COPD patient on the ventilator to get them off in a timely manner and in good shape.
 
You asked if you are given oxygen during surgery.  Even healthy folks are given "some" amount of oxygen during surgery/anesthesia.   Some patients are placed on an anesthesia ventilator for the procedure then transferred to a long term ventilator when they get to the ICU.  Some patients are hand-ventilated, depending upon the circumstances.  Some are intubated for their procedures, while others may receive their anesthesia and breathing support by mask.   It is all determined by the anesthesiologist when they evaluate the patient.
 
The body box method of measuring "volumes" (plethysmography) is considered "most" accurate.  It is significantly more accurate than those done by "gas dilution" - - - inhaling helium mixed with oxygen and nitrogen.   Flows are more accurate when measured in a body box as well.   But, the difference in accuracy is not as significant as the difference in lung volume measurement technique.  It is hard to say what caused your "lousy" results.  You could simply have been having a lousy breathing day and THAT was reflected in your poor measurements.  Bad coaching can produce a bad test, too!   The point to remember is that if you felt lousy and your test reflected it, the test results are NOT reflective of your true condition.  Hope for the best that next time you're tested, you'll feel better and do better as well!.   I would always recommend asking for your measurements to be done in a body box, if it is available. Regards, Mark

Q. I have just dug into my cuboard and found my Voldyne, I was given this in 1993 after Surgery..it only goes to 3000..I just tried it, and with great effort managed 1500. My question Mark is..will this help me? or make me as light headed as it just did, or will that feeling go away? I will try any thing to help my-self to breath better.. Thanks a Lot..Anne in PHX..

* * *

A. Will regular use of the Voldyne help you breathe better?   I would say that the chances are excellent that you would see improvement in several aspects of yout breathing if it becomes a part of your more comprehensive daily exercise program.
 
Studies have shown that breathing exercises like "Incentive Spirometry" (IS) (which is what 'kind' of technique Voldyne is) can produce significant improvement in ability to move a greater volume of air under differnt ventilatory conditions and reduce breathlessness to some degree under various conditions.   Used as a solo exercise, it cannot cause meaningfully significant changes in breathing dynamics.   BUT, as part of a program that includes aerobic conditioning (walking/leg-biking) it can result in remarkable changes for the better.
 
Any light-headedness you experience is likely the result of improper technique.  If you do too many inhalations too quickly, you can cause light-headedness.   If you don't take one and only one deep inhalation for your SMI (Sustained Maximal Inhalation - the concept that is targeted as the goal with IS) you can pant yourself to light-headedness.    So, be sure you do only 10 'individual' SMI's each time you use it.   Be sure to hold your breath at the top end of each SMI for a few seconds, before releasing it/exhaling.   Be sure to rest between SMI's, so that those 10 SMI's take you between 6 and 10 minutes (similar to what Kathy Wolford suggests she does - - - 8 minutes) to accomplish. Regards, Mark

Q My question is what is the proper way to take the c0mbervent inhaler? Russ was first told to take a puff whole it for a minute if he can then wait 2 minute and take the second puff and hole it. Now when he was in the hospital they told him to take a puff whole it then take the next puff right away. which way is right. could use some feed back on how some of you that use this do it. Susan from Pa.

* * *

A. Basically, the first method you described that Russ was "taught" is closer to the "best" technique.   A couple of points to correct.  He should hold his breath for as long as he can, up to about 15 seconds.   You said they told him to hold it for "a minute"!    Wow, THAT would quite be a feat!   <|{:>)
 
It is 'preferrable' that one waits 5 minutes before taking the second puff (inhalation).    2 minutes will do in a pinch.  As far as the 'one after the other' in the hospital is concerned, there are only two explanations I can come up with for that.   (1) Those who delivered the MDI treatments simply did it wrong - - - for whatever reason.   Several studies over the years - - - and more recently, done by a group of students from the RT program for which I teach - - - have been conducted observing and documenting the MDI administation and teaching techniques od RT's vs RN's vs MD's and in some cases, other health care personnel.   They have documented up to more than 60 % error in techniques among "non-RT's", rendering MDI therapy ineffective up to 60 % of the time.   These factors could have been at play in Russ hospital experience.    (2) Because they're often rushed for time and over-loaded with treatments, if the MDI's were administered by RT's, they might have given the inhalations one after the other simply because they were trying to expedite their schedule and get through their many treatments in a timely fashion.   This is NOT an "excuse"! ! !   Rather, it is merely a plausible explanation, however inappropriate the action was.
 
In the end, I hope that a holding chamber (often also called a spacer device) is in the equation, somewhere, as the CFC-charged MDI's require uise of one to optimize delivery of medication (takes amount inhaled into the lungs from about 8 - 11 % to as much as ~35 % of the plume that comes out of the canister.  Two popular holding chambers are Aerochamber and Optihaler.   Ideally, a holding device should have a large volume reservoir and valves to keep flow 'directional' through the device. Regards, Mark

Q. Hi, I am a new member who keeps several 2 litre aluminum containers of medical oxygen at home for use in emergencies, while waiting an ambulance to arrive, as I live in a rural area with a 30 min help delay My question
is, what is the shelf life of stored oxygen kept in cool cupboard conditions. I've had two containers (untapped) for 3 years in storage, All were brand new Medicare, and I needed 3 as refilling had a week turnaround.  Best regards, Dave

* * *

A. When I learned to fill oxygen cylinders while working for an oxygen provider I was told that full and sealed cylinders were good for five years. I beleive they would be good for longer that this if stored in the proverbial "cool dry place", I think the five year number comes from the FDA. John

Q. I know what bronchitis,  bronchieactesis, Emphysema and asthma are, but what is COPD?  I always  thought it was either asthma or chronic bronch coupled with emphysema? And  how is it possible for a clinician to diagnose emphysema, treat  accordingly, than following a neg CT change diagnosis from emphysema to  COPD?? Don't take the latter literally; I know these docs can do all manner  of wonderful or strange things <(:>)  e in  az

* * *

A. it can be confusing.  COPD (Chronic Obstructive Pulmonary  Disease) is the collective name for any of the lung diseases characterized  primarily by an obstruction to expiratory airflow.  These include emphysema  and bronchitis.

In the past, asthma was also considered a form of COPD, but it is being separated out today.  During an asthma attack, a person has a pulmonary  function that looks very much like a patient with emphysema, except that it  returns to normal in response to a bronchodilator.  Pure emphysema does not  respond to bronchodilators.  It is irreversible.

Obstruction to expiratory airflow is demonstrated with low FEV 1.0, low FEF 200-1200, etcetera.  This defines an obstructive component.  As the obstruction worsens and lung damage extends, the lungs hyperinflate (become
over-inflated) and the person begins to exhibit an increased Total Lung Capacity  (TLC) on their pulmonary function.  This defines obstructive disease.

So, if you have emphysema or bronchitis (or by extension bronchiectesis), you have COPD.  It is like saying, "I have a Chevy, I have a car.  I  have a Ford, I have a car.  I have a Renault, I have a car."  Some  would also have said you have COPD if you have asthma, but that classification  is changing (I could make a case either way for including it or not including it  in the group COPD). Kind of like saying, "I have a Caravan, it's kind of a car,  but it's an SUV instead."

Understand that the Gold Standard definition for diagnosing COPD (and specifically any of its component members) is PULMONARY FUNCTION, not CT or  X-ray. However, a CT could reveal that the kinds of lung destruction  expected in
pure emphysema are not present, so the diagnosis could change to the  less specific COPD.

Hope this helps rather than further confuse. Larry Conway

Q. Has anyone tried (the breather) and what sort of results they got. I am considering buying one, I have tried other devices such as the flutter without much success. Regards Barry

* * *

A. I have used "The Breather" with a number of my pulmonary rehab patients and have documented some very good results with it. I use a negative pressure manometer (that's a pressure gauge that measures how hard they suck) to measure the strength of their inspiratory muscles. I have documented as much as a fifty percent increase in strength this way. I would add that you can probably get the same results with any other ventilatory muscle training device. The Breather allows you to generate resistance by breathing through a small hole. It has five settings for inspiration and four for expiration. This resistance is like "weightlifting for the lungs" making your muscles work harder which can help them grow stronger. If you didn't see it check the EFFORTS archives for a recent thread of messages about an article regarding ventilatory muscle training in COPD patients. Also keep in mind that like weightlifting this type of exerciser gives a benefit that will fade once you stop using the device. I know many people use a ventilatory muscle  trainer as a part of their regular daily routine, some say it helps them clear their secretions as well. I hope I answered your question, John

Q. Is it  normal for people with COPD to sleep a lot at night? I can go to  sleep sometimes at 9:30 and sleep till 7:00 or 7:30. Is it because of all  the physical work I do usually or just something that goes along with  our illness. Sometimes in mid afternoon I feel like I could take a nap but  I do not.

* * *

A. Have you been evaluated for a sleep disorder?  As you describe it, it does not sound like you are overwhelmed by sleepiness, but if you feel you are - especially if you have problems falling asleep at inappropriate times during the day. Chances are good that this is just your normal pattern of sleep need, but many COPD patients have the characteristics that predispose to sleep apnea. Larry

Q. Jim had to have that this morning, the woman who did it said he was 10 points low. She wouldn't say what it should be or if he would need oxygen. Don't want to wait to hear from his doc. We are to fly out the 19th to Las Vegas and wonder if he needs oxygen if we will have time to make all the arrangements.  What should his ABG Be? Thanks for any info. Peg

* * *

A. Health care workers who provide these kinds of "half-a**ed" answers drive me NUTS! This is not an easy question to answer since I do not know WHAT he was "10 point" below.  Textbook normal for PO2 is 85 to 100 with a Saturation (SaO2) of above 94%.  If he is 10 below the 90 to 100 range, he should be OK.

If he is 10 below HIS NORMAL resting PO2 (which could be as low as 55 or 60) he might be in big trouble flying without oxygen. If he is 10 below the Medicare recognized level that approves Oxygen reimbursement, he would also likely need oxygen for flying.

Call the office.  Insist on talking to someone who understands and can give you detailed information. Larry

Q. First....Why would the specialist wait 6 months to even discuss my test results.  Is it in fact good news that I don't have emphysema as opposed to COPD.  Do all specialists automatically refer to COPD as Emphysema which in my
experience is a word shunned by most people. I would so much appreciate some clarification here as I am very confused.    Is COPD also a progressive disease like Emphysema. Thank you for any advice . Jonathan

* * *

A. First, it is not uncommon to make the 'clinical' diagnosis of emphysema from spirometry, clinical data and information and history.   While COPD and emphysema are considered interchangeable terms, you are correct in seeking specific definition since the relationship is not a two-way street.   In other words, emphysema IS COPD, but a diagnosis of COPD does NOT automatically indicate emphysema is a significant part of the diagnosis.   While CT scans are considered the 'gold standard' in diagnosing specifics of ailments, they can also fall short of providing sufficiently definitive data to 'literally' confirm a diagnosis.   It is possible that you have very homogeneous emphysema and it is not so obvious on CT scan.   I am also curious about the mention of "nodules" (nature, type, size, location).    Your FEV-1 of 44 % is definitive for moderately severe COPD.   Your decrease in saturation certainly suggests that you have 'some' component of emphysema.   Here's where the if/and/or/but part comes in.   IF you have emphysema significant enough to adversely affect your diffusion capacity, that would lend explanation to why your saturation falls as it does, even though you are still 'reasonably' high on your FEV-1.  We usually do not see desaturation due to COPD - - - regardless of what 'flavor' it is - - - with FEV-1's of 44 %, unless there is another defect present along with the COPD.    I'll say more on this a little later.

What would really be helpful is if they did lung volume measurements on you, especially if those measurements were done using body plethysmography (commonly called the "body box").   Lung volumes are also measured using inhaled gas equilibration techniques (Helium dilution technique), but are increasingly unreliable in folks with COPD because of the nature of the disease and disparities in where air goes in the lungs according to physical changes of the lungs caused by the disease.   So the body box is a more accurate tool, because it is not affected by those factors that throw-off measurements using inhaled gas dilution techniques.   Anyway, a "residual volume" could go far to help illuminate the presence or absence of emphysema.   It is usually elevated with emphysema and not so with other COPD's (of the Chronic Bronchitis or incompletely reversible Asthma types).   If your lung volumes are not shifted such that a more exact label can be put on which component(s) of COPD you have, then there is another possibility that is clouding the picture.

It is possible that you have some component of fibrosis that is sufficient to be responsible for the desaturation you currently exhibit.  If that is the case, then the CT not showing emphysema could be explained by that.   HOWEVER, I would expect that fibrotic changes sufficient to cause desaturation would be evident on that scan, as well.   So the mystery remains in view of the various possibilities accountable for the numbers you report.

As to why your doctors would call it one thing rather than another and any stigma you might attach to the differences in labels, I wouldn't think that they were 'deliberately' attempting to 'deceive' you.   Unfortunately, your experience seems to have created the stigma to which you object.   Yet, I don't know that it is fair to consider such a distinction between stigmas.    As happens so often, the doctors don't equate a huge difference between flavors of COPD since there is little difference, if any in the approach to treatment/management of each specific disease.    I think it is fair to say that the stigma comes from the fact that folks have a pretty good idea of what emphysema is and from what one comes  y it.   But, the terms COPD and Chronic Bronchitis are MUCH less known or understood, so people don't attach any stigma to them as they do emphysema, simply out of ignorance, NOT because COPD and/or Chronic Brinchitis are any higher in esteem. 

All of the COPD's are progressive.  To distinguish between one flavor or another does not affect the predictability of progression, either, as that is fairly consistent across the population of those who are affected.   It is also the case because deviations from the average rate of progression vary from individual to individual according to their unique clinical course - - - severity of symptoms and how they affect the persons well being, function and activity, how many exacerbations they experience, how active they are able to be, with regard to exercise and conditioning, etc.   While I agree, to expect you to wait 6 months for your test results lacked consideration, the need to see you for management of your disease is not likely, since you would not be expected to change significantly in 6 months time, barring exacerbation of your symptoms. Regards, Mark

Q. Anyone know of a place on the internet that you can purchase a mask that you ware with oxygen and will not allow CO2 to build up? Especially for smoke, something I could carry in the car and also use at home.

* * *

A. Have you tried an N-95 or N-100 high efficiency filtration mask?   You can purchase the N-95 most anywhere, including Home Depot.   The N-100 (which has a reputation of being easier to breath through) is a bit more difficult to come by.   But, I'd bet a pharmacy could get it for you without much trouble.   I don't know how effective it is for completely eliminating the odors accompanying smoking.   But, I've been told by folks who've used it that it works great for them.   You shouldn't have a problem with CO2 build-up with either one.   Especially if you have oxygen running into it via the cannula in your nose. Regards, Mark

Q.  I'm wondering if some of you can help me understand this.  I have been experiencing shortness of breath lately but when I check my 02 saturation, it's above 90%.  I don't understand this and am hoping that someone has an understandable explanation. Thanks, Mary Ellen-GA

* * *

A. SOB does not 'necessarily' have *anything* to do with having a low oxygen level!   More often than not, for folks who are not sufficiently active, SOB is the result of activity imposed on poorly conditioned muscles.  In these circumstances, the cause is carbon dioxide, rather than oxygen.   The poorly conditioned muscles produce carbon dioxide at a rate higher than would well-conditioned muscles.  The 'drives' the individual to breath more in an effort to purge the additional/excess carbon dioxide from their body.  When you consider that increased ventilation is required and THAT is the very thing that is most disturbed with COPD, it is not a difficult stretch to arrive at the conclusion that SOB would be a predictable result in these circumstances.
 
Now, since inadequate oxygen ALSO is a cause of SOB, we need to consider it in context to clear your confusion.   You said that your oxygen levels are always above "90 %", when you check them during your SOB episodes.   The fact is that just because the 'medical wisdom' is that saturations over 90 % are acceptable insofar as maintaining safety and reasonable health with less than optimal lung function, it does NOT mean that you should 'not' experience SOB and similar/related symptoms when your saturation levels are below normal, but still above 90 %!   Indeed, while there are a lot of folks who 'don't' feel significant SOB when their saturations fall to or below 90 %, there are just as many or more who feel SOB when their saturation is still well above 90 %!   When these folks are given supplemental oxygen sufficient to raise their saturation to > 96 % ('textbook' normal), their SOB improves sufficiently that function and exercise  performance have been shown to improve by a statistically significant margin.  (Casaburi, R; Chest: Dec. 2003).   
 
So if your confusion is in the notion that so long as your saturations are above 90 % you have no right or reason to expect to feel SOB, then hopefully, my points should allay your concern and reduce/remove your confusion.   If you have further questions, please post them and we'll try to answer them for you. Regards, Mark

Q. Can I fly (with the assistance of an airline, of course) without supplemental 02 although I am dx'd "severe" and am not currently prescribed 02?  Am guessing my Fev1 is between 25 and 30% (was a recorded 33% three years ago and I am a smoker) and the average cabin pressure is 7,000 ft.  I live at 4500 ft. elevation and when I go to 6,000 feet, an exacerbation is automatic if I spend several hours in Virginia City (NV).  How often should one get a PFT?  My last one was at least two years ago and I only see a doctor every 5 or 6 months when I need a prescription renewal..... Dana-NV

* * *

A. Regarding Oxygen in flight, I think you answer your own question in your letter. If you can't tolerate time at 6000 feet it is a fairly safe bet that you will have trouble in an airplane cabin pressurized to an equivalent of 7000 feet. Regarding PFT's I like to see them every year or two at least, but that is one I leave to your doctor (after you express your concerns to him). Many people hate any kind of testing so doctors may hold off testing for that reason. Regarding the continued smoking-- Please try to quit-- even though I don't know you, you seem like a nice person to me and I like having you here on the planet with the rest of us for as long as possible. John

Q. What effect does second hand smoke have on people with end stage emphysema? Sandi

* * *

A. You ask a very broad question, Sandi.  Incidental exposure, such that it is only on occasion and infrequently occurs has essentially no more detrimental effect than the discomfort of the moment.   Folks with "severe" COPD will often react adversely to inhaling the smoke much as they would strong odors, perfumes and other noxious inhalants.  It may take their breath away and cause anxiety in doing so, thereby triggering an immediate uncomfortable and reactive episode.   But, beyond these considerations, the likelihood of direct or consequential harm in terms of worsening the disease is essentially nonexistent.
 
Of greater concern would be the person with "severe" COPD who is exposed to second hand smoke daily and for significant periods during the day - - - say someone who lives with a smoker who continues to smoke in their presence - - - as in 'in the house' - - - contaminating the air they must breathe in common.   That can easily cause a sustained increase in progression rate of the disease, as well as amplify symptoms along the way.    It can be equated with the sufferer of COPD not having stopped smoking, regardless of whether or not they themselves light up and puff!   Beyond that it can simply make life more miserable for the sufferer than it needs to be.   
 
This kind of behavior is of great concern to those of us who treat COPD and look towards prevention of its spread and rapid progression.   Smoking in the home of one who has "severe" COPD - - - in my concerted opinion - - - is as close to criminal action as you can get.   I personally equate it with "assault and battery".   From time to time, the prospect of seeking ordinances and/or statutes against this behavior pops up, but usually goes nowhere.   This is especially disturbing to me in view of my next point.   It is ironic and mind-boggling to me that communities pass ordinances that forbid smoking outside, in outdoor public spaces where exposure is momentary and rapidly diluted - - - and is arguably harmless to 'most' within exposure range, aside from being a rude imposition and a nuisance - - - and we let people literally kill their 'loved ones' (and I use this term loosely) and relatives by forcing them to inhale their second hand smoke within the captive confines of their home!    Talk about an infringement upon one's basic rights by the will of another.   I wish the "do-gooders" would work towards seeking criminal penalties for smoking in the home of those with COPD, rather than the ordinances against public, outdoor smoking which result in no significant benefit to anyone, but look good as headlines in the local newspaper and a sound bite on the national evening news.     But, I digress . . . and rant . . .      <|{:>)
 
Continuing to work in an environment where second hand smoke is pervasive is also problematic for the same reasons as someone continuing to smoke within the home of another who suffers COPD.   So, the obvious remedial action is to get out of that kind of employment, if conditions cannot be forced to change. Regards, Mark

Q. Does the size of the lung (128 lb. woman opposed to 200 lb. man) have any difference as to how we progress in this disease? Thanks Pat H/MA

* * *

A. You asked a very interesting and good question.   Actually, weight plays little part in predicting size and volumes/flows of the lungs.  The main factors used in prediction equations are age, gender and height.   While there certainly is consideration allotted for extremes in weight - - - WAY too much and WAY too little, there are no "standardized" predicted values for pulmonary functions parameters.
 
So, part of the answer to your question is "No."   Given two individuals who are, say, 5'6", same gender and age, but one is 128 # while the other is 200#, there should be no significant difference in the basic size and predicted for their lungs.  The "Yes" part of the answer to your question would be that it would be expected that the person at 128 pounds would come in closer to the highest possible measurements while the larger individual would come in lower on the same measured values.   Nevertheless, unless they have a chronic disease, we wouldn't expect for them to be out of the range of what is predicted as "normal" (> 80 % of predicted values for their age, gender and height).
 
In your question, you also asked about whether or not the difference in weight would alter 'rate' of progression (or that's what I perceive you to be asking).   The answer would be "Yes and no".   Of course, the person who carries around a lot more weight would have greater difficulty providing oxygen for and removing CO2 from their body mass than would the smaller person.   In that they would be "feeling" worse.   BUT, depending upon their tolerance of the added work and discomfort, they may or may not suffer different results from the differences in physique and symptoms.   If, in spite of their added mass, they are able to keep more active and functional than their smaller counterpart, they may live longer and be more productive/functional, having a better quality of life.  Yet, being larger, they might be more likely to develop diabetes and heart complications related more to obesity, than to having COPD.   So, even if they can tolerate more discomfort, they might fare worse for the added complications related to their obesity, off-setting any advantage they might have over their slighter counterpart who doesn't have those problems.
 
So, while there may be no significant difference in "lung size" between those individuals, their rate of decline can be either the same or different and is dependent upon a combination of other considerations with regard to co-existing conditions.   In any case, someone who is overweight by more than 10 % DOES potentially add adverse influence to their disease progression and symptoms that is avoidable.   So, they should make every effort to shed pounds as is possible and safe.
Regards, Mark

Q. Please explain the difference in walking (carrying one's oxygen); walking the treadmill ( while using 02 from a concentrator) and riding a recumbent bike (again using 02 from a concentrator vs carrying it).  I maintain the latter two are easier as one is not supporting one's self nor carrying the 02 load.  I know they are all beneficial--but are they each equally beneficial? Assuming one is capable of doing all three, which means of exercising would one derive the greatest benefit from?  How would you rank them in order of benefit? Thanks, Fran

* * *

A. Walking - - - from 'point 'A' to point 'B' - - - while carrying one's own oxygen supply will generate the greater load as compared with walking on the treadmill AND 'not' carrying the O2 you are using - - - that is at the same speed and grade(s), as well.   Next, comes by riding the recumbent bike, using the same rate of 'energy expenditure.   So, to answer your question of "equality", No, they are not equally beneficial as a straight comparison when you hold energy expenditure as the constant.
 
NOW, if one gets VERY vigorous with the bike, they c-a-n exceed the conditioning of a slow walk, either on land or a treadmill.   You can concoct variations to this effect for comparison between exercise types and come up with greater or lesser comparable benefit.   So, everything is relative. Regards, Mark

Q. I was having trouble breathing at night with the O2 set at 2lpm. We called Apria Health and they sent out a new one (concentrator) and it works terrific. We talked to the Tech about concentrators and found out they only need to produce 88% oxygen to meet Federal standards. Also they should be serviced every 3 months. Mine had not been serviced in 10 months due do a putor malfunction at Apria.   He told us to mark it on our calendar in case this happens again. Maybe you can answer this.  Oxygen out of canisters is 99% pure oxygen.  This is over a 10% difference.   Should the concentrator be set a little higher to compensate for this difference? Pat in Wis.

* * *

A. While the manufacturers specifications for concentrators allow for an output as low as 88% in some cases, the actual output is usually closer to 93 to 97% at least on the ones I have tested. This means that it is not really that different from the 99.9% purity of cylinder oxygen. The liter flow change you would make to "exactly equal" delivered oxygen from your concentrator and your cylinder would be such a small fraction of a liter in most cases that you would not have a device at home that could accurately measure it. It is a good concept for the theoretical world, but not of practical value in the real world. However, it does bring up a great point. My Grandfather in law was on oxygen at the end of his life staying at my mother in laws house. He was on a concentrator and they had cylinders for portable use. Every time my mother in law went out she would come home and find him on one of the cylinders. when she asked him why he replied "the cylinder oxygen is better" She thought he was nuts and called me to ask me about it. I brought home an oxygen analyzer from the hospital where I worked and analyzed the output of the concentrator. It was delivering 60% oxygen. I told her to call her supplier and get it replaced as he was right, the cylinder oxygen was in fact better than the oxygen from his concentrator.

My point is this, you as the oxygen user know how it feels to breathe it. When you feel a difference between two sources of oxygen report it to your supplier. They can analyze the output to be sure you are getting the quality and purity you deserve and require. Some health care providers always seem to think the patient is wrong or overreacting or even just plain goofy. This has been my secret weapon for many years to help me solve problems others sometimes can't: When my patient tells me something, no matter how far fetched it is, I try as hard as I can to believe them until they are proven wrong.
John

Q. Tiredness is one of the most difficult aspects for me to deal with.  I have never been one to drag around and now I have to plan, plan, plan everything I do! And lots of times, I don't have the energy to get through it all. Why does this disease make you SO VERY TIRED? Libby

* * *

A. Being tired, we like to call it fatigue, is a very common symptom of COPD. Fatigue is born of a thousand little things that all add up. Some of the contributing factors are: You use more of your energy just to breathe, that is energy you used to have for other things. Often individuals with COPD do not get proper nutrition, the disease makes it harder to shop for, prepare and eat a healthy balanced diet. When Newton said "a body at rest tends to remain at rest, a body in motion
tends to remain in motion" he was talking about inertia, but the theory applies to exercise also-- the more active you are the more active you can be.

People with COPD are at risk for depression (can't eat, can't breathe, can't go anywhere or do anything -- why would someone be depressed?) Feeling "down" can sap your energy and leave you in a heap on the couch- (if you manage to get out of bed).

It's all pretty common sense stuff if you think about it, visualize yourself at 20 years old when you had (at least I had) unlimited energy, a well conditioned body and a sunny attitude. Now look at yourself as you are now and look at what is different. It's not hard to see where the energy went. This discussion makes me think of the principles of "Conservation of energy". It can help to think of the energy you have for each days activities as being like money, you have a finite amount to spend and when it's gone, it's gone. Just like cash money you need to budget your energy and spend it wisely. If you blow it all on cleaning the house in the morning you won't have any left in the evening to go out dancing (or even watch dancing on television). People were talking on here about making a plan for the day before they start doing things. I tell my patients to do just that, then go through the list and decide what on there you really need to do, and get rid of the activities you can do without so that you can save your energy for the things you really must do or that you really want to do. I need a nap after writing all that, John

Q. Had appointment with Pulmo this week and he put me on Spiriva without me even asking.  Have 12 days of free capsules and HandiHaler.  Walgreens says it will cost $122.59 for a month.    I am very excited about trying Spiriva, but am also a little bit concerned as I have taken Albuterol and Ipratropium Bromide for so many years now.   I was fine until I read the Patient Instructions that came with the capsules .. so wondered if any of you (Mark?)have had any problems with the following regarding Upper Respiratory Tract Infections.

Table 1: Adverse Experience Incidence (%Patients) in One-Year COPD  Clinical Trials  ~~  Ipratropium-Controlled Trials ~ Spiriva/Ipratopium Respiratory System (upper) section:  Upper Respiratory Tract Infection 43-Sprivira / 35-Ipratopium.    Also 7-Pharyngitis Sprivira/3-Ipratopium.

I live in fear of respiratory infections, so the above gave me some concern.  Most everyone has had such good reactions to the Spiriva that I am going ahead with positive thoughts, but did wonder about the above. Thanks for your input which I have come to value very much. Ruth

* * *

A. My best advice to you and others who read the 'fine print' on drug studies like those for Spiriva is to realize that EVERYTHING has to be reported in the drug literature, whether or not it is pertinent to concerns about the drug or not.   The statistics you give from what you read suggest that there is comparability between Spiriva and Atrovent with regard to infection rate.   It does NOT mean that using Spiriva "caused" folks to develop infections.  It simply means that during the time those folks participated in the studies, that rate of infection among them was 'observed' to be that which was reported.
 
For your concern about infection, the best things anyone can do is optimize their wellness and physical condition - - - eat right, exercise regularly, etc. - - - maintain good airway integrity - - - take appropriate medications to keep airways clear and allow best movement of air, and be diligent about clearing secretions from their airways.  If I sound like a broken record on this, there is a good and obvious reason for that . . .
 
Insofar as your concern for starting to take the Spiriva, I recommend you go ahead and make the change.  You s-h-o-u-l-d end up being happy you did, in a few to several weeks. Regards, Mark

Q. I use Advair 500/50 which is an inhaled steroid, and when I received my flu shot last fall one of questions on the form asked if I was on steroids.  I wrote down the Advair and the technician told me "that doesn't count." Now why was that?  Isn't Advair a steroid, and since you inhale it twice a day isn't it in your system? Charlotte in Virginia

* * *

A. Good question, Charlotte! It IS indeed a steroid.   BUT, with immunizations, the concern with steroids is; are you taking enough to suppress your immune response - - - in which case, your response to the immunization would NOT be what they want, since your system's ability to respond to the stimulus of the vaccine would be distorted.  Your response to the immunization could range from no beneficial effect at all, to experiencing the worst negative reaction possible from the agent.   In the case of the flu, it would most likely be a waste of time, were you on significant doses of oral steroids, since they would be throughout your system AND in M-U-C-H higher concentration that would inhaled steroids potentially be.   That's whay he said they didn't matter.   It wasn't the mere fact that you are taking steroids.   Rather it was "how much" steroid you were taking and how much might potentially be in your system and how it could affect the efficacy of the immunization. Regards, Mark

Q. Perhaps I am wrongly assuming that Emphysema is mainly concentrated in the Alveoli (bottom of the lungs) and the rest of the lungs are relatively fine. I am undoubtedly wrong. Would a CT SCAN show where the lungs are damaged and if a LVRS would be a possible alternative to a full-fledged transplant? Melody

* * *

A. The "alveoli" are the "terminal" units of tissue in the lung, similar in appearance to a bunch of grapes that are all 'stuck' together.  They are the "air sacs, of which we have spoken many times.  They are the site of exchange of oxygen and carbon dioxide between the air contained within their extremely thin (membrane-like) walls and the blood vessels that cover them and carry blood through the lungs to facilitate gas exchange.   Alveoli are found EVERYWHERE within the lungs, in their outer-most tissues.    Emphysema involves the breakdown of those walls and the coalescing of individual alveolar units into larger and larger units, destroying those walls and their blood vessels and reducing the blood-gas interface that allows exchange to occur.     Emphysema occurs in either a homogenous or heterogeneous types.  In homogenous emphysema, the disease is spread out evenly throughout the lungs and doesn't concentrate in any particular area.  In heterogeneous disease, the damage is concentrated and confined to one lobe - - - usually the upper lobes - - - or to areas of a couple of lobes, but still discrete and resectable.
 
For someone to be a candidate for LVRS, their emphysema must be heterogenous and therefore, concentrated in one area of each lung.  OR, they must have the bullous type and the bullae be big enough and "resectable" to undergo the bullectomy form of the LVRS procedure.
 
CT scans are indeed one of the definitive tests done to screen potential candidates.  Ventilation-perfusion scans are another definitive test.    Usually LVRS is looked at being an alternative when lung transplant is not the desirable course to pursue, OR the candidate needs a bridge to transplant, somewhere down the line. Regards, Mark

Q. I just received a concentrator yesterday (am now a new 02 user) and have a couple of simple questions.  After you put on the cannula, obviously you inhale through your nose.  Does it matter whether you exhale through your nose or mouth?  Is one more preferable than the other?

* * *

A. From the standpoint of function of the cannula and the concentrator, it will make no difference.  People are generally advised to breath in through their nose and out through their mouth.  This is a helpful pattern to get into if you are going to need to use pursed lip breathing (PLB), because breathing out through the mouth is vital for PLB.

Breathing in through the nose is not critical from the standpoint of receiving the oxygen, but it is important because the nose is designed to "condition" the gas as it is inhaled, filtering out dust and adding humidity to the gas. IF you are using an oxygen conserving device instead of a simple cannula, breathing in through the nose is more important. Larry, RRT

Q. I was wondering about the criteria that's involved when specialists decide as to whether one would benefit  by having a LVRS or a TX. Thanks, Melody

A. There are multiple considerations in deciding between those two procedures.   LVRS is NOT for as wide an audience as is transplant.   Candidates must have a certain kind of emphysema, located in (usually) the upper lobes of the lungs and concentrated in discrete areas.  It cannot be spread out throughout the lungs in any kind of generalized or even manner.    
 
For those who would fit the criteria for LVRS and/or transplant, general questions include, will LVRS result in reasonable improvement that will last for a reasonable amount of time?  Is it the best option between the two procedures?   Can LVRS serve as a stop gap, or bridge to transplant later, down the line?   It the candidate symptomatic enough to warrant the risk of going through the procedure?    . . . now?   There are many more questions.  And these are not in any kind of prioritized order, either.  But, it should give you some idea.   Maybe others can suggest yet other questions/ considerations. Regards, Mark

Q. Was at the pulmo today asked him about that lung exercise thing that was mentioned in the e/mail yesterday, he said that it would make my breathing worse because we tend to trap air and by sucking in harder it complicates matters could you address this please...Bob

* * *

A. I always assume that anyone here's Doctor who has examined them knows their individual needs better than I possibly could. That being said up front, I would point out that the discussion of Inspiratory Muscle Trainers was initiated because Joy asked about a confusing paragraph from the American Thoracic Society's "Standards for the Diagnosis and Care of Patients with Chronic Pulmonary Disease." Here is a quote directly from that document:  Decreased dyspnea has been demonstrated after ventilatory muscle training in patients with COPD compared with untreated control subjects (135). One group of investigators has shown improved symptoms, decreased dyspnea, and improved ability to perform daily activities when inspiratory resistive loading training was added to the pulmonary rehabilitation regimen (136).

So, the American Thoracic Society says that ventilatory muscle training helps patients with COPD. I very seldom argue with doctors (I did call a brain surgeon an idiot once, but that was in a traffic altercation about a mile away from the hospital) and I would assume that the American Thoracic Society has never examined you. Your doctor my have seen something that makes you a poor candidate for ventilatory muscle training but in general it has been shown to be beneficial to individuals with COPD in well documented studies. Please note how hard I worked to never say your doctor was wrong, John A. Richter RRT

Q. I have been trying to find out what effect a high powered ion/ozone generator would have on my lungs since I have severe emphysema. William McCoy

A. Any machine that puts out ozone poses a danger to you and others wh9o have COPD or Asthma or other lung diseases.   Ozone is a strong pollutant, the measurement of which is used to set standards of air quality for federal environmental code purposes.   That is because ozone is a strong respiratory irritant, responsible to cause worsening of breathing symptoms when it occurs in too high a concentration.   The threshold for irritation is very low at concentrations of only a few parts-per-million.   When we have had folks discus air purifiers/negative ion generators in the past, the prevailing wisdom has been to seek purchase of one that has the lowest ozone output (as an unavoidable by-product), or "NO" ozone output.
 
According to mostly anecdotal reports/information negative ion generators seem to have a beneficial effect on breathing.   Yet they are the most common source of inadvertent ozone generation.  It seems to be related to (but is not directly tied to) cost/quality of machine.   So, check carefully and be sure not to get one that will generate significant ozone, but is enticingly less expensive than a better, less problematic machine. I hope this helps.  If not, ask any additional questions you have and we'll try to answer them for you. Best Regards, Mark

Q. I thought I knew which you go by for your lung function but know I'm not sure. Is it FEV1 or FEV/FVC.  Thanks, Sherrie in Mich.

* * *

A. The FEV1 is most often the number quoted to exemplify lung function.   However, FEV1/FVC is also an important number.   Neither expresses "absolute" lung function.  By that I mean, some folks will say: "My lung function is only 23 %.", thinking that their lungs are only working with 23 % efficiency, or that they only have 23 % of their lungs left, in some physical sense.   All the FEV1 of 23 % tells you is that "BECAUSE" your lungs are as diseased as they are, you can only blow out 23 % of the air that your are supposed to be able to blow, as compared to if your lungs were NOT diseased. (We call this condition "normal".) Indeed, with what your lungs have left, they are working 100 % and as efficiently as possible within the confines of your overall condition. Regards, Mark

Q. I know that we in the USA are often accused of being overmedicated.  I can remember growing up and having a friend who's mother dragged him off to the doctors every time he sneezed.  He was ALWAYS on some sort of medication and was also always sick.  Once he got away from mother hen his health seemed to improve immensely.  It always seemed to me that if you gave your body too much 'help' with medication the body would almost say, "Gee, why should I do anything? Whatever I need is being supplied supplementally."  So my question is that if I get on a program of 'maintenance' drugs should I figure on being on them for the rest of my life?  I also wonder the same thing about supplemental O2. Once you start using it are you committed to it for the rest of your life?  Last question I have is this.  Why is it that people seem to be on O2 during the night when they first start using it?  I would think you would want the supplemental O2 when you are using O2 up the most....when you are active. Just seems backwards to me.  But then again I'm suffering from terminal ignorance.  :O)  John

* * *

A. While I would say you are on target with your story about the friend and the medications, as there is MUCH evidence to show that THAT relationship exists.   Similarly, folks who have led extremely sheltered and "clean" existences have been shown to lack immunity against many common opportunistic pathogens, compared to those who live on the streets.   But, these analogies cannot be applied to the treatment of COPD or other chronic diseases like heart disease, diabetes or arthritis, to name a few.
 
The medications used to maintain optimum function in COPD are NOT substances that would be produced by the body.  So there can be no correlation of the nature you suggest - - - "Gee, why should I do anything?   Whatever I need is being supplied supplementally." - - - since NONE of these substances are "supplementing" otherwise natural production.   Oxygen may be called "supplemental", and is such in its application, but it does not supplement a substance being made naturally by the body.   Instead, it supplements what is being taken into the body, but is in insufficient quantity without the supplemental supply.
 
If you are found to have better pulmonary functions or significantly reduced symptoms when taking any of the drugs I suggested in my earlier post were truly considered "COPD maintenance" drugs, then you can expect them to be needed for the balance of your life.   When your lungs deteriorate to the point that they cannot pull in all the oxygen your body needs from the 21 % provided by ambient air, then supplemental oxygen is necessary and can be expected to be needed for the balance of your life.    These are needed because your body cannot obtain them through natural or other means.   Depriving the body of them will not "force it to work more efficiently with less."   Indeed, without sufficient quantities of needed substances provided supplementally, the body simply declines and fails.  This is especially true of oxygen.
 
You ask about why oxygen is needed at night when it seems it should be most needed during the day when activity raises demand.   That is a common question and was partially answered by some folks in their responses to your query.  But, to be most accurate, It has NOTHING to do with CO2, as a few folks suggested.  It has everything to do with breathing pattern and simple numbers of oxygen molecules coming into the lungs and therefore available for diffusion into the blood.   When we sleep we breathe slower and shallower, by nature.  This pattern does not significantly change, even though we develop seriously diseased lungs.   We know that folks who desaturate during exertion also tend to desaturate similarly during sleep because of the slower, shallower breathing pattern.   THAT is why night time oxygen is so necessary.   While many are prescribed night-time oxygen as a first introduction to that therapy, chances are that they also would benefit from it during exertion/exercise too.   It's just not always thoroughly investigated to find that final fact. 
 
You are correct in your thinking that one WOULD want to be using oxygen when they are most active.   But the bottom line is that any time during which one would desaturate presents an indication that they should use supplemental oxygen.  Finally, one CANNOT use oxygen for a while, take it off and THEN expect it to benefit them for an equal amount of time after removing it.  In other words, supplemental oxygen has no "cumulative" effect.   It ONLY provides benefit during the time it is being used.
 
Keep asking those questions, John!   Your ignorance is FAR FROM terminal.   Incessant curiosity is ALSO a "good" thing!   Have fun and learn a LOT! Regards, Mark

Q. My wife is in hospital. This is third exacerbation, in as many months. Pulmo. and PCDr.  talked to her while I was not present.They advised her as to having a DNR certificate with her if she wanted such, and other depressing news. Seems combination of CHF, poor kidney function, and of course E, have taken their toll. I think they are being pessimistic. She  looks good , but keeps getting edema and SOB.    Anyone have any "pick me up news"at this point ?? Larry H. FL

* * *

A. If they're telling her they want her to agree to DNR status - - - as in they think she should declare that, then they ARE being pessimistic and maybe a little more than presumptuous.   If they are recommend she put her desires down in the form of a directive to them as to what she wants them to do in case she is unable to direct them in an emergent moment, then that is reasonable, and not necessarily judgmental, one way or the other.  We have discussed advanced directives, living wills and durable power of attorney for health care many times here on the list.   With this disease - - - and when one reaches the point where they are experiencing increasing hospitalizations or increasingly severe exacerbations - - - it is good to lay out just what you want done and what you DON'T want done.   That can certainly save a lot of angst and heart break down the road!  
 
I'm glad she looks good and you both don't think her time is likely to be up any time soon!  Now's the time to get the not so pleasant, but necessary business done and behind you.  That way y'all CAN enjoy life, from here on! Best regards, Mark

Q. John, I have recently read on the list where a couple of people are keeping their concentrator in a closet.  Isn't this a no-no?  I no longer have one but I seem to remember being told to keep it in a well ventilated space. Any thoughts?  Sue

* * *

A. That's a great point that you make. Concentrators need to breathe just like you or I. In the ideal world ( I really am going to move there one day) concentrators are kept in a well ventilated dust free area. The only time a concentrator should be in a closet is if you are not using it and you want to hide it. The machine needs fresh air to "make" it's oxygen and it needs to be able to get rid of the heat it generates. Running it in a closet will adversely effect both of these requirements unless you have some huge closet. We were instructed to also choose a spot away from heating vents and/or radiators for optimal performance. We also would look for a location which was not in a carpeted room if possible with the idea that it might help to keep dust and fibers away from the concentrator.

By the way, if you have a concentrator please be sure to clean your external filter(s) at least weekly, more often if you have a lot of dust or fibers in your home. It always amazed me to go into someone's home and see life support equipment which was not being well cared for, often when I asked the family why their equipment was in such a sorry state I would find that they had never been properly instructed in how or why to maintain their equipment. I guess I have the old time Respiratory Therapist's love of equipment which can make me overly focused on this type of problem, but it just seems logical to me that if you need a certain machine to breathe (or live for that matter) it would be worth the time to take the best care of it that you possibly can. John A. Richter RRT

Q. If I am understanding the exercise routine correctly it is a matter of building duration by slowing my pace walking.  And I understand that building muscle tissue is also a goal.  Physically I'm in pretty good shape other than my lungs.  I remember that in body building lifting 500 lbs didn't do you any good. However, lifting 5 lbs 100 times did.  Is this a decent correlation to the object of walking and pulmo rehab?  I'm slowly finding the pace and distance that I am comfortable with... one that doesn't leave me SOB but does leave me with a slightly elevated breathing effort.  Once I've rested for maybe 10 minutes so I am totally back at rest, I get up and repeat the whole process again. This is what I'm trying to do during my work day....find the time to do as many repetitions of this as is practical and comfortable. John

* * *

A. You've got the overall concepts pretty well sorted out.  What I recommend is that folks push them selves to a point that they are 'working' to breathe at a manageable level of discomfort, BUT not at such a level of discomfort that they can't achieve their target duration.   In shorter terms, push yourself, but don't push too hard.  Duration IS more important than load. Regards, Mark

Q. When is the best time (if there is any) to take your blood pressure?

* * *

A. I don't think there is necessarily a "best time" to take your blood pressure.  I would recommend taking it at three or four times-per-day, at different times of day each time, but the same times each day, over the course of several days to see what your "trends" are.    Always take your blood pressure under the same conditions - - - preferably at rest for several minutes, while sitting.   Realize that if you've been exerting, are angry, excited or otherwise emotionally at unrest or under influences that do not constitute being quiet, calm and at rest for several minutes, your blood pressure will not be comparable to other measurements made under better circumstances.  Also keep in mind that body position matters.   Your blood pressure will be higher while laying down than when sitting.  It will always be higher when sitting than when standing, even if not by much.   So don't measure serial blood pressures for trending purposes with your body in different positions during the measurements.   Realize that one blood pressure does not a problem make.  If you measure a bad B/P, repeat it to confirm or refute its accuracy.   ONLY with a good set of measurements made at different times over a reasonable period of time (say, four times-per-day over a period of a week) can you establish what your trends are. Regards, Mark

Q. A friend tells me that continual use of oxygen produces 'free radicals' which cause disease and aging.  I don't have much of a choice as I do like living.....but was wondering if anyone has heard this before.  Thanks! Karen-AZ

* * *

A. Before you and the folks get to comfortable with the uninformed responses pooh-poohing the question you posed, let me give you some accurate information.

Oxygen - - - even the 21 %, atmospheric kind we breathe in and MUST have to survive - - - DOES indeed produce free radicals that have detrimental consequences to our body.   This is not a new discovery or little known fact.    Action of free radicals have long been in the equation of disease and aging.   BUT, the question becomes one of degree and balance.   Many chemical reactions in our body produce oxygen free radicals.  In the balance of things, those free radicals are neutralized and/or rendered harmless by yet other reactions that follow.    So we don't deteriorate, age and die at some point very early in our existence.  Instilling more oxygen into our body - - - especially that which doesn't get used in helpful reactions - - - increases the potential for reactions that produce increased numbers of free radicals.

In Tamp, Fla, in December of 2002, at our AARC International Conference, Dr. John B. Downs, the Keynote Speaker at one of our premier scientific lectures, (and the man from whom I received the vast amount of my initial training and pulmonary medicine education, when I was a 'baby Respiratory Therapist', back in 1972) presented a talk on: "Controversial Aspects of Oxygen Therapy".   He cited numerous instances when oxygen free radical formation is initiated through the therapeutic application of oxygen.   He cited a number of studies wherein the phenomenon was identified and validated.  He cited many controlled studies - - - in non-humans, of course - - - where organ damage, especially to the liver - - - was induced through exposure to oxygen.    He proceeded to lay out means by which some of our most revered and common practices in acute and critical respiratory medical care cause potentially hazardous numbers of oxygen free radicals to be formed and allowed to circulate and damage the body for lack of the naturalizing mechanisms to hold them in check or remove them from circulation.   He even walked us through steps and scenarios of our common practice of using high concentrations of oxygen to treat the hypoxia of Acute Respiratory Distress Syndrome (ARDS) - - - which actually 'directly' w-o-r-s-e-n-s the illness because of the use of the high oxygen (this has little to do with the standard concepts of oxygen toxicity) - - - and showed how erroneous some of our thinking - - - and therefore actions - - - are in treatment of ARDS AND potentially why the (poor) survival rate is the same as it has been for more than 30 years.   He supported he criticism of the use of such high oxygen with autopsy findings and other 'histological' evidence (physical characteristics/changes of tissues) as well as numerous cases where 'less oxygen' and more alternative maneuvers were used with significantly better outcomes and less permanent lung damage to successfully treat ARDS.   (My RT colleagues will recall PEEP and "super PEEP" studies of the early and late 70's and studies thereafter, among which were those that brought APRV into mainstream use).

Yes, even the low-flow supplemental oxygen we prescribe for those with COPD who are hypoxic without that supplemental support causes the formation of a higher-than-normal number of oxygen free radicals.   In conversing with Dr Downs after the lecture - - - and realizing the impact upon those with COPD and other lung/heart conditions that involve consequential hypoxia - - - I asked him specifically about the consideration of the COPD patient.  His response became one of those fore-head-slapping moments for me, because it was purely based upon the 'practicality' of the matter.   He said (paraphrased by me) that a few things have to be considered.  (1) Hypoxia in COPD causes pulmonary hypertension.  (2) Pulmonary hypertension hastens progression of COPD through secondary heart failure.   (3) The benefit of the oxygen therapy outweighs any detriment from oxygen free radical activity, when you consider the complication of pulmonary hypertension.  (4) Since the deterioration we see in advancing COPD is attributable to many things other than free radical activity AND we have no evidence to show that the increased number of free radicals aren't mitigated by defense mechanisms, we cannot make a convincing argument for withholding oxygen therpy in the face of knowing its distinct benefit.

SO, should you folks worry about oxygen free radicals when you are using your supplemental oxygen?    No - - - BUT - - - the damage from skimping or from avoiding needed supplemental oxygen therapy can pretty well be guaranteed to hurt you and cost you survival time!    So, if you want to incorporate this free radical stuff into your local Trivial Pursuit Game, by all means, have at it.   Otherwise, its simply not worth your panties getting in a bunch over.   At the same time, the notion about free radicals is far froim being "baloney"  (or should I say 'bologna'?!) Best Regards, Mark

Q. I find that I cough a lot in spasms, and when I do move any mucous, I am extremely SOB, to the point sometimes of being close to panic.  I am lucky I suppose because I can sometimes shift it with steam inhalations and essential oils.
Should coughing up mucous make me short of Breathe?

* * *

A. Coughing most definitely can make you short of breath! ! !    You expend a tremendous amount of energy coughing.   Couple that with the fact that you are imposing the cough upon an already tenuous breathing pattern and you can easily see how things can get 'thrown out of whack'!   For many folks, it is often a necessity that they cease what ever activity they may be engaged in to devote ALL attention and effort to coughing.  Then, they sometimes require no small amount of recovery time.  For some, it can ruin their whole day!
 
Coughing with so much vigor when mucus is not easily lossening or moving can be even MORE frustrating and fatiguing.  You do well to inhale steamy moisture (as long as you don't get it too hot and/or too close and hot.   That will help loosen your mucus.  Sipping a hot beverage (I understand teat is pretty popular where you reside :>`o ) is helpful to get things moving, as well.   Whenever you can, it is nice to "plan" your coughing efforts.   Doing a bronchodilator treatment, inhaling some moisture and then a concerted effort to cough and clear mucus is a good 'habit'/'regimen' to follow.   Whenever you can schedule your efforts so as to have control over time, place and conditions is always a plus! Regards, Mark

Q. I've asked my supplier about using more than 50 ft. of tubing, and they told me it would decrease the oxygen concentration. I've wondered about it, because where would it go? Mary - California Desert

* * *

A. The fifty foot limit on oxygen tubing is for concentrators. A concentrator cannot operate properly when there is too much resistance to flow coming out of it (also sometimes called back pressure). In the face of excessive resistance the purity of the oxygen put out by the concentrator can and will be decreased. The flow will also be decreased by resistance which you
can see yourself by setting the flow on your unit then adding a bunch of tubing and watching it (the flow rate) go down. Compressed gas systems are not effected by tubing length (as long as there are no leaks), and some but not all liquid systems can be effected by the length of the tubing, with the added resistance sometimes causing them to fail or freeze.

So the deal is if you use tubing more than fifty feet long with a concentrator everything may -look- OK, but it might not actually -be- OK. I personally don't feel safe with tubing longer than fifty feet on a concentrator. John Richter RRT

Q. If I am exercising at home and struggling to keep it at 90, then I take it I should be using 02 to exercise? trying to do 35 minutes, can't keep it above 90 without stopping four times. Going 1.8 mph, I thought as long as I could hang  in there at 90 I wasn't doing any damage. guess I'm looking for a concentrator. My question, is our minimum 02 level for exercising actually higher than that which we get prescribed 02 at?   So it is not okay to be exercising and maintaining a sat level of 88? Linda W/NY

* * *

A. I like to keep my patients at or above 92% with exercise. My thought is that I am asking their body to do much more than it normally does so I want it to have a little extra oxygen to do it with. It is also very important to me to keep the Rehab patients from getting discouraged, to this end I want them to feel as comfortable as possible while exercising. Also, I always make sure I have a Dr.'s order that allows me to adjust their oxygen level as I need it with exercise so that my actions are within the letter as well as the spirit of the law. I would suggest that dropping to 88% with exercise is not the best thing to do if you have oxygen available, also if your saturations are dropping to 88 with exercise and your Dr. can document that, it that would qualify you for oxygen from Medicare or most private insurance carriers. John

Q. My Questions:  (1) what are symptoms of CO2 retention?  (2) Etiology of CO2 retention?  (3) How treat CO2  retention?  Thanks, Erlyn

* * *

A. (1) Q: "What are the symptoms of CO2 retention?"  A: Until CO2 retention is severe (say a paCO2 > 70, with poor correction of the pH) there are no 'overt' symptoms of retained CO2.  The body has a very efficient mechanism to 'buffer' the system, so that the CO2 can rise quite high and one might still not "f-e-e-l" any sensations or other indications that it is as it is.    There is a colloquial disorder called "Pickwickian Syndrome" (nowadays, we refer to the problem as 'chronic hypoventilation'), in which CO2 retention (most often, with hypoxia) occurs in very obese folks who also often have upper airway obstruction, causing them to suffer sleep apnea.   One way they were treated *years ago* was to give them bicarbonate pills to help alkalinize them to raise their blood pH to counteract the somnolent affects of the elevated CO2.   They were described as often being lethargic and somnolent.   Yet others showed few, if any, outward signs of affects of elevated CO2, even when their CO2 exceeded 100 mmHg.   I have cared for two patients in my carreer whose CO2 exceeded 100 mmHg (one averaged 125 mmHg) who were awake, aware and coherent with those CO2 levels. 
 
(2) Q: What is the "etiology of CO2 retention?"  A: The "etiology"of CO2 retention is advanced lung disease in which lung residual volumes (that volume left within the lungs at the end of a normal breath) are significantly increased (RV-residual volume > ~ 200 % of normal and FRC-functional residual capacity  > ~ 250% of what it should be) such that the tidal volume a person moves with each breath is of insufficient volume to adequately 'dilute' the air in the lungs to lower CO2 to normal levels.   I have described this using a balloon as an example.   Picture a balloon into which you have blown a breath.   This represents the lungs in their resting state.   They always have a certain amount of air in them at the end of a normal breath.   Next, picture blowing a breath of air into the balloon and then letting just that much back out.  On a repeated pattern, this would represent normal ventilation.  Next, picture the balloon with about three or four more breaths in it AND that this NOW represents the resting state of someone who has COPD.  Now, you blow a breath into the balloon (representing a normal tidal volume) and let just that much out.  you repeat this pattern and now you have the breathing pattern of a person with COPD.   Their lungs are always *over-inflated*.  Even though their tidal breathing may remain at normal 'volumes' it now can only dilute the air within the balloon a portion of what it could when the lungs were normal.   CO2 within the lungs is regulated by the dilution and expulsion of air during ventilation.   Since the CO2 remains elevated AND we know that the pressure of CO2 i