Working with O2

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

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

Rapid Heart Rate on Exertion

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

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

Antibiotics and Vitamins

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

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

Purchasing a Treadmill

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

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

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

Sterilizing a Nebulizer

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

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

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

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Chronic Bronchitis/Emphysema

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

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

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

Variation of 6 Minute Walk

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

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

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

PFT Reading 0

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

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

MDIs Routinely Short

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

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

GERD and COPD

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

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

Avasular Necrosis

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

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

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

Should We Buy an Oximeter?

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

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

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

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

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

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

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

Dental Work and Transplant

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

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

Monitoring Sats

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

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

General Anesthesia (Being Under)

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

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

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Difficulty Swallowing

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

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

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

Continuous Prednisone

Q1. Hi everyone! Just had a small question for the group. I noticed a few people are continuously taking prednisone daily. Can anyone explain why they are on it long term? Just curious...Thanks

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

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

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

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

PFT's: How Often

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

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

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

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

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

Medicare Age Limit on Transplant

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

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

Lack of Oxygen

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

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

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

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

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

Wet vs Dry COPD

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

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

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

Flu Symptoms??

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

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

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

Sats and Exercise

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

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

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

Handling of Nebulizer Treatments

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

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

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

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

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

Spiriva Use with Other Inhalers

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

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

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

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

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

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

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

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Intubation

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

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

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

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

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

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

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

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

Steroid Dependence

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

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

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

Small Pox Vaccine

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

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

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

Hunching

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

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

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

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

Unusual Test Results

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

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

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

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

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

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

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

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

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Runny Nose with Exercise

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

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

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

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

Altitude and Air Density

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

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

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

Small Pox Vacinne & COPD

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

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

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

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

Lazy Lungs

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

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

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

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

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

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

Coughing Due to Stomach Acid

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

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

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

High Calorie Drink

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

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

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

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Coughing

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

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

Comments on TTO (Transtracheal Oxygen)

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

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

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

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

Weaning Off Oxygen

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

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

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

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

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

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

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

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

How Much Water?

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

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

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

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

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

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

Using Upper Chest Muscles with PLB (Pursed Lip Breathing)

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

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

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

Exercise Programs

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

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

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

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

Exercise and CHF

Q. People usually think of heart failure as a condition where the heart does not pump out enough blood. That is call systolic heart failure. Recent medical studies have indicated that moderate exercise is beneficial to these pts. However, many CHFers and I have a different kind of heart failure which is caused when the heart cannot fully relax so it can't properly fill with blood. This is called diastolic heart failure (DHF). In DHF, the heart's stiffness prevents it from stretching to increase its size and pts get