Working with O2

Q. I've been a teacher for a number of years. Now there's a slight opportunity of getting a job as head teacher, but I'd like to know if it would be possible on O2. I'm not on it, and it's probable I won't need it in near future, but just for knowing: can you be active in a real work on O2? Fernando

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A. I had a patient who was a "hunch back" (kypho-lateral scoliosis), who had a tracheostomy and used oxygen for his COPD and CHF. He was active as a "roofer"! He climbed up and put roofs on for several years with his oxygen strapped to his back!!! Teaching in a classroom ought to be a breeze, compared to that!!! Regards, Mark

Rapid Heart Rate on Exertion

Q. My Dad has been on Spiriva since Oct. He has noticed that he has a rapid increase in Heart Rate upon little exertion. For example, walking down a short hall way in his house, it goes from 90 to 126. His O2 levels remain fine. Does anyone have any insight to this or a similar situation? What are you doing about it?? Thanks so much, Maura - Ohio

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A. Hi Maura, Changes like that often indicate little more than deconditioning. Is your father in an exercise program? Does he have heart disease? Is there a cardiac reason for the increase? He could have an electrolyte disturbance. He could be dehydrated. There are innumerable reasons - - - some serious and requiring treatment/intervention--why his heart rate would jump up like that. I recommend his doctor evaluate him--sooner than later, too--to be sure it is nothing acute! Regards, Mark

Antibiotics and Vitamins

Q. I read someplace that if you take vitamins while on a antibiotic it will weaken it down to half strength. My last flair up I stopped taking my vitamins and I'm satisfied that I got an earlier control on the infection and gone before the 15 days were up but I finished the prescription as you have to do. Syd - Ont

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A. I don't think that is correct--at least NOT as a "general" rule-- nor, certainly in the case of "every" anti-biotic. Pharmacists can give you specific information like that by simply asking. You need the specific information for each drug you take. Ask your pharmacists!!! It is getting scarey to read more and more of these "I read somewhere . . ." kinds of posts that have broadly stated, highly questionable information, being passed on seemingly as advice. Regards, Mark

Purchasing a Treadmill

Q. I need some advice. I had an older model treadmill that I had to get rid of a couple of years ago because the "petrol" odor was offensive..made me more sob to just have it in the apt. My doc told me recently that newer machines don't offend like that and he urged me to get a new one. I have decided to do that and have looked at ads, etc.

There are so many models to choose from !!! I don't want bells and whistles, just good treading at a good price. My son will also use it and he is 6'2 and 235 lbs so we need a heavy duty model. Suggestions, anyone?Virginia n Va

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A. Hi Virginia, That's a mighty tall order you're trying to fill! If you go with the home treadmills, you'll probably be looking at around $700.00 for enough motor to handle the load of your son. I would advise "against" getting a padded belt surface, as while it is OK and even helpful for those who jog, having walked on one for 30 minutes, I found that my calves ached 'because' of the extra muscle work I had to do to accommodate the padded surface. Jogging was great! I would fear that a big guy like your son would wear two ruts in the padding in a fairly short time, as well. You would need a motor that is at least 1.5 horsepower, too. Its too bad you got rid of your other machine. I have had success with patients placing a $15 fan to blow across the motor and carry the fumes away from their face while also diluting the odor such that it was minimally perceptible, or 'imperceptible' to them. That might have been worth a try. Best of luck to you and finding a machine to meet your needs! Regards, Mark

Sterilizing a Nebulizer

Q. I never heard anything about sterilizing a nebulizer. What part do they say to sterilize? Do you sterilize your toothbrushes? your glasses? your cups? Sounds ridiculous to me. If you use the same machine, I assume you use different mouthpieces. No sense in sharing germs. Nothing that helps you breathe is going to make it harder for you
to breathe on your own. My units have been rented and the only time the first one was replaced was when I was hospitalized and got a new prescription. As long as the motor is running, I see no reason to replace it. What should be replaced once in a while is the tubing and the mouthpieces. The machines also seem to get smaller so a newer
"generation" might take up less space. Ethel

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A. Hi Ethel, You are correct. The word/term "sterilize has been carelessly bandied about in posts on this topic over the past day or two. You DO NOT sterilize the nebulizer, by instruction. The instructions 'correctly' use the term 'disinfect', which is all you can do unless you use a quaternary ammonia solution, boil or gas sterilize the device with ethylene oxide gas. Sterilization is recommended ONLY for the PARI nebulizers, as the plastic material of other nebulizers does not have the integrity to withstand
sterilizing procedures without losing functional integrity.

While booklets and websites--even the wonderful Natl. Jewish Hospital website--still recommend the vinegar solution soak for nebulizers, the latest recommendations from the CDC are to use a 'touch' (MY term, not theirs) of bleach in the soapy water and forego the vinegar soak, as it becomes superfluous after cleaning in bleach. The vinegar has always been recommended because it kill "pseudomonas Aeruginosa" the most common respiratory contaminant and pathogenic bacteria. BUT, bleach also kills p. Aeruginosa. So the vinegar soak is unnecessary after cleaning in bleach. Because the conversion foregoing the vinegar soak has not been accomplished, nor completely adopted/endorsed by the powers to be, the vinegar soak is still part of the recommendations and most certainly will NOT hurt anything to do, even redundantly! Regards, Mark

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Chronic Bronchitis/Emphysema

Q. 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. Let me add a bit to what Dr. Ron had to say. He pointed out that cigarette smoking can cause BOTH Chronic Bronchitis (CB)
and Emphysema. When you query your doctor, you might also inquire as to whether you were to understand that you 'previously' had "only emphysema" or whether that term was used because it was what you seemed to present with primarily. While it is very common for us to see folks with CB who have a cough and sputum production of the characteristics Dr. Ron described, and
indeed our main definition of CB states that it is suspected in those who have a productive cough for three months out of the year, for two years in a row", there are some who have CB who 'don't' produce significant sputum, but have the "metaplastic" (cell types) changes when tissue samples from their airways are examined under a microscope.

So while the strong and best advice is to see your doctor and ask questions about these changes, you may learn that what you are experiencing is the onset of the more common symptoms of cough and sputum production of CB, if that is indeed what you have, rather than an "acute" problem of infection or inflammation, as we might otherwise be concerned about. In any case, let us know what you learn. . . . and please see your doctor soon! Regards, Mark

Variation of 6 Minute Walk

Q. is there a variation of the 6 minute walk test for those that cannot walk? But can use their arms? Or a bicycle? I'm
thinking back when I spent 9 months on crutches for a knee injury. I guess one can always crutch it for the walk test. It's a moot point now, but nonetheless I'm curious."

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A. Hi Sandi, There are those who do 'modified' pulmonary stress tests, using arm biking or when possible, leg biking. Those modified tests are not referred to or considered as any variation of the 6MW test, per se. But, when you consider that what we are looking for in the stress test is changes in breathing dynamics, heart rate and rhythm and endurance, you can see how variations like biking of both kinds can potentially provide answers to our questions. I have to say that in those in whom I have done and seen done modifications, that more often than not, the modified test didn't help much in predicting changes and tolerance of greater loads of exertion.

Another consideration is that in those whom walking is not possible or practical, the question of suitability for rehab comes into the picture. Medicare requires, under all but the most exceptional circumstances, that the candidate must have potential to achieve better control of breathing under independent function to accomplish daily activities. That is presumed, if not explicitly stated to include ambulation. So, if a person is temporarily laid up, as with a knee injury, they may need to postpone participation in a rehab program until they are better able to utilize and benefit from the more vigorous exercise regimen. In those who have no
ambulatory potential, candidacy for rehab is highly questionable and Medicare wants to see justification for expenditure of their dollars with what the rehab team expects to produce as a medically necessary outcome. Does this answer your curiosity? Regards, Mark

PFT Reading 0

Q. Is it possible to take a PFT test and it come up 0 reading? If you can't, I understand. Thank you, Mari

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A. Hi Mari, If a person is indeed "alive" when they undergo a PFT, they CANNOT blow "0" (zero), no matter what. Now, having said that, IF one is unable to measure any flow on a subject on whom they are doing a PFT, then several "technical" problem possibilities can account for that. If the mouth is not completely sealed, the leak will cause zero flow measurement, or at least less than is actually happening. If the nose is not clamped and the subject is breathing in and out through the nose, no or less than actual flow will be measured. So, you can see that technical problems can account for poor and inaccurate measurements. BUT, all living beings breathe and move air in doing so, even if it may be severely reduced in velocity. Regards, Mark

MDIs Routinely Short

Q. I know mine are Mimi. One last month had 160 doses in it. I have two on counters so I will know how much I have after 160 it was empty I mean EMPTY. A lot of mine sure don't have 200 metered doses in them. Maxine NC

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A. If you are finding that your MDI's routinely are short--and you are using a r-e-l-a-i-b-l-e method to count doses/monitor output, you should NOT hesitate to contact both the manufacturer and the FDA. If there is a problem, the manufacturer will want to correct it. They will also in all likelihood send you free replacements, or additional MDI's. If they are shorting the MDI's deliberately, or consistently, the FDA will take action. BUT, unless they receive complaints, they may not look for the problem. So, they need YOUR help to bring it out into the open. Again, I stress that you will need to produce reliable evidence of short filling of the MDI's. No guessing, or hunches, or "it seems to be short of doses". Regards, Mark

GERD and COPD

Q. Is there a relationship between COPD and GERD?Especially the relationship between specific meds. I presently take Spiriva, 2 puffs of Serevent twice a day and 1 puff of QVar 80 twice a day. Thanks, Edna-CO

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A. It is a common co-morbidity with COPD. It can be brought on or worsened by several of the medications you take for symptom control of COPD.Theophylline and steroids are big culprits. Beta-agonists act on "smooth muscle" which is what the alimentary tract is lined with. So that can increase stomach secretions. Yours shouldn't be affecting you much, unless you are extra sensitive. There are many other contributors to GERD, that are NOT related to having COPD. So you can't stop with just the COPD meds
and think you've got the major, let alone entire cause. Your doctor should be able to help you review your lifestyle, drugs and other factors to see if there's anything you could be doing differently to help your situation. Regards, Mark

Avasular Necrosis

Q. I want to find out if any one has been DX with avasular necrosis. And if there is any treatment for it. I have been dealing with pain in my left hip, upper leg and left knee for a little over a year. My PCP a year ago DX it as arthritis and pulled muscle. They sent me to physical therapy, treated it with exercise. The pain continued getting better for a while and then back to hurting bad, this went on for a year. I recently changed PCP my Doctor now ordered a MRI done. They found that I have avascular nercrosis in my both hips,The left being the worse, also in my left knee and three places on my left femora bone. >From what I understand about it is that the blood flow is not getting to the bone and that the bone is dying. They have me an appointment with an orthopedic but I cant get into see him for nearly two months. MY PCP said I would probably need HIP replacement and possible knee replacement. If any one can share any information or experience with any of this I would like to have that. PCP said she believes it was brought on because of Steroids. Virgil from Kansas

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A. Hi Virgil, Avascular Necrosis IS indeed caused by steroid use. It is, as you indicated a condition wherein the bone dies from loss of blood flow. There is no conservative treatment that is curative. Surgical replacement of the affected bone IS the indicated treatment.

I hope you are able to get that taken care of. It can mean the difference between being mobile or immobile--and we all know the price of immobility with COPD. I hope you are back up and dancing--or at least walking--ASAP! Best Regards, Mark

Should We Buy an Oximeter?

Q. Frankly I find this all so confusing. Are you saying we should invest in equipment to monitor ourselves? Are we at risk if we don't? If one can't afford this type of equipment should we check in with a Dr. to have these tests performed? How often?

From my specialist I got the impression I just plain soldiered on - if there's an emergency go to the hospital. Other than that, get a lot of exercise and take my meds. Rita

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A. Hi Rita, YES, it CAN be confusing, at times! ! ! My recommendation would be if you feel you 'need' to monitor yourself, certainly try to get the oximeter. If you learn through measurements at your doctor's office that your oxygen is subject to significant fluctuations, especially when you are active, then whether or not you 'feel' you need it, the idea attains greater merit and import.

What you risk by not being aware of what your saturation does under various conditions is the potential to desaturate repeatedly which, over time, will damage your heart. If your doctor measures that your oxygen drops into the 80's when you walk for more than 1-1/2 minutes (less measurement time can easily miss your decrease and underestimate your actual changes) then you
should begin using oxygen, or increase the flow of what you are already using to raise it to at least 90 % and preferably to 92 % or more (again, MY educated/experienced opinion/recommendation).

If you cannot afford to purchase an oximeter, it is all the more important for your doctor to measure your oxygen saturation when you visit for your evaluations so as to determine what flow you require to keep you in a safe range. Thereafter, if you don't have an oximeter, you just make sure you turn your flow up at least to that level determined adequate in the doctor's office. You THEN might increase it by 1 or 2 'additional' liters when you are working extra hard, feeling badly, or just plain not sure if you are
getting enough. During exertion, it is better (IMO) to be getting MORE oxygen than you need, r-a-t-h-e-r than LESS. Even CO2 retainers are not at considered (by those who worry about such things) to be at increased risk of harm when using higher flows of oxygen while exerting.

You DO need to "soldier on" as best you can. BUT, you should be 'prepared for your battle', as would a good soldier. You should know what your oxygen requirements are and try your best to meet them. If you don't know what your oxygen requirements are, you should prod your doctor to help you determine them. That can ONLY be done definitively through measurement. Guess work is NOT definitive. Nor is an arbitrary recommendation like, "use 2 liters at rest and 3 with exercise". 2 liters may be more than you
'need' at rest and 3 liters may not be enough for your needs with exertion.

Most folks see their pulmonary specialist (or PCP, whoever manages their COPD disease care) every 3 to 6 months. As long as you are stable, that should be sufficient. Major changes, without a cause - - -like pneumonia/infection - - - are not likely to occur, so you should be able to safely assume that your oxygen will remain stable in the interim. Regards, Mark

Dental Work and Transplant

Q. I'm contemplating needed dental work and I have heard that if you go for a transplant you have to have your teeth pulled if there is the least little thing wrong. Is this true? Linda W in NY

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A. While others who have been through the process can tell you their experience, it is my understanding that you DO have to have A-N-Y work that is indicated in your pre-transplant screening done b-e-f-o-r-e transplant. The only other stipulation I have run into is that your dentist needs to attest to the prediction that you will not need any dental work for at least 6 months post-transplant. If that involves pulling teeth, so be it. BUT, just because you have a badly decayed or damaged tooth that can be cleaned up, rooted (canal) and crowned, does not preclude doing just that. To my awareness, discretion is left to the dentist, as long as he/she can certify with confidence that when you go to transplant, you 'should' not need predictable dental work for at least six months after transplant. Regards, Mark

Monitoring Sats

Q. I've been doing water aerobics 5 hours a week to work out. My heart rate can get pretty high pretty fast (over 140) so I've been monitoring it with a heart rate belt. But I haven't been using my oximeter. My thinking is this: if I started to de-sat my heart rate would be high and I would be aware I should slow down. Is this correct?Sandra WA

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A. Not in my opinion, Sandra. Many folks get NO sensation to indication that their oxygen saturation is low. Your heart rate is unreliable as an indicator when it is also increasing in response to exercise. A pulse oximeter is the only reliable means to assess your oxygenation. Regards, Mark

General Anesthesia (Being Under)

Q. I have to have extensive surgery and the gyn/onc is reluctant to allow me to have an epidural. I am really concerned about being "under" general anesthesia for several hours - I don't want to end up on a vent. Any suggestions and/or input would be appreciated - Cat

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A. A "G-O-O-D" Anesthesiologist should be able to get you through the general anesthesia just fine, barring unforeseen complications. Go shopping--EARLY--and ask lots of questions in picking your 'gas-passer'. You may want to start with those who usually work with your surgeon. Regards, Mark

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Difficulty Swallowing

Q. I have difficulty swallowing to a point where sometimes I get a pain in my chest and come close to blacking out, and it feels like it is sitting on my diaphragm before it goes down. It is very painful. I eat small portions, and small mouthfuls at a time, but it still happens now and then. I have been told I have a hiatle hernia and then not. I have been through testing for blockage and passed. No one can find out why this happens. PatH/MA

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A. Pat, Have you had a swallow test, where the whole sequence was observed/recorded with fluoroscopy--a kind of low intensity x-ray that allows one to view processes "in motion", in 'real time'--done by either or both an ENT specialist and/or Speech-Language Pathologist? If you've only had a GI series and endoscope, that's not enough.

Swallowing difficulties, as you describe yours to be can 'often' be the result of muscle 'dysfunction' or dis-coordination. You might try pursuing that line of investigation with your doctors. Regards, Mark

Continuous Prednisone

Q1. 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

Q2. Adding to John's question and subject line, with the continuous dosage of prednisone, has the issue of getting off of it been addressed? Some folks have some bad effects while being on it for a long time and usually they are taken back off of it. Is there a point where you cannot get off of prednisone? If so what problems are associated with it? Gary

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A. Good questions! The whole issue of folks "getting off" Prednisone is very subjective when you sort through all the camouflage. From a purely objective and physical point of view, folks shouldn't ever become permanently dependent upon Prednisone in a "physical" sense, such that withdrawing it would 'harm' their function or wellbeing. Success in coming off Prednisone is determined by whether or not the individual is able to withstand the resurgence of those feelings that were present when they went on Prednisone, but have been masked during the time they have been taking it. That's the big problem. The reason you take it and have a bugaboo of a time getting off it is because it makes you feel better by blunting the bad feelings you had to begin with. Those feelings return when you reduce it and discontinue its use. It is those who are successful in tolerating those worse feelings who succeed in getting off of it.

W-H-Y all this is true is still very much a mystery. That is because while we know an awful lot about what Prednisone seems to do to the human creature, our understanding of HOW it does everything it does is still rudimentary. We don't know all of the multiple actions and interactions that occur when we administer Prednisone. We know that it does what appears to be miraculous things. But, we don't know how it does all of them, nor how what it does to one thing affects another. Sure, we know it causes several side effects, but we haven't got the whole process figured out--or even much of the broad process, beyond a point.

Who can and cannot come off Prednisone is not predictable. So, when confronted with the request/desire to become free from the drug, we can only trial and error that action and hope for the best! Regards, Mark

PFT's: How Often

Q. Mark When I first went to my pulmonologist in 1997, I was given the PFT to get a basis of where I was, I think was the way it was put. I had a couple more thru that first year, for evaluation purposes, it was said. I am now in my 6th year, and I get a PFT each and every time I go, no matter how short a time between my visits. Normally 3x a year, but this past year, had a couple of episodes, and even had a couple 6 weeks apart. Is all that necessary, do you suppose? Of course, I guess it is the reason that I can see by my numbers, too, that I must be going downhill. I was just questioning the necessity of so many. Thanks. Betty NC

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A. Hi Betty (and Fran), There are several reasons why PFT's might be helpful at intervals more frequent than once-per-year. You indicate that yours are changing at a fairly rapid rate. That is certainly one good reason. Folks with frequent exacerbations, especially if they are severe and folks who have rapid decline from fibrosis all warrant frequent PFT's. So, yes, they may indeed be necessary.

PFT's are not done as a means to re-qualify you--or anyone else--for oxygen. The only "testing" for oxygen therapy that is required is a blood gas for PaO2 (oxygen pressure within the blood), or SaO2 (saturation of the hemoglobin with oxygen), or a pulse oximetry measurement showing a resting saturation of less than 89% while breathing ambient air. If measurements are marginally high, other tests like an ECG, or Echocardiogram might be required to additionally establish need. But, while PFT's can suggest the possibility that oxygenation 'might' be a problem, they do not give any 'definitive' information until derangements are fairly significant and other tests--like pulse oximetry have long since established the existence and degree of oxygen deficit.

While I'm at it, Fran White asked about DLCO and the other diffusion capacity data. While DLCO tells us general information about "ability to exchange" gas, it does not correlate with hypoxia or CO2 retention. Only a blood gas can tell us that information. DLCO usually needs to be reduced below 30 % of normal to see any predictable desaturation in the subject. Even then, it does not mean the person "necessarily" will be hypoxic. CO2 retention is also quite independently variable with DLCO. "VA" stands for "Alveolar ventilation" rate per minute. It means how much air is moved in and out of the lungs, minus that air which has no opportunity to participate in exchange with the blood.

I have learned that DLCO is only of limited value because of the "technical" artifact to which it is subject in those who have COPD. I don't put a whole lot of stock in any critical information that it can tell me, since there are other more direct and accurate means of obtaining meaningful information about diffusion than through DLCO measurement. It remains popular only because it was a crude way to quantify gas exchange under very narrow conditions in the days before we could easily measure arterial blood gas values. Its one of those things--old habits die hard--that keeps it popular today. Regards, Mark

Medicare Age Limit on Transplant

Q. Does medicare have a age limit on lung transplants? I am 67 and want to look into it . thank you, Don PA

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A. Yes they do, don. You must be under 65 when you are listed for transplant. I'm afraid that at 67 you have passed the Medicare point of candidacy. But, you might check with individual programs, if you can afford to pay for it yourself. There are a few who will make exception if one is beyond 65, but otherwise a very good candidate. Regards, Mark

Lack of Oxygen

Q. Took my husband to the doctor today and told him he had been having severe cramps in hands mostly, but also in legs, and toes.

Doctor said it was lack of oxygen, circulating through the blood stream, I said huh? My husband is on oxygen 24/7 so that sounded surprising to me. But he said even though you are getting the oxygen you are not GETTING the oxygen, clear as mud to you? Jan

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A. Hi Jan, While the way you put what the doctor told you certainly 'seems' confusing and contradictory, it is not necessarily inaccurate or nonapplicable to his situation. There are several factors that influence how oxygen is taken up, transported throughout the body and utilized by the tissues. Disturbances in any or several of the many mechanisms can add up to having sufficient oxygen "available" - - - as when we measure it on a blood gas test - - - but NOT reaching the specific tissues that need it, this creating a deficit in oxygen supply that can result in hypoxic operations within the tissue, OR anaerobic operations, where the cell manufactures its own oxygen supply. Some of those alternate mechanisms can result in cramps, sometimes due to the by-products of the process, sometimes from the response to lack of oxygen.

So, while your husband may indeed be receiving supplemental oxygen 24/7, as you relate, it is also possible that it is not enough - - - for reasons that go beyond the simple condition of 'inadequate flow' - - - to meet his needs so as to keep him from experiencing the effects of localized hypoxia of various kinds. Further, it is also possible that the problem cannot be
'directly' resolved by any interventional means, let alone by simply turning up his flow and increasing the amount put into his body.

As the disturbances of which I speak are complicated and several, I won't try to go through the list. BUT, you should ask your doctor to "tell you more" about what he means that your husband is getting oxygen, but still has oxygen deficiency in his body. He s-h-o-u-l-d be able to tell you more. If not, then perhaps another opinion would be helpful to shed light on the
problem(s) and provide explanation. Regards, Mark

Wet vs Dry COPD

Q. I was wondering why so much mucus was produced in one E. patient and not the next........ just curious. I'd never before heard this definition of "dry" versus "wet" COPD. Joyce - Ont. Can.

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A. Hi Joyce, Despite the fact that John's doctor explained emphysema to him this way, you have not heard of the terms wet' and/or 'dry' emphysema because they are NOT standard nomenclature for describing emphysema. Indeed, "emphysema",
per se, has NO secretion production in its definition or description. The fact that someone who has COPD produces secretions indicates that at least ONE component of their COPD is chronic bronchitis. Now, there is reasonable application of the terms "wet" and "dry" to chronic bronchitis (CB), as some with CB produce mucus and some don't. The presence of mucus production is an indication that a person has CB, 'rather than' emphysema.

So outside of John's experience, you won't find anyone using this description as if it is the "standard". Regards, Mark

Flu Symptoms??

Q. I have been sick for the past 4 days started with pleurisy which I get occasionally then turned into flu like symptoms everything hurts to move headache chills etc. My question is would this make my pulse rate faster I
am not having breathing problems but my pulse rate is in the 90's at rest that is awfully high. anyone else have this problem. thank you, francine

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A. Francine, Despite what it 'seems' to you, a pulse rate in the 90's for someone who has significant COPD AND is acutely ill with flu symptoms most certainly is NOT "awfully high". If it were around 120 at rest, I'd call that high. . . . 130- 140, now THAT is "awfully high"!

The greater question in my mind is; have you called your doctor about your symptoms? Have you begun definitive treatment, if any is indicated? Regards, Mark

Sats and Exercise

Q. I just had a test done while exercising and my stats sayed in the 90's. What I don't understand is why I am so SOB when I move around at all. I had a treadmill test and was unable to finish it ( I lasted less than a minute.) Because of my stats I can't have oxygen so what to do? I am so out of breath it makes exercise impossible. Any ideas? Sharon

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A. Hi Sharon, What exercise test did you have done? How was it done? How was your oxygen saturation measured - - - was it measured at intervals, or continuously during the whole time your were exerting? How long did you exercise for the test? What exercise did you do? What was the lowest saturation that was measured?

If indeed you are adequately oxygenating, then your breathlessness is most likely the product of being out of shape from no/too little exercise. As with other folks who are in your shoes, you'll have to find a way to "tolerate" the windedness and discomfort to exercise, so that you can improve your condition and reduce your work to breathe. Being so winded, or so 'easily' winded is no excuse or reason to consider that you cannot or should not exercise. It is certainly NOT easy to do. BUT, if you are to survive and thrive, you will HAVE to find a way. It simply can't and won't happen any other way. Regards, Mark

Handling of Nebulizer Treatments

Q. What is the recommended handling for Nebulizer Treatments while in the hospital, in regard to use and cleaning of the equipment, types of medicines used in what containers and what is the RT supposed to do? Does he/she stay with the patient or what? Mine as I have said, used the liquid Albuterol in a bottle for each and every patient, opened in the rooms, closed in the rooms, etc. They used one ampule of Atrovent with it. I asked each of them. Some rinsed them out and stuck them into slots on the unit. Some wrapped the line around and tucked the cup and stuff into the unit. Some of them rinsed them out when done, none dried them out, a few put them back in the original plastic bag. Also, none waited while I took them, as a matter of fact they went on and started others then came back much after mine had been completed. My DX was Albuterol/Atrovent every 4 hours. Gary

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A. Hi Gary, The answers are not as clear as the questions. Some of what you ask about does not fall under "standardized" procedure with regard to the country, as a whole. Indeed, it is individualized hospital policy in all cases. Whether or not to use unit doses of Atrovent and place 0.5 ml of 'straight' Albuterol into the nebulizer with it, or use a unit dose of each - - - a larger total solution quantity = longer aerosol duration - - - or to use MDI's instead of nebulizers on those who qualify by protocol, you can find the range of possibilities quite sizable. So, that aspect can and may vary from hospital to hospital.

Insofar as the question of the bottle of Albuterol; if it is handled properly, there 'shouldn't' be a question of cross-contamination. Hand-washing, contact or proximity with multiple nebulizers by the dropper and types of 'bugs' carried by patients, among other things, all factor into the equation. Certainly, using a community bottle of Albuterol DOES present probably the best opportunity for cross-contamination. But, it is not against any rules, or recommendations.

Handling of the nebulizer IS standardized, at least by clinical practice guidelines. Recent recommendations from the CDC for Cystic Fibrosis have implications for the greater nebulizer population. But, first, the AARC Clinical Practice Guideline (CPG) clearly states that nebulizers should be discarded or changed (if not disposable) every 24 hours. It also recommends either a rinse with "sterile" water, OR nothing--no cleaning--between treatments. It specifically recommends 'against' tap-water rinsing of nebulizers. The CDC recently specified that sterile water should be used to rinse nebulizers between treatments for those with CF. The catch here is that these are recommendations. And, while the AARC CPG is a procedure intended to standardize care, that is a far cry from it "being" the 'standard of care'. Hospitals have the choice to follow those guidelines or not to follow them. Any consequences of not following them in one's practice/hospital is a matter of possible litigation with the hope of proving negligence. At this time, failure to adopt and follow the CPG's, even the CDC guidelines is NOT negligence, by definition.

Insofar as "treatment-stacking"--the sequential and simultaneous starting of several treatments and rotating between them to observe and collect data (vital signs, breath sounds, coughing results, etc)--this is widely practiced--out of necessity--perceived, if not real--though it is specifically advised against in 'white papers' of various professional organizations, including the AARC and is 'technically' illegal, in the case of Medicare, though certainly not enforced. Unfortunately, you witness therein , the product of budgeting and staffing restrictions produced both, by insufficient professionals and insufficient dollars to hire enough professionals to provide the 'ideal' process and care.Most often, I'd say that it is done in order to accomplish the largest number of treatments in the shift that can be accomplished, so that noone goes wanting for needed treatment, simply for the lack of someone being able to provide it. Too much of the time, one RT has many more treatments than he/she can accomplish within the limits of his/her shift UNLESS "treatment-stacking" is practiced. Were we in a utopia, treatments would be given one at a time, with the RT present, throughout. Regards, Mark

Spiriva Use with Other Inhalers

Q1. I was under the impression that Spiriva was the only inhaler needed and that it was used once a day. Maybe the once a day usage is what got my attention. If Spiriva is so good that everyone is sending away to Canada for it, why do they still need the other inhalers?

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A1. Hi Kathy, As you've been discovering since becoming a member of this list, COPD is not a simple, cut 'n' dried disease with a plain vanilla flavor to it. Indeed, it is multifaceted and complex, affecting individuals differently and to different degrees, while also progressing at differing rates. Treatment of the various symptoms is equally diverse, calling for sometimes multiple medications to bring those symptoms under control. Because airway "tone" (the balance of constriction and dilation that produces the best caliber of size for the lumen [internal tube] of the airway) is affected by several 'separate' and 'different' mechanisms, it follows that to alter tone would A-L-S-O require an agent to affect each of the separate mechanisms.

The current result is that we have several "classes" of 'bronchoactive' medications, all targeting improvement of bronchial tone, through dilating activities. Spiriva and Atrovent reside in one such class. Albuterol, Salmeterol, Formoterol and others reside in yet another. The actions of one class are NOT produced by actions of another - - - hence their separation into different classes.

Folks with COPD need different and multiple medications to exert action on each of the separate mechanisms that influence their airway tone. The combined effect of the separate medications is intended to produce their overall airway tone and bring about airway stability. Herein lies the reason why no one medication will "do it all", nor why just because one medications works well - - - in its intended way - - - other medications might still be needed. Regards, Mark

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A2. Hi Again, Kathy, While I don't presume to shunt the responsibility you cite away from the doctor inappropriately, with regard to taking medications they prescribe, I would argue that especially today, the pharmacist shoulders the critical responsibility for instructing folks in how to properly use medications. This has ALWAYS been the case, whether or not it has been apparent or obvious. It has been the assumed responsibility and task of the pharmacist to convey necessary information about drugs/treatments they 'dispense' to facilitate the proper use of those drugs. That is called for through their licensure and is a legal point of fact. But, with so many details today as well as medications choices, the pharmacist has become all the more important, with regard to doing his/her job thoroughly.

I don't know about y'all out and about the rest of the country, but the pharmacies I have observed here in my area--especially the larger/chain ones (and that includes Wal-Mart and others)--all go to lengths to provide verbal information and instruction sheets with each medication. Our particular pharmacy has a tow-the-line procedure that each customer must be verbally instructed in each prescription (by receiving them at a pick-up and instruction window, after moving there from the payment window), in addition to receiving the printed material. For medications that are long term, where we get to know the pharmacy personnel and have heard the information, they lax off after we have 'verbally declined' more than a few times. It can seem a nuisance, but I credit them for ensuring that no opportunity is missed to convey necessary information, nor chance taken to allow the possibility of missing the boat. This should be the effort, no matter where the pharmacy, nor its size.

In any case, we can't summarily load the blame upon the doctor, attributing all failures to his/her short-comings. Regards, Mark

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Intubation

Q. My doctor........today, after being released from the hospital Dec. 13 with shortness of breathe and being intubated for 2 weeks, informed me intubation WOULD happen again, how long did I want to give it, and basically, why would I put my family through that again.

I just turned 60 yrs of age. Have been healthy in the past ------ diagnosis was 3 yrs ago (COPD) 5', 98" female, on oxygen (1 1/2 liters at bedtime), albuterol and atrovent (nebulizer) 4 times daily. Present diagnosees: Acute chronic obstructive pulmonary disease exacerbation and Hypoxemia. This doctor has given me no hope for a future. HELP. I simply want to get back to functioning prior to this hospitalization and intubation. Thank you, Nicki

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A. Hi Nicki, You are right to feel uncomfortable about what you relate your doctor has told you. When you are discouraged from having hope, life can become awfully difficult. We generally encourage our members and other folks to 'thumb their nose' at those who would advise them to 'roll over and die'!!! Is the doctor recommending the 'doom and gloom' path your primary care physician or your pulmonologist?

If you are using oxygen at night time only, either you are not as ill as many on our list who fight on mightily, OR you may not be completely evaluated and optimally treated with regard to your hypoxemia. While you may indeed expect to have episodes of acute respiratory failure requiring intubation and mechanically supported ventilation, it is YOU who must go through it. It is YOU who are being "put through" the ordeal. Yes, it IS hard on your family. BUT, no one has the right to advise you that YOU should not go on living because "it is too hard on your family"! Now, I am not advocating hanging on in misery disregarding 'the writing on the wall', or enduring unreasonable misery. BUT, simply to refuse 'heroic measures' like intubation and mechanical ventilation, because "It will happen again" and it's a lot to "put your family through", is about as lousy a rationale as I can think of UNLESS the inevitable is immediately pending AND the prognosis - - - ability to recover and regain your function and quality of life - - - is reasonably and predictably poor. You must live for YOU and not anybody else. That's all I'm saying.

I am concerned that you are on oxygen only at night, especially if you are supposedly so ill and end stage AND are recovering from a recent exacerbation. Has your oxygen saturation been measured while you are walking for at least three minutes, since you got out of the hospital? ? ? If not, it should be. You may be dropping your oxygen level every time you get up and move around. If that is the case, then you should be using oxygen more than just at night. Failure to adequately cover your oxygen needs/demands will guarantee the rapid repeat of your recent ordeal with the ventilator. Indeed, it could be a "forced fulfillment" of your doctor's prophecy-- when it shouldn't be and doesn't have to be!!!

You are not on a lot of medications and you don't mention being on Prednisone. Is that correct? It doesn't sound like you are that sick/far gone!

What level of function are you able to engage in at present? Do you have a pulmonary rehabilitation program nearby that you can get into for some help in regaining your maximum possible condition and function? I will assume that you meant that you weight 98 pounds. Surely you are not 5-feet AND 98 "inches" tall, as you typed ! ! ! LOL! ! !

As Gary indicated, there are lots of folks here ready to help you. All you need to do is holler! And, as indicated by my quip about your height/weight, we even try to laugh a little around here! ! ! Best Regards, Mark

Steroid Dependence

Q. What does it mean if you are steroid dependent. That you can't come off Prednisone? I have such a hard time coming down from Prednisone. Mari

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A. The problem with coming off Prednisone is that you return to experience full and 'un-masked' sensations. This includes aches and pains from 'non-respiratory' conditions like arthritis. For many folks, this is unbearable. You see, while you are taking it, Prednisone covers up ALL symptoms and 'spoils' you with 'feeling good' -- actually, feeling better than you otherwise would. When you come off the stuff, there is some rebound symptomatology that causes you to feel bad for 'some' period of time after decreasing your dose, or discontinuing the drug. Folks who can manage to persevere through the 'feeling bad' period can successfully come down and off Prednisone. Those who can't, get 'stuck' on it and become (labeled) dependent.

To correct one error in Chuck's otherwise good explanation, the adrenal glands do NOT "atrophy" and quit producing Cortisol. Rather they DO go through fluctuations in production - - - especially after long term Prednisone use - - - and can be slow to get back to full production when supplemental steroids are reduced too quickly. Otherwise, the reasons you feel so bad coming down from and off of steroids are due to the factors I mentioned in the last paragraph. Regards, Mark

Small Pox Vaccine

Q. In the late sixties/early seventies children were vaccinated (myself included). The vaccination left a small round scar on the upper arms where the shot was given. I always thought that was for small pox. Am I losing my mind? Probably, but was that vaccination for small pox or something else.? Thank you for any insight into this you can give me. Mona

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A. Hi Mona, Smallpox vaccinations were not actually a "shot" (injection). A small drop of solution containing Cowpox virus was placed on the surface of the upper arm and a special device--a cross between a needle and a lancet--was used to make several "pokes" into the arm--piercing the skin and inoculating the 'dermis', below (the living part of the skin). Over the course of several days, a cowpox infection formed, causing a blister at the inoculation site. Fever and assorted additional symptoms occurred during the course of the illness. The blister dried and scabbed over, eventually falling off. What was left was the round, ruddy-looking scar. Cowpox, like Smallpox, is contagious, until the scab has fallen off. The virus that causes Cowpox and Smallpox--Variola--is from the same family. As a result, the antibodies built against the Cowpox virus are also effective against the Smallpox virus.

MY brain is faltering here now and I don't have my written material at my fingertips. But the Smallpox vaccination was ceased some time in the 60's or early 70's, as I recall. The CDC Smallpox site says the last infection in the United States with Smallpox occurred in 1949. So there are a couple of generations who have not been vaccinated against the disease. You can learn more about it if you click on the following link: http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp Regards, Mark

Hunching

Q. Does anyone know a trick one can employ to stop hunching up the shoulders? I think I do this almost all day because my shoulders are always tired and aching and when I think about it, I notice they are hunched up trying to touch my ears. Even my grandson asked why I sit this way. Must be trying to stretch to make room for big lungs, huh? It's bad enough to struggle to breathe without hurting all the time. What the heck can be done? I thought about posting a thousand sticky notes around the house "Shoulders Down." Virginia

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A. What you are doing with your posture may or may not be a problem. If you are pushing your shoulders up when sitting and leaning on your elbows, that is OK. If you are holding your shoulders up excessively when walking with your arms at your side, that is not necessarily good. The whole concern in my mind would be is if your shoulder posture is helping or inhibiting your ability to breathe from your abdomen. You can answer that question by watching yourself breathe while looking in the mirror. If when your shoulders are up and you breathe IN, you see your abdomen 'pooch' out/become fuller and larger, you are OK. If, on the other hand, you see your shoulders ride up W-H-I-L-E you are breathing in AND your stomach moves INWARD, then you are using too much upper-chest accessory muscle breathing and the result is what we call "paradoxical respiratory motion".

If you are breathing with the undesirable pattern I described and want to improve/correct it, you can do so by finding a high-back chair, or high counter or even lean against a wall. Place your folded arms against the surface on which you lean, bending about 15 - 20 degrees at the waist, placing one foot in front of the other and on the floor roughly directly below your face. This is called a "lordotic" position. Your shoulders should be tucked up against the side of your neck--almost touching your ears, if not indeed touching them. Hold this position foe several minutes--at least five--and breathe, feeling your belly drop down toward the floor when you breathe in and pull up toward your chest when you breathe out. Do this several times each day for as long as it takes to learn to breathe like that without having to "lean and lock" (I say lean, as explained. The "lock" is for your shoulders which you 'lock' into place with the lean and the posture assumed with the lean. You are trying to "lock out" your accessory muscles, so they can't interfere with better breathing technique.

In any case, if you are doing a lot of obligatory accessory muscle breathing, you won't be able to successfully change it by simply trying to pull your shoulders down. So save your sticky note pads - - - OR - - - write instead, "Belly breathe!" on them. You need to replace the bad breathing technique with an effective and better method, before you can expect the shoulder posture to change! Regards, Mark

Unusual Test Results

Q. Thanks for all the good thoughts about my improved PFT after my lobectomy. I am grateful, but I'm also confused, and so is my doctor. Without oxygen, my sats are 88 or 89 sitting still. Movement of any kind immediately takes them down to low 80s or high 70s. I really can't function without supplemental oxygen now, but I could fairly easily before the surgery. So, although my surgery could have served the same purpose as LVRS in some respects, something else must be going on too. Pulmonologist thinks something else will show up on diffusion test and on ABG test. Mark, is it possible to have one pulmonary function test (PFT) improve and have others get worse? And, if that's possible, what does it all mean? What really has me concerned is that I've applied for disability based on what my doctor and I assumed my PFT results would be, which in turn has been based on my increased need for oxygen. Now, it seems we're in for a fight with SSD. Anne

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A. Hi Anne, Based upon the little bit you've shared with regard to actual numbers (you haven't told us what your FEV1 and FVC are) I would still confidently speculate that you shouldn't have any trouble with your SSD claim - - - PROVIDED the hypoxia isn't just a passing thing. PFT's and Diffusion studies may not be helpful to do more than identify what is going on right now. That may all change as time goes by.

You ask if it's possible for one PFT to change for the better while another changes for the worse? In the case of ventilation and oxygenation, that exact scenario is possible to occur - - - and indeed does occur more often than you might imagine! I will try to illustrate why and how with the following explanation.

One of the theoretical points I have made for years is that while "ventilation" - - - the movement of air into and out from the lungs - - - and oxygenation happen to occur in the lungs, AND occur at the same time, they are two very distinct functions relying upon very different mechanics and mechanisms. Ventilation - - - the removal of carbon dioxide (CO2) - - - cannot happen unless bulk quantities of fresh air are moved into the lungs mixed with the CO2-rich air within the lungs and a bulk quantity of that mixed air is moved back out of the lungs. Without ventilation, CO2 cannot be 'shed' from the air within the lungs.

Oxygenation, on the other hand, does NOT rely on ventilation in any way similar to the clearance of CO2. As a matter of fact, oxygen is diffusing ALL of the time, at a pretty constant rate, whether or not breathing is going on. Oxygen molecules are 'bigger' (relatively speaking) than CO2 molecules and so diffuse at a rate that is about 20 times slower than the rate at which CO2 molecules diffuse. Further, because the diffusion of oxygen is based upon stronger attractive forces within the lungs, it is (theoretically) possible for one to continue oxygenating just fine, as long as a flow of oxygen is put into their lungs without actual breathing (ventilation) occurring - - - as would be the case if your breathing muscles were paralyzed. Of course this cannot happen in a practical sense, because we cannot do without constant ventilation and still survive. But I use that example to make the point.

When oxygenation is worsened, it is because the 'surface' area to which oxygen is exposed within the lungs has been lost (as in emphysema, for example). Another reason is because circulation is lost and there is not enough exposure of the blood passing through the lungs to the oxygen within the lungs. (Again, emphysema involves the loss of circulation within the lungs as part of the tissue destruction.) Apparently with your lobectomy, you lost enough surface area tissue AND circulation that what you are left with isn't enough to do the job.

Yet, the lobectomy effectively reduced volume of your lungs and shifted them within your chest, improving the position of your diaphragm. This improved the "mechanics" of your breathing so that you can move air more efficiently - - - with less work - - - and more comfortably. The result is you breathe more comfortably, but you cannot oxygenate as well as you did before.

In any case, being on supplemental oxygen is qualification enough to warrant disability, regardless of what your PFT's show!!! I hope this helps. Regards, Mark

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Runny Nose with Exercise

Q. When I exercise to the point of SOB my nose starts running - big time. Is this phenomenon symptomatic of this disease, or is it just me? Clyman

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A. Hi Clyman, What you describe is a autonomic nervous system mediated response to the exertion. While some folks find relief to some degree using various nasal sprays, I would caution you not to expect too much. The runny nose is not from the same mechanisms as, say Gary's or the other folks, whose runny noses occur at times other than during vigorous/strenuous exercise.

I have had a few patients who were able to slow the runniness using Atrovent nasal spray. Even that didn't work all that great. Gary suggested and antihistamine nasal spray. That may or may not do the trick. But, if you try it, you need to realize that you can't use it or other antihistamine sprays too often, or you will develop "rebound inflammation/congestion" which could be more uncomfortable and inconvenient than the runny nose is now. Mari suggested that her nose runs when she exercises "too much" and gets SOB. I would bet that what she calls SOB is expected windedness from the exertion and that she doesn't really exercise "too much" at all. Indeed, the runny nose should be a sign that you have achieved the level of vigor you WANT to when exercising!!!

So, beyond trying one of those nasal sprays, my best suggestion is to target that level of exertion that gets your nose running and stay there as long as you can. When you get "winded", work hard to use pursed-lip-breathing to control your breathing and allow you to remain at that level of vigor as long as you can. Carry several Kleenex, if you need to so you can mop up and blow that runny nose, as often and much as you need to. Yes, its a nuisance! ! ! But, beyond the minor discomfort and nuisance, it is NOT a bad thing!!! Regards, Mark

Altitude and Air Density

Q.At an increase in altitude above sea level,air becomes less dense, at increase in temperature, air becomes less dense. This equals density altitude. Does the oxygen content vary in proportion to the density altitude? That she would soon become acclimated to the lower altitude and have to use the O2 the same as here. Thanks for any info helping me better understand the questions. Fuzz

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A. Hi Fuzz, I would add that while folks may find that moving to a lower altitude causes their oxygen saturation to average higher, there is no evidence that it is a temporary condition. The only expected cause of continuing decrease after moving to lower altitude would be disease progression and continued loss of lung function. That is not tied in any way to changing altitude by any evidence I've ever seen.

Also, with respect to the term oxygen "content", when we use the term 'scientifically' accurately, we DO speak of number of molecules. So while "partial pressure" relates to "oxygen content" and changes with altitude, the "percentage" of oxygen in the total gas mixture at ANY altitude does not change. There is always 20.85 % oxygen in Earth's atmosphere no matter the altitude. But, because of changes in density relative to barometric pressure, there is a difference in oxygen content at various altitudes.Clear as mud, now? Regards, Mark

Small Pox Vacinne & COPD

Q. Since the smallpox vaccines are live virus', I would be kind of hesitant to take it. I wonder how our immune systems would react to it.

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A. Your immune system will react to it like it did when you had it as a kid. You get sick and run fever for a day or two and then the blister forms and you wait until it falls off to breathe easy and resume your life.

This is all on the presumption that you will qualify for vaccination. My bet is that most with any significant degree of pulmonary impairment will be excluded from vaccination. The risk of serious illness and/or death is too great.

The question about live virus has been expressed by a few, too. The virus was "live" when we all got it as kids. It is no different, now. But remember, it is live Cowpox virus - - - a less virulent form/strain, but one effective for invoking immunoglobulins against Smallpox. Because there is the risk of illness or death from the vaccination process, most folks here on the list won't even be getting it. Regards, Mark

Lazy Lungs

Q. I have a rather strange question that perhaps Mark can help me with...four years ago I had heart by pass surgery and encountered complications and spent a week on a respirator. Over the years I have noticed a definite increasing of shortness of breath til now it is difficult to walk up hills etc without getting very out of breath. My dr says I'm just deconditioned and to keep exercising. Well I decided to use Dicks Nonin and keep track of my 02 levels and discovered my level drops to 87-88 when walking up a hill or exerting myself more than normal. So I decided to start treadmilling and have found the longer I'm on the treadmill the better my sats are..........will go from 88 after 15 minutes but will jump back to 91 if I push it a little and go 30 minutes. I have never been diagnosed with COPD and before my surgery never experienced any SOB in fact I was actually able to walk 2 miles at a good clip (well, good for me) and never get out of breath. After I was removed from the respirator I remember my sats were very low and they wouldn't let me out of the hospital till I got them up. Until we got our Nonin I had no idea what my levels were till recently and now I'm concerned that perhaps for years my levels have been below normal. When sitting now I find them to be around 92-93.......never any higher. I just wondered if it is possible to have lungs that perhaps are damaged but seem to respond favorably to my exercising? .... Carol

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A. Hi Carol, An interesting bunch of information you provide. IF, your heart function is decreased because of poor conditioning, then exercise could be expected to bring it up. But, you are decreased overall and within a range that warrants concern. As long as you are dropping below 90 % during exercise, your ability to achieve a moderate to maximum load is thwarted.

My impression and recommendations are--at this point, based upon this information--you are hypoxic for reasons that are unlikely to improve, simply with exercise--but this remains to be verified and requires time. It is unsafe and impractical for you to exercise in the manner in which you need to in order to achieve the level of conditioning you need to to determine whether or not your baseline oxygenation will indeed improve. Meanwhile, all the time you are trying to exercise under these conditions, you are stressing and straining your heart, predictably counter-acting any potential benefit you might chance to reap. That you have had bypass surgery is even more disconcerting in view of your oxygenation pattern. You don't say whether or not you have a significant smoking history or other predisposing criteria for COPD. So I can't determine whether or not you need to see a pulmonologist, or simply go back and present your findings to your cardiologist and see if he/she will make the necessary adjustments--or do the usual--claim your heart is FINE, it MUST be your lungs and send you to a pulmonologist, anyway, who may be concerned and aggressive about it, or complacent, like a lot of them out there.

I think you need oxygen for exercise and probably for sleep, too. You should use enough to raise your saturation to at least 92 - 94% at rest and with exercise. It may take little to none to keep you there at rest. But, with sleep and exercise, I would say you should use the same flow for both. PLB s-h-o-u-l-d work for you, too. If it doesn't, then I would be more suspicious that your heart is the cause, rather than your lungs.

Understand, there are many holes in your information and I can only speculate on most of what I have told you. But, I think my concerns are founded in a decent amount of information that you HAVE been able to provide.

Get checked soon and make the necessary adjustments. The longer you go without answers and treatment, the more damage you are doing and danger you are putting yourself into. Let us know what you learn/do. Regards, Mark

Coughing Due to Stomach Acid

Q. Hello Everyone, I have a question about coughing caused by stomach acid backing up into the esophagus. Is that cough a mucus producer like bronchitis or other infection? Is the "acid cough" supposed to produce anything or just be a dry hack kind of cough? Is it usually accompanied by wheezing? Maybe Mark could help me understand what to expect considering there is no mix of conditions...Virginia

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A. Hi Virginia, As best I can put it, there isn't so clear a correlation or causal relationship between cough and acid reflux as you might intimate here in your post. Where there is cough in response to acid reflux, the question of mucus production would be dependent upon a couple of factors that exert and influence on it. First, if one has acid reflux and tends to aspirate the acidic fluid, it would be expected they would produce mucus in response/reaction to the invasion of their airways by the caustic substance. If they "don't" aspirate any of the refluxed fluids into their lungs, then they might or might not produce mucus depending upon other factors and the presence of chronic lung disease, along with the reflux problem. There is just no "necessarily so" relationship when no fluids enter the lungs.

I hope this answers your question. If not, give me a little more to go on and I'll try again. Regards, Mark

High Calorie Drink

Q. Could someone help me please? My dad use to drink something to help him get more calories. I think it was Pulmocare or something like that. My mother-in-law has some sort of fungus in her lungs and has trouble breathing and now has lost her appetite. I think dad drank it for the calories since just breathing uses up so many. Thanks, Ann

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A. While Pulmocare is certainly an option, there are other choices as well that are as good and some much better than Pulmocare. Additionally, they are in many cases cheaper than Pulmocare, too.

Nutritional balance as carried in Pulmocare, along with the extra fats that makes Pulmocare stand out among supplements as being better for pulmonary patients, can be achieved in a few other ways. You can make a homemade shake that at about 14 ounces (compared to Pulmocare's 12 ounces) carries as many as 750 calories. There are supplements like Boost-plus (525 calories in 12 ounces) that are over the counter. Nestles makes Nutren 2.0, which is 500 calories in 250 ml (8.45 ounces). It is even better for folks with appetite problems because of the fats it contains, a large portion are "MCT's"--medium chain triglycerides--which are much better on the GI tract, with regard to tolerance and absorption AND it is lactose-free and gluten-free. I have found this one to be the best. BUT, it is not the least expensive and while I don't think it is restricted to prescription only, it has a printed recommendation to "use as directed by a health care professional." Regards, Mark

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Coughing

Q. I have one question. I have a terrible cough...and lose my breath completely while coughing...are there any tips at all for that? I definitely feel that I am about to suffocate...have even passed out because there is no air at all getting my lungs..my dr merely shakes his head when I tell him, and says I will get in enough air "after a while" but this absolutely scares the heck out of me while it is happening. What to do? Anida

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A. Hi Anida, About all you can do is learn to "roll with the punches", when you get on a coughing jag as violent as you describe. There's certainly no preventing it, as it is a 'reflexive' occurrence--in other words, beyond our willful control. Rest assured, that with rare exception, if you pass out, you will expectedly return to normal breathing very quickly. AND, when you once again awaken/regain consciousness, you will be back to normal. Certainly there are exceptions to this prediction, but they are not as likely to occur as what I have described. Regards, Mark

Comments on TTO (Transtracheal Oxygen)

C. Mark, In 1996 I had a respiratory arrest episode, and left the hospital on O2 - 24 hours a day 2 liters at rest 3 sleeping and 4 when exercising. I had Emphysema, Bronchitis and Asthma. These settings remained this way for 4 years, during this time I had constant nose congestion and exercise problems due to running out of breath. In 2000 I suffered a nasal hemmorage, which caused me to almost bleed to death and required major surgery to eliminate. I also opted to switch to Transtracheal oxygen at that time to avoid further nose problems. I found that then I seemed to be able to utilize the oxygen better with this delivery. The result was that I was quickly able to start increasing my exercise difficulty and duration. Within a year I had accomplished more progress than I had the previous 4 years just because I could use the oxygen that was being delivered. In 1 1/2 years after going to TTO my lung Doctor told me I no longer needed O2 at rest as my resting sats were in the 95 to 97 % range. I could walk on level ground any length of time slowly and not drop in saturation. I still need O2 for sleeping and exercising, but as long as I'm resting or "taking things easy" I don't need it. I might add that I have a riding lawn mower and cut the grass all summer It takes me about an hour and a half to two hours non-stop, and I don't take my O2 with me - I've never been SOB. Prior to the increased exercise that would have been impossible.

The supplemental oxygen will make the reconditioning of the muscle strength so much easier and quicker, and with the conditioning comes the decrease in the need for supplemental O2. Tom

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A. Hi Tom, Thanks so much for telling your story! While I would love to hold you up as a 'poster child' for TTO, I know very well that you rarely miss an opportunity to extol the benefit TTO has provided for you. So you are already that 'poster child'! I just hope lots of folks read what you had to say - - - read it closely - - - and realize that while the road can be long - - - four years - - - and rough with obstacles, it CAN lead to remarkable improvement.

In your case, as in others who have been able to reduce their oxygen use, you ultimately had enough lung tissue to provide for your oxygen needs, unlike probably most other folks with much worse disease. In you case, your acute illness and difficulties were playing a large part in interfering with the complete function of that tissue. It is very true, that exercise played a major role in your body's improvement in oxygen utilization, thereby reducing extraneous demand. But, as with other like yourself, you were able to come off the oxygen as you did very much because after the four year period of inadequate function, your lung function improved towards its greater potential. Keep up your good work! Regards, Mark

Weaning Off Oxygen

Q. Until last June my wife was on o2 only at nite. She ended up in hospital after an exacerbation, pneumonia,etc.,for about 8 days. Drs. ordered 24/7 o2. Now ,with help of oximeter, we are trying to wean her off of daytime oxygen.Her nos. seem good to me. Low 90's-up to 95 most times. Is this practice okay, or harmful?? As usual Pul.Dr. is no help, he doesn't even think we need oximeter of our own. Thanks for responses.... Larry

A. Hi Larry, First, the use of oxygen is transient ONLY when absolute lung function is adequate and intact, but is only 'temporarily' compromised. As an acute illness resolves, oxygen can be safely 'weaned', removed and not needed thereafter. When COPD advances sufficiently to warrant supplemental oxygen, it is usually because the absolute commodities of lung function have been reduced below a critical minimum. This does NOT resolve. The only solution is to provide supplemental oxygen to overcome the lack of lung tissue/function.

You do not indicate whether or not those 90 - 95 % measurements are with or without using oxygen. You do not indicate whether or not she is at rest or moving about when those measurements are being made. As others have said, if she is able to maintain her resting saturations on "room air" (no supplemental oxygen use) only in the 90 - 95 % range, then it is very likely that she drops below 90 % with exertion. She should NOT be allowed to drop below 90 % at any time IF it can be avoided. Repeated drops, over time, will damage her heart and cause her to progress more rapidly. Ultimately, it can be expected to lead to her earlier demise. Since one does all their consequential moving about during the day, that is just as important a time period for them to use their supplemental oxygen as would be the use of it during the night/while asleep. As has also been correctly said, you/she should NOT limit her activity or movement simply to avoid using supplemental oxygen, or to avoid having to use more than used while at rest. Inactivity leads to worsened symptoms and increased severity of disease at a more rapid rate, again, leading to an earlier demise.

Use of oxygen should facilitate mobility, allowing for the greatest level of activity with the necessary saturation level. While I disagree with your doctor about the advisability of having an oximeter, one argument made by physicians and others who object to non-medical professional folks having such devices is that they can utilize them improperly. We would not want to see you falling into that pit. You can go "too far" trying to 'micro-manage' your wife's oxygen, turning it up or down frequently, based upon measurements of the moment and measuring at very frequent intervals. Indeed, what you should do is find out what her general trends are/pattern is and then adjust her oxygen according to work load, keeping future measurements to a minimum, once you have found the necessary pattern of adjustment.

Frequent adjustments of the oxygen AND forcing her to exist on the margin around 90 % are not advisable, necessary or helpful. Also, there is nothing beneficial about "toughing" it out without oxygen when one's saturation is below an acceptable level. It is better to have more oxygen than needed, rather than too little. So think about these points and let us know what you decide to do! Regards, Mark

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[Response] Dear Mark, and others, Thanks for response and opinions on "weaning off of o2". I guess I was not to clear on what we were trying. I am not cutting out 02 for my wife. She was on nighttime 02, before we went north , and she got sick there. 8 days in hospital, and Drs. put her on 24/7 02. They said at that time, it was probably temporary. That was last June. She had a very slow recuperation, and is only now feeling better. That is why we are trying to slack off on o2. She does not drop off with exertion, that is normal exertion, not exercise. We haven't gotten to any exercise attempts,as yet. We do not change nos on concentrator or portable o2. Thank you for input, I was thinking 88 was cutoff , but now I will use -90 as a danger mark. Does this sound better ? One efforts lady said she did this over a six month period and weaned herself off of daytime 02, except for exercise. Lost her address. Thanks again Larry FL

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[Mark's Response] Hi Larry, Thanks for the clarification! While I am less concerned than before, I remain concerned that you are/she is focused on 'weaning' from the oxygen in the first place. My concern is fortified by the news that as yet - five months after her acute exacerbation -- exercise has not been attempted, let alone well established as a part of her daily regimen. You do not specify her level of activity around the house/in the community, but I'd bet it is extremely sedentary and minimal. One cannot sit around for five months, without exercising, and have any appreciable amount of strength or conditioning. With a resting saturation of 93 - 94 %, one has little to no cushion to maintain adequate saturation in the face of consequential activity. This is all the more reason why (IMO) weaning off oxygen s-h-o-u-l-d be of lower priority than maximizing its use to engage in a meaningful exercise program to regain strength, endurance and function.

While I have seen all too many folks take the course it appears you are/your wife is - and let me say very frankly, it IS her right to do whatsoever she pleases, regardless of what I and others may think -- I have not seen successful outcomes from this pattern in many hundreds of patients over many years. Regards, Mark

How Much Water?

I drink several glasses of water a day to keep my airways free of mucus buildup. Do you drink several glasses of water every day as well? Just curious, Kathleen

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A. Hi Kathleen and folks,Thanks for bringing up your recommendation about fluid consumption to allow for the timely opportunity to repeat my periodic caution about fluid consumption for our membership.

While for healthy folks the recommendation has always been to consume eight to ten, eight to ten ounce glasses of water per day for "healthy" results, there is NO objective evidence upon which that recommendation is based. In recent review, this recommendation was criticized for lack of evidence upon which to base it as well as the potential for harm to a variety of folks, mostly with health conditions that may suffer from excess consumption of fluids.

Additionally, while the general recommendation over the 30+ years I have been practicing respiratory care has been to encourage adequate to increased fluid intake for those who produce copious mucus "to keep it loose and mobile", this too has NO evidential basis. Indeed, the only two studies that I have seen over the years showed absolutely no influence of fluid consumption over the consistency and mobility of mucus. In fact, when fluid intake was increased over the study period, the only significant correlate was increase in urine production/output. When fluids were restricted, the only significant correlate was--you guessed it--decrease in urine production/output. No difference in consistency of mucus was observed. I have never seen A-N-Y studies that have lent any evidence that increased fluid intake is effective in any way to enhance mucus viscocity or mobility. ('though if any one knows of such study[ies] or come across any, I would be most appreciative if I were to receive a heads up so I could review it/them.)

I bring this up periodically because there are MANY folks who have COPD for whom excess fluid consumption is a real possibility, while occurring within general and even low-normal ranges of consumption of recommended amounts of fluids. Folks on diuretics, steroids, who have CHF, hypertension and/or diabetes are all in increased risk populations. Too much fluid intake can result in fluid retention, less than effective results from diuretics and worsening swelling/edema of CHF.

So, my recommendation in light of these considerations is A-L-W-A-Y-S consult with your doctor about how much fluid you should consume. After all, it is "your" doctor who will have to contend with the results of any difficulties you may encounter with respect to fluid consumption. Regards, Mark

Using Upper Chest Muscles with PLB (Pursed Lip Breathing)

Q. Mark, I'm glad you explain these things. If I learn to do this PSB correctly, will it mean that those muscles in the upper chest are no longer used, or are they used, but in a lesser way? And will this excercise increase my overall intake of air over a period of time? Or am I misreading the whole thing and need a slap on the wrist to sit and listen better? Julie

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A. Hi Julie, PLB in and of itself cannot shift you from using upper chest (accessory) muscled of breathing to abdominal muscle breathing. That takes different exercises. PLB CAN help you stretch your wind, by what ever means you happen to get it in. If you do it effectively--where the expiration is 3 - 4 times longer than the inspiration (with regard to time/duration)--you CAN effectively increase the depth of your breathing from the standpoint that better and more complete exhalations mean more room for deeper inhalations. But you will not "expand" your total lung capacity (which you DON'T want to do anyway!!!) nor do you want to do so.

No slap on the wrist, in any case. This stuff is tricky to learn/understand. AND, when you are trying to be the "old dog" learning "new tricks" AND you are having to do this at the worst time in your life AND when you are distracted by so many symptoms and bad feelings, its no wonder you get confused! ! ! Regards, Mark

Exercise Programs

Q. What would a feasible exercise program be for a person with severe COPD with a FEV1 in the 20's? Would you expect that person to be able to compete with someone with moderate COPD as long as they are on oxygen therapy? While exercising, if my saturation level drops to 89, should I just turn up the oxygen to maintain a safe level? Thanks for any input...Marie

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A. Hi Marie, I encourage ANYONE to work towards their maximum potential, with regard to exercise. Different folks handle a given FEV-1 differently, from one to another. I refuse to be arbitrary about setting a target for anyone. That makes it too easy to achieve and become complacent--or, worse yet and to my dismay, more frequently the case-- its too easy to concede declaring the goal too great/unrealistic.

The fact is that how one tolerates windedness and its attendant discomfort determines how much/fast/far/load they can achieve. Some folks have a very low threshold while others can take a heckuvalot! Ultimately, IMO, you can't do too much. You can do too much, too soon, but never too much, overall! So start easy and build up as fast as you can tolerate increase. Keep in mind that time/duration is MUCH more important than speed. Try for walking--as your main aerobic exercise (or FAST bicycling) --rather than anything less. Shoot for at least 30 minutes. Keep grade level until you have achieved your maximum comfortable speed.

You answered nicely, your final question in the same sentence. Yes! ! ! IMO, if you drop to 89 %, just turn up your flow. Until and unless you reach your maximum load/speed, do NOT use holding or slowing down as your means of controlling your oxygen utilization. Turn the thing UP and stay as high as you can ! ! ! Regards, Mark

Exercise and CHF

Q. People usually think of heart failure as a condition where the heart does not pump out enough blood. That is call systolic heart failure. Recent medical studies have indicated that moderate exercise is beneficial to these pts. However, many CHFers and I have a different kind of heart failure which is caused when the heart cannot fully relax so it can't properly fill with blood. This is called diastolic heart failure (DHF). In DHF, the heart's stiffness prevents it from stretching to increase its size and pts get very tired and SOB when the heart rate and BP elevate during execise. The rise in heart rate and BP makes the heart work even harder which screws the entire pumping cycle. These changes increase diastolic pressures which reduce lung function and make breathing harder. So Mark, does your comments regarding exercise apply to these patients as well? I was told to restrict my activities. Thanks - Cat

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A. The distinction in types of heart failure you cite here, Cat, are applicable to those primary disease of the heart muscle as their diagnosis. This do not apply to congestive heart failure (CHF) except that CHF would be considered a systolic heart failure-type of condition and one that is secondary to pulmonary compromise.

With exception of those who have heart muscle disease before and separately from their COPD, the DHF characteristics do not and would not apply. So my remarks DO apply to those with CHF secondary to COPD. They DO NOT apply to those with primary cardiac disease. If you have DHF, you would not fit into the realm of my comments. But, I would caution you to confirm that with your doctor. My bet is that if you do have DHF, you should be well aware of it and have been so for some considerable period of time--likely before your COPD became a clinically significant problem.

Many folks are wrongly instructed to restrict their activity--as an avoidance behavior against breathlessness. They are advised by doctors and other healthcare professionals who mean well, but are poorly informed and just plain do not understand. Regardless, those who restrict their activity loss function. They deteriorate at a more rapid rate and they die sooner, while having considerably more misery--with regard to symptoms--in the interim.

Everyone chooses their path. You must choose also. Because attempting to remain active and stay in best physical condition requires some level of discomfort in itself, it is a tough choice for many folks. Only you can make what ever choice you deem is best for you. Best wishes! Regards, Mark

Pursed Lip Breathing Confusion

Q. Mark, all these years later I'm still confused about psb.When I'm exercising apart from gentle psb should I deliberately suck in my stomach to expell air..if i dont do anything my stomach or is it lungs hardly moves at all. After I've been exercising a bit and get into a rythmn my stomach/lungs start to work on their own..is this natural?? Marie

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A. Hi Marie, You should not "suck" anything, at any time (except maybe for sucking in the next breath of air) when doing pursed lip breathing. BUT, when you do it correctly, you should notice 'some' amount of movement of your abdomen--inward when you are 'pushing' out the air, during exhalation--and outward, when you are breathing in/pulling in your next breath.

If you don't see ANY movement of your abdomen, you might be breathing more with your upper chest and accessory muscles--NOT a good thing. While it is normal for the abdomen and lower chest to move together during abdominal breathing, the abdomen should clearly be moving the most AND leading the movement of all parts of the torso.

You can ascertain just which muscles you are using by watching yourself breathe while standing in front of a mirror. You may have to turn sideways to observe yourself on profile. You may also need to remove sufficient clothing, if it obstructs your view because of its lack of conforming tightly enough to your 'shape'.

You can practice abdominal breathing and assure that you are removing assistance from the undesirable accessory muscles by leaning against a wall or high counter, chair back or other object that will support your weight Face the surface to be leaned against while standing 1 - 2 feet away from it. Raise your arms above your shoulders and cross them so you lean on them with your forearms and elbows in contact with the surface and your waist bent slightly. Place one foot forward of the other, with your knee bent and shift your weight to the leg that is farthest from the wall/object upon which you are leaning. You may want to rest your head against your forearms. This position is called a "lordotic" position/stance. When correctly in this position, your shoulders will be pressing towards your cheeks and your upper chest will be "locked" in an immobile manner. Your chest will have the ability for greatest expansion, as well. When you breathe in you will definitely see and feel the power to breathe generated by your abdomen. You will also notice that it will be virtually impossible to breathe in with your upper chest structures and muscles. In this manner, you will be breathing in the singularly most efficient manner possible.

Doing this as an exercise a few times each day for a few weeks can 'transfer' breathing work to your abdomen, as it should be under optimal circumstances. For many folks I have trained to use it over the years, this has proven to dramatically reduce their SOB, once they mastered the technique without having to "lean and lock". This technique also avoids the criticism that was cited in an earlier post (and in the GOLD report) about the problems cited with "diaphragmatic breathing" techniques of days gone by. This method does NOT promote the "thoracoabdominal dyssyncrony" that has been observed by some researchers. Regars, Mark

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PFT's and Percent Change

Q. There's a lot of talk about bronchodilators. When I made the [Pulmonary Functions] test with them, there were little changes (6%).

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A. Hi Fernando, 6 % can be a LOT for someone with COPD/Emphysema/ Chronic Bronchitis/incompletely reversible Asthma. Because our standards are currently focused upon changes in FEV1--the amount of air you can blow out in the first second of the biggest, hardest, fastest breath you can muster up--AND, because the standards are tied to the diagnosis of Asthma --AND, because changes are not considered "statistically" or "clinically" significant unless they amount to 15 % or more, many clinicians poo-poo changes of less than 10 % and inconsistently consider changes of 10 - 15 %.

However, because breathlessness in Emphysema and Chronic Bronchitis has been theorized to be attributable--at least in part--to the amount of air-trapping, the reduction in inspiratory reserve capacity and the position of the diaphragm (flattened, pushed downward), recent literature and discussion has suggested that the small changes we see in post-bronchodilator measurements of FEV1 may translate into significant reductions in air-trapping, and increases in inspiratory reserve capacity and return of diaphragmatic position more towards normal. This all translates into the "perception" of easier/improved breathing on the part of the affected individual. So, nowadays, unlike days gone by, more of us are acknowledging the "reality" of benefit, rather than dismissing the claim of improvement to placebo affect or somatic (all in your head), like we used to. Best Regards, Mark

The "Shakes"

Q. I am taking less theophylline and less albuterol than I took before this latest "episode" of mine, but my hands shake so badly that there are many things I'm not able to do. Yesterday I started to think that I should get my thyroid checked. I'm now taking 200 mg of theophylline twice a day. Before the latest "episode" I was taking 300 mg twice a day. I'm still on prednisone, 10 mg a day. I started, of course, on solumedrol in the hospital, 600 mg 4 times a day; after a week, it was 300 mg 4 times a day. From there I went to 60 mg a day of prednisone and after 2 weeks down to 30 mg. At Burke, I went from 30 mg to 10 mg in 3 weeks. When I asked the doctor what the taper was, he said there is none. I have to get around to asking him if he means forever. Ethel

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A. Ask him about cutting the Theophylline back to 100 twice a day. If that helps the shakes, then see about 50 twice a day, down the road. That should be a good maintenance dose for you. Realize, it won't give you any kind of blood level range like they try to put asthmatics into. You don't want, or need that. If you get a blood Theo level of 2 - 4, and preferably closer to 2, that would be all you want to have! Much as you might hate the thought, don't be too eager to come off the Prednisone too soon. Certainly, ask about how long he plans to keep you on it. But, don't be hasty about coming off it right away. You should probably be thinking about a slow--1 mg-per-day--taper, from here on out, as others here on the list have described going through. Regards, Mark

Working Outside with Oxygen

Q. I'm kind of fumbling around on my own. If I interpret all this correctly, there's nothing wrong with my form of exercise. While it is a bit more strenuous than walking, it is the same kind of continuous steady effort. However, if Mark is correct, I need to be using oxygen during exercise and that is a big problem since I have not yet figured out how to use oxygen outdoors. City people have a hard time understanding that there is no concrete out here - no sidewalks, no paved driveways, no nothing except large distances. When the oxygen co. installed the concentrator, they agreed the little tagalong cart with tank would be useless here. They suggested the so-called portable unit but that is little better. It is designed to hang on your shoulder like a purse but is large and cumbersome and doesn't allow freedom of movement to do anything more complicated than walk. Doesn't hold much oxygen either.

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A. Hi Elaine, I would recommend you try getting the E-cylinder system with an oxygen conserving device--if you choose to stay with a gaseous oxygen system, rather than liquid. A system like that may allow you to use a 25 foot tubing and still be able to trigger the conserving device. The E-cylinder with a conserving device would provide 10 to 12 hours of oxygen at 2 - 3 liters/minute setting.

With liquid, as some have suggested, Helios certainly would allow you the best portability with free hands with which to do your work. BUT, you would need to be sure you can get enough oxygen with its settings. As Peter Bliss discovered when he bench-tested Helios, its maximum liter flow is "actually" closer to 3 liters than to the four it is calibrated to. Whether or not it would meet your needs can be determined by checking your oxygen saturation during vigorous activity to see if Helios' settings will give you enough.

If you are a considerable distance from your supplier, liquid alone, may not be an option that would make them happy. Liquid only, systems need refilling weekly, a significant cost to the supplier if you are far from their office. Perhaps they would consider a combination system--concentrator for in-home needs and liquid for portable needs.

In any case, you need to find a system to which you can attach a long tubing, so you don't have to carry it, or with a case that has straps to allow you to wear it like a back-pack. With your current portable, you might be able to secure it and free your hands so that you can work, if you place your strap over your head, resting on the opposite shoulder to the side on which the tank hangs. Regards, Mark

6-Minute Walk Test

Q. Regarding the [6 minute] " Test ", I have been in and out of rehad. a number of time over the past few yrs. Each time the test was given by my pul. Dr. by hving me walk at a steady pace on the t-mill hooked up to an o2 meter to see if I was phys. able to take rehab., at the hosp rehab. the same test was given prior to starting the exercise program. Both tests were given at a steady pace and not at a increased rate. The o2/pulse rates are taken during and after each individual exercise, as is also the B/P readings. Bill

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A. Hi Bill and Folks, It doesn't matter that your doctor or others may have "called" the test you describe as a "6-minute walk test". By description of THE 6 minute walk test, it was NOT a 'true' six minute walk test.

By "official" description the 6 minute walk (6MW) test MUST measure/assess subject effort, as exemplified by distance covered under subject's OWN effort. In this test, there are three variables--time, distance and speed. As with ANY test having three variables, if you control 'one' variable, you necessarily control them ALL. By putting you on a treadmill, at a given speed, for the 6 minutes, they have discovered nothing of what the "true" 6MW" test is intended to reveal.

By definition, the 6MW test MUST be conducted with free-walking, so that subject capabilities can be ascertained. ONLY the subject should have control over speed and distance. Even if you, as the subject, could control/adjust your treadmill speed, because of response time and arbitrary control imposed by the treadmill, your unencumbered potential cannot be ascertained.

So ANY TIME your doctor, or other health professional puts you on the treadmill to walk you, they are NOT doing the "true" 6 minute walk test. They are simply walking you on the treadmill for 6 minutes (or some other amount of time). Regards, Mark

Oximeter Readings

Q. I am wondering about oximeter readings. I tried on my wifes oximeter on the other evening, and got readings of only 92-95. As far as I know I have no lung problems. I don't think it is the meter, as she gets readings of 97-98 when on O2. Or should hers be higher when on concentrator ?? Thanks for response. Larry

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Hi Larry, Even if you can find no source of artifact, the saturation as measured by pulse oximetry is subject to a measurement error of + or - 2 %. The only way to accurately assess your saturation is through blood gas measurement. Even then, the purist would insist that your blood would have to be analyzed by co-oximetry, after being tonometered (homogenized in a special machine) in order to be 'truly' accurate.

Realize and remember, when you first put the monitor on your finger, you will see fluctuations in the initial "numbers" displayed on the monitor. You must allow at least 15 seconds, but even more - - - say 15 seconds AFTER you have a green light with a regular rhythm.

I would recommend advising your doctor about your observations IF: (1) you are consistently b-e-l-o-w 94 % as a "stable" reading, (2) have breathing limitations with moderate exercise and/or (3) notice that it consistently drops and *stays* less than 94 % with exertion. Regards, Mark

Hands Shaking & Wheezing

Q. My hands do shake a lot. I wheeze after doing my meds for 15 to 20 min. I told the doctor but he just nod his head. I was thinking of asking him for valium for when I feel very anxious. I get panicky if someone knocks on the door and I never was that way before. But then again I wasn't on oxygen, predisone, Albuterol, Atrovent and Serevent. LOL

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A. Hi Mari, The Prednisone can make you shake, also! Often, the shakes are more a product of the Prednisone than other medications! The wheezing "after" your treatments is intriguing, since the medications are supposed to relax and improve the tone of your airways. HOWEVER, often, wheezing that onsets 'after' bronchodilator treatments is the product of MORE air movement AND sometimes incomplete benefit from the bronchodilators. Does your doctor know you wheeze more after your treatments? Regards, Mark

Mucus: will it go away

Q. I quit smoking like 5 months ago. My primary doc at the VA says the coughing and mucous will never go away. Anyone have any insight into this. I'm not quite sure I believe it cause it wouldn't have made a whole lot of sense to quit smoking. Thanks, Lou

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A. Hi Lou, It ALWAYS makes sense to quit smoking - - - continued mucus production, or not! ! ! The fact is predicting whether or not mucus production will or will not continue requires a well-working crystal ball. But that, in and of itself should not be the 'primary' reason one quits smoking. The fact that regardless of the amount of damage done to the point of quitting, further irritation, damage and deterioration can be reduced and/or avoided--the real reason to quit! Hang in there . . . . . and keep moving! ! ! Regards, Mark

SOB and O2 Level

Q. I just had an oxygen test where I walked around with a thingy on my finger to measure my o2 level. I get very sob by moving even a short distance but my o2 level stayed above 90%. I am just fine when I am not moving. I was told I have emphysema in 1995. I had a pulmonary function test last month and my FEV1 was 43. I am really confused about what is going on. Thanks, Sharon

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A. Hi Sharon, If your saturation is above 90%, but less than 95%, you can still have a component of low oxygen driving your breathlessness. It is hard to sort out. Once you get your oxygen saturation up to 95 or more, breathlessness is more likely due to deconditioning (as Chuck posited). Your remark about how you feel when you are 'not' moving is SSSOOOOoooooooo typical of folks with COPD!!! Regards, Mark

Retaining cO2 without emphysema

Q. Can you retain c02 without having emphysema? I was talking with a fellow beautician, who is now on 02 they said that hers was not E but bronchitis and from the fumes of the chemicals that she had breathed in all these years. Oh,she had pneumonia and was desaturating in the hospital. Vicki

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A. Hi Vicki,To answer your initial question: NO. Without serious lung dysfunction, NO ONE should ever retain CO2, except in a few vary unusual and infrequent metabolic conditions.

While no one can say for sure without good and complete pulmonary functions tests and perhaps a CT scan, your friend can have primarily Chronic Bronchitis (CB) and a-l-s-o have emphysema, but not as much or as bad as is the CB. I would bet there is some pulmonary fibrosis (PF) of significance, as well, as many of the chemicals to which you refer cause irritation, inflammation and scarring damage to the lungs, as well as a lot of acute bronchitis. If she smoked, she has more reason to develop potentially both CB and PF. Regards, Mark

Nebulizers

Q. Can you become dependant on the nebulizer? I have just started using it about 5 weeks ago, which leads to my second question. Can who ever sent a list of things to clean with that doesn't hurt our lungs please resend it. I remember reading it several years ago, but at the time my lungs was fine, thanks to some strong cleaning agents, they are not now. Thanks Peg

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A. Becoming dependent upon the nebulizer--in the manner of becoming addicted is kind of a misnomer. While folks can have breathing difficulties that cause them to increase the number of treatments they take in a day to the point that they are 'over-dosing' on the medications IS a possibility. Such times would generally include exacerbations that come on and the user is usually trying to avoid going to the doctor, or the hospital, or at least putting it off. Other times, you will have an exacerbation building and the doctor will instruct you to increase your treatments as an interim measure short of going to the hospital. Even when you go to the hospital, the usual approach is to step up your treatment interval for a period of time until your breathing improves and other treatment measures have a chance to begin working.

But, if you mean taking the medication when you don't need it, 'most' folks will usually find reasons to 'skip' scheduled/ordered interval treatments because they take time and are to some degree inconvenient. Beyond that, if you take treatments when you 'really' don't need them--and especially if you are taking a beta-agonist medication, like Albuterol--you will find that it makes you MORE uncomfortable than any help it gives you.

Recent recommendations from the CDC include washing your nebulizer parts (disassembled) in dilute dish soap with a small amount of bleach (1:50 to 1:100 concentration) and letting them soak in that solution for at least 20 minutes. Rinse them and let them air dry on a clean (paper) towel. Do NOT wipe them dry.

Bronchodilators & PFTs

Q. Hi, Can anyone tell me which bronchodilator is used in PFT? Whatever was used when I had my tests was fine with no discernible after effects. The prescribed meds I have had have all left me very shaky and with headaches. I would like to find something with the fewest side effects. Any suggestions? Many thanks, Maureen

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A. Hi Maureen, There are no 'necessarily' usual drugs used in a PFT. Most often a beta-agonist is given. Most often it is Albuterol. But some labs use a nebulizer, while others use an MDI. Some use two puffs from the MDI, while others may use 4,6,8 or more.

You would need to tell US what medication they used on you AND how much, for anyone to be able to give you an answer of any kind. Regards, Mark

LVRS

Q. I keep reading about LVRS and the fact that Medicare may approve this for those who are "good candidates".......I'll then read other notes on those who have had the surgery and most comment that they believe it worked because they were "good candidates" Just what constitutes a "good candidate"? Age...FEV1....overall health...what are they looking for ?? Any thoughts? Carol

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Hi Carol, "Good candidates" have emphysema that is "heterogeneously" distributed (i.e.; it is concentrated in localized areas--usually the upper lobes) within their lungs AND in whom those areas can be removed leaving good tissue that can expand into the 'gaps' created by the procedure, so that > they can resume functioning. That 'normal' tissue is usually being compressed by the emphysematous areas, so that it cannot function properly. Those with "homogeneous" distribution of their emphysema--that is, it is evenly interspersed with normal tissue--are not good candidates, because to reduce their total lung volume would involve taking out too much 'good' tissue with the bad. It would also leave them with too much 'bad' tissue to have to carry on with. The other necessary criteria is that your TLC (total lung capacity/volume) must be at least 130 % of predicted. You have to have enough excess lung volume so that when the 30 % is removed, TLC will return to 100 % of what it should be, or close to that amount. There has to be the expectation that reducing your over-sized lungs toward normal size will allow the diaphragm to shift up into a more normal position. This one factor is what is believed to be responsible for the significant reduction in breathing difficulty. Beyond these considerations, you should have as healthy a heart as possible. Age makes only minor difference, but candidates preferably are under 75 years of age. In testing for candidacy, the CT scan and ventilation-perfusion scan are the critical tests are the most telling and critical in determining who should benefit and who would likely not benefit. Regards, Mark

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Using only Atrovent without Albuterol

Q. Does anyone know why some use only Atrovent and not Albuterol and some both. I use both. When Ethel complained about using the nebulizer taking too long, her pulmo said "Just use the Atrovent". Mari

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A. Actually, while it DOES have very specific benefit for those with COPD --moreso than for those with asthma--Atrovent is most surely prescribed for asthma, as its action is also of therapeutic benefit to many with asthma.

For many folks with COPD, the Albuterol has more side effects than any benefit it provides. It is those folks who are advised to use the Atrovent as their 'maintenance' medication and to reserve the Albuterol for times when their breathing is worse AND during which it brings them sufficient relief when they use it to override the unpleasant side effects. Regards, Mark

Forehead Probes-Oximeters

Q. Mark, Could I have your opinion on the forehead probes used with the Nonin 8500 and some of the Nalco models of dosimeters as compared to the finger probes. It looks to me as if the forehead would be better i.e. more actuate. Jim

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A. Hi Jim, So far as I know--and my information is as fresh as October in Tampa at our national meeting--the only two manufacturers who are making "forehead" (reflectance) sensors for pulse oximeters at this time are Nellcor and Massimo.

In any case, there is little doubt that reflectance sensor technology is superior to finger transducers for a few rather technical/complicated and physiologic reasons. My study results showed that, too. But, there is no low-price pulse oximeter that is compatible with reflectance sensors, so they are not available/practical for home use. Regards, Mark

Spiriva and Severe Emphysema

Q. I am wondering if it would be a good idea if those that are using Spivira, could tell us what their fev was when they started and how they feel since taking it. I have very severe Emphysema and just don't feel it would help me. Just a thought.

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A. Hi Mari, I would suggest that you not discount the potential benefit from Spiriva simply because you think your emphysema is too severe. There are folks out there realizing remarkable improvement who also have very severe Emphysema. Regards, Mark

Problems Lying Down

Q. When I lay down. It starts to feel like I have wet rags in my chest. My breathing gets real short and difficult, and it feels like I'm drowning. As of today I haven't found a remedy for it either. Any info would be appreciated. Always me, Julie

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A. Hi Julie, The flutter valve is a plastic device that resembles a stubbed pipe with no tobacco bowl. Instead the bowl is closed and has holes in it like a salt shaker (holes are bigger, though). Inside the bowl is a steel ball bearing that blocks off the path through which you blow air out through the device. When you blow on it, the ball rocks back and forth inside, alternately stopping and starting the airflow through the thing. This gives a vibrating sensation and fluctuating pressure that transmits to the airways. It is supposed to help loosen mucus, so that you can more easily cough it out. If you can get it cheap, it might be worth considering. Our site has some information about ordering one.

Pursed Lip Breathing is the technique of blowing out through your lips, as if you were trying to blow out a candle that someone is holding out a ways in front of your face. You use it to help stretch your wind, relieve windedness/ SOB (Shortness of Breath) slow your breathing down and make more of the air you are able to move. The more short of breath you are, the harder you squeeze together your lips.

If you are having dyspnea and heaviness in your chest with laying down, you should bring that to the attention of your doctor. If there is nothing acutely the matter, you may have reached a point in your lung disease that you will need to sleep with your head elevated. You can do that either by adding pillows behind your head and upper body, raising the head of your bed--as in placing the legs up on 8-inch cinder blocks, or something similar--or sleeping in a recliner. Let your doctor know about your difficulty laying down. And do it soon! Regards, Mark

Inappropriate Exercise

Q. My question is what is "inappropriate" exercise. My problem is definitely not too little exercise. When I was diagnosed in June, they wouldn't let me out of the hospital unless I agreed to take the concentrator because my oxygen level dropped into the 80s after walking. I use the concentrator at night and while sitting at the computer but obviously not outside. My dr. has said only that I'll live longer if I use it. Guess I'd better buy that oximeter and maybe I'll find out how much of this is inappropriate! Elaine

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A. Hi Elaine, I hope you understand that while heart compromise IS a 'natural' part of the COPD process AND can be the ultimate cause of your demise, there is FAR from 'nothing' you can do about it!!! AND, it is NOT from being "over-worked" from your efforts to breathe!!! It is "over-worked" when it is forced to work under the difficult conditions of hypoxia without any help from supplemental oxygen.

Oxygen !!! Use what you need when you need it so that your saturation never has an easy chance to drop below 90 %. This is key to preventing progression/worsening of congestive heart failure (CHF) and Cor Pulmonale.

Exercise !!! A good exercise regimen that will produce and sustain endurance is a must. Your work in the garden and yard, are great, but you need to walk for 30 - 60 minutes--NON-STOP--to get the 'kind' of conditioning that will help you stay healthy and ward off degeneration. When you DO rake those leaves, or work in your gardens, be sure you are using your oxygen !!! Without the oxygen, that work--and the desaturation that is occurring during that work-- are harming your heart!!!

So, GET movin' and KEEP movin' AND use your oxygen to do it !!!!! Regards, Mark

Heart Rate at Exercise

Q. My heart rate on normal (bathing, folding clothes, walking, etc) is running 131, at exercise, walking on the treadmill it will get as high as 151. I am seeing my pulm doctor tomorrow and maybe he will figure this out. Also I am feeling very shaky. What do you think is going on? Thanks. Carrie

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A. Carrie, My crystal ball fell off my desk the other day and shattered into a bazillion pieces! (LOL) I'm glad that you are going to see your doctor. 131 is a bit high for light activity and 151 is a bit high for exercise--UNLESS--you have other obvious reasons for the increase. Perhaps you are taking a medication that elevates it. Perhaps you are dehydrated. Perhaps you have something wrong--not yet detected/recognized--that is causing it. You certainly haven't given me sufficient information to try to say what could be the cause--AND--I haven't asked enough questions to be able to get a picture of where you are at the moment. That is all information I'm counting on your doctor to have so that he can put his finger on your cause/reason. Let us know what you discover/learn tomorrow! Regards, Mark <|{:>)

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Severe SOB Despite Good Saturation

Q. I can get so SOB I can't walk but my oxy level will be in low 90s. I just stop and rest for a few minutes and continue what I was doing.

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A. First, while it is hard to argue that SOB with exertion in the face of saturations that are above 94 % are rarely attributable to not getting enough oxygen, when the saturation drops below 94 %, your difficulty CAN be increasingly from not enough oxygen, even though yours saturation is still above 90 %. As I learned from the data I collected in a study I've just completed, you can have good oxygen "pressures" in your blood and yet have low saturations along with SOB that are corrected by giving you yet more oxygen to increase the pressures even higher. Also, my data and that of several others before me indicate that with exertion, performance of activity and tolerance of increased work to breathe during that activity can be significantly improved by pushing the saturation up to 95 % and higher, as compared to performance and tolerance at 90 - 94 %. So for those of you who have a lot of trouble breathing with activity when your saturation is in the low 90's might find that you can improve how you feel and tolerate that work if you are able to increase your oxygen so as to raise your saturation up to 96 %, for instance.

For those of you who have high heart rates AND good saturations with exertions and SOB, unless you are on medications that are increasing your rate, you can attribute it to being in poor physical condition. Indeed, if you have become increasingly used to stopping and letting windedness pass and have been practicing this pattern for a long period of time (more than 6 months) you can attribute the ongoing/increasing difficulty to being out of shape. The pattern of stopping when breathing gets rough breeds deconditioning and makes your problem grow, such that you can do less and less, or go less far before getting winded and "having" to stop and catch your breath. Until and unless you can begin to "achieve windedness and discomfort and "begin" to increase the time you 'c-o-n-t-i-n-u-e' to press on, using controlled breathing and controlling your anxiety, you will continue to lose ground and function.

BUT, if your oxygen drops AND you have increasingly horrible breathing AND your saturation drops, but not far enough to qualify for supplemental oxygen during activity, you are left with no choice but to stop and do the best you can with what you've got.

I'll close with the point that, in and of itself, a high heart rate (up to 150/min) for M-O-S-T folks, is not harmful. It is also NOT a reason to stop and rest, AS LONG AS YOU DON'T HAVE OTHER SYMPTOMS, like chest pain, dizziness, or other symptoms like that. Regards, Mark

Desaturating w/Exercise

Q. A non-COPD friend told me he "and everyone else I know"desaturates with vigorous exercise too. Curious. What does he and everyone else dessert to??? (yes) since receiving the Gift, I'll go from 100% to maybe 96.97, but usually no lower than 98%. One of my doctors is always amazed--he tells me he can't do that. So, the question. who or what is normal?? Sam

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A. Hi Sam, As I've posted before; "textbook" normal for oxygen saturation is greater than or equal to 96 %. ALL people who have no compromise of their pulmonary function should fit into that range. I've never seen anyone--in 32 years - - - who was "normal be any lower than 96 %. Also, one's oxygen saturation should NEVER drop below 96 % during even the most strenuous exertion (under normal atmospheric conditions- barometric pressure, that is - AND near sea level) if they are ALSO without pulmonary function compromise. Regards, Mark

Long Lungs

Q. I noticed in my xray my lungs are much much longer that i guess before. do other people have this condition. i thought that our lungs got wider rather than longer. Marie

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A. Hi Marie, COPD and especially the emphysema component, results in an increase in your "total lung volume". This is the result of the 'trapped' air that you cannot expel. Depending upon an individual's particular physical features and their ability to accommodate the increase in lung 'size', they will either 'displace' their anatomy 'downward', or 'outward', or a combination of both. Those who primarily displace 'downward', will end up with no significant increase in their chest cage, but will notice an increase in their, shall we say, 'paunch'. Those who primarily displace outward end up with the classic 'barreling' of the chest that you mention. Those who displace both ways, will notice an increase in their girth, as well as an increase towards barreling in their chest. This is often accompanied by other changes that correlate with the dimensional changes in the chest. Those who displace downward 'tend' to be slender. Those who displace outward can be anywhere along the spectrum from slender to portly. Those who displace both ways tend to be portly.

Clark had a good suggestion for those whose lungs are "long", when it comes to assuring a good x-ray the first time around. That is to tell the tech that you have emphysema and "long lungs". That way they can be sure to use a long cassette to make the shoot. Regards, Mark

Oximeter Purchase

Q. I want to buy an oximeter and can't figure out what, if any, difference there is between those that anyone can buy and those where you need a dr's prescription. Is it worth asking my dr. for a prescription or can I get the same results by picking one out of the hat from the many available to anyone?

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A. Hi Elaine, There aren't a lot of pulse oximeters out there that are "affordable"/"low-priced" as you may think. While there are a lot of oximeters, they run from $900.00 up--IF--you don't get one of the Nonin onyx-type clones. There are some you can get without a script. All the script does is make it a legitimate medical expense (tax-deductible) AND save you from having to pay the sales tax on it. The ones of which I speak run from $295 - 500, depending upon from where you purchase them. There is information about ordering one on our website. Regards, Mark

6-Minute Walk Test

Q. Hi, could someone point me in the right direction. Been trying to find info re: the six minute walk test and other criteria required to be put on oxygen, went to EFFORTS home page but can't seem to locate it. Dorothy

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A. The 6-minute walk test (6MW) IS indeed a 'stress test'. While the results are sought to serve a variety of informational purposes, a 'formal' 6MW test is performed to ascertain (1) how FAR one can walk in 6 minutes, (2) how their vital signs change - B/P, heart rate, respiratory rate, (3) how their breathing dynamics change - dyspnea, SOB, etc., (4) what their oxygen saturation does, (5) determine progress after a period of pulmonary rehabilitation exercise has gone by and (6) assorted miscellaneous information - gait disturbances, degree and number of non-respiratory symptoms/complaints.

Several approaches can be used to determine one's need for oxygen during exercise/ambulation, among them being the 'formal' 6MW test. Many doctors use an 'un-timed' variation in their offices to check one's saturation during ambulation. The timed-distance is not necessary to determine that, so they don't walk the subject for the full 6 minutes. This is fine--as long as they allow sufficient opportunity for desaturation to be detected. Most folks need to walk for a minimum of two minutes to exhibit decreased saturation as there is a lag time between when saturation 'actually' drops and when the (finger) pulse oximeter picks it up. If walking is too short, or ends too soon, or if monitoring is stopped before 1-1/2 minutes after stopping walking, desaturation that 'actually' occurs can go undetected.

So when you are doing the 'formal' version, exert as much as you can. Cover as much distance as you can. Give it your all. For walks to determine only how much oxygen you need, go at a steady pace, speeding up/pushing harder if you are on the margin. Regards, Mark

Knowing Sats

Q. What does it matter if we "know" our sats? Do we do anything about them if they are different than what we would expect? Is there a "normal" for all folks? Or does it vary, person to person? Thanks again. Diana

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A. Diana, Normal saturation for EVERYONE is > or = 96 %. Acceptable range is 90 - 95 %, marginal range is 88 - 90 % and below 88 % one s-h-o-u-l-d be using supplemental oxygen to prevent adverse cardiac changes. Notice, I said EVERYONE. This is NOT an individually varying measurement. Regards, Mark

Serevent/Atrovent Schedule

Q. I take Serevent and Atrovent for Emphysema, so my question is now I take the Serevent first like at 7:30 in the morning and then I take the Atrovent at 8 am and then 4 hours apart for 4 times total, and then I take the Serevent again at 7:30 PM now am I doing it right or should I take the Atrovent first thing in the morning and then the Sevevent 30 minutes or so later? Thanks for any information and I appreciate it. I could write to Mark individual but I think he told me once and I forgot. Thanks and all have a nice day. Harold

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A. Harold, the way you are doing it is just fine. Don't change it. Regards, Mark

Breathing Thru Nose

Q. I read or was told? the reason to breath thru the nose is to filter, warm and moisturize the air, seems there was more but can't remember. Ruby

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A. Hi Ruby, You read and recall correctly--and there isn't really any more to it than that. That comment/instruction/axiom is written in innumerable books, both professional and lay. But the fact is, there is no scientific basis upon which it is based! ! ! The 'evidence' does not suggest that there's anything to that old myth, either.

When we look at the amount of filtering--and its consequence on the upper airway (from the outside to the epiglottis) and the first third of the"lower airway" (trachea and first several branches of bronchial tubes), we find that the difference between temperature, cleanliness and humidity of air that passes through the nose versus that which passes through the mouth is insignificant when you look at the two within the lower airway. The fact is that by the time both reach the "isothermal" point, it is the same. The iso-thermal point is the point within the bronchial tubes at which ALL in-coming air is 100 % humidified, to body temperature and is sterile. The tracheo-bronchial tree and the mucus layer do well over 95 % of the cleaning of in-coming gas, even when one breathes in through their nose. The hairs and mucus membrane within the turbinates of the nose can only catch large particles, few of which exist in the bulk of the air we breathe.

With the nose being such a restrictive pathway through which to breathe, panic and discomfort and their accompanying effects can be avoided without ANY negative consequence by breathing through the mouth.Regards, Mark

COPD Getting Worse

Q. I have end stage COPD, been on O2 for 3 years 2l @ and 6 for walking.I take albuterol 4 x a day, Spiriva once a day and Advair 250/50 twice a day. It seems my condition is getting worse. I have a peak flow meter that I use 2 or 3 times a month the readings have stayed about the same. Is the peak flow meter a good indicator for my condition? I was told that i could regain a little lung power if was to loss weight as I am 60 # over weight. has anyone out there been helped by a weight loss. Don

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A. Hi Don, Despite the anecdotal endorsements you may receive from a few folks here on the list, all standards and recommendations are a-g-a-i-n-s-t use of peak flow measurements as an indicator or acute change in those with severe COPD. The reason is that the peak flow meter is sensitive only to significant changes in airflow (greater than 200 l/min.) Folks with COPD have low flow to begin with and acute changes in them can be accompanied with very little change in peak flow measurement. Conversely, the same changes in peak flow can mean NOTHING in those who may or may not be experiencing acute changes. The peak flow meter is intended for use in those who have significantly reversible asthma. No other pulmonary disease population has been identified as whom also should use it. Regards, Mark

Inspiratory Muscle Training

Q. Where do you get specific inspiratory muscle training? Carrie

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A. Don't clamor to get hold of devices and rush to do inspiratory muscle training/strengthening exercises with dyspnea related to COPD.

First, the mechanisms of dyspnea in COPD are different, owing to hyperinflation and obstruction to "exhalation". In studies of EMG measurements, diaphragm strength has been shown to be normal to increased, secondary to increased work of breathing related to dyspnea. So, the value of further increasing strength of the inspiratory muscles AND of what help it would be are two questions not addressed by this group or others. Further, variability in measuring maximum inspiratory force has been demonstrated among many groups such that, without specifically describing technique, readers cannot tell whether or not their method of measurement produced the change they claim, rather than a real training effect having taken place.

I bring up all this because several consensus statements of treatment for COPD have concluded--across the board--that inspiratory muscle training has not been shown to produce statistically significant improvement in exertional dyspnea.

Having said that, I will say that I don't discourage you from doing inspiratory muscle strengthening exercises - - - as part of your complete exercise program - - - but, I do caution that they, ALONE, cannot produce appreciable benefit. And, if you do them, for considerable time and at considerable load, but still suffer from a prohibitive level of exertional dyspnea, realize that these exercise have never been shown to produce consistent, let alone consequential benefit.

In that interest, I admonish you NOT to spend big bucks for fancy devices with which to do inspiratory muscle training exercises. Use cheap, household items like coffee-stir-sized straws for strong and sustained inspiratory exercises. The effect will be the same on your lungs, but tremendously better on your pocket book. In the end, don't expect much, or much of great note, to occur. Regards, Mark

Inflammation and Medications

Q. Hope you can help with answers to my following questions:

1) Is Prednisolone same as prednisone?
2) Albuterol = Ventolin = Salbutamol?
3) Combivent = Ipratropium+Albuterol What proportion and how much distilled water is mixed?

It is said that all corticosteroids are to reduce bronchoconstriction and inflammation. I have been using Atrovent/Salbutamol both MDIs and nebulizers but I've never felt my airways to be "inflamed" except for the SOB which I get some relief after applying. What are the feelings we get when our airways get "inflamed"? Thanks, Larry

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A. Hi Larry-Prednisolone and Prednisone are both steroid preparations and are essentially the same in their action and benefit.

Albuterol is the generic name for Ventolin and Proventil and is a short-acting beta agonist bronchodilator. Salbutemol is the generic equivalent to Albuterol, but is what it is called 'outside' the USA.

I don't know what the portion (quantity) of Albuterol and Atrovent are in Combivent. Nor do I know if sterile water is the diluent in Combivent, nor how much. It would seem a superfluous question/piece of information, since Combivent is supplied in a MDI. Each actuation carrying the intended dose (in milligrams) of drug in solution, is a miniscule drop, if reduced to its single-drop size. Why do you ask?
Regards, Mark

Exercise/Sputum Color

Q. I have one question about exercise. Do you get the same benefit from exercise if you do it on and off during the day? My smoking quit date is Nov. 17 and I know I will be on it more then.

About the color of sputum(sp), mine has always been yellow to greenish especially in the morning. Why am I different? Janice

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A. Hi Janice-Exercise dispersed throughout the day in short spurts DOES benefit you. BUT, for example, one hour of walking, "without stopping" is going to benefit you significantly more than will walking four times per day for 15 minutes. The slower you move and against less load, the greater the difference in benefit between one continuous exercise period and several shorter exercise periods, adding up to the same total.

Your discolored sputum being more pronounced in the morning suggests a common problem among folks with COPD - - - post nasal drip. That isn't uncommon. So, at least in THAT respect, you are not any different than a great number of folks with COPD! <|{:>)
Regards, Mark

Increasing Oxygen Quickly

Q. Has anyone else had this problem with having to increase their oxygen level as quickly as I seem to have had to increase it. I went into the hospital on February 17th of this year and was placed on oxygen for the first time in my life. I was put at 2.0L per minute. When I started rehab, around the 1st of July, the Pulmo increased my 02 to 2.5L at rest and 3.0L when up moving around and exercising. After 10 weeks of pulmo rehab, my blood pressure dropped to 87/54 - my heart rate declined to 77 and my 02 SATS dropped to like 84 - while I was still on oxygen. I was referred to a Cardiologist, who informed me that my heart was not in the best condition, but that my real problem was my lungs - that they were excessively hard to help me breath - so, the Cardiologist referred me to a Pulmo and my 02 was increased to 3.0L at rest and 5.0L when up moving around and exercising. This has only been 10 months folks. This has me a little concerned about the future. Has anyone else had a similar problem or have an answer as to what might be happening? Thank you. Don

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A. Hi Don-You don't give any corresponding saturations, but my bet is that your oxygen is being increased because your doctors are trying to find a higher point at which to get your saturations rather than your oxygenation getting worse. A lot of this is arbitrary and guess work, without elaborate testing and evaluation. They start conservative and add as indicated according to symptoms that are not being reduced or eliminated.

So you very possibly/probably have not worsened at any fast rate. Instead, it has taken this long (and will maybe take yet longer) to find what minimally reduces your major symptoms.
Regards, Mark

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Exercise and Barrel Chest

Q. Does any one know if there are any exercises that would correct this[barrel chest]? I had been thinking that the LVRS would probably be the only thing that might help but if there is anything else that might, I would be interested in hearing about it. Also, her comment about the prednisone and it's weight distribution to the shoulder, neck and face is exactly what my doctor told me when I had to take it the first time.Vera

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A. The barreling of the chest is not something that can be changed by exercise. It is the result of the distended lungs pushing out on the chest wall, increasing the distance between the ribs, flattening the diaphragm and increasing the diameter of the chest. In such a configuration, the muscles are stretched and less able to contract to pull the chest into smaller dimensions. Lung Volume Reduction in folks with barreling of the chest often results in some degree of return to normal dimensions, as you suspected. But, how much is variable among individuals. Although taking Prednisone predictably results in increased fluid and fat deposits around the head and upper chest, that does not hold necessarily true for those who are wasted secondary to their lung disease. With the fat already catabolized from those regions, they rarely have much change beyond the development of a 'modest moon face' and maybe puffy eyes. Folks closer to normal weight tend to exhibit the characteristic changes more pronounced.
Regards, Mark

Elevated Potassium Levels

Q. Have any of you been told that you have elevated potassium levels? Any ideas why this should be? My doctors don't seem to know what has caused it. Kathleen

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A. There are many reasons why one's potassium can be elevated. Your doctor probably didn't know which one of them was responsible. He couldn't tell you why, not because the causes are a mystery. unknown, or anything like that. Its just that in your case, he didn't see any obvious reason.

The greater question has to be not that, or why your potassium is elevated but was he concerned enough to decide to "do" something about it? Did he prescribe a treatment for you to undergo to reduce it? Did he instruct you to do anything with regard to adjusting your diet? Or did he just mention the fact as a passing remark? Then the question would have to be asked: how much was it elevated? Other questions that would come into play in determining the answer include; what were the rest of your electrolytes (Sodium, Chloride, Bicarbonate) ? How's your kidney function? How's your liver function?

See, there are a lot of other questions just to determine if there is even a problem with the elevated potassium. Mark, Respiratory Care Practitioner, Registered Respiratory Therapist

Carbonation

Q. While out West in the late '70s I met up with an actor who did a lot of Westerns. While working with real Indians, he 'learned' a couple of things which he passed on to me. The first was to avoid ice-cold anything: beer, popcicles, water, and etc. The Indians, he said, believed the temperature imbalance caused by the very cold fluid upset the temperature balance of the throat and other tissues leading to the stomach.

Secondly, his Native American friends frowned on beer and carbonated drinks because they harmed the lungs and circulatory system.

One reason for asking is the number of our members with throat, stomach or intestinal issues based on type of drugs which they say they take on questionnaires and in email. Jeff

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A. Hi Jeff-While my gut feeling is to dismiss a lot of those points as myth and mysticism, I have no good evidence one way or another. There are indeed a lot of folks who cannot tolerate iced, or super cold beverages. There may indeed be something to that. Yet there are a number of folks--and no 'small' number, at that--myself, included--who don't have a problem with iced beverages.

Conversely, we lavage folks stomach with iced saline when they have a sudden and serious gastric bleed. This also has an effect to lower their 'core' temperature. This has not been shown to have more than temporary effects. So I can't believe (at this point) that it does anything permanently harmful to them. Regards, Mark

Emphysema Getting Worse?

Q. My question is - How do I tell when my emphysema gets worse ? I have complications with another disease that makes me SOB, can't walk far or stand too long, and can't hold out to do hardly anything. The other disease has been with me for seventeen years and I've been on Prednisone for that long (20mg-day now). I was diagnosed about a year ago with the beginning of emphysema and I don't know the progression stages exactly. I hear yall talking about oxygen, Spiriva, and other stuff that I'm not on. I am on a nebulizer taking four treatments a day of albuterol and have combivent inhalers for travel. I don't cough much and don't produce much (hardly any) sputnum. When I exert myself, I can go too far as when I sit down, can hardly catch my breath ... sometimes have to sit for ten to fifteen minutes to get back to breathing normally. When I'm at computer or watching t.v., I don't have any diffuculty breathing ... no trouble breathing in or exhaling. One reason for giving out so quick is I'm over-weight - haven't been excersising. I know all this is going to catch up with me and I've started back excersising on my cardiac machine and plan on walking but that is what REALLY gives me out is walking. I've also been scared a few times and find myself now avoiding going places and really just stay at home most all the time. The main question tho, is what should I look for in the progression stages of emphysema. By the way, when I first caught my primary disease (muscular), my doctor told me it would affect ALL muscles including my pulmonary muscles. Since then, I've had three heart attacks and open-heart surgery (1999) ... (heart is also a muscle). Duan

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A. The most important and strongest one I can give to you is that you must find a way to safely get moving again. The more you sit around and avoid exertion and the difficult breathing, the worse your symptoms and progression will be AND faster, too. As hard as it is to move and breathe, that is what you must most importantly do!!!
Best Wishes, Mark

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Oxygen Flow

Q. I have a concentrator, in addition to the Helios, was using the concentrator today....set at 2lpm, with a 50 ft. hose, I would venture to say there is no pump on the concentrator,so....at 2lpm going thru a 50 ft hose, is it delivering 2 lpm?? How, if there is no pump..would you get the oxygen more efficiently with a shorter hose?? Carol

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A. Hi Carol, I would add that there are times when what is set is not what is delivered. You can have it set at 2 liters and be getting somewhat less. Some folks on the list have purchased an "Erie Liter Meter" for a nominal cost (ordering info is on the website). With this device, you can measure the 'actual' flow at the end of the 50' segment and adjust the concentrator output as needed to receive the desired flowrate.

Short of the liter miter, you can set you flow at 2 and connect to the flowmeter only your 7' cannula and put the flow-delivery end into a cup of water, cover or pinch-off one nose-piece and observe the 'rate' of bubbling. Then put the 50' tube back on and dip it into the water and look at the rate of bubbling. This is a very crude method and only to detect an obviously major difference between the two segments.

The other thing you can do is call your oxygen company and ask them to check the flow. They should have a liter meter with which to check it.
Regards, Mark

Carbonated Beverages

Q. I'm not sure where I read it, but is it true that drinking carbonated beverages, which contain carbon dioxide or, eating carbohydrates ( such as potatos) which break down into sugars which in turn produce CO2, will introduce the carbon dioxide into the blood. Then, when there, it displaces oxygen in the hemoglobin, thus adding to our breathing difficulties?

I know this might be a very basic question, but I'm just trying to get a good grasp of the connection beween drinking a coke or eating french fries, and breathing. Tom

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A. Hi Tom, You're not far from the truth, however, you will be happy to know the truth, especially if you like drinking Coke and eating French fries.

Short chain sugars---when consumed in large quantities---readily break down into CO2 and water (H2O) as waste products. For those with CO2 retention, enough consumption (and it DOES take a LOT) will load your system with additional CO2, ultimately placing increased demand upon your work of breathing. So, consume sugars in moderation and you'll be alright. And judge the content of potentially problematic sugars by the "sweetness" of the food.

Drinking sodas in moderation will not do anything measurable except to the very sickest and worst folks---none of whom I suspect are on this list! :>) The CO2 in ANY carbonated drink is NOT consequential to breathing. Most of it you will remove from your system by burping. The rest will pass through or be utilized as needed in production of bicarbonate (a form of 'bound-up-CO2, within our body). BUT, under most all circumstances, most all will pass through. Understand also, when you consider CO2 in your body, that bacteria within your intestine (so-called: "normal flora") produce CO2 in LARGE quantities, compared to the amount you consume in a soda! And they also produce methane and sulphurous gas mixtures, etc., etc. You can guess where that thread leads. :>)

Potatoes and other "less- sweet to non-sweet starches (sugars) have "long-chain" sugars that do not directly or significantly affect CO2 production in your body. They are the 'preferred' form of sugar for your body! ! ! So French Fries are not a problem with regard to CO2 production and breathing! ! ! Now, if you eat too many and get a big belly, like mine, you could have a breathing problem from the 'ballast'. Don't blame that on me, though! ! ! <|:>)
Regards, Mark

Long-Acting Inhalers and PFTs

Q. I am scheduled to take a pulmonary function test Friday afternoon. Standard prep is no inhalers within 4 hours of test. How do people handle long-acting inhalers like Foradil or Serevent? I suppose I could take my Foradil at midnight the night before (either an extra dose or a delayed dose) though not sure I can make it through 12 hours without being really SOB. Suggestions welcome. Bill

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A. It is standard practice to withhold bronchodilator medications for at least four hours before performing pulmonary functions testing (Spirometry, in particular). For long-acting bronchodilators---Foradil, Serevent, Advair---you should skip your morning dose. Then either take it when finished, or wait until your PM dose, after testing, to resume. If you take it after completing your testing, you would still take your usual PM dose, at your usual time.

DO NOT stop steroid inhalers (that are steroid only, or do not have beta-agonist bronchodilators in them). Also, do NOT stop oral Prednisone. Do not stop Singulair or Accolate. This recommendation is generally applicable UNLESS your DOCTOR tells you to stop---so the test will reflect your airway health without the drugs, compared to when you are on the drugs.

For mercy's sake, NEVER stop your oxygen!!! If you need to have a blood gas measured while not on oxygen, you can wait until you get to the clinic/lab to stop your oxygen. Even then, you only need remove it for 5 minutes, or so to return to your steady state, sans oxygen. Once the oxygen saturation measurement or blood gas has been obtained, you can put it back on.

Let me close by repeating that except for the admonishment about oxygen, these recommen-dations are "general" and "standard". If your doctor tells you to do something different, that is another thing, altogether.

Diffusion

Q. My question is this...Diffusion,exchange of gases in the aveoli, if a persons diffusion is severe, does the use of supplemental O2 help ? I realize that it helps prevent further damage to other organs, but if the exchange of gases is poor, how can O2 help?? What could help difusion? Would the SATS be lower despite O2? Does inhalers reach the aveoli, would they help?? Carol

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A. Diffusion is impaired by two main processes in COPD: (1) loss of numbers of alveoli to receive and diffuse gas and (2) thickening (for what ever reason) of the membrane between the gas in the alveoli and the blood that passes by. Measured diffusion deficits can be from the two reasons I just named AND from poor movement of gas into and out from AND 'w-i-t-h-i-n' the lungs. Some areas get gas better than others. Some areas get more blood flow than others. The matching of fresh incoming gas to blood flow is important in determining how much oxygen will have the 'opportunity' to diffuse. Folks with COPD usually have lousy matching, compared to folks with 'normal' lungs. Moreover, when folks with COPD get up and move around, they breathe harder and faster which further messes up the matching of fresh gas to blood flow.

To correct these problems, we need to maximize the capacity of those alveoli that ARE exchanging gas . We boost their exchange rate by putting more oxygen molecules into them and increasing the pressure for them to cross over into the blood. This is what you are doing when you breathe your supplemental oxygen.

There is nothing you can do to "directly" change your diffusion. You'd have to be able to grow more alveoli, or replace thickened tissue with more normal, thinner tissue, both actions that are still in conceptual and laboratory research stages (with the exception of Forte, which is presently being tested on humans.) There are no MDI medications that can change what needs to be changed. So, even if they could reach the alveoli (which they can't, because there is not enough flow/velocity of flow to carry them that far into the lungs) there aren't any drugs that can do what needs to be done.

Lastly, because despite the availability of more oxygen molecules to enter the lungs, air movement changes for the worse with exercise/exertion, even extra oxygen flow doesn't always accomplish the objective of actually getting those molecules to where they need to go. That is when you will see desaturation continue, despite being on many more liters of flow than you need at rest. Some folks can even increase from 2 to 6, or more liters and find that all that extra flow isn't enough to keep them adequately saturated. Its not because they are using any more and faster as much as it is that the extra flow isn't getting to where it needs to go.
Regards, Mark

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MDIs and Alveoli

Q. Hi Mark, your remark about MDI medication not reaching the alveoli stirred my curiosity. If one has emphysema and no other clinically signficant element of copd such as chronic bronchitis, then how do MDI's help or why do folks use them? Virginia

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A. MDI's help because the sites at which the drugs they provide are within the airways to which particles are carried. There are no muscles or receptor sites within the respiratory bronchioles and alveoli, so muscle-active agents like Albuterol and Atrovent would do no good to be deposited within the alveoli.

It is the conducting airways whose swelling and spasm needs to be controlled and reduced so that the air can be 'conducted' with less resistance. This kind of improvement applies to both those with Chronic Bronchitis and Emphysema.
Regards, Mark

Hy'po'ventilation

Q. Hi Mark, I just described the same sats as Carol reports and you responded regarding a primary hypoventilation component. Boy, this sounds famliar but I cannot place the term. Could you do a quick definitation for us? Thanks, Karen

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A. Hi Karen, As most can guess, "hypoventilation" means "too little"/"not enough" ventilation. The term 'primary' is more descriptive than anything, an indicates that the primary reason for the change seen on blood gases---and in our context, oxygen saturation---is because of insufficient ventilation to hold carbon dioxide levels to normal. Without getting too confusing for everyone, you need to understand that the oxygen saturation you measure with the pulse oximeter is the product of both factors of oxygen levels in your blood AND the influence of ventilation.

Folks can hypoventilate for several reasons, among them being neurological (Ondine's curse) causes and metabolic disturbances. Posture and being very sedentary and/or obese (Pickwickian Syndrome) can also contribute to the phenomenon. When they get up and move about, unless the cause is a metabolic disturbance, often they will be observed to improve their ventilation, increasing their oxygen saturation in the process. In those cases, the improved saturation will be from both improved ventilation AND some increase in PO2 (oxygen pressure in the blood).
Regards, Mark

FEV1 and Abdominal Surgery

Q. I'm not sure what my FEV1 was when I had my bladder surgery, but I do know that 8 months later when I had a PFT, it was 19%, so I am sure it was pretty low at the time of surgery. They made a 5 or 6 inch incision in my abdomen to correct my bladder. I was not on a ventilator when I woke up. Not sure if I was on one during surgery. It was more difficult for me to recover than the average person, but I did pretty well. I didn't know that when a person has bad lung problems, they don't do abdominal surgery. But why is it that you can't get off the ventilator? Is a person's body just too dependent on it or something? Pat

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A. There are several contributing reasons why folks get "stuck" on the ventilator. All too often, it is an arbitrary process. Doctors don't like letting you get rid of the "security" of the 'tube' and machine if you retain more CO2 than they are comfortable with. This is probably the single most significant reason I've seen folks stay on the ventilator. Because we can artificially lower your CO2 with the ventilator, when you are allowed to breathe on your own--as in trials to "see if you can come off the ventilator"--and your CO2 goes up to where it would normally be (as a CO2-retainer), doctors get all nervous and bent out of shape and put you back on the ventilator to push your CO2 down. It is more for THEIR comfort than your own. Others are practical and "bold". They realize you go to surgery as a CO2 retainer. If you come out of surgery maintaining a reasonable approximation of your pre-operative values, they will 'bit the bullet' and let you cruise on your own, as long as you don't slide into trouble.

In many locations, there are "long term ventilator facilities"---the former Vencor chain, now Kindred hospitals. Patients who are "ventilator dependent/stuck on the ventilator are sent to these facilities for "weaning or transition to home with the ventilator. As best as I know, few folks are sent home with ventilators. Those who come to their facilities get off the the machine.

These are just a few of the main influences on the phenomenon of "ventilator dependency". IMO, most of the incidents do NOT need to happen. But, alas, I am but a lowly respiratory therapist and not always able to influence the doctor's action "before" they (and the patient) get into trouble!!
Regards, Mark

O2 Increasing w/Exercise

Q. Carol sent a message to EFFORTS which indicated that her O2 saturation increased when she persisted with her exercise program. As you may remember, I had asked you some time ago about the advisability of persisting with strenuous exercise when my O2 fell into the high eighties. You indicated that as long as it stayed in the 88% plus range, that it was probably OK and that I should continue to push myself. As a result, I have continued my regimen. Now the question. My O2 sats vary during the regimen but they are almost always higher at the end than at check-in time. Could it be related to the fact that my heartrate is lower at the onset (usually 85 to 95 with an O2 sat of 94) than at the check-out (yesterday 125 at end with a O2 sat of 96)? If you think this might be of interest to others, feel free to post it. Thanks again for your help. Otto

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A.When I spoke of the changes Carol has, I must qualify that to include those whose saturations are 'significantly' below normal range. It also applies increasingly to those whose saturations drop very low --like hers, which drop into the low 80's and high 70's--and THEN increase so dramatically. Whenever we see increases from a resting saturation in the mid 80's (hers was 85 %, as I recall) to an end result in the mid 90's (essentially to within normal range) we have to consider the causative factor to be due possibly to one or a combination of two primary factors (1) alveolar recruitment from the increased breathing (effective minute ventilation) and/or (2) better matching of ventilated areas of the lung to blood flowing through them. The first factor influences the second, in this case. In any case, we have to sum it up as being due to an increase in ventilation in contrast to the 'steady-state' condition of primary alveolar hypoventilation. This is not something we often see. Moreover, my observation is that much of the time, I see it in folks who tip the scales toward fairly significant obesity (though certainly not the rule, that I am aware of, as supported by the literature). Lastly, This is NOT typical or even a common observation in those who have fairly severe COPD. Indeed, it is necessarily seen only in those with mild to moderate COPD who ALSO have hypoventilation as a component of what is responsible for their blood gas changes.

Of necessity, heart rate plays a factor in both the influence to change and the degree to which change is seen. If cardiac output is increased with the increase in heart rate AND oxygen delivery to the working muscles remains stable or improves, then it is not surprising to see the saturation creep up a few points. But, important to remember is that an increase from 94 % to 96 % represents a miniscule absolute, or meaningful change as compared to an increase from 80 to 82 %, because they lay on quite different points of the "oxyhemoglobin dissociation curve", to which the value of "saturation" relates.

Ultimately, in your case--and in answer to your question--while the heart rate can play a part, and ventilation can play a part, since you are so high on the curve AND within reasonable normal range, the how and why is of moot importance. It could even be that changes in circulation in your finger, or monitor error are responsible for what you see. Your saturation (were it to be checked by a blood gas) might actually begin AND end at 96 %, but your monitor AND the fact that it is being measured on your finger might be solely responsible for the changes you observe. Indeed, it is also possible that some part of the change Carol sees is attributable to the same phenomenon.

So keep up your good work and don't sweat the saturations as long as they are up in the 90's!

Best Regards,
Mark

Air Purifier/Cleaners

Q. Does anyone have an opinion or experience with a good air purifier/cleaner? My mom, who's got COPD, lives here in humid new jersey. She also has a wood burning stove in the house that is used in the winter. she is on oxygen 24-7.

She was just diagnosed, so the family is trying to get information on what we need to do. thanks, Mary Jo

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A. I would advise playing it by ear. See what her complaints end up being and then act accordingly. There is no general recommendation to purchase various air-modifying equipment based solely upon diagnosis. And since there is so much variation between folks with the same problem and severity, it is nearly impossible to make general recommendations or predictions.

You may find that is she is bothered by the humidity, it will be problematic in the warm seasons and a de-humidifier will be advantageous. If she can tolerate the indoor pollution resulting from burning wood in the fireplace, then don't waste money on any kind of air purifier. If she can't tolerate it, or develops increasing intolerance to it as time goes by, you/she will naturally cease to burn wood in the fire place and resort to air conditioning/ heating system support. At that time, you can then determine if further devices are warranted/needed and obtain them at that point.

So for now, just observe and communicate to identify problems as they arise and address them as indicated. If you run into specific problems/difficulties, bring them to the list and we can help you as best we can, then.

Regards,
Mark, Respiratory Care Practitioner

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