| 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
*
* *
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
*
* *
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
*
* *
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
* * *
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
*
* *
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
Return to top of page |
| 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
*
* *
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."
*
* *
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
*
* *
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
* * *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
Return to top of page |
| 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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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.
*
* *
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
*
* *
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
*
* *
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
*
* *
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?
*
* *
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
*
*
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
Return to top of page |
| 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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
Return to top of page |
| 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
*
* *
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
*
* *
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.
*
* *
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
*
* *
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
*
* *
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
*
* *
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
Return to top of page
|
| 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
*
* *
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
*
* *
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
*
[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
*
[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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
Return
to top |
| 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%).
*
* *
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
*
* *
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.
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
Return
to top |
| 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
*
* *
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
*
* *
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.
*
* *
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
*
* *
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
*
* *
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
*
* *
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 <|{:>)
Return
to top |
| 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.
*
* *
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
*
* *
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
*
* *
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?
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
* * *
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
Return
to top of page |
| 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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
Return
to top of page |
| 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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
Return
to top of page |
| 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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
*
* *
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
Return to top of page |