Previous Questions & Answers of RRT Mark Mangus,  categorized and alphabetized by "topic"    for  2011  

For  "current"  Q&A's -  click here    

For 2010 - Click here        

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CO2 Retention & BiPAP

CO2 Retention, SOB but Adequate Oxygen Saturation

CO2 & Stomach Gas

Oxygen & CO2 Retention

Potential CO2 Retention

Ridding Ourselves of CO2

Symptoms of CO2 Retention & Trapped Air



Exercise - Equivalency

Exercise - How Much is Too Much?

No Exercising Before a Breathing Test

Respiratory Muscle Trainer

Shortness of Breath After Exercising

Swimming & Oxygen Saturation

Walking as Exercise After a Foot Injury


Finger Pulse Oximeters

Accuracy of, and Exertion


Medicines for COPD

Anti-Inflmmatories (Serratiopeptidase, NAC)

Azithromycin (Antibiotic) Therapy





Medicines & Dosages Q

Order of Meds

Prednisone Withdrawl

Prednisone Tapering Problems


Spiriva & Symbicort Dosing Questio

Ventolin Frequency

What Meds are Available for COPD



Misc COPD Questions

Allergies to Dogs & Cats with COPD

Anesthesia & Lung  Disease Progression

Breathing Ability/Extreme Variations & Drops in Oxygen

Bronchiectasis Q's

Bronchospasm Clarification

Catching a COPD Patient's Germs

Chemotherapy Exposure & Emphysema

Chronic Bronchitis & the Lungs

CT Scans

Disease Progression

Dry Mouth

Emphysema Progression

End Stage

Fevers & COPD

FEV1 Unchanged - Disease Progression

Indoor Temps & Effect On Breathing

Infrared Saunas

Infrared Saunas 2

Longevity/Life Expectancy

Low FEV1 - Coping Info Q's

Lung Function, Exercise, Sneezing & SOB


Lung Infection - Ongoing

Multiple Health Issues

Post Fall - Reduced Oxygen & Difficulty Breathing

Questions on Oxygen, Transplant,   Medical Personnel - Misinformation/Knowledge/Actions

Resistance Breathing

Sleep Apnea

Smells - Sensitivity

Stem Cells

Stem Cell Treatment - Mexico


Weight - Thin & Lacking Muscle Mass



Bronchiectasis Q's

Hydrogen Peroxide



Oxygen & Oxygen Saturation

Alcohol Consumption & Home Oxygen

Continuous Flow vs Pulse

Face Creams


Litres Not High Enough

Low Oxygen Levels, Potential Damage Long Term

More on Saturation/Desaturation & Hypoxia

Nocturnal Oxygen

Oxygen & CO2 Retention

Oxygen Tanks, the Types & How Long

Oxygen, Too Much or Not Enough

Overuse of Home Oxygen

Reduced Oxygen After A Fall

Swimming & Oxygen Saturation



Pulmonary Function Test (and Spirometry), Arterial Blood Gases

ABG's - Interpreting a Test Part 1

ABG's Follow -Up Part 2

Blackouts During PFT

High Altitude Test (HAST)

Normal Numbers - But Having Symptoms

PFT (Pulmonary Function Test) Results (Interpretation)

Review/Analysis of Numbers

Understanding PFT's




Scans & X-Rays

CT Accuracy /History of Smoking





Reduced Bronc Irritation & FEV Decline

Still Smoking



Bullous Surgery

Lung Transplant Age

Lung Volume Reduction Surgery (LVRS)

Transplant Q's

Expand A Lung Exerciser

Hi Mark
On our local TV station a women was saying Expand a lung would help copd patients
Do you know anything about this ?  Would it help with SOB


Hi Elaine,

"Expand-a-lung" is an exerciser that provides resistance to airflow while breathing in AND out against it's restriction.  It is a ventilatory muscle exercises and as such, can help strengthen the muscles that help you breathe.  If those muscles lack maximum strength, use of the device will help the user get closer to that maximum which, in turn, "can" help relieve/improve upon the symptom of shortness of breath (SOB).  

But, in my experience, the chief causes of SOB experienced as COPD advances are two: (1) changes in the physical structure of the lungs makes effectively moving air OUT much more difficult than with normal lungs owing to the structural changes and how they impact air movement.  The loss of airways results in fewer bronchial tubes - bronchial tubes that are change in structure and other characteristic - such that they cannot accommodate the necessary "rate" of movement of gas out of the lungs.  The result is air-trapping.  That air-trapping increases as one moves around with increasing intensity. This is called "dynamic hyperinflation" and can be combated to some degree with use of pursed-lips-breathing (PLB).  So, the more effectively one can use that technique (especially with regard to the "expiratory" phase of breathing - where PLB does ALL that it does and ONLY what it does to assist in and enhance gas movement -  as opposed to the 'Inspiratory" side where many PLB descriptions get crazy - IMO - with instructions that are meaningless and not helpful) the better they will be able to control SOB.

(2) Too many folks with COPD spend much energy avoiding SOB.  The primary means by which they do this is by remaining sedentary. Face it, SOB is NOT fun! It does NOT feel good.  It's about the scariest feeling you can experience among all the symptoms you have with COPD.  AND, it can make you feel like it will surely 'do you in' any moment, if you keep up activities in the face of SOB. 

BUT, exactly the opposite is true!  SOB, while scary and feeling terrible, will NOT hurt you.  AND, keeping up activity while having even significant SOB will NOT harm you, though it might feel like it will.  By living a sedentary life to avoid SOB, one becomes physically deconditioned.  It is well known that a deconditioned muscle requires more oxygen and produces more carbon dioxide 'per-unit-of-work' done, which taxes breathing and INCREASES SOB all the more.  So, exercise and keeping active - and breathing hard all the while you are maintaining your active life - are essential - no, "imperative" - to being able to keep muscle strength as high as possible AND therefore, the highest efficiency of oxygen use and lowest possible carbon dioxide production possible.

So, getting back to the issue of respiratory muscle strength and the use of exercises like the one you inquired about is only a small part of the total picture.  If you have the strongest respiratory muscles, yet have weak muscles of propulsion and work (limb muscles, to be exact) then to continue to exercise the respiratory muscles will have little effect, if any, to reduce SOB.  So, you can certainly try the device.  But, without the other components to enhance the total picture, it will be of limited, if any benefit in helping to reduce SOB.

Best Wishes,  Mark

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Oxygen (Canulas)  & Face Creams

I use 2 ml of oxygen at for hypoxia. I have severe emphysema. I use a concentrator with a nasal cannula. Can I use commercial night creams that don't have petroleum specifically in them? Is there any type of cream with certain oils that are okay to rub into my face? I get extremely dry skin in the winter.

Thank you

Hi Moe,

Use of petroleum-based creams and/or ointments is a specific action recommended against when one is using oxygen.  Petroleum ointments provide one of the three components for combustion - fuel (the other two being oxygen and source of ignition) - that increases danger of mishap and injury in the presence of higher oxygen environments.

There are plenty of non-petroleum based creams and ointments that can effectively provide the moisturizing action you need for your dry skin.  Talk to your pharmacist about what products they stock that can meet your needs, if you are unsure of your own knowledge to choose such products.  You should always try to avoid use of anything with a petroleum base when you are an oxygen user.

Best Wishes,  Mark 

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Azithromycin (Antibiotic) Therapy

Hi Mark. Hope you and the family are well.

I tend Mark to suffer from low grade lung flare ups. Nothing too bad to see a doctor, never any fever, but you just do NOT feel like yourself at all.

My pulmo said it is due to the fact that my lungs with COPD do not clear inhaled bacteria away like healthy lungs, making you more susceptible to
mild lung infections, on a more regular basis.

I am wondering Mark if daily antibiotic therapy would be of benefit here? I know many have commented that it cuts way down on infections, and exacerbation's.

I am just afraid that the body would get used to the antibiotics, and they won't work when you really need them.

Your thoughts always welcome.


Hello Philip,

There is continuingly increased evidence coming to light that Azithromycin, taken daily, may be beneficial to reduce inflammation and bacterial counts within the lungs of those with COPD.  It is currently in widespread use for those who undergo lung transplantation and is showing to be effective WITHOUT development of resistance of the bacteria to its effects.  In some instances it is given a month at a time with a month break - and at other select intervals - for those concerned about the possibility of development of resistance.  Yet, in those who have now been on it for years without interruption, it still seems NOT to become a problem with regard to resistance.

Now, the caveat is in selection of patients in whom to use it.  That is where the research is still not adequate or complete.  We just don't know yet if it should be applied across the board to all who exhibit your kinds and degree of symptoms.

But, with that said, I would suggest you inquire of your doctor if he thinks you would be a candidate for a trial of Azithromycin therapy, both to see if it has a reasonable and sufficient effect upon your symptoms and your incidence of infection.  And I would reassure you that the likelihood of developing resistance to it is smaller than you might think and really unlikely, as it seems.

Best Wishes,Mark

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Med Question....  Brovana and Pulmicort

Mark,  I was told to take Brovana  with Pulmicort Q12 ( 7am and 7pm) . is this correct? I was told that Brovana should be taken by itself and not mixed. thanks for your website. its been a great help.


Hi Eric,

While some folks don't have a problem with mixing Brovana and Pulmicort, the evidence I have seen regarding the 'nebulizing properties' of each shows them to be sufficiently different AND significantly altered during combined nebulization that I recommend using either two separate nebulizers or taking the Brovana first and then the Pulmocort AFTER rinsing the nebulizer well between treatments.  But, in any case, I recommend taking the time and putting forth the effort to do each as a separate treatment, though one immediately following the other.

Both are intended to be taken at 12-hour intervals, under usual circumstances.  However, it is not out of the ordinary or uncommon for Pulmicort to be taken up to 6 times a day (every four hours), for those with especially difficult symptoms that respond well to increased doses/usage of inhaled corticosteroids.

Best Wishes, Mark

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Oxygen Therapy... Too Much or Not Enough?

Dear Mark,
My friend who is fev1 15%, has copd, and is a  C02 'retainer' ,is wondering why the community nurse takes a pulse ox reading when she visits him.  He did tentatively raise the subject with her but she just replied that a pulse ox measures your 02. Knowing that the pulse ox cannot distinguish between 02 and co2, is its use still reliable or in any way meaningful? He does have his own pulse ox too, though is not sure whether to use it anymore. Please can you throw any light on this subject for us? Incidentally, he was on one to two litres of 02, but since becoming a retainer his use of 02 is minimal - no more than 1lpm.

Thanking  you in anticipation ( we look forward to being educated on this!)  and with best wishes from 'across the pond' , Vanessa .


Hi Vanessa,

While I will say at the onset that WAAAAAY too many health care providers are 'obsessed' with the phenomenon of "CO2-retention" and that it is to the avoidable determent of more than 90 % of the patients they impose their concerns upon, their concerns are - according to the 'preponderance of the evidence' - unfounded AND poorly understood.  Education they receive mis-represents and mischaracterizes the effects and incidence of difficulties related to CO2-retention.  But, more than that, it causes them to practice interventions that actually FORCE advancement of one's disease severity AND hastens deterioration and therefore death from COPD! 

How does it hasten worsening of COPD and earlier death than would otherwise happen?  It is because they restrict use of oxygen - the single most effective therapy PROVEN to both improve function and quality of life and the ONLY therapy shown to prolong life - to doses that are far too little to do any appreciable good OR to thwart changes for the worse in condition and physical function that occur in the face of inadequate oxygen use as COPD advances.  Medications are ONLY effective to relieve symptoms.  But, NONE are shown to prolong life or slow progression of COPD. 

When one fails to use sufficient oxygen to keep their oxygen saturation above about 85% at ALL TIMES, as much as is possible, they develop increased blood pressure in their lungs. (This is NOT to be confused with 'systemic hypertension" which is high blood pressure in the body, 'exclusive' of the lungs which have their own blood pressure and 'separate' circulation.)  The increased blood pressure in the lungs is called "secondary pulmonary hypertension" and puts great strain on the right side of the heart.  Over time, the right heart fails to adequately pump blood through the lungs (That is the purposed function of the right side of the heart, by the way.)  Blood literally backs up into the right heart, causing it to strain and change its physical properties.  Over time, with the increased strain, the heart falls into a pattern of failure - called congestive heart failure or "cor pulmonale".  Once the changes occur, they are difficult, if not impossible to reverse and the downward spiral is set into motion.  Survival of folks who reach that point of deterioration is predictably less than two years.  Worse yet, for the four or so years it takes to reach that point, the person is progressively suffering loss of function, increased breathlessness, especially with exertion and severe loss of quality of life.  So, they are miserable AND getting worse for a LONG time before the effect hits them hard and kills them in a relatively short period of time.

The culprit is the notion and practice - completely unfounded insofar as supportive research evidence is concerned, BUT, nevertheless, still taught in many medical professional educational programs - of prescribing 2 liters oxygen use AND NO MORE and even, as in the case of your friend decreasing that prescription to 1 liter.  Clearly, the result is low oxygen levels which are NOT always evident with "resting" measurements of oxygen saturation.  Indeed, when the oxygen falls most predictably AND "severely", is when the individual gets up and moves around.  Their oxygen saturation can fall into the low 80's to mid 70's very quickly.  This repetitious fall and the continued deficiency in oxygen saturation is what causes the damage to the heart over time.

In all this, clinicians will sternly warn the user that "IF they turn up the oxygen - and therefore 'use too much' - they will cause their CO2 to increase to dangerous levels which will cause them to STOP BREATHING and DIE!" That is balderdash! Even among the sources of 'research' cited and subscribed to by those who believe in this theory, the evidence does not suggest that using too much oxygen will raise CO2 levels in any significant amount and not to such a degree as to be dangerous - unless one is already in trouble, like heading into an exacerbation in which they develop "acute respiratory failure". Moreover, some warn that using too much oxygen can "make one BECOME a CO2-retainer". That is simply NOT true or even a part of the fallacious theory to which I refer. So, the warnings about using too much oxygen are 'more appropriately' restricted to a VERY FEW individuals who are "really bad" AND in trouble with an exacerbation, if they are to be applied to anyone at all. But, again, insanely, too many clinicians insist that you just don't know "who" will be "the one" who will fall victim to the risk they forewarn. SO, you must treat ALL people as if they are "the one". In doing so, they are directly responsible for the hastened demise of those they care for AND the root of their lousy living experience while they are sliding down that dastardly slope to disaster and demise!

Now, two strategies are generally recommended for observed 'desaturation' with activity.  Those obsessed with CO2 -retention actually can practice two versions of one strategy.  That is, they tell the user to stop all activity each and every time their saturation drops below 85 % to allow it to come back up to more acceptable levels.  This is nuts, IMO, in that they 'start-stop-start-stop' with activities every minute of the day and it takes a huge toll on their energy, their psyche and the tasks they are trying to accomplish.   Some would say: "If you can't keep your saturation up high enough, you simply must stop doing those activities that cause it to drop so drastically!" - hardly a practical or desirable solution for those who MUST do certain activities to live and function each day. 

The other tack they will take is to tell the person that: "Their body is "used" to the low oxygen level and will tolerate it just fine.  So, don't turn up the oxygen for ANY reason or it will harm you!"  That is also balderdash!  The heart NEVER adjusts to the low oxygen because when the oxygen level drops too low, the blood vessels in the lungs constrict and cause the flow of blood through the lungs to decrease OR require more right heart pressure to push it through against the increased vascular resistance.  (Oxygen is a POWERFUL dilator of the blood vessels in the lungs!) So, this is simply NOT an acceptable method of oxygen therapy.

The other and more appropriate strategy is for the user to increase their oxygen to maintain their oxygen saturation at least 88 % - 90 % during activities, if possible.  They can turn it down for resting and sleep, though sleeping oxygen flows would most often be one or two liters higher than that required for resting saturations, when awake.  That is because one tends to drop their saturation during sleep, often, comparably to the drops seen during activity.

Having laid all that groundwork/background, we can now talk specifically about your friend. It is GREAT that he has his own pulse oximeter! And, YES! He SHOULD use it as much as needed to discern his pattern of oxygenation - and to detect those times when his saturation falls. When he detects falls in saturation below 90 %, he should TURN UP his oxygen to thwart those decreases and try to keep his saturation at or above 90 %. He should also know that it may take a large increase in oxygen flow to accomplish that goal. He might find that he needs 5 or 6 liters to keep even above 85 %. And, he could find that he simply can't keep his saturation above 85 % even with 5 or 6 liters which may be the maximum his system can provide.  So, he would need to use as much as he can to get his saturation as high as possible and THEN stop his activities when/if it drops below 85 % to allow it time to return to a safer level before resuming his activities.  That's the best he can do with the limitations of the technology of today.

So, in light of all this, were I in the shoes of your friend, I'd be pushing back against the doctor and nurse, if necessary, to use more oxygen - most certainly more than the paltry 1 liter your friend is using.  I'd use the pulse oximeter regularly to assess that the oxygen flow is high enough to keep the safest oxygen saturation possible, especially during activities.  If he can't keep it above 85 % (90 % is really the more preferable level) then, he will have to figure out how to accomplish activities in the best fashion to accommodate the low oxygen levels and minimize the effect of the low levels on how he feels.  When the nurse comes to measure his pulse oximetry, he should INSIST that she tell him what she records for his measurement.  That way, he can compare her results with his own to se if she (or he, for that matter) is maintaining accuracy in those measurements.  IF his saturation is 94 % (especially if it is measured while he is NOT using his oxygen) or less while at rest, then her SURELY desaturated significantly with exertion.

He should ALSO get up and, while using the oxygen flow he normally uses during activities, walk around for at least 90 seconds, non-stop and have her IMMEDIATELY take another reading.  That is because taking ONLY resting measurements is NOT reflective of the most dangerous and frequent times when oxygen saturation tends to drop.  She should be reporting to his doctor BOTH measurements.  If 'exertional'  measurements are not done, then the greatest part of the story is NOT being told AND the health care providers are NOT getting a true picture of your friend's disease severity!  As well, they are NOT addressing his treatment needs as a result.

I hope this long, but necessary explanation is helpful to you and your friend to better address his needs AND to make significant improvement in his life with such advanced COPD!  Failure to  adequately address his oxygen needs WILL 'predictably' put him in the ground within two years!

Best Wishes, Mark


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Enhanced CT (contrast dye)

Hi Mark,

I am an ex smoker ( smoked 23 years) and my doctor ordered a CT scan of the chest with contrast. I told him I was concerned with the damage caused by smoking. Does the dye help process clearer images of the lungs ? Does this type of scan visualize the lungs as well as the blood vessels? Thanks for any information you can share.


Hi Scott,

CT scans are the best way to "see" the details of the lungs.  Either a high-resolution CT or a CT with contrast are both good tests and should reveal much detail about what is and isn't right about one's lungs.  That test should tell your doctor what, if anything, is wrong with your lungs. 

Still, while abnormal tissue changes on CT scan can be apparent AND appear significant, changes MUST be correlated with blood gases and pulmonary functions testing to determine "clinical" significance.  One can 'show' a lot of emphysema on CT, for instance and not have significant clinical (or functional) changes or symptoms.  So, even if you get a less than great CT result, that won't mean you have lung disease of immediate concern or in need of significant or urgent intervention, if any.

Best Wishes,  Mark

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Oxygen Saturation, Exercise, Still Smoking

Vic has been diagnosed with COPD 7 yrs ago.  Still smokes;  his oxygen level in his artery left hand read @72 % blood stream but if he exerts himself he huffs and puffs like a steam engine.  Why is this happening?   He walked 5 times around small perimeter and he needs a break.


Hi Cynthia,

It seems you have some of your terms confused or at least mixed up.  So, I can't tell you anything about Vic's condition at this point. Oxygen "saturation" is expressed as a 'percentage'.  If Vic's oxygen saturation on blood gas is 72 %, then he is in BIG, BIG trouble, especially if he continues to smoke. A person who runs oxygen levels that low while at rest qualified for oxygen long ago and should have been started on the therapy quite some time ago in the past.   

But, judging from other comments you made, I doubt seriously his oxygen saturation is anywhere near that low.  Partial pressure of oxygen in the blood, if running at 72 "mmHg", is not bad at all and more likely what is actually the case.

Folks who continue to smoke while having significant COPD will have trouble when walking as you describe Vic as having,

I can tell you that one of the most common problems of folks with COPD is that because of breathless with exertion/walking, they tend to avoid moving too much in order to avoid the breathing difficulties.  In doing so, they become deconditioned such that when they HAVE to get up and move, they experience more and more difficulty breathing.  With Vic being sedentary (if that applies to him) AND still smoking, I'll bet that he is indeed out of shape.  That is likely the major cause of his breathing problems when he gets up to move. 

I need not tell you what Vic should do the help his situation.  But, without spelling it out, I can tell you that there are TWO very important things he MUST do in order to improve his situation and decrease his breathing problems.  One of those two things is to get up and move and exercise - simple walking will do what needs to be done.  I'll leave the second for you two to figure out.  If Vic is unwilling or unable to do those two things, then you can expect that he will continue to deteriorate, possibly at a more rapid pace, as there simply is NO other way to stop the deterioration under current conditions.

Best Wishes,Mark

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Alcohol Consumption & Home Oxygen

What could be the effects of using home oxygen when a person is drinking alcohol?


A.    Hello A. M.

I must say, I am a bit curious to know why you ask this question.  But, the answer is that there would be no expected interaction or contraindication, much less harmful effects resulting from consumption of alcoholic beverages when one is using oxygen, insofar as any direct correlation between the two.  Using oxygen has no special or specific implications with regard to any effect from the influence of alcohol upon your body.  So, it amounts really, to a non-effect, if you will, or a non-relationship.

Drinking alcoholic beverages could/would instead have greater implications with regard to one's overall health and condition if they have a lung disease that is severe enough to require oxygen.  Still, those implications would be dependent upon how severe their lung disease, how much is consumed and what medications one might be taking that could be affected by alcohol in their system, to name a few considerations.

Best Wishes,


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Emphysema Patients - Thin/Lacking Muscle Mass  vs  Overweight - Differences

Hello Mark;

Why is it that some people with COPD are overweight while others are very very thin with no muscle mass?  Does it have anything to do with how their body frame was even before they developed emphysema? 

Thanks, Cleo

Hi Cleo,

 Your observation is astute, indeed!  Because "COPD" entails several different specific obstructive lung diseases, you will find different body types and physical characteristics and disease-related changes among the COPD population.  Those with more predominantly emphysema, 'tend' to be on the slender side, while those who have more predominantly chronic bronchitis 'tend' to be at or above their ideal body mass.  If one has tended towards obesity or been on the slender side of body mass for their height, age and gender, they will tend to exaggerate towards those extremes as their lung disease advances.  For those on the slender side, losing too much body mass directly affects prospects for survival AND how well they are able to live with COPD.  Those on the high end of body mass tend to have much less risk of early demise owing to nutrition than those who are severely malnourished. 

We used to classify folks with emphysema as being "pink puffers" who worked hard to breathe while maintaining pretty good oxygen levels well into disease severity and those who had chronic bronchitis as being "blue bloaters" who had lousy oxygenation AND ventilation and who, because they sat around a lot (couldn't move well because of breathing limitations) tended not to burn as many calories breathing.  Today, because those labels are not PC, among other criticisms, we no longer adhere to those definitions/labels in favor of simply identifying a person by their specific COPD "flavor".

Best Regards,   Mark

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Lung Transplant "Cut Off" Age

What age is eligible for lung transplant


Hi Barry,

There are no "official" age limits for lung transplant.  Generally, folks over the age of 65 have greater obstacles to being good candidates for transplant.  In the US, folks as old as 74 (that I know of, personally) have received transplants.  I do not know of any child younger than 3 years of age who has received a lung transplant - anywhere in the world.  With children, the smaller they are the less likely they can tolerate lung transplantation since there are such significant differences in lung tissue, maturity and function with even as little as 6 months difference in age, up to about 6 years old.  The lungs do not stop growing - or more accurately - reach maturity until one is about 12 years old.  So, lungs from a 10 year old would not do well in a four year old, even if they were the same size.  Yet, they would do better in that four year old than would the lungs of a four-year old transplanted into a 10 year old!

The bottom line is that except at the extreme ends of the age spectrum, age itself is NOT a determining factor to eligibility for lung transplant.  Nor is it necessary to transplant lungs from one person to another based upon trying to match the age of the donor to the age of the recipient.  I know of transplants from a 60 year old to a 30 year old and vice, versa.  My daughter at the age of 26 received the lungs of a 12 year old.

Best wishes,Mark 

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Bronchiectasis - Meds/Treatments/Devices to Help Loosen Mucus

Hi Mark, I am writing to you about my Mother...She is 76 and was born with bronchiectasis, (back in 1935) they had no idea at the time what the problem was until she was in her late teenage years that she was finally diagnosed...Sooo, 76 Female, her parents both smoked during and after she was born....When she was young she would bring up mucus like clock work with any percussion about 1/2 a cup twice a day..(and no she does not have (CF).  At age 40, she had one of her lungs removed from scar tissue and  it was partially not functioning...they sawed thru her back and opened up the rib and took it out.....She takes the following drugs;

Advair 500mg        1 puff
Spirivia                  1 puff
Omnaris Genbelco Spray    2 puffs each nostril
calcium Nose Spray           1 puff 1 nostril
Apo - theo                         1/2 a pill
azithromcin 250mg             1 pill a day
Tecta for 6 months             1 pill on empty stomach

Her specialist also prescribes what we call a cocktail which is a combination of Salbutamol and Muco Mist in a nebulizer

In the last year we have found that her mucus has become more difficult to get up especially in the mornings....She goes into a terrible coughing spell that is hard and exhausting that last about 20min...a cough that is overwhelming.. it takes up a lot of her energy.   She is also very sensitive to the change in weather...the weather almost controls her now. 

She does her drainage twice a day (morning and night) and has done this faithful since I was born.
My questions, is there any other types of medications that help loosen up the mucus so she is not put through the ordeal of coughing to the point of exhaustion...its not a slight cough by any means.. She cannot control the there any new methods or remedies out there to help her...

Concerned daughter, Lori

A.  Hi Lori,

What a great post.   Thanks for the thorough run-down and all the good information.

I would suggest a couple of things for y'all to consider.  first, while your mother is taking Mucomyst (N-Acetylcysteine) by nebulizer with her "cocktail", she might find benefit from dosing it orally, as well.  The supplement "NAC" is a powder form of that the Mucomyst liquid is.  BUT, it does more than just help thin mucus.  It stimulates production of glutathione in the lungs, a substance that decreases inflammation (and therefore mucus production), so has a two-fold benefit for the mucus problem.  As well, it is an excellent antioxidant!  The usual dose is 1200 mg once or twice a day.  Some folk take 1800 mg (1200 in am and 600 in pm) for a moderate doses between the extremes.  One should also take at least 2000 mg of vitamin C with 1200mg or more of NAC.  The vitamin C reacts with the byproducts of metabolism of NAC - a salt that can aid in formation of kidney stones.  She can take the oral NAC without consequence to the inhaled Mucomyst.

Another consideration is hydration.  Now, while I'm NOT one who touts oral fluid intake in regards to any link to helping to thin mucus (no evidence, though touted a LOT in the literature), the elderly are prone to dehydration which can, in the long term, insidiously lead to drying of mucus throughout the body.  So be sure your mom is drinking plenty of fluids during the day.  A caution/caveat to this recommendation is if she is taking a diuretic and/or has compromised heart function that would put her at risk for fluid overload, even with consumption of normal amounts of fluids.  So, consider that when evaluating the adequacy of her fluid intake and hydration status.

Another means of hydrating the mucus is inhaling moisture.  A steamy bathroom is good, if tolerated.  Cool mist from a room humidifier (at close range to the airway) is another effective measure.

Hypertonic saline (3 % to 7 %) is being used with very good results in CF and other conditions where mucus is abundant and tenacious.  That could be added to her cocktail for inhalation.  Ask her doctor if it might be a desirable addition to her regimen.

Yet another thought is the use of a mucus clearance device.    There are positive pressure breathing devices, like Acapella, Resistex and a new one I just saw this week called "Quake" (Thayer Medical - a great little device that is very easy to use and very effective to loosen mucus).  Then there are devices like the 'Metaneb' (Hill Rom) "Intrapulmonary Percussive Ventilator" (IPV - Percussionaire) and the various vest - high frequency vibration devices (I like "Smart Vest" the best) that she might inquire about.  These are at least as effective as the old standard percussion and postural drainage and serve as great additions to that therapy to increase mucus mobilization and clearance.

So, those are some suggestions for you to consider and inquire about.

I hope your mother is able to try one or several of those and find the combination that will work better for her.

Best wishes,   Mark


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Oxygen & CO2 Retention

Hi Mark
I am really confused about co2 retention.  My nurse that comes to my house says all copd'ers are co2 retainers.  If that is so how come some patients use highflo o2 and they tell patients like me never go over 3 L no matter what I'm doing. Please explain how some can use high and some can't. Thank you Georgia

Hi Georgia,

The first comment I have to make is that your nurse is unequivocally WRONG.  Not “all” COPD’ers are CO2-retainers.  ONLY those whose FEV-1 has dropped severely – most prevalently, those whose FEV-1 is below 25 % of predicted and often, not until it drops below 20 % of predicted – are seen to retain CO2.  She is misconstruing the long-standing notion about CO2-retention and its impact upon those who use supplemental oxygen, that if they use too much oxygen, they will somehow be inhibited from breathing effectively, even losing their drive to breathe and potentially facing consequences that can be as severe as to include death.

I have written about this extensively and fairly recently on COPD Canada in an effort to try to alleviate concern while dispelling the often professed dangers of using what is ACTUALLY ‘enough’ oxygen to keep organ health in a safe range AND to avoid earlier demise that predictably results from inadequate use of oxygen to keep saturation in a safe range.

Only a blood gas test can determine if one is a CO2-retainer.  Unless you have had such a test, neither you nor she can say that you are indeed retaining CO2.  Even then, it depends upon how much you retain.  Mild retainers are NOT at risk for any problems or danger.   Only those who retain significant amounts of CO2 would be included in the risk population according to the long-standing (but, unproven) theory.  As well, as proponents who understand the theory well will tell you, we would ONLY see the purported effects in a VERY FEW of those who are considered most at risk.  So, even if it were true, the number of folks at risk is few and far between.  AND, it is not enough folks, in the end, to warrant or justify the practice of withholding adequate oxygen from EVERYONE, as she suggests.  So, unless your doctor has measured your CO2 AND determined that you not only retain CO2, but also retain it in significantly, you are NOT at risk for any problems or danger.

The bottom line Is that folks like you are much more at risk for ill effects from not using enough oxygen than you will EVER be from using too much.  And, in reference to your question,  there aren’t folks who can use high flows while others can only use low flows.  How much oxygen one uses should be dependent STRICTLY upon the results of measurements under the conditions of rest, exertion/exercise and sleep, all of which most often require different flows, sometimes QUITE different from the low flow at rest that will adequately correct one’s hypoxia (low oxygen level)  You should ALWAYS, try to keep your oxygen saturation above 90 %, if at all possible, using whatever flow is necessary to get it up there.

Best Wishes,


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Oxygen - Continuous Flow vs Pulse - Differences &

Nocturnal Oxygen Settings


Hi   Mark;

Couple of questions.....
 Was talking to a few of my COPD friends about POC, oxygen conserver's and continual flow ( CF) o2.   We all have  Stage 4 and Fev1s between 16 and 20..

The thing we've noticed is we all use CF (continuous flow)  at home but out in the community either use Pulse driven POC's or tanks with Pulse conservers.  We all have noticed our breathing rates climb, our sats drop,  even if we're on our "standard" CF settings on these portables. Even if we're in wheel chairs and not doing much..... same thing.

My belief is because we're on a pulse system, , either the timing mismatches with us and we get less o2 or our breathing rates are higher and mismatch. Its funny- we all have noticed if we're low sats at the Dr but plug into the wall O2 our sats go up .. which makes me think its a pulse verse CF issue... am I right?

Also.. one of my friends on palliative care for this disease uses 3 1/2 L ( per Dr) during the day but on her own drops her self down at night to 3 L. cause she believes since she's just sleeping she's not using as much energy so she doesn't need as much O2. And no .. she hasn't remembered to tell her Dr this .

 I thought we can actually less effectively use O2 at night due to shallow breaths, poor muscle etc. so I'm pretty concerned that she just drops hers. I know for me the first use of O2 was for sleep due to the problems I mentioned... so again... am I on the right track to be concerned for her?


Hi LJ,

You ask some very good questions!  And your suspicions are closer to the truth than you might realize.  So, let me compliment you saying: "Good thinking!" 

There IS a difference between continuous flow (CF) and pulsed oxygen, no matter the source.  To make matters yet more confusing, the difference is variable between particular POC's and conserving devices.  But, we can't stop with just the device types and their individual differences.  When you add rest vs sleep vs activity/exertion into the mix, you throw yet another variable into the blender that increases the magnitude of the other differences and explains why - at comparable settings between devices and CF -  you see such disparate results.

 Each POC has a maximum capacity for how much oxygen it can produce per unit of time.  For example, small POC's - in the 5 pound range - can produce between 750 mls and 1 L of about 90 % pure oxygen per minute.  They are calibrated to dispense that oxygen up to so many mls-per-breath and to a maximum rate of ('X') number of breaths-per-minute below which they can guarantee the advertised purity.  Often, the maximum number of breaths is below the number to which folks respiratory rate will increase to during exercise/exertion.  So, they end up either generating breaths that do not receive oxygen, or more often, a breathing rate that exceeds the maximum for purity of oxygen dispensed which results in decreased purity of delivered oxygen. 

Conserving devices tend to operate as advertised up to some maximum response rate, above which they simply don't respond.  Further "where" in the inspiratory phase the oxygen is delivered will further determine how much oxygen actually reaches the gas-exchanging units in the lungs and how much stays in the bronchial tubes where it has no opportunity to participate in exchange (That is what we call "dead-space" ventilation.)   If the pulse is delivered during the first 2/3 of each inspiratory cycle, it has a better chance of being 'used' than if the pulse is delivered over the whole duration of the inspiration.  As well, when you increase your activity and respiratory rate, the volume you take in per-breath can also increase.  With CF and pulsed oxygen, the resultant concentration  - portion of the total volume of gas taken into the lungs - during each breath varies and becomes lower when larger volumes are taken in against a fixed volume of oxygen delivered during each breath.  In comparing CF to pulsed oxygen changes in respiratory rate and volume actually favor pulsed oxygen with regard to which delivers MORE oxygen volume-per-breath, when we look across the spectrum of the many pulsed oxygen devices.  Some fall short in comparison, while other will always beat CF.  (This is not well understood by MANY doctors, nurses, RT's and consequently, oxygen users who tend to think that CF is ALWAYS better than pulsed, without exception.  That is just not true for MANY pulsed devices.

 So, the overall result is less oxygen received from the pulsed systems and POC's under conditions of exertion than for CF WHEN IT IS INCREASED appropriately.  Therein lies the crux of the matter.  No one should assume that the same CF setting is fine for activity - or sleep.  It is not in the least unusual to find that one needs several more liters flow to maintain comparable saturations during activity than when they are at rest.  It is not surprising to find someone who saturates just fine with, say, 2 L while at rest, but who needs 5, 6, 8 or more liters to stay comparably saturated with exertion.  Yet, the common practice is to prescribe only 1 or 2 additional liters flow for activity - clearly NOT enough, as your measurements/observations have borne out.

As well, among conservers ("OCD's", hereafter) and POC's are significant differences in what constitutes equivalencies.  Our saying for that is that "2 is NOT equal to 2", to nut-shell it.  POC's vary in how much they deliver with each pulse AND how much they deliver with each pulse as settings change.  In some cases, as demand increases, the same 'total' volume of oxygen is simply cut up into smaller pieces, since each POC as a maximum production rate capacity.  So, even though a setting may be increased, it can either become reduced in pulsed volume as demand increases, or, worse yet, while the volume may stay the same, demand beyond a POC's capacity can cause dilution of purity so that the pulses are of decreasing concentration, effectively lowering oxygen support by lost purity of the delivered oxygen volume.

 With conserving devices, some will respond to a maximum breathing rate (20 or 30 or 40 breaths per minute, for instance) if respiratory rate exceeds the maximum rate capability of a device, it simply fails to deliver oxygen on some breaths.  Additionally, while each manufacturer sets an "assumed volume of air taken in per breath in determining the volume of each pulse, if the user's actual inspired volume exceeds the 'assumed volume for a certain setting, then the "effective" concentration delivered will be lower than what the manufacturer states. 

It is well known by those who understand the 'foibles' of POC's and OCD's and advanced COPD, in particular, that while the user's respiratory 'rate' and 'per-breath volume' may increase as demand for breathing during activity increases, we also know that factors like dynamic hyperinflation, changes in blood flow through the lungs and change in matching of blood flow to areas being ventilated occur, even though more volume may be taken into the lungs at higher demand, less "effective ventilation" often - almost always, and very predictably - DECREASES.  Too often, those who have poor understanding of this critical process will attribute decreasing saturation during exertion to a simple explanation that the muscles are demanding more oxygen than the diseased lungs can provide and building up CO2 in the process.  While blood gas measurements may seem to suggest that to be the case, the truth is that it is more owing to increased ventilatory disturbances than to significant increase in oxygen demand that cause the observation of decreasing exertional saturations, than to much increase in muscle demand or oxygen.

 All that said, CF is not always or inherently better than pulsed flow.  Which is true depends upon the individual device in use and what it's capacity to produce oxygen and meet ventilatory demand are AND to what setting the device is being used at.  How to know or determine the difference is a complicated process and beyond the scope of what I am trying to explain, here.  The rule of thumb for folks who CAN'T ascertain those exact parameters is to acquire a pulse oximeter and closely and frequently monitor their saturation under the various conditions of their lives and adjust the setting to best meet the objective of a minimum allowable saturation where and when possible.  AND, if the POC or OCD they have is NOT meeting the challenge, they should do everything in their power to change to another device that CAN meet their needs.  If they cannot change devices, then they need to learn how to pace themselves so as to minimize drops in oxygen levels and to avoid the discomfort and potential organ damage that goes with repeated and prolonged inadequacy of blood oxygen levels.

 Finally, you are correct to be concerned about your friend's decrease in her oxygen flow at night.  AND you surmised correctly that while asleep one does NOT demand as much oxygen based upon less activity, because of changes in breathing pattern (shallower and slower) less 'molecules' of oxygen enter the lungs and therefore less oxygen is available.

Sleep studies of oxygen saturation patterns show that one should almost always use a flow setting that is similar to the setting they need for exercise/exertion.  At the least, they should arbitrarily use one liter more for sleep than they use for resting conditions while awake.  We do NOT tend to sense dangerous drops in oxygen when we sleep.  What we usually observe is decreased energy, changes in thinking/judgment and progressive organ dysfunction, especially where the right side of the heart is concerned.  Nocturnal hypoxia can lead to secondary pulmonary hypertension, right heart failure, edema, often seen in the lower extremities and/or weight gain that fluctuates a couple of pounds over the course of a day as one sheds the excess water through urination.

 Best Regards,  Mark

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Oxygen Levels - Litres - Not High Enough

I am on oxygen concentrator. I was told by respiratory therapist to keep my no @ 4. I  guess my question is . Why when I am on it and I am busy around the house, or if I walk. does my oximeter read at 84/85 and sometimes even lower.. I am receiving oxygen but still feel SOB. When at rest oximeter reads 91/92. Why does it go up and down like that.

I get the same feeling whenever I am overly tired.

My medication is
Daxas (6 weeks now on it)

plus blood pressure medicine.


A. Hi Ann,

The flow of 4L/min is NOT enough for you when up and moving around!  It is barely enough to meet our needs while at rest.  You need to consult with your doctor and let him/her know that your oxygen saturation is dropping to that 84 – 85 % when you get up and move.  DO NOT let him/her respond by telling you not to move so much.  COPD and other lung diseases are ALWAYS “move-it-or-lose-it” situations such that if you cannot keep moving and stay in the best physical shape possible then you WILL lose it sooner than later (that is, die from the disease). 

You did not say what your diagnosis is. But, it is apparent that your disease is severe if 4 L/min corrects you only to 91 – 92 % while at rest.  AND, it is no surprise that you drop like you do – and experience such difficulty breathing along with the drop – when you get up and move around!  You need a system that will be able to give you probably 8 liters or more when you are up and moving.  At the very least, you need to turn it up to 6L/min and see how well that corrects your saturation.  If 6 pushes you back up to 91 – 92%, then you are good with that.  If not, you need more.

Best wishes, Mark

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Emphysema & Chemotherapy Exposure

Why shouldn't someone with emphysema be around a person receiving chemotherapy? What are the risks for the emphysema carrier?


A.  Hi Fle,

I am not aware that there are or would necessarily be any risks or restrictions with regard to someone with COPD/emphysema "being around" someone who is receiving chemotherapy.

Now, speaking generally, when one is undergoing chemotherapy that suppresses their immune system such that THEY are susceptible to 'opportunistic' infection, THEY should steer clear of other folks, especially those who are fighting infections, flus, colds and other communicable illnesses. It is the recipient of the chemotherapy who is at risk for difficulties.  So someone who has COPD/emphysema may be one to potentially share a lung infection, if present, with such a person.

The only other condition where all, including those with COPD/emphysema would want to stay clear of one who is receiving a treatment for cancer is when radioactive seeds (as used in treatment of prostate cancer) have been implanted.  But, whenever that is employed, all concerned strongly cautioned and instructed in safety measures to avoid exposure.

Can you be more specific about why you ask your question, or about what your are concerned?

Best Wishes,  Mark

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Blood Gasses Interpretation Follow Up From Sept. 22, 2011


Hello Mark, and thanks for reply last week.  I use 1 and a half  lpm oxygen at night and 2 lpm  in the day prescribed by the pulmonologist now over 5 years ago, but then he told me 1 lpm at night,  I upped it to 1 and a half, because on 1 lpm I used to wake up with a high pulse over 90 rpm. He also agreed. The reason he gave me for having less when sleeping was CO2 retention and not needing 2 when sleeping, I use a BiPAP too.  When I take off my oxygen sitting I get low sats of 87 in 30mins.  I use my oximeter. That's why I can't understand high PO2 of 126.    regards Val.

A.  Hi Val,

While to be concerned about the possibility of you retaining CO2 because of using a higher liter flow is a commonly voiced concern among many health care professionals, it is not a well-thought-out notion in your particular case.  If you are using BiPAP, you are receiving ventilatory support that not only will PREVENT any possibility of CO2-retention, it will actually be lowering your baseline CO2 in the process, while using it.  So, as you can surmise, it is a ‘non-issue’. 

At the same time, BiPAP also tends to ‘raise’ oxygen levels because of the constant positive pressure which puts more oxygen molecules per volume of gas in your lungs, so, for that reason alone, you might not need the additional oxygen flow during the time you are using the BiPAP.

A heart rate of 90, while somewhat elevated at rest, relatively speaking, is not significantly elevated, all things considered. Factors other than low oxygen can be the case.  But, to be safe, the 1.5 L/min flow is a good idea when on the BiPAP.  Were it not for the use of the BiPAP, the argument – supported by the preponderance of evidence – that one’s oxygen saturation is comparable to that which they hold during exercise is still the prevailing premise and should warrant the use of the same flow during sleep as that used during exercise until and unless proven otherwise (through sleep saturation monitoring, for instance).

The 126 still is reasonable and not significantly high, much less a point of concern and may simply have been reflective of a ‘good day’ for you when it was measured.

I am curious to know if when you take your oxygen off, then measure your saturation 30 minutes later, as you reported doing when you found that it was 87 %, if you THEN continue to monitor it for another couple of minutes while taking in many deliberate and slow, deep breaths will increase.  If so, how much does it increase?  In other words, can you force your oxygen level to increase with very controlled and deep breathing for several minutes while breathing ‘room air’ (a.k.a., using no supplemental oxygen)?  Try doing that and write back and let me know what you find.

Best wishes,


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Mold Problem

Hi Mark..spoke to u some time ago.  I am a copd patient who operates at about 23 %.  was 30: about 4 yrs ago and slowly decreasing but totally functioning.

I have twice daily home treatments (neb) and see my resp every three months.  Last night 'live' black mold was discovered in our new home and the floor has been off since.  I have definitely inhaled the spores as  my face was over it looking at a few times.  My question is (it is due to be removed later today) am I at risk?  How much is too much mold? Will it cause me problems? How will I know and how long does it take for the spores to grow within your lung after you have inhaled them???? 

Please send me some answers as I have been searching everywhere since last night !!
thank you thank you thank you

A.  Hi Barb,

Wow!  Mold as you found is not a good thing for healthy lungs, let alone those diseased with COPD or other chronic lung ailments!  First, while “most” molds found in homes are NOT toxic, or of the species of toxic molds that can cause serious problems, to expose one’s self to them for prolonged periods of time or in significant concentration is what is required for most health problems to occur.  You didn’t say “how much” mold you found.  But, speed and severity of reaction to molds is “dose-related” and depends upon one’s immune system response and adequacy of integrity.  It is likely that you have been inhaling spores for quite some time, even though it was lurking covered up by your carpet, though certainly not in significant concentration/numbers of spores.  It is possible that you have developed antibodies to the species you have growing in your home through exposure in low concentration for however long it has been growing.  So, you may not have any adverse response to it at all.  On the other hand, if a lot of spores were kicked up when the carpet was removed and the mold exposed without barrier containment, then you could experience a reaction to the sudden increase in spores in the air within your home.

The best advice I could give you or anyone facing your scenario is to LEAVE the premises!  Remaining in the environment with the mold spores free to circulate in the air invites trouble that is avoidable.  You should NOT be around when the mold is cleaned up as that will also kick up spores into the air and make them available to be inhaled.  Wearing a mask – even an N-95 or other high-efficiency mask - would not be enough protection to ensure you wouldn’t inhale potentially high enough numbers of spores to cause trouble IF the mold you have turns out to be of one of the toxic species.

As for how long it would take for you to react, if that is in the cards, I can’t tell you that for reasons already discussed.  But, the likelihood of a reaction being significantly delayed from the point of exposure is not likely.  So, if you haven’t begun to exhibit symptoms – increased breathing difficult and sputum production, for instance – then you likely are OK and shouldn’t expect to have any difficulties.  If you start having problems, don’t delay getting to your doctor for treatment.

Best Wishes,


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Bronchospasm Clarification

Hi Mark;

We've a question on our forum that we're hoping you can clarify for us. 

Some have termed /described the    "symptoms"     of bronchospasms   as pain in their chest, like a cramp or "charlie horse" of the lungs. 

Others, myself included,  believe it usually involves coughing and/or wheezing, a narrowing of the bronchi, difficulty breathing,  with mucous production.  The coughing can become perpetual making it even harder to breathe.

So; what are the symptoms of a bronchospasm?  And; Assuming it's the 2nd option, what would be the the pain/cramp feeling be that makes breathing harder?

With our thanks,

A.  Hi Jackie,

A-c-t-u-a-l-l-y, “both” descriptions hold some degree of truth! While the ‘parenchymal’ tissue of the lungs – that is the tissues that form the alveoli, connective/structural support network and blood vessels – are devoid of pain nerves, so don’t ‘sense’ pain, the bronchial tubes and “parietal pleura” – that is, the membranous lining of the chest wall that with the “visceral pleura”, combine to enclose the lungs, provide a negative pressure hold that keeps the lungs inflated AND contains a slippery fluid that allows the lungs to ‘slide’ during the inflation and deflation of breathing – are very sensitive and DO sense pain. Folks who have had pleurisy know well about the pain that occurs when the pleura become inflamed. That pain is the result of insufficient fluid to allow the pleura to properly ‘slide’ against one another, acting more like sand-paper than the thin slippery membrane they are. But, it is the pleural lining that is attached to the chest wall (the parietal pleura) that ‘feels’/senses the pain, NOT the membrane that is attached to the surface of the lung (the visceral pleura).

Bronchial pain can be sensed due to a variety of causes. Acute Bronchitis causes inflammation which can be accompanied by pain – often a burning and/or aching sensation – that subsides as the inflammation decreases and the cause of the condition resolves. Insofar as bronchospasm is concerned, pain is possible, more in the form of aching, but, certainly not characteristic of the classic pain of a “Charlie horse”. A Charlie horse is classically limited to “striated” skeletal muscles during spasms. As such, one can have a Charlie horse occur in the intercostal muscles – those which attach the ribs to each other. But, because the muscles of the bronchial tubes are comprised of “smooth” muscle which is not striated and not of the same type as are skeletal muscles, when they spasm, the pain potentially associated with their spasmodic activity will be more of an aching-type pain, if anything. Cough, wheezing, increased mucus production and difficulty breathing are also symptoms of bronchospasm, though not of the type of discomfort that would be considered or labeled as “pain”.

I hope this clarifies the issue and questions to which you refer.

Best Regards,



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Marijuana & COPD

What is the prognosis for someone like myself, diagnosed with COPD?
Does the prognosis depend on the stage of the disease?
Does marijuana help relax the airways for patients with COPD - as it is purported to do with asthma patients?


A.  Hi Mary,

Prognosis does indeed depend heavily upon what stage one is in.  But, even more so, what determines rate of progression and is a matter over which you have control is what you do to care for yourself.  Exercise and being as vigorous and robust as you can in lifestyle go extremely far in not only increasing survival with COPD, but also to influence the quality of life you enjoy while contending with COPD.  Smoking cessation – of all kinds of materials – and good nutrition are very important components, as well.

While some hype about marijuana’s ability to effect bronchodilation has been published in the past, the prevailing consideration is that smoking of ANY kind – for those with Asthma AND COPD, along with other lung diseases – is much more harmful that any possible help it could impart.  There’s just nothing good or helpful about smoking marijuana when you consider imbibing in the interest of helping with lung disease symptoms.  And the evidence we have shows that it causes further damage and deterioration in one’s lungs and their function.  So, to stay away from it is the best and most appropriate advice I can give you.

Best Wishes,


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Blood Gases Interpretation

Dear Mark,

I am worried about the blood test I did at my 6 months revision with the pulmonologist on 15th Sept because it shows a high Oxygen reading. The results are ph 7.47, pCO2 47.00 pO2 126.00, HC03 34.20, TC02 35.00, excess at base (Beb) 9.30, So2 saturation of oxygen 99.00. I feel that the p02 is very high of 126.00, when the pCO2 is quite low. Six months ago the same happened, my oxygen pO2 was 108.oo. Before these last two tests, my pO2 never went over the 80's. Do these high levels of oxygen mean that my lungs can't cope with oxygen now, I only use 2lpm resting and 1 and a half lpm sleeping with Bipap. I usually use 3 lpm when walking. Can you throw some light on why I now get much higher pO2 than before.

Thank you Mark. regards Valerie

A.  Hi Valerie,

Actually, it is no big mystery that your oxygen has fluctuated as it has.  It is NOT a sign of ANY problem, instead actually being a good thing.   I am curious to know if when you had the 80 pO2 measurements that your oxygen was turned off.  If not, it could easily have been a bit off from the 2 L/min you try to set it to.  But, if you were not in similar condition back then to what you are now, it’s certainly possible that you have improved to some degree and are able to get more oxygen into your lungs than when the previous tests were done.  Finally, simple small but significant differences in how exactly the flow was set could easily account for the differences you see between the tests.  In any case, the changes are positive, NOT negative as you characterize them to potentially be. 

Higher measurements of oxygen in your blood do NOT indicate your body’s inability to “cope” with oxygen!  If anything what it may indicate is that you do NOT need to use 2 L/min at rest as it is pushing your oxygen level up to that 126.  I am also puzzled as to why you use more flow when awake and at rest than when you sleep.  Your flow “should” be comparable during sleep to when you are exerting, or at least equal to your waking/resting flow.

Lastly, I want to thank you for including the entire blood gas results.  Because you told me both the pCO2 and pH, I am able to tell you that your carbon dioxide is NOT “low’ let alone “too low” as you said.  Normal blood CO2 ranges from 35 to 45.  With yours being 47, it is actually a bit elevated, meaning, when considered with the pH, which is also elevated (normal range 7.35 – 7.45) at 7.47, you are mildly retaining CO2, a sign of the advancement of your COPD and its current state.

While you need do nothing with any urgency, I would suggest you ask your doctor if you can use less oxygen while at rest OR to remove it when you are sitting.  It would be nice to see what your pO2 is while OFF oxygen, breathing only the air in the room.  While I do not believe that the 126 oxygen level poses any potential danger to you, it is not necessary or specifically helpful in any way to keep it that high.

Best Wishes,


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Sensitivity to Smells & Infrared Sauna Issues

Hi Mark,
I'm a 50 year old female with severe copd and emphysema, 2 ml oxygen at night, spiriva is only med. I work full-time. I have started exercising and for the most part I'm doing okay. My issues/questions? Smells of all kinds really bother my breathing. I've change cleaning and laundry supplies, etc. But I can't convince my husband and son that the smells of their soaps, deodorant and baby powder really bother me. Am I being to sensitive here? Also, my son bowls and the bowling alley reeks of some sort of grease or oil. Is it safe, practical to wear some sort of mask/respirator an hour per week to watch this? Isn't it best to not be around air pollution at all?
Also, I have chronic muscle and joint pain. I have an infrared sauna that I'd like to use at lower temperatures but a nurse who works for the pulmonologist said saunas are bad for lungs.

Any thoughts or suggestions? Thank you so much.


A.  Hi Moe,

Your sensitivity to odors of the nature you describe is not at all unusual.  Many folks who have Asthma and COPD become increasingly intolerant of odors, especially scents used to add fragrance to every day materials we use, like Kleenex and toilet tissues, soaps and laundry and cleaning products. Perfumes, colognes and other hygienic products can wreak havoc with one’s breathing.  It is specifically because of these tendencies among those with lung diseases that we RT’s are careful not to wear scents or clean ourselves with products that emit significant fragrances when we work with our patients.  So, your husband and son really do need to heed your complaints and try to keep from aggravating your breathing with unpleasant odors and/or those that trigger breathing difficulties for you.

Insofar as the question of pollution you ask about, while all folks who have COPD should avoid breathing polluted air, because fragrances are present that bother you does not make them constitute pollutants.  As for the bowling alley, it is common knowledge that the lanes are coated with oil.  That oil has no significant fragrance or odor to it.  As well, that oil has never been shown to become ‘airborne’ or to pose a threat to one’s health.  You may be overly sensitive to that particular presence more because you ‘know’ it is there, rather than because it emits any significant fragrance or odor.  One other possibility would be to see if there is a concession that fries a lot of foods.  That oil can become airborne, but predictably not in sufficient quantity to place anyone at risk for harm, even those who work there, in close contact with it, every day (unless they are exposed to it for a matter of years on a daily basis).

In any case, wearing a mask of the type you suggest – or that would be necessary for the type of filtration you suggest, were airborne pollutants actually present because of the oil used at bowling alleys – would be not only impractical, but a visual distraction and potential embarrassment since there is no known or suspected danger posed by breathing the air within that environment.  If, as in many areas here in the USA, smoking has been banned from bowling alleys, then the greatest source of actual air pollution has been removed.  And the remaining air may be safer than it has ever been.

I have to agree with your pulmonologist’s nurse that on the whole, saunas are high-risk environments for those with lung disease.  It is curious and quite incongruous that you would be so highly sensitive to odors and fragrances as you are and still able to tolerate the high-humidity of a sauna (at lower temperatures or not!).  Beyond the assault of the humidity on your breathing, they tend to support growth of molds if not maintained at an impeccable level of cleanliness.  Are you prepared to or able to assure that strict condition in your home sauna?   As well, I don’t know what benefit a cooler sauna would potentially have for the aches you describe.  Even a hot sauna wouldn’t significantly benefit achy muscles and joints.  Better to get in a whirlpool tub or a hot tub (also risky) for that kind of benefit.

I have concerns about your oxygen needs.  What we see a lot of the time in folks who have extreme sensitivities of the nature that you describe, BUT whose lung disease is not so severe as to prohibit their ability to work full time and maintain an active lifestyle is "hypoxia" (decreased blood oxygen levels), especially during exertion.  You note that you use oxygen only at night.  Do you have an oximeter to monitor your oxygen during waking hours and especially with exertion?  You could be desaturating (dropping your oxygen level) during exertion, in which case you may need to increase your oxygen use to more than just while sleeping.  Further, it is fairly well documented that folks who desaturate during sleep most often desaturate similarly during exertion.  So if you have not had a walk test with oxygen monitoring performed as you walk for at least three minutes, non-stop AND you do not own or use a pulse oximeter, then you should have that test and/or consider purchasing an oximeter and adjusting your oxygen use accordingly.  It is certainly an issue you should discuss with your doctor. 

One other concern is that you’re using ONLY Spiriva.  While there may be a few folks out there who need only an “anticholinergic” medication to maintain their airway tone, with your apparent sensitivities and symptoms related to odors and fragrances, I would be that you also need to be using a beta-agonist medication along with the Spiriva.  You may also specifically benefit from an inhaled corticosteroid which would help reduce your sensitivity to fragrances/odors.  Ask your doctor about the advisability and potential benefit of adding something like Symbicort or one of the other combination inhalers that contain each of the types of drugs I suggest.  What you may see is not only overall improvement in your breathing, but a significant reduction in your sensitivity to some of the offending odors.  Part of your underlying propensity for intolerance may simply be airway reactivity of the type that those two medications specifically resolve and/or prevent.

Best Wishes,


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Symbicort, Spiriva Dosing and Emphysema Progression Questions

Dear Mark:

I was recently diagnosed with COPD(Emp). I am a 47 year old female ex-smoker, I quit 12 years ago. My breathing has worsened over the year, apparently when I had the PFT test last year COPD was evident. I was told it was allergy related. I have since started taking symbicort and spiriva together. Is this safe?   My dosage for the symbicort is 2 puffs 3x daily. How fast does emphysema progress?  I have to loose weight and I was active until this year because of my shortness of breath, I am hoping the medication will make this easier. My next test is this Monday should I ask what stage I am at.


Mary Ann

A.  Hi Mary Ann,

It is safe and appropriate – actually, ‘recommended’ – that you take the Symbicort and Spiriva together – or close to each other in interval.  COPD is NEVER “allergy-related”.  Allergies cause asthmatic symptoms of inflammation and constriction that are reversible with bronchodilators, anti-inflammatory medications and others, without necessarily having continued reduction in FEV-1 when reversal is successful and/or complete.  COPD represents specific and permanent structural changes that do NOT respond to ‘reversal’ interventions.

COPD/Emphysema progresses at a variable pace among individuals that is dependent upon a lot of factors.  As such one cannot simply say “Your will get worse (this much) every year.” Or anything like that.  Because you have a LOT of control over how fast you progress, you can also expect your rate of progression to vary according to what and how much action you take to slow its progression.  Exercise, good nutrition, smoking cessation and the rest that goes into an overall healthy life style are key elements of successful intervention to slow progression. 

Despite difficulty breathing and windedness that comes on when you exert/exercise, it is absolutely imperative that you get moving again and keep moving, especially to return to a regular and as vigorous an exercise program as you can manage.  Your breathing symptoms will be controlled but, NOT likely eliminated with use of the medications you now take.  They are not able or intended to completely stop all breathing symptoms/difficulties.  Further, the person who is successful in achieving control and long term slowing of their COPD progression is one who through exercise and breathing control learns to function at a high level DESPITE working hard to breathe.  While breathing hard may “feel” like it is “bad for you”, it will NOT hurt you to force yourself to work hard physically and breathe hard – and uncomfortably – while doing so.  Those who cannot manage to push on in  the face of difficulty breathing during exertion progress faster and succumb sooner than those who do succeed against breathing difficulties.

Asking what stage of COPD you are in is simply not enough information.  You should ask what your FEV-1 is (as a percent of predicted), your lung volumes (TLC & RV, especially – Total Lung Volume and Residual Volume) and Diffusion Capacity ( how easily oxygen gets from the air in your lungs into your blood).  For these numbers, you need to undergo a “complete pulmonary functions test” which includes, “spirometry”, lung volume measurement and measurement of diffusion capacity – three different groups of tests measurements.  If your test includes these, you can come back and let me know what they are – or contact me directly through the help of this forum/Jackie Whitaker) and I will help you make sense of them.

At 47 and with what seems likely a modest smoking history, you should ask to be tested for the genetic form of COPD – Alpha-1 Antitrypsin Deficiency Emphysema.  If you have that form, you need very specific treatment that is different and beyond the usual treatment for COPD of other forms.

Best Wishes,


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Getting Back Into Walking After Foot Injury

Hi Mark. The very best to you and your family.

My exercise program was put on hold these last 6 weeks due to planters F, in my left heel. Doctor said treadmill not recommended for this type of injury.

I still walked but it was painful. I would like to start my exercise program again, but getting started is always difficult. Have lost 25 lbs and feel great, but do not know how to set the numbers on the treadmill again. Before this problem I was at 45 minutes 3 incline 3.5 speed. Due to the layoff Mark what is your suggestion as the numbers to start with. Not too sure if I can resume the 45 minutes as the pain is still there but much better then it was. Was actually walking with a noticeable limp before. Could you also tell me at what pace I can increase the start numbers?

Your thoughts and advice always most welcome,

Kindest regards Philip

Hi Philip,

I cannot give you any hard and fast recommendation, as there is no hard and fast standard.  Additionally, not knowing about your condition beyond what you’ve told me I am not in a position to be specific with any recommendations.  You are the one experiencing the pain and who has sat out for the last 6 weeks.  You should feel free to use your own judgment to determine what will be the best settings in terms of duration and intensity.

Generally speaking, I would say remove ALL grade from your treadmill.  Find a speed that challenges your breathing and allows you to go at least 30 minutes, if not the full 45, right from the gitgo.  Add speed and grade over the next couple of weeks to return to your previous duration and load.  Let your foot pain be your guide in terms of how much and how long or even IF it is wise to return to a walking program before you let all pain resolve completely.  You don’t want to aggravate the condition and cause a return of acute inflammation.

I do have a curiosity.  Do you have a pool nearby that you can access to do water aerobics or even lap-walking?  If one can use a pool, there should be no need for totally stopping exercise because of conditions like you suffer.  The buoyancy of water and the almost complete removal of pressure related to weight-bearing of walking on land make it ideal for continuing exercise during episodes of orthopedic difficulties. 

Hang in there and push carefully, but not too cautiously and you should be back in the saddle shortly.

Best Wishes,



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Post Fall, Now Experiencing Difficulty Breathing; Reduced Oxygen Levels

Can you tell me if or why the fall I had last weekend would affect my SATS?  I fell on  Sun. and broke my collar bone and severely pulled my rib and chest wall muscles.  On Mon. I started getting really SOB and  having to wear my O2 most of the day and night.  Now I have to wear it constantly.  I don't know why I didn't check my SATS earlier in the week, not like me to forget, but I finally remembered last night and found out just how bad I am.  Since I started checking at about midnight, I have been running at about 82 to a high of 85 when not on my O2.  I can get it up to 94 with the O2 but within less than a minute of taking it off it's dropped right back down again.  All of the testing times have been at rest since I'm in too much pain to do much of anything more than walking to bathroom, kitchen, or nebulizer and back to chair.

I have been having a difficult time breathing because of the pain, but also not able to get a good inhalation with my Spiriva and realized really fast that I depend on that med.  I had just gotten over a long exacerbation, too, when this fall occurred.  Another fly in the ointment is that I have developed steroid myopathy and wondered if those muscles could be affecting my breathing, too.  So many things to wonder about and nobody to ask right now.

Thank  you for any advice you can offer.  My pulmonary dr. has been out of town and won't be available until Mon.  I know I'll probably talk to him before you can answer my question, but would really appreciate your thoughts and experience on the subject.


 Hi Sue, 

Some initial thoughts that come to mind are that you likely have a pulmonary contusion and other difficulties that accompany that kind of injury.  Have you had a chest x-ray?  If not, you should definitely get one.  You may have cracked a rib or two.  You probably have some pleuritic inflammation in response to the injury which is ALSO decreasing your ability to effectively ventilate and oxygenate.  If you have some inflammatory response in that area of your lung, it could also be affecting your ventilation and blood flow to that area and consequently your oxygen uptake.

A fall wherein one who has significant chronic lung disease AND especially one who has taken any amount of steroid treatment injures their chest/rib cage should NEVER be taken lightly and should ALWAYS warrant a chest x-ray and maybe a CT scan, also.  With your history, that should have been first on your list after you picked yourself up and got back into a semblance of stability.  So, if this happens again in the future, do NOT wait to see if something worse will develop.  Nip it in the bud and get checked out.

I suspect that your doctor will order at least an x-ray, but may go straight to a scan to see if you have lung tissue damage that only a CT can best 'see'.

Best Wishes,     Mark

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Prednisone Tapering Problems


Good Afternoon Mark

All in all our summer has not been too bad. The only problem Fred is experiencing trouble tapering down off Prednisone. We live in a very small town, the consistency to having the same Dr. is not great. We have Dr's that come for a week and they are great but everyone has its own views on COPD.

Every time Fred tapers down from Prednisone he crashes he has a terrible time. We go back to the hospital and they put him back on it.

Since April he has been on it about 2.5 weeks a month, We had a new Dr the other night and he suggested instead of tapering off at 5mg for 8 days maybe he should take 15 to 20 mg for a month then go down 5mg from there but taking a much longer time.

Can you tell me in your experience have their been some patients taking this route like Fred.
Fred is end stage Emphysema, when on Prednisone he can do almost anything within reason. I just am not sure when a Dr. here sees him they seem to give him a fix then they are gone and its up to us to figure it out. I did write his respirologist in Toronto, you can imagine this Dr is extremely busy and may not respond to me right away. Just wondering what your thoughts are.
Thanks Mark


Hi Mitch,

My thoughts are that Fred may be experiencing the infamous "prednisone let-down', or rebounding of his symptoms as he tries to come off the prednisone.  That he has been using it 2.5 weeks per month tells me that he does indeed stop it altogether for short periods - an action that can amplify the rebound effect.  I don't remember if Fred is using an inhaled corticosteroid medication.  But, using one may help him slide off the prednisone more easily.  He needs to understand that coming off the prednisone will likely entail some return of symptoms that he will need to consider 'overcoming' through perseverance through the post-prednisone period. 

He might try a longer more gentle tape of the prednisone.  rather than stopping it altogether for those short periods, he could consider dropping it 5 mg at a time on a weekly basis until he reaches 15 mg after which he would cut his dose by 2.5 mg per week until he is completely off the medication.  At the same time, if he is not using an inhaled steroid, that would be something to ask his doctors for. 

It might turn out to be that he will require prednisone for long term use in which case, finding the lowest tolerable dose will be of advantage.  See if his doctors will agree with a slow taper as I have described to see if he can truly come off it or if he can at least get down to where a maintenance dose of 2.5 to 5 mg might give him a balance of enough benefit to be comfortable and as highly functional as possible, yet not on significant doses of prednisone.

It is apparent that for him to try to do without it as he has been trying to do is not working for him.  I would also consider going ahead and trying to write to his Respirologist in Toronto, anyway, if for no more than to run my suggestions by him and get some affirmation.  If he answers, you're good.  If not, you tried.  But, in any case, I would give it a try.

Best regards, Mark

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How Much is Too Much When Exercising

Hi Mark,

Hope you and Kimmy and family are well.

I am on the march to loose 45 lbs and I am half way there. I am down 23 and what a difference in my breathing. It is like night and day. I was also taking Mark 10MG of Altace for my high blood pressure and a water pill every day. When I went for my monthly check up the doctor took my blood pressure and it was 94/65,
and he said it was too low. He quickly changed my medication. I am now taking 5mg of Altace not 10 and no more water pills. He said the better result was from loosing the weight.
My question Mark is this. Can I now say " Push " myself a bit harder when it comes to my exercise. Due to the weight loss I should be able to put up better numbers, but always afraid that pushing myself at my age may be asking for trouble.

Also Mark you have probably come across this in your rehab class. I seem to have developed heel pain in my left heel. It is quite painful. I have tried insoles but not working too well. Do you have any advice on how to get rid of this pain. I am sure a few of your people in your rehab class have complained about his type of thing from time to time .

As always kindest regards and thanks Mark for all your assistance over these many years.


A.  Hi Philip,

Congrats on the weight loss!

I would recommend pushing yourself as much as you can.  Your body.lungs will let you know if you re pushing too hard.  Age is not a necessary dictator of how hard one can push themselves,physically. So don't set age as a limiting variable for your effort.

As far as the heel pain, I would suggest seeing a podiatrist as it can be from any number of causes which I cannot suggest from where I sit.

Keep up the good effort!

Best Regards, Mark

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CO2 Retention & Bi-Pap

I am in stage 4 emphysema. I am a co2 retainer.  I wear a bipap at night to blow off the co2  .Is it ok to use a pillow nose piece  with this machine? I am claustrophobic. I really need your ok on this because my daughter and I don't agree on using it.  At least I will wear it willingly.   Thanks


A.  Hi Nedra,

I'm happy to be able to reassure you and your daughter that you can receive the same benefit from use of nasal pillows as you can from other appliances like full face mask, nasal mask or nasal CPAP cannula.  Indeed, for claustrophobic folks and for simply better comfort, the "Nasal Aire" CPAP cannula works even better then the pillows, as with the pillows, you still have a head gear and bulky apparatus holding the tubing and pillows in place.  With the Nasal Aire CPAP cannula, there is no bulky head gear AND the cannula fits nicely in place even allowing more ability to sleep 'other than' on your back.  Check out this website.  I don't endorse the proprietor of the site as where to purchase one.  I include it only because they have a great picture of it in use. .  From a personal point of view I can tell you that my daughter, who require the use of ventilatory support during sleep before each of her double lung transplants used all the available appliances, settling on the Nasal Aire as her appliance of choice.  So, for her, it worked best among the choices ALL of which produced equal benefit in terms of delivering the pressure.  But, if you have the pillows and like them better than the nasal mask or full face mask, then you should use what feels/works best for you.

All that said, while there has been a lot of enthusiasm for the use of CPAP/Bi-level pressure therapy for "blowing off CO2" for those who retain it, the evidence is sketchy at best and - IMO - very 'underwhelming'!  CO2 -retention becomes a compensated metabolic process that "normalizes" the body and its tolerance to chronically elevated CO2 such that it need NOT try to adjust CO2 downward.

While anecdotal evidence from the studies done to date "suggests" that some folks "feel better and have more energy when incorporating positive pressure ventilatory support to their sleep periods, the consequential evidence -what does it ACTUALLY and MEANINGFULLY do to CO2 levels and pH - is just NOT there.

We know well from decades of data and observation that "during" the time positive pressure is used to assist ventilation, CO2 can be 'acutely' driven down.  But, when you remove the positive pressure support - as you do every morning when you arise and hang up the tubing and mask/pillows - your CO2 rapidly returns to its compensated level.

The pushing of the use of night-time ventilatory support in an effort to alter/reduce compensated CO2 reminds me of the Russian efforts back in the mid-20th century to produce wheat that would grow in the harsh winter climate of Siberia and similar regions.  Scientists placed generation after generation of wheat seeds in the freezer predicting to be able to acclimatize them to germinate under winter conditions. Needless to say, results were completely disappointing when none of those efforts produced seeds subsequently hardy enough to conform to the Russian scientists 'imposed' theory.  There is another analogy of Russian scientific efforts that is similar and entails the same resultant failure (recall the experiments wherein they tried to produce rats/mice with no tails, forcing the Chang by cutting off the tails of offspring and measuring successive generations for shrinking tail size in response to the removed tails).

I offer the preceding explanation NOT to discourage you from continuing to use the positive pressure therapy while you sleep.  But, given that regardless of choice of appliance you make, as long as the modality is correctly used, you WILL achieve predictable benefit "only while wearing it" and may NOT achieve any permanent change in your CO2 level or benefit in how you feel or your energy level as a result of using the modality.  So, if you do not achieve significant changes, understand that it is not because of you or anything you did, as long as all was done correctly.  Rather, it will be because the theory of what it should do and how it should do it is extremely flawed and a set-up for failure, with regard to achieving the intended, even declared benefits.  BUT, while we have much reason to doubt its ability to help, we have no evidence - theoretical or measured that it will cause any harm or negative result.

Best Wishes,Mark


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Oxygen Saturation Levels While Swimming

Hi Mark
Using a modification based on equipment used by some friends in the States, I have been able to swim freely at the cottage this summer. As you can imagine it's fabulous. However I'm wondering just what is happening to my 'sats' when I swim and being wet I can't use my oximeter. I thought perhaps you've looked at this scenario before and might be able to give me your thoughts. Generally for exercise I use 6 LPM continuous. When swimming I use the same flow level. However when I swim freestyle I still use proper form which means my head goes under the water when I breathe out and I bring it up to the side to take my breath via mouth. ie the normal way. I am using a standard nasal canulla. I seem to be fine. I do not feel out of breath and as I do occasionally get wrapped up in the tether I just flip to my back until it floats gently away. As a prior distance swimmer this is like getting a bit of heaven back but I can't help wondering what is happening with my oxygen levels. As the oxygen is coming into me continuously, albeit via nasal prong, when I life my head to get my breath through my mouth am I still getting my oxygen. Hope this all makes sense. I would very much like your thoughts on this.
Many thanks


A.   Hi Shelley,

While studies show folks tend to desaturate much more modestly during water activities, thanks to buoyancy and reduced oxygen consumption, owing to the water medium, one cannot predict what your saturation might be while you are swimming. 

That you are using a cannula and swimming 'freestyle' using usual breathing methods 'should' be resulting in a decrease in oxygen delivery to your airway because of the coordination of a blocked nose during the mouth-breathing you do.  Were you to
be somehow breathing through 'BOTH' your mouth and your nose (not recommended) when you take in your breaths, you might have a chance to receive some of the volume of oxygen being administered.  Even at 6 liters, I doubt you are getting any appreciable amount, simply because of the physics and the anatomical dynamics at play with that breathing method. 

That said, if you don't seem to be experiencing significant increase in breathing difficulties, then you may not be dropping near as much as you might while walking on land at atmospheric pressure.  A mitigating factor is the breath-holding you do between intake of air while you swim.  That necessarily involves increased pressure within your lungs and has an effect similar to and probably great than using pursed lips breathing.  So, you might be pushing up or better holding your oxygen saturation thanks to the increased pressure in your lungs while swimming.  Considering that you probably stop at intervals and DO breather to some degree through your nose, you probably boost your oxygen level sufficiently to keep it reasonably adequate. 

You didn't say if you're swimming in a lake or a pool.  But, if in a pool, try placing a towel and your oximeter at the edge of the pool.  Swim a couple laps - or what ever interval you go between rest periods and stop by the oximeter.  Quickly dry your finger off and place the oximeter on it and see what it measures.  You can measure your oxygen with your finger still a bit damp.  So just remove the excess water and get the device in place as soon as possible.  Provided not more than 30 seconds has elapsed since you stopped swimming to measure your saturation, you can figure that the measurement represents at least 90 % of your "decrease" experienced during swimming FOR THAT TIME INTERVAL.

See how that works for estimating what's happening to your saturation while you swim.  If you have further questions or difficulties, write back to the forum and I'll try to help with further suggestions.

Best Regards,


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Low FEV 1-  Seeking Ideas/Suggestion  on How To Manage/Cope Better

Hi Mark;

Thank you for joining us; you are very much needed here it will be wonderful having you with us.

Question:       I am copd stage 4 since diagnosis  on first pumonary  visit  in 2005. I  have been on advair and spriva since then and also albuterol as needed  Of course I have lost some function since then;  been real sick a couple times.  Last time my pft was 13 for first one and 20 for the next one.  20 took longer and was given albuterol.

Ok I want to know what I can add to make me breathe a little better.  Can I add a steroid inhaler?  I have recently started taking 5mg pred by mouth 1 time a day but  ir doesn't  help that much. I have actually gotten on hospice but I am very active.  I still take care of my housework and shopping and take care of my animals but it is very hard sometime and I am thinking there got to be something else I can do . My hospice nurse will write a   prescription for whatever I need but I don't know what I need so maybe you can help.. Thank you for your time.  I look forward to hearing from you  and again welcome!!   Georgia

A.  Hi Georgia,

Thanks for the welcome - though I've been here for perhaps more than a year.  But, I'm glad to be able to help where I can with questions and problems COPD-Canada members (and others) have.

Unfortunately, when one's FEV-1 drops down into the teens or low 20's, as has yours, there's nothing significant that you can do to push it back up to any appreciable degree, short of lung volume reduction surgery or transplant, for those who are good candidates.  You are kind of 'stuck' with what you have to work with.  So, your work to breathe will always be increased, though not necessarily unmanageable or unbearable.  What folks who are successful at remaining functional and mobile do under your circumstances and conditions is to work to "desensitize" themselves to the difficulties associated with working hard to breathe.  The ONLY way to do that is to get up and move, use pursed lips breathing and keep coaching yourself to accept the "FACT" that while, at times it 'may' feel like it's harmful to you or might 'do you in' at any moment, IT WON'T!  That's the single most difficult thing to do (IMO), but certainly possible. 

Ultimately, the more you move and "push through" breathing difficulties, the better your physical condition will become and the less oxygen you'll require, per unit of physical work and the less carbon dioxide you'll produce which, in turn, reduces load on your lungs to breathe and therefore your overall work and discomfort.  This is easier said than done, needless to say.  But, you MUST master it if you are to see appreciable improvement and to continue survive with reasonable ability to enjoy life.

I can't comment on your being in hospice, as that is 'usually' entered for the purpose of keeping comfortable during the 'predictably short life expectancy' that remains.  But, you sound like you're actually far from that point.  So, hopefully, while the services of hospice may be helpful for the time being, you will improve sufficiently such that you'll need to be discharged from hospice care because you are doing too well to need it.

As to the question of adding steroids to your medication regimen, you can certainly try adding an 'additional inhaled steroid, maybe 2 times a day to your Advair and Spiriva.  You already have a steroid in your Advair, so what I'm talking about would be in addition to that - IF - your doctor thinks it would be helpful and not contraindicated, for any reason.  I would suggest you consider trying a course of using an additional inhaled steroid instead of the oral prednisone, if it works adequately.  That way, you will reduce your chances of side effects of steroids which tend to be greater with oral (total body) dosing than with topical treatment, such as inhaling the medication.  So, if you decide to try more inhaled steroid, try also to discontinue the oral prednisone.  If in doing so you find that you feel worse after a couple of weeks, you may need to resume the prednisone.  Remember that initially, you might feel the 'steroid let-down' which often causes folks to jump back on the steroids, thinking they are getting sick or heading for an exacerbation.  So, you have to give yourself a couple of weeks to get past the initial 'slump' in how you feel. 

Another point to consider and ask about is the pattern and dose at which you take prednisone.  For perhaps most folks, an initial course of higher dose prednisone for a few days, tapering off to the lower dose - and even off it completely, as time passes - works more effectively than simpl starting to take a low dose without a 'loading' regimen.  To do that, you would start with 30 or 40 mg and decrease the dose by 5 or 10 mg every two or three days.  Dose packs for this pattern also come with one to three days of loading dose, say, 40 mg, then a daily taper until the pack is gone, which may cover five days or more.  So, a change in your oral steroid pattern would likley impart greater effectiveness/symptom improvement, if you were to change to that pattern.  At present, you could increase your daily dose to, say, 30 mg for 3 to 5 days and then reduce to 20 mg for another 3 days, then to 10 mg for another 3 days and then to 5mg for 3 to 5 days and then stop it altogether and see how you do.  If you also add an 'additional' inhaled steroid for between the steroid doses provided by your Advair, you should at that when you reach 10 mg, so that you have gradually bridged the transition off the prednisone.  The choice of steroid to use could be more of the Fluticasone that is in the Adviar, or a different one, like Pulmicort, which is Budesonide, another steroid version. 

Best wishes,


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High Altitude Simulation Test (HAST)

What is a 17% oxygen test? And how is it performed?


A.   Hi Lil',

What you refer to is called the HAST test - High Altitude Simulation Test - used to estimate the potential for one to desaturate while at altitude, as in air flight at normal cabin pressures of 8000 feet (2.44 Km), average and if visiting locations that are at elevations greater than a mile (1.61 Km).


A mixture of gas that has been 'reduced' to 17 % oxygen content from the 21 % oxygen content of normal atmospheric air, at sea level, is breathed by the subject for several minutes. During that time, oximetry may be used to monitor changes in the subject's oxygen saturation. An arterial sample of blood may be obtained for measurement of blood gases to more definitively determine the effect of breathing the low oxygen containing gas mixture after several minutes of breathing it either in addition to the saturation measurements or instead of oximetry measurements alone.


If the subject can maintain an acceptable oxygen saturation - usually equal to or above 88 %, then they are deemed adequately oxygenating to be able to travel to altitude without need to use supplemental oxygen.


17 % is selected as the likeliest lowest 'equivalent' concentration of oxygen the subject might be exposed to if they travel to no greater than 10,000 feet (or a little over 3 Km) elevation. While we understand that the atmosphere is comprised of 21 % oxygen at ALL elevations, the partial pressure of oxygen at the altitudes simulated by the 17 % concentration is very close to equivalent at sea level or modest elevation, where the test is performed.


If the subject cannot sustain an adequate/safe oxygen saturation under HAST conditions, most doctors will then recommend and prescribe oxygen for in-flight use and for use during the high-altitude travel period. Or, as happens all too often, the doctor will simply forbid the subject to be able to travel under those conditions, or will divest responsibility for consequences if the subject decides to travel against the doctor's recommendations/instructions.


Best Regards,  Mark


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COPD Action Plan-Does Not Include Fever Symptom

I recall reading that it’s suspected that 50% of COPD exacerbations is caused by bacteria.  I would think that might mean (at least sometimes) that a person might run a fever.  BUT, on the COPD action plans for both the United States and the one from Canada, a fever is not included in the yellow/caution zones (symptoms area).  Any idea why it’s not included?

Thanks, Dell

A.  Hi Dell,

While some sources suspect and even estimate based upon some measure of data that exacerbations are caused by 'bacterial infections', the use of the term 'bacteria' is broad and encompasses viruses as one of those 'bacterial' sources.  Some of the culpable viruses do not produce fever as a symptoms, at least not initially and in many cases, even as infection advances to pneumonias.  Some bacteria that often produce fever in those who don't have COPD will fail to manifest the symptom in those who DO have COPD, again, at least not as an early warning sign.

Strange as it may seem, fever is NOT an obligatory symptom of infection - for those with COPD OR for even other ailments.  And, in COPD, when it becomes a feature it may be well into the manifestation of an episode/exacerbation.  Folks who are taking immunosuppressives, like prednisone, whose ability to develop fever is blunted, would not manifest fever on a predictable basis.

Ultimately, fever is simply not a prominent feature of much of the infection seen in COPD.  That's the main reason why it is not one of the listed warning signs, as you note. 

Best regards,  Mark

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What Medicines Are Available for COPD?

Hi Mark,
My Step - mother has COPD.   She was wondering what medicine was out there so she can ask her doctor about it to see if their is one she may not have tried yet. 

Thank - you


A.  Hi Dorothy,

Your question is very difficult to answer without knowing a whole lot more about the 'details' of your mothers illness and most importantly her level of severity at this time.

Generally speaking, COPD symptoms are what's treated with the various medications available.  Those medications include a group called bronchodilators - medicines that relax the bronchial tubes to improve the ease with which air moves through them.  There are two classes of inhaled bronchodilators from which 'usually' one of each class is prescribed. 

Another class of medications often used is inhaled corticosteroids - medications that reduce and inhibit inflammation and swelling of the tissues that make up the bronchial tubes.  Reducing that swelling also 'opens' up the bronchial tubes and helps ease movement of air into and out from the lungs (using less energy to breathe).  Inhaled steroids also reduce irritation that causes increased mucus production which further makes breathing difficult as well as serving to foster the development of infections that can lead to pneumonias.  Corticosteroids are also administered as a medication taken by mouth, in pill form, when it is deemed necessary and appropriate, at times.

When COPD becomes well advanced, the use of oxygen becomes increasingly necessary as more and more lung tissue and function is lost and one's ability to get enough oxygen into their blood from what is contained in the atmosphere becomes insufficient as a result of their impairment.  So, oxygen becomes a 'medication' that plays an important role in treatment of COPD in later stages.

There are other medications that have been introduced more recently that can address specific features of the disease for some individuals.  Leukotriene and phosphodiesterase inhibitor medications have more recently been introduced to treat patients in whom their use is found to be advantageous and appropriate.

The COPD-Canada website has a list of medications commonly used in COPD, if you wish to learn more about specific drugs and what they do.  Go to the website and look for " a guide for Canadians' which contains the following link to that list. 

Beyond this information, I cannot be specific to tell you what your mother should ask her doctor about as I don't know which medications she now takes or has taken to this point.  Her doctor likely will know best if there are medications available of which he/she has not given trial.

Best wishes,   Mark

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Concern re:  COPD, Coughing & Catching the Patient's Germs

I work with an annoying woman who says she has COPD and she coughs like crazy and she does not cover her mouth.  She is rude and obnoxious.  Is this a danger to my health being in the same room as her because of the COPD and the coughing?


A. Hi Robyn,

That is a tough one to answer.  If the 'room' is of sufficient size, any danger is commensurate with the air volume and exchange ratio of the room.  If she is coughing toward you, the less the distance between you the more you will be exposed to any germs in her expelled air and 'fomites' (particles expelled during her cough).  If she is actively infected, the danger increases commensurately with the two above factors.  The presence of cough in COPD (likely mainly Chronic Bronchitis, if cough is a prevalent and frequent feature) in and of itself is not the primary risk/problem.  It is when there is active infection that risk increases to those exposed to such a situation. And the mere presence of her persistent cough is not necessarily and indication that she has an active infection Thereafter, as with anyone - COPD sufferer or not - your own susceptibility to bacteria spread with a cough plays the key role in your susceptibility to contracted ailments.

COPD is not a 'contagious' disease.  So, there is no danger of you 'coming down' with it as a result of exposure to the consequences of her cough.  If you are a smoker or have other predisposition to developing COPD, yourself, then that would become a risk factor for you, specifically.  Generally speaking, the bacteria usually found in the airways of those with COPD will not necessarily be those for which you have the same degree of susceptibility, as folks with COPD tend to have poorer immunity to 'opportunistic' bacteria and infections (that is, bacteria which do not normally produce infection in healthy individuals).   

Are you able to diplomatically make her aware of her unprotected coughing and to let her know how annoying it is to you that, while you realize she can't help coughing so much, she CAN help the situation by covering her mouth and being diligent to keep her hands clean, so she doesn't spread her germs about when she handles things that others must touch.  Try keeping a bottle of hand sanitizing gel in plain sight and offer it to her, while using it yourself as often as you feel advantageous.  Perhaps she'll get the message and begin using her own source of hand gel to help ease your concerns and those of others.

Best Wishes,   Mark

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Chronic Bronchitis & The Lungs


Having just been diagnosed with mild COPD, I read with interest your article "Pulmonary Function 101". The article appears to address what happens to the lungs as a result of emphysema.. My COPD right now appears to be more of the chronic bronchitis type, although I realize that emphysema may be present or develop later.

Can you discuss what affect chronic bronchitis has on the lungs?

Thank you.


(Webmistress Note:  The PF 101 that is referenced can be found by clicking on the following link)  Pulmonary Function 101

A. Hi Jim,

Chronic Bronchitis and Emphysema are the two 'biggies' under the COPD umbrella.  For smokers, chronic bronchitis tends to be the predominant COPD component, though for the majority of those with COPD, it is rarely a stand-alone affliction and is in observed in combination with emphysema, as you correctly understand, which develops later as the result of loss of airways to 'remodeling' and destruction from inflammation and infection.

Airway remodeling in chronic bronchitis is a process wherein normal tissue components of the airways are damaged or destroyed, being replaced by scar tissue and other abnormal cell types.  Airways have underlying structural cells upon/to which the (predominant) surface cells are connected - cells like the primary 'ciliated columnar epithelium' (CCE) - cells that bear the cilia that move the mucus blanket as they beat rhythmically, 'sweeping' secretions toward the larger airways for expulsion (coughing, etc).  Interspersed at intervals are ducts connected to 'mucin' and 'goblet' cells that produce the components of mucus that blend to create the end/resulting substance that is in liquid form coating the airway surface and the cilia and transitions to the gel form as it is exposed to the air passing through the airways which removes water from the mucus. 

What we cough up is the transitioned liquid form that has become the gel form and is abundant enough to reach the larger airways, rather than being absorbed back into the bronchial tissue (as is most mucus produced, under 'normal' - non-diseased- conditions).  In the normal lung model, CCE are observed to be very uniform in size and placement relative to each other along the inside surface of the bronchial tubes.  Number of cilia and their beating action is very uniform, as well.  To see them in action is actually quite an impressive 'dance' with perfect rhythm and sequence.  That action is the result of the uniformity of size, placement and proper function of the CCE. 

Ciliated cells tend to become abnormal in size and number, with loss of and derangement in size and number of cilia.  As a result, if one observes the beating action in the airways of those with chronic bronchitis, they would see 'dysrhythm' resulting from loss of uniformity in size, number and placement of cilia, as well as loss of the uniformity and number of CCE due to abnormal growth and invasion of inflammatory and scar tissues among the remaining CCE.  One would also observe increased Numbers of mucin and goblet cells which as well, would be variable in size and placement.  Instead of fairly uniform sized cells, some would be normal and some would be increased in size, even to a degree that they are described as 'giant goblet cells', because they are so relatively large.  It is the proliferation of mucin and goblet cells (in response to inflammation and need to increase mucus production in the effort to more effectively flush the airways of debris and irritating substances) that is responsible for the increase in production of mucus that we see in Chronic Bronchitis.  Combine that proliferation and the increased 'amount' of mucus with the physical and functional derangement of CCE and you have the process that presents the conditions for the pathological variants we contend with in those with Chronic Bronchitis - infection, pneumonias and increasing difficulties in adequately clearing mucus from the airways.

Increased mucus production and the decreased efficiency of clearance set up the scenario for increased bacterial growth (mucus is made up of sugars, proteins and water and is in a nice warm and wet environment - very inviting to bacteria and their proliferation) which has its additional influences to perpetuate the difficulties and changes seen within the airways.  Bacteria release irritants/toxins that invoke inflammation and invasion by immune cell types that engage in war with the bacteria to kill them and thwart the inflammation.  Dead cells release yet other irritants and add solid debris to the mucus, further contributing to changes in its volume and character and so on.  As irritation destroys normal CCE and underlying structural cells of the airway, fibrotic/scar tissue replaces more and more of the previously normal cells further contributing to 'airway remodeling'.  And so, you can see how the process is cyclical and self-perpetuating.  There are yet additional changes in inflammatory substances that contribute yet more to the process and so it goes on and on.

Variants in the process result in some folks who experience production of large volumes of mucus and some who don't produce so much extra mucus, but in whom if tissue samples are obtained, the abnormal (metaplastic) changes in cell types and numbers can be seen.  so, just because one doesn't have abundant.over-production of mucus, does not necessarily mean they don't have Chronic Bronchitis.  

Treatment, then, is directed at reducing/eliminating irritants (smoking cessation, for one), attention to clearance of mucus to reduce 'stasis' (settling and retention) of mucus and invitation to bacterial growth and infection and treatment with agents to reduce the inflammatory process, as well as to enhance increased diameter of the airways to aid in more normal flow of air through them.  Active bronchodilation with the familiar inhaled medications and use of steroids - both inhaled and taken orally, etc. - to reduce inflammation/swelling of the tissues is another tactic employed. 

That, in a nutshell (though, maybe a large nutshell) is the Chronic Bronchitis in simplified terms.  It really is a complicated and multifaceted process - which is why it's so difficult to sort out and create interventions to counter the process.  That is also why it take so many different kinds of medications to attack the process and why one or two alone, cannot do much to affect the whole process.  And there are still several major components of the process for which we have yet to discover and develop effective interventions.  What research continues to provide is yet greater and more detailed information/knowledge of the 'cascade' process that causes and perpetuates Chronic Bronchitis.  As time passes, we gain greater understanding of what is going on and what leads to potential points on which to concentrate future treatment efforts.  But, it's like lifting a rock and continually uncovering new secrets hiding beneath that rock  - - - and the next one under it and the next one and the next one, etc.

Best regards, Mark

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Accuracy of Finger Pulse Oximeter Readings & Exertion

Perhaps this has been addressed but I can't find the answer :)  Now that summer is here and am working in my big yard (425 ft deep on a slight hill), I find when I walk uphill and come in for a break every 45 min or so, my SpO2 can be anywhere from 88-91 with a heart rate in the 140-150 range.  I do practice PLB while working, especially if I have been dong a lot of bending over.  Within 60 seconds both numbers start to improve to SaO2 96 and heart rate 120-130.  I think you have said that you need to let the oximeter settle down for 40 seconds or so.  Am I right that this transient reading is of no significance?  My last PFT FEV1 pre/post was 48/52 and DLCO remains at 30.  Thanks for explaining this again


A.  Hi Doris,

The 40 second stabilization suggestion is a 'general' rule, especially when one sees fluctuation that is significant after initially placing the oximeter at start-up.  If no significant fluctuation is observed - saturation and heart rate remain reasonably stable, even with the "gradual" increase in SaO2 measurement and decrease in heart rate, then - looking over your shoulder, you can assume that the initial readings were fairly accurate.  What you relate sounds like in your case, the measurements come in accurately almost immediately.  So, the 88 - 91 % and 140-150 heart rate are likely the actual case.  One trick you can do is to count your pulse as you head for the house and see if your heart rate counts near the same range as you observe when you place the oximeter.  If that is the case, you have more information to indicate that your measurements are reasonably accurate from the outstart of placing the oximeter.  Another point to consider is that if you are relaxed and still when you take those measurements, then they are more likely to come in accurately sooner than if you were moving around.

All in all, it's great that you're working to get your heart rate up and receiving the benefit of the conditioning that working in your yard imparts.  At 88 - 91 % as lows, you should not be hurting yourself, as long as you can continue to contend with the added breathing discomfort and still exert.  The benefit outweighs the risk, in your case.

Keep up the good work!

Best Wishes,         Mark

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Hydrogen Peroxide Treatments

I suffer from very severe Emphysema and I have been reading several articles recently on Hydrogen Peroxide treatments, what are your views
on this subject?.
Thanking you in anticipation.


A.  Hi Tony,

Stay far, far away from any of the H2O2 (peroxide) interventions.  They will do NOTHING good for you and could easily inflict harm.  There is not a shred of empiric evidence that H2O2 does anything beneficial for lung diseases of any kind. It is the proverbial snake oil.  There is plenty of mainstream warning regard H2O2 therapies.  So, dig deeper and look for the words of warning.  As well, consider that if H2O2 truly held any potential benefit, it would be a mainstream treatment and legitimate health care professionals/doctors would be using it commonly. 

Best Wishes, Mark

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  Serratiopeptidase (as an Anti-Inflammatory)

Have you heard about  Serratiopeptidase and can it help to clear the lungs. I have a friend that takes it for back pain and he thought it might help. Of course I would not try it without consulting my Dr and pharmacist

Thanks for all your good info

A.  Hi Roly;

Serratiopeptidase (Serratia E-15 protease) is a proteolytic enzyme that has been touted for over 40 years as having anti-inflammatory, anti-edemic and fibrinolytic properties that in effect change the viscocity of mucus from the 'nose to the toes', so to speak.  There are some pretty wild claims on various easily accessed websites.  Wikipedia has a petty good write up on it, conveying skepticism of it's benefit, with one manufacturer of a preparation deciding to pull it from the market for lack of evidence of its claimed benefits.  Some claims of benefit that clears out bad tissue allowing the body to 'replace' it with functioning tissue, thereby improving pulmonary function are likely without merit as no drug or substance has been demonstrated to actually accomplish that process in that manner, to date.

While it appears to have undetectable negative action and consequences, it lacks proof of effectiveness beyond what have been called poorly controlled trials, anecdotal evidence ('testimonials') and lack of randomized, placebo-controlled trials, in reviews of the literature as recent as 2002.  If you think you would like to give it a trial, I would definitely recommend you discuss your plans with your doctor, as you say you would do.  If between you two, you decide to try it, that would be up to you and your doctor.

There are other better studied approaches to reducing inflammation that accompanies COPD, with NAC continuing to hold a place as a better studied substance with more likely anti-inflammatory benefit.  My chief concern about serratiopeptidase is its fibrinolytic effect which causes blood thinning and reduced ability to clot.  While none of the easily accessed information suggests bleeding problems as a common or frequent side effect AND state it has been used expressly for that feature, it is a point of concern that should be addressed and monitored by your physician, should you decide to use it, especially if you take other blood-thinning medications or NSAIDS/Aspirin.

Best Wishes,                                    Mark

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Order of Meds & Frequency of Ventolin

Hi Mark,

I am stage 3
I am On Foradil Spiriva and Ventolin.
I take the Foradil every 12 hours and 2 hours later the Spriva every 24 hours. in the morning at 9 and 11.
Around 6pm I get   SOB just moving around the house so I take ventolin but it doesn't seem to help.
Should I be taking the ventolin more than once a day. What order should I take the medications.
I was on Spiriva and Ventolin before , but I was getting sob all the time so the Dr. gave me Foradil
which helped quite a bit. I don't wake up sob anymore. When I do get sob I sit and do plb which helps.
Thanks Elaine

A.  Hi Elaine,

I would suggest you take your morning Spiriva between 10 and 20 minutes after taking the "Foradil", so that you get the little bit of synergistic effect that taking them close together provides and that is missing when you now take them two hours apart.

You certainly may use the Ventolin more than once a day, if needed.   Be sure that you don't take any Ventolin within two hours BEFORE you are scheduled to take the Foradil.  That way you can maximize the effect and benefit of the Foradil.  Understand that Ventolin is not a cure all for ALL SOB.  If the Ventolin doesn't work when you use it three times between Foradil doses, then you should call your doctor and seek evaluation.   Something acute might be trying to brew.

Best Wishes,Mark

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CO2 Reduction Exercise & Bullous Surgery

Hello Mark,   I have emphysema and on oxygen for 5 years now all day and at night with a BiPAP. In 2006 I had my last hospital stay, 2 days in the intensive care and 7 days in ward after having an infection and Acidosis.  When I was in hospital my CO2 was not lowering and so I was given a plastic bottle two thirds full of water and a piece of oxygen tubing stuck through a hole in the top of the bottle.  The pulmonologist told me too blow all I could during the day through the bottle as this would help reduce the high CO2.  I did this religiously in hospital and at nights used the BiPAP.   I was told to continue with the bottle 15 minutes every hour when I went home.  Well five years later I still do this exercise, always in the afternoon when I'm more relaxed watching TV.  My FEV1 was 4 years ago 2.8, but now it's 2.4 to 2.2.,  It seems to be going down quickly.  Could this blowing into the bottle now not be beneficial to me.  I have not been in hospital since then, and had infections which have been cured at home.  The action of blowing through the tube into bottle seems to be the same as pursed lipped breathing, perhaps a bit stronger. Could this action repeated many times every day be destroying the aveloi  more. I already have bullus one of which is 10 to 11cm in diameter.  I have asked my pulmonologist  here (who is not the same doctor who set me this exercise in hospital,) but I get no concrete answer.  I would be grateful if you could help me know whether continuing with this is not such a good idea, I've been doing it for 5years.   I do not have any mucus problem.  Thank you,    Joan

Hi Joan,

Wow, you have worked hard to keep in the shape you have managed to maintain.  What dedication!

First, you told me how your FEV-1 measurement has declined, BUT, not the percentage of predicted it represents.  While I'm pretty sure you've lost some ground on the percentage of predicted consideration, I suspect that it is not terribly significant considering that you have significant bullus formation that is likely increasing.  You've lost approximately 100 ml of FEV-1-per-year over the four years which is fairly close to what might be expected under relatively normal circumstances (though you did not mention your age to put it into better perspective).  2.2 L for FEV-1 is still pretty good, all things considered, though, again, without knowing your age and height, I don't have anything to compare it with to know what 'normal' would be for you. 

That you are on oxygen for this long period AND using BiPAP for ventilatory support interjects a bit of mystery, since I suspect that most folks with your FEV-1 would not normally require oxygen at this point in their disease.  So, I suspect there is more to your condition than simply emphysema with a bullus disease component.  Yet, a bullus of 10 - 11 cm is huge and can account for much in your current condition.  So, it may not be such a surprise after all that you require supplemental oxygen.

I wonder if you might be a candidate for bullus reduction/removal or wedge resection lung volume reduction surgery, if it is even an option for you where you live and under your health coverage.  Have you asked about that possibility?  It might be worth investigating as it could improve your FEV-1 and overall ventilation and perfusion matching, ultimately improving your gas exchange, even reducing your need for oxygen, if not eliminating it, altogether.

Insofar as your question about the resistance breathing exercises, I seriously doubt that any harm may be occurring, at least not that outweighs the benefit you derive.  Between the gentle pressure you are blowing out against, which should be maintaining as much of your lung that can be kept expanded and functioning, the simple act of the vigorous breathing that goes with the exercise has to have contributed to the decent lung function you have been able to maintain. While I doubt the device and the expiratory resistance you exhale against are doing much if anything to alter your CO2, again, the action of the breathing that goes with the exercise certainly lowers your CO2, acutely, for some period off time associated with doing the exercise.  So, I wouldn't recommend ceasing it without considerable discussion with your doctor and his agreement that it would be a reasonable course of action. 

All in all, it seems you are doing the right things to help yourself maintain the best lung function you can with what you have to work with.  I would again mention checking into bullus reduction or wedge-resection lung volume reduction surgery, which ever might be appropriate for your particular condition to see if it has potential for improvement for you at some point.  It is not a procedure without risk.  But, if/when the potential benefit becomes greater than the risk of any complications, you might want to consider having it done.

 Keep up the good work, in the meantime!

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SPO2 Reading of 93, Short of Breath, Potential CO2 Retention


Would I be right in assuming that if person with COPD had  an spo2 reading of 93 or so and having trouble breathing, would it probably be C02 retention?  I realize the only true way is an arterial blood gas test but if a person presented themselves to an ER under those circumstances, would they normally do an ABG test?

Thank You, Dan

A.   Hi Dan,

I would change your "would" to "could" and tend to agree with you.  Elevation of CO2 can certainly be responsible for the 93 % saturation you suggest, though, as you stated, only a blood gas can confirm that it is indeed the cause.  And, I would say that , "Yes," a blood gas test should be done and likely would be done if one presented to the ER with breathing troubles and a saturation of 93 % while at rest. 

Best Wishes,  Mark

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Multiple:  End Stage COPD, Lung Transplant, Living  With One Lung

Dear Mr Magnus,
My question is this:  What are the final stages of COPD?  and  Can these people have a lung transplant?  and  Can a person  live with one lung?    Thank-You. 

Sincerely Sandy

A.  Hi Sandy,

I'm not sure what you are asking when you say "final stages" of COPD.  The Global Initiative on Obstructive Lung Disease has classified COPD into dour stages of severity according to measurements of pulmonary function.  You can read more about the staging and definitions of severity at:

People who are evaluated and found to be suitable candidates for lung transplantation include those with very severe COPD, especially if they are considered unable to survive for more than a year or two without undergoing transplantation.  It is certainly an option for those with very severe COPD, should they choose that treatment path.

People can live quite nicely with one lung and many do.  While some folks who have had a lung removed do have 'maximum' exertional breathing limitations, they function and breathe quite comfortably while doing normal daily activities - as long as the remaining lung is healthy and functions reasonably normally.

Best Regards, Mark

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Dramatic Variations in Breathing & Decreased SPO2 & BiPAP


Me again Mitch. How can a person with COPD have a great day, everything going good. You go out for a little drive then bang on their way home labouring for breath. My husbands day was just like any other day nothing different. This has happened a few times. He gets home and his stats are down. He goes to bed with his BiPAP and within a few minutes his stats are normal. Is it because he is a CO2 retainer and his lungs just have too much in them??? I am trying so hard to have Fred with me as long as I can.

Thanks Mark,    Mitch

A.  Hi Mitch, 

Without a blood gas test, no one can tell if elevated CO2 is a problem or the cause of Fred's difficulties.  It is no surprise that BiPAP will raise his saturation to normal within a few minutes, regardless of what causes the drop in saturation..  Whether or not it was decreased due to elevated CO2 levels can only be determined by doing a blood gas test under very specific conditions.

As you are seeing with Fred, for some folks, COPD presents a lot of difficult to explain circumstances.  All you can do is roll with the punches and appreciate the time you DO have with loved ones.

Best Wishes,  Mark

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 COPD & Multiple Health Issues (Comorbidities)

My son-in-law is 51 he has sleep apnea, copd.  He is on a trach and humidified oxygen and a Biped machine at home.  He is obese and he won't leave the house.  He feels he doesn't breath as well leaving the house or he may quit breathing.  He is depressed not being able to leave and about his weight.  He was in the hospital and we almost lost him 3 times, they put him on a vent and was planning to move him to a different hospital in a different state that can handle long term vents and that can work on getting him off.  His Co2 was so high.  As God chose to bless us and him he was determined to get off the vent.  The drs. were shocked, but pleased.   He also is diabetic.

He has a dental problem but he won't go because he is afraid if something would get down the trach and with his oxygen on how can they work on him!  So he won't go. 

He wants to lose the weight but  sitting at home 24/7 isn't helping.  Not moving around other than getting up to the bathroom and getting something to eat is his only exercise he has. When he does move around he feels he can't breath as well.  I know that if he doesn't move around and get the blood flowing and lose weight he will never get off the trach and he will deteriorate.

Is there help out there for someone to come to the home and give him some exercises he can do to help him  or what can we do to let him know to do?  I know walking and maybe when he is sitting he could do leg and arm lifts or something.


A.  Hi Vicki,

Your son in law  is in a difficult predicament, the resolution of which you stated in your information and story about his plight.  As I do not live in Canada and am not familiar with what resources may be available to him, I'm at a loss as to what to suggest.  But, from where I sit, there is nothing I can suggest, specifically, that you haven't already said is necessary.  All I can suggest is to talk with his doctors and see what you can do to get him the help he needs to move toward a healthier situation.  You are right.  If he doesn't get help and get moving, he will continue to deteriorate and likely lose his life at a much younger age than is avoidable.

Best Wishes,  Mark

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PFT Review/Analysis

Hi Mark,

I am 36 years old and my Doc told me I have early COPD. He took a chest xray and said that I was trapping air. He said it is Chronic Bronchitis and not emphysema. I got very anxious over the next few days and went and saw him and he put me on Prednisone for 5 days to take the swelling down. I had one day left on my pred before my PFT but I took it after the test. I did have bronchitis about a month and a half before all this. I can run and do the Coopers fitness test and I score average. I could have gotten a Good rating if I pushed my self harder. I did not smoke for very long, maybe 3 years total but grew up in a home with smokers. It seems that I get phlegm when I eat certain things. I also fell heavy chested sometimes in different weather. I do have allergies to some foods and to seasonal factors. I did go for a PFT about 9 years ago and the doc said that my lungs didn't fully develop when I was a kid and to not smoke.

My test results are attached. Can you please let me know how bad my situation is and if I do have COPD.

Thanks in advance,


A.  Hi Mike,

While you might be having some difficulties with acute bronchitis and perhaps some component of asthma which may be showing some air-trapping on x-ray, the prednisone and other treatment which you have undergone seem to be effective to resolve your difficulties.  Your PFT's are within normal limits and are the most important measure of whether or not you have any significant problems with lung disease.  with such a brief smoking history AND at your tender age, I would not worry about COPD for many years to come, if at all.  If you continue to have recurrent bouts of bronchitis and/or asthma, you might look for further evidence of developing lung disease.  But, at this point, you are doing well.  Why you were told that your lungs did not fully develop is beyond me and, IMO, simply not true.  If that were indeed the case, it would be reflected in abnormal PFT measurements, which you simply don't have.

Continue to live a healthy and active life and you should be fine for many years to come.

Best Wishes, Mark

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Meds, LVRS


Hi Mark

First of all I must say that this is a great page and is really helpful and informative. Many thanks.
So I was diagnosed a little over a year ago, Fev1 23% when I took myself to hospital with breathing
difficulty/congestion/pneumonia after foolishly doing some work in a dirty dusty attic without a mask.

My own doctor had already told me that there was nothing wrong with me when I suggested to him that I might
have copd. Got a new doctor now :)

I am using spiriva tiotropium  and ventolin salbutamol. I feel that the spiriva is doing nothing for me to help me to breathe
more easily, I have tried taking it at different times and holding off using the salbutamol to give it a chance to work but it
is really only the salbutamol that gives me any relief, I find it wonderful for helping me to breathe and stopping my chest
feeling so tight, I seem to need it every 4 hours or so or I start to get out of breath just moving around the house.
Do other people find spiriva useless ? I have read a lot about people saying how good it is for them.

It is several years now since I stopped smoking, I feel very well apart from the SOB, I take my vitamins, omega 3, NAC, ginseng and cordyceps. I am not on O2. Are there any other meds that I could benefit from taking. I am 60 years old.

I hope they hurry up with the stem cell research. Would LVRS help me ?  Any other surgery, I did read that some ops
were being carried out on airways such as stents and re-routing to help expiration. I am in the UK.
I have just passed the fit to fly without supplemental oxygen test :)

Thank you again for all your time and effort here.




Hi John,

Tiotropium is a very good medication.  However, because of the way it acts, you cannot "feel" it working like you can your Salbutemol.  The Salbutemol works on a 'nervous' pathway that makes one 'feel' it working.  Spiriva does not work on that same pathway.  Instead, what folks notice is that they find they can do tasks that were more difficult to do before taking Spiriva, much easier once they've been taking Spiriva for a few weeks and months.  We can also measure improvement in pulmonary functions tests that may not necessarily be 'felt'.

If I made any suggestion it would be that you should ask for a "long-acting" form of the medication Salbutemol.  Salbutemol is a short-acting drug, which explains why you must take it every 4 hours.  Medications like Salmeterol and Formoterol will last 12 hours and might offer you greater benefit, especially when combined with the Spiriva.

Lastly, you should take the Salbutemol and Spiriva close together,  Take the Salmeterol and follow it with the Spiriva within five minutes, or so  Of course, you still only take the spiriva once a day.  So, take it with your first morning dose of Salbutemol.

With an FEV-1 of 23 %, I am surprised that you say you do not need oxygen, especially when flying.  Your FEV-1 is awfully low and in a range when most folks have at least some amount of exertional desaturation.  I suspect you need further more careful testing to determine if that is indeed the case.  I'm wondering what kind of test was done to determine if you need oxygen for flying or not.

If you are interested to see if LVRS might be an option for you, you should go to a center that does the procedure and be evaluated to see if you're a good candidate.

Stem cell research for application to humans is still in very early stages, but shows potential promise.  It will be several years before we see clinical trials, though.  So, it is not something I would encourage you to hold out for.

Best regards, Mark


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Why "NON" Exercise Before a Breathing Test?


Before having a PFT, why do they oft times tell a person not to exercise heavily beforehand?

Thank you for taking my question.



Hello Felix, 

The caution for one not to exercise strenuously prior to undergoing PFT testing is two-fold in purpose:

(1) Exercise can bring on asthma - EIA = Exercise-Induced Asthma - in those at risk for this problem.  The purpose of the PFT testing for these individuals is to determine if they have EIA and how severe it might be, as well as how well and to what it responds, in terms of reversal.  If they exercise before having a PFT and bring on EIA, they will likely have to treat it with a bronchodilator, skewing the subsequent testing, both for presence and severity determination and for response to reversal.

(2) In view of the above, it is a safety concern.  Those individuals who are suspected of having EIA and who have not received bronchodilator medications before undergoing PFT's could put themselves in serious trouble by exercising hard before having a PFT - and that may be from the time the test is ordered until it is actually performed.  So, the caution could pertain to days or weeks of duration until testing is done and intervention, if found necessary, can be put into place.

When EIA is the reason for testing, exercise is a part of the PFT and bronchodilators are part of the intervention to test response.  So, the PFT, itself, will entail exercise as part of the testing process.

Beyond that, for others who are known to be ventilatory-limited, the fatigue factor of exercising to a point that is, for them, considered strenuous can cause under-performance on their PFT's, again, skewing the results.

Another reason, though not often the case, considers that if a blood gas is done as part of the PFT, they may also measure blood lactate as part of the process.  Blood lactate levels can remain elevated from baseline for hours after exercise.  So, that might throw off measures of what is supposed to be baseline. 

The most prevalent cautions we almost always give is for folks to hold off use of inhaled bronchidilator and sometimes steroid medications.  We usually will do measurements of some of the tests before and after administering a bronchodilator, in which case, we want as little medication/influence from what is the 'usual' routine in the system so as to better measure the true response of the airways to broncodilators.

Best Regards, Mark


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Ongoing Lung Infection

I live in the Uk, in the country and am retired, my COPD was diagnosed in 2000, I have had an infection since the beginning of April spent 8 days in hospital been out a week and coughing up plugs now back on LEXOFLAXIN 1000 MG A DAY how long would expect this to start to make a difference, I am beginning to give up, I have done rehab and have managed my condition well but since this infection I am really getting more and more depressed.


Hi Marian,

Your frustration is understandable and not unique.  While all seems never-ending at this point, rest assured, that virtually all infections DO come to a resolution. 

Generally speaking, when multiple courses of antibiotics do not seem to clear up and infection, one can surmise that the infection is likely caused by a virus.  Viruses do not respond to antibiotics.  And only those for which there are effective anti-viral medications will respond to treatment.  Instead, they must run their course with treatment confined to symptom control and reduction where possible.  It may be that this is the scenario you are faced with at this time.

Another possibility is that while you have felt rotten for several weeks AND it certainly may have begun as an infectious process, what you continue to contend with is 'not' infection-related, but rather, is an ongoing exacerbation of your symptoms triggered by the initial infection and continuing to plague you these several weeks later.  You could be more deconditioned now than you were when this episode onset, owing to the imposed sedentary life style you likely have experienced due to your sickly condition.

In any case, if 'any' antibiotic doesn't effect improvement within 5 to 7 days, then it is likely that the infection, if indeed present, is not susceptible to it.  In that case, changing antibiotics would be a course of action to consider.  What does your doctor think?  Are you also on oral steroid therapy?  While steroids will not thwart an infection, they can help to reduce your breathing symptoms.

Ultimately, I have to say that for having been diagnosed 11 years ago and having done well for these many years, you are doing well to have done so for this extended period of time.  It could be that your disease has progressed significantly over this time and that your symptoms may be related to that advancement, rather than solely to a current infection.  As you do not indicate what your FEV-1 is, I cannot tell more than what I have suggested, at this point. That is little consolation, I realize.  But, this is the frustrating territory that folks with COPD traverse as their disease progresses.  Hopefully, it will resolve soon and you'll be back up to par, as much as your disease severity will allow.

In the meantime, as difficult as it is, your best course of action is to try to keep moving - even exercise - as working through the difficulties and gaining conditioning will go a long way towards helping you fight this current battle.

Best Wishes,


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Overuse of Oxygen Q.

Can anyone  overuse home oxygen?



 Hello A.M.,

The 'nut shell' answer to your question is an emphatic "No!"  What we see more often is folks NOT using their oxygen enough!

That said, there are those who would argue contrary to what I've said, for a number of reasons which I could dispell.  Some believe - without any empiric evidence to support their contention - that avoiding using oxygen or using enough oxygen to 'normalize' one's saturation will somehow 'toughen' them to the throes of hypoxia.  To that I would argue that plenty of empiric evidence shows that failure to use oxygen in the face of desaturation hastens the development of right heart compromise and failure and indeed, as statistically well demonstrated, shortens survival.  Some go on to suggest that you should only use enough oxygen to raise your saturation to 88 - 90 % and that raising it any further is both unnecessary and by some arguments, dangerous, leading to negative consequences.  Neither argument has strong support from the body of evidence we have gathered to date.  As such, they represent notions based in unproven and questionably accurate theory. 

After that, strong argument can be made regarding the issue of "comfort" with regard to breathing symptoms.   It is well documented that the difference in comfort level and therefore, the ability to sustain and better tolerate activity of increasing intensity is greater when oxygen saturations are closer to normal levels than when they are raised only marginally to 'safe' levels with regard to sustaining organ health and function (the heart, in particular and also the brain).  Richard Casaburi and others have nicely demonstrated that fact in several well-designed studies reported since 2003.

Some argue that "over-use" of oxygen - which, by the way, is defined by them in many different  and incongruous ways - will lead to "addiction" to oxygen, meaning that the addicted user will then use oxygen when they can be defined as not needing it.  Yet, such addiction is NOT considered a physical phenomenon.  Rather, they define it as purely psychological, again with inconsistent criteria as to what that psychological addiction condition entails or by what it is identified.  Again, I suggest, as does the available empiric evidence, that this notion is falacious and unsupportable.

The bottom line is that if you desaturate significantly under various conditions and are prescribed oxygen, then you should use it appropriately to avoid those instances when your saturation would otherwise drop to unsafe levels.  If you own an oximeter and can monitor your saturation so as to adjust your oxygen to meet your needs, all the better.

I hope this answers your question and your curiosity, as you did not attach any qualifications or conditions to your initial and short question.  If you have more specific concerns, come back with a question (questions) addressing them.  I'll be happy to explain further.

Best Regards, Mark

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BiPAP's & Co2

Loved the explanation ( Understanding your Lungs.) Can you explain to me what a BiPap does in getting rid of the CO2? I have noticed over the last four years, that when my husband seems to be short of breath or just not feeling good he puts on his BiPap and he does feel better. I am not saying his BiPap is saving his life but I am saying it helps him feel much better. Do you know if the BiPap is getting rid of all the CO2 or is this something that can only be told thru a Blood Gas. I just love reading all the letters ppl send in. The questions help me understand COPD more and it helps me understand how to make my husband feel as comfortable as possible.

Thank You

A.  Hi again, Mitch,

The BiPAP does indeed "blow off" CO2 ONLY during the time it is in use.  Whether or not that CO2 is excessive - that is, greater than normal levels - can indeed ONLY be determined by doing a blood gas test.  Insofar as BiPAP or any other ventilatory supportive maneuver getting rid of "all of the CO2", I would caution you and everyone else to understand that NOTHING ever gets rid of "all" one's CO2.  Even under normal circumstances, we breathe/ventilate a given amount per unit of time in order to keep CO2 levels at a fairly constant level/partial pressure in the blood - specifically 35 - 45 mmHg - when measured on a blood gas.  CO2 is a by product of metabolism.  As such, as long as metabolism is going on, CO2 will be produced.  Without this condition one would not be living/alive!

Your hubby uses the BiPAP because it augments his respiratory efforts and reduces his work to breathe.  That is has any appreciable effect on his CO2 may be arguable and again, cannot be ascertained without doing a blood gas.  Even if it momentarily shifts his CO2 to a lower level, the effect occurs ONLY during the time that he is using the BiPAP.  Once he stops using it, his CO2 level will return to it's pre-BiPAP level within minutes and remain there, though he may "feel" more comfortable and feel better for having used it.  Yet, that is not a bad thing.  If he has the ability to use the BiPAP and it helps him feel better - especially if that feeling is sustained for significant duration after its use, then one would be hard-pressed to argue against its use.  So I would encourage him to continue, especially if its use will help him be more active.

Best Regards, Mark

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Daxas,  PFT's Causing Black-Outs,  Lung Sounds (or not)

Hi Mark,

There have been some asking about " Daxas ", and I was on it for about 2 weeks and had to stop. It seemed to effect my pulse rate. Just walking around with little exertion was 145/  . Also in general I just felt " Rotten ". I did try to take 1/2 a tablet each day, and it was not much better.
For me it was not the correct fit. I have heard that many can not tolerate Daxas due to the side effects.
My pulmo has decided not to prescribe it anymore.. Too Many problems with it.

I was told Mark I do not have to take anymore PFT tests. I have a problems with breathing out with force as it makes me faint. It seems to effect my " Vegas " nerve in my neck. When feeling faint at the beginning of the test I do not breath out with sustained  effort, therefore the number showing is incorrect. Last time I had to be revived with " Smelling salts ".

My pulmo was most pleased with my last visit ( 3 days ago ), as my lung according to him were " Clear as a bell ".

Thanks Mark for all you kind assistance in the past, and best to Kim and family.

Regards Philip

A. Hi Philip,

I didn't find a question within your missive, so I'll make a couple of comments on your points, if that's OK. 

Roflumilast does have some nasty side-effects for may who use it.  It has a more limited application than I think it has been prescribed for.  While I don't like to see physicians swear off its use completely, I would like to se more of them learn more about for whom it is more specifically targeted.  When folks who use it DO realize benefit, it is dramatic in many instances making it a drug of value for some.  It just needs better help in finding its appropriate audience, so to speak.

In regards to your problems with passing out while performing the maximal exhalation maneuver during a pulmonary function test, I would point out that the vagus nerve is NOT in your 'neck' as you stated.  It is in your chest.  But, while part of your problem may indeed relate to the "vaso-vagal" response, it is reduction in blood flow to your brain that ultimately causes your blackout.  That is a function also of increased pressure within the chest that slows blood flow to and from the brain.  It is unfortunate that you cannot tolerate the procedures required to produce a quality PFT as without it, ALL assessment and treatment is speculative.  But, there ARE folks who, like you have that very reaction to performing the maximal exhalation maneuver making them more difficult to manage without the PFT data to guide us.

Lastly, while having clear lungs on auscultation is always a good thing, I would caution that in and of themselves, negative findings on auscultation are not uncommon in COPD as with airflow being progressively reduced and breath sounds dependant upon sufficient movement of air so as to create the 'noises' we listen for, the reduction or absence of those 'noises' can have both negative and positive implications.  It is apparent that you are doing well, at the moment.  So, for that we should be very appreciative.

Thanks for your kind thoughts for my family and my Kimmy.  She is doing well, working at her job in respiratory care at the affiliated children's hospital at Vanderbilt University, in Nashville, Tennessee.

Best regards, Mark

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Daxas - Right Decision?

I saw my doctor recently and she had a sample of "DAXAS".And asked if I wanted to try it .  I had read about it Roflumilast and knew it had been used in Europe for some time ,so even though she (my  doctor) told me about all the possible side effects I decided to try it !! Was my decision right or not ?? Thanks !!


A. Hi Ken,

I wouldn't characterize your decision to try Daxas as "right" or "wrong".  It 'shouldn't' hurt to try it.  You will either find that it helps or does nothing or that you have side effects that make it not worth continuing.  If your doctor felt it was worth a try and gave you samples, that should say a lot about what she thinks of the potential for it to benefit you.

Best Wishes and I hope you find it beneficial!


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Have had COPD for officially 10 years now.    Recently I have spent some time looking into using MSM 1000 mg caps for improving my breathing.
Do you have any other info or experience on this product and it's use by people like us??
Sure would like to find something simple to help me out.    Am on Advair, Spiriva and ventolin of course.    Have reduced my time on O2 by about 45% over the last 3-4 months.    Not sure what is working or why.     Just need a little bit more and I'll be set.
Thanks  for any help or info you can give.


A.  Hi John,

Dietary supplements used for medicinal purposes entail many potentially slippery slopes for those who look for much in that regard.  While I am versed to some degree in a number of dietary supplements and indeed use some myself, I caution others that I can only share "non-professional" or "un-official" information with them in regards to dietary supplements and hesitate to recommend their use as a general rule.

Having said that, it is my understanding that MSM is touted for improved joint and connective tissue health and would have nothing specifically to offer for lung health.  At the same time, NAC (N-Acetyl Cysteine) has received a fair amount of controlled study by mainstream scientists and facilities and has been shown to be beneficial for a couple of different aspects of lung function.  First, we know it is a powerful antioxidant.  Secondly, for those with lung disease, it seems to help loosen/liquefy and mobilize mucus for easier clearance from the lungs.  Thirdly, NAC stimulates the increased production of glutathione in the lungs, a substance that has several beneficial actions among which are anti-inflammatory action.  So, it would seem to me that if you wish to take a supplement that has some known benefit for the lungs, then NAC would be the better choice as I am aware of no empiric study of MSM in regard to lung health or function.  If you are interested, consider taking 1200 mg NAC per day along with 2000 mg of Vitamin C which counteracts the body's tendency to metabolize NAC and form kidney stones in the process.  The Vitamin C reacts with the byproducts of NAC metabolism and prevents formation of kidney stones while imparting yet other benefit.   

I will close with strong admonishment for you to check with your doctor to be sure it is safe for you to take ANY supplements and for you to specifically take NAC and increased doses of Vitamin C, BEFORE you embark on any trial of either.  MSM, shouldn't hurt you to take, even with NAC and Vitamin C.  But, again be sure it's OK and that you collaborate with your doctor on your course of treatment - even if he or she doesn't fully support or approve of your choice of intervention.

Best Wishes, Mark

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Infrared Saunas - Safe to Use?

Is it safe to have Infrared saunas if you have COPD?  The gym I attend allows a 10 minute session.  If so, what is a safe temperature?  Thank you.

A. Hi Marilyn,

Having COPD, in and of itself is not a contraindication to being able to use a sauna.  And, I don't know of any specific safety issues with infrared saunas in regard to lung function and health.  I cannot tell you what would be a good or safe temperature for you as that depends upon your type and severity of lung disease and how you respond to breathing hot air and high humidity.   Only you can be the judge of that.  Ask your doctor if he/she sees any contraindications to your using a sauna of that type.

Best Wishes, Mark

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Stem Cells ..... To Do or Not

Hi Mr. Mangus,
My father has COPD. He was recently in Mexico and met Dr. Ron Rothenberg from Encinitas, CA and they had a conversation about stem cell treatments for COPD. Dr. Rothenberg is involved in stem cell collection and treatments. The treatments would take place at his clinic in Tijuana, Mexico due to the prohibitions on stem cell manipulation in the US. I've done some googling about stem cell treatments for COPD and am very skeptical. It seems that there may be a few clinical trials that have been recently concluded but I haven't been able to find any information on the results of these trials.
Do you have any information on stem cell treatments for COPD or any idea where I could find that information? I am also interested to hear if you have an opinion on this. Have you heard about successful stem cell treatment of patients with COPD? Do you know if this is being done anywhere in Canada?
Thanks in advance for your advice. I want to ensure that my father isn't being sold snake oil.

A. Hi Judy,

MD or not in the US, there's something more to be said and concerned about than the restrictions on stem cell therapeutic applications as a reason why he is doing his interventions in Tijuana!  All of the reliable and official sources here i9n the US caution against virtually ALL therapeutic applications of stem cells that are not currently approved by the FDA or under legitimate clinical investigation.  Your concern is well-placed.  I would recommend against your father wasting time and money on it NOW and until specific benefit has been discerned and substantiated!

Best wishes, Mark

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 Breathing Tests  Are Within Normal Range;  But Still Having Symptoms

I have been trying for a very long time to find out what is causing my shortness of breath on exertion and dry cough. Elevated pulmonary pressures of 51(3 months ago) seem not to be the problem as I had a right heart catheterization two years ago for a pressure of 48. It was normal.
  here's my PFT values last March:

FEV-1 of 2.82L (98% predicted)
FVC of 3.36L(99% predicted)
VC 3.45 L(100%)
TLC 4.65L(92%)
RV 1.2L(76%)

I had them repeated 2 weeks ago:
FEV-1 2.65L(93%)
FVC of 3.13L(93%)
VC 3.15L(92%)
TLC 4.24L(84%)
RV 1.09L(69%)

The pulmonologist reading the last one said that all were within normal limits but the decline was "age related". I am a 47 year old female.  Does this make sense to you? The RV seems quite low.  Is that significant at all? I know the DLCO being normal is really important.


Hi Lori,

Hmmmmmmm.  You present an interesting and possibly perplexing scenario.  Your complaint is SOB on exertion and dry cough.  Your FVC and FEV-1 are indeed within normal limits as are your VC and DLCO.  However, normal as they may be individually, when considered with your at least, two-year history of elevated pulmonary artery (PA) pressure - now having reached clinical significance, at 51 - your reduced RV and TLC (the TLC still being within normal limits) and the overall picture presented by the combination of complaints and abnormal proportions to your PFT, there is reason for concern and further investigation, IMO.   So, you are correct to question the significance of the reduced RV, as you do.

Your reduced TLC and RV in the face of normal RV/TLC can lead one to believe that all is well and that you  are just one of those who falls into the lower end of the predicted normals for lung volumes.   BUT, generally speaking, when one falls into the lower end of normal predicted, ALL volumes tend to be more equally reduced, which is not the case in your scenario. 

Your TLC and RV have fallen by 8 % and 7 %, respectively while your timed-volumes (FVC and FEV-1) have remained disproportionately high.  As well, your FEV-1/FVC's, an important ratio to consider, have been 99 % over the period of the two PFT's.  I suggest that is NOT normal!  While we consider FEV-1/FVC ratio to be normal when it is > 70 %, when it exceeds 90 %, one should ask "Why?"  That yours is 99 %, should send up a red flag in the face of your elevated PA pressure, disproportionately reduced TLC & RV and dry cough and exertional SOB complaints.

Dry cough is a common complaint in the presence of both pulmonary artery hypertension (PAH) syndromes and restrictive lung diseases of both interstitial (within or between the lung tissues) and fibrotic types.  I wonder if you have had a CT scan of your lungs, preferably a high-resolution CT.  If not, that would be the next test I would recommend requesting.

Your abnormalities within your 'normal' numbers suggest that you might have a restrictive process at play, though I would expect that your DLCO would be somewhat more reduced than it is.  Still, your TLC and RV are not reduced enough at this point - even if a fibrotic or interstitial process is in progress - to suggest that it is significant, or that hypoxia is necessarily a part of the process, at this point.  And the question of the likelihood of a fibrotic or interstitial lung disease process is confounded by your PAH, which could be the cause of all of the abnormalities.  As well, PAH is a 'dynamic' process such that if while laying on the cath lab table, your PA pressure is now 51, it can be increasing further during exertion, again, a common cause of your SOB and cough complaints.  And, it is possible that your reduction in TLC and RV are related solely to the PAH as it has developed to this point.  So, you can see how the picture becomes confounded and unclear as to cause.

In any case, at 47 years of age, I disagree that you should have changes like you exhibit AND elevated PA pressure on top of those changes attributable simply to "age".  Elevation of PA pressures does NOT occur as a process of lung aging.  Elevated PA pressures, alterations in lung volumes as you exhibit and SOB and dry cough, especially with exertion are NOT a normal age-related, lung-change-caused combination.  I would suggest seeking another opinion, perhaps at an academic facility, if one is reasonably close by AND you have the ability to make that happen. 

While you may find that you have either or both an interstitial/fibrotic lung disease and/or PAH, neither has progressed significantly to suggest that treatment is as yet or imminently necessary.  So while a more definitive diagnosis may prove your pulmonologist's impression to be inaccurate, it may not alter the suggested course of action at this time - that is, to do nothing interventive and to continue to monitor your PA pressure and PFT's aty intervals, looking for more significant changes to trigger intervention.  On the other hand, a more comprehensive evaluation and 'sorting out' of your situation may lead those perhaps more expert in those disease processes to suggest intervention sooner than later.  Those remain the questions to be answered at this time, as best I can surmise.

I think that in the meantime, your immediate challenge is to continue to function as normally as you can, contending with the COB and cough as best you can to keep moving and stay in the best physical condition you can.  Exercise as much as you can (walking for cardiovascular benefit) without letting the SOB and cough inhibit your effort any more than you can prevent them from doing so.  And, if you do indeed get a diagnosis that is different from that which you already have, double-check to be sure that you can continue to work safely and fairly vigorously in the face of the SOB and cough.

Best Wishes,


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Prednisone Withdrawl

Please explain to me when my husband is finished a two week course of prednisone, what are some of the withdrawals I can expect. He has been on prednisone before when he had pneumonia but this time the Dr put him on because he thought it would do him some good. He did not have an infection nor a fever but he breathing was laboured but not all the time. Anyway he is ready to come off and for some reason he is concerned taking prednisone so many times what can he expect. Once again I hope I able to explain well enough for you to comment.

Thank you very much


A.  Hi Mitch,

Typical withdrawal symptoms from taking prednisone are feeling worse.  Prednisone, among its other effects "masks" how bad one feels.  So, when coming off it, they can feel like they are 'relapsing', when they are just seeing a decrease in the therapeutic effect of the drug.  He should be sure to taper the dose as he comes off, especially if he has taken it for more than a week or two.  If he can, he should weather the worse feelings, as they will ALSO subside with time.

Best Wishes,Mark

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Potential Sleep Apnea


I was diagnosed with copd 3 years ago but have not been sent to a specialist for a confirmed diagnosis or taken an air flow test.  I do trust the diagnosis however.  I am going to ask my new doctor to send me in for the test and possibly to a specialist. 

The reason I am on this site is to find out if a symptom is sleeping anytime I lay down??  I am fine if I keep moving I work graveyard shift in healthcare) but at home if its a day off, I can sleep almost round the clock??

I so need an answer, my house is falling apart, I have little energy...there is no weight loss, in fact I am gaining...but this sleeping thing is disrupting my relationship and my quality of life.

I so appreciate the opportunity to ask this question and hope to hear from you.

A. Hi Mary,

I'm glad you are going to ask for a PFT!  There is no excuse (IMO) for someone to be diagnosed and treated for COPD for three years without having had a PFT!

It sounds to me like you may have sleep apnea - either obstructive or central.  Your complaints are classic for the problem.  You should insist on having a sleep study done and SOON!  Folks who have obstructive sleep apnea gain weight, develop high blood pressure, diabetes and sleep enormous numbers of hours while feeling like they haven't had enough sleep and complain of somnolence, lack of energy.  They can also develop heart disease. 

So get checked out, soon, please. With treatment (CPAP - positive pressure breathing support, during sleep) many of the symptoms can be reversed.  But, the greatest benefit is improved quality of sleep and energy, as well as normalization of blood pressure and weight.  

Best Wishes, Mark

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Longevity Expectancy

I need some straight-talk. My husband of 47 yrs just had a PFT after saying
"I can't breathe" for over five yrs. His FEV1 is 18%. He was breathing at about
a 4-5 (out of 10, 10 being worse). In Feb had a sudden downturn and struggles
every day. Good days are 6-7, bad days he says are 8-9).

These seem very serious to me, but the docs aren't saying much. How much time
are we talking about here? It's important for me to know in order to help him
as much as possible, and encourage him when he needs it. Am I reading too
much into this? I realize everyone is different, but a educated probability would
help me cope. Thank you.


A.  Hi Patricia,

First, an FEV-1 of 18 % is very reduced and good reason for why your hubby struggles so much.  Is he using oxygen?  If not, has he been tested for low oxygen - especially during activity and sleep - for hypoxia?  I suspect he should very likely need oxygen with an FEV-1 of 18 %.  And, using it can go a LONG way to help him in many respects.

Second, only fools will try to predict how much time someone has with COPD of ANY severity.  So much depends upon what the person does.  Getting in the best shape possible, receiving the best medical management, achieving the best medical condition possible can help someone with even as severe COPD as your hubby has survive for a matter of years.  Even so, all it takes is one severe infection/pneumonia and it can be all over.

Your best option is to encourage him to work hard to get in and stay in the best physical shape possible.  He needs to work hard 'against' the breathing difficulty her experiences, especially when he moves.  His breathing may be VERY difficult AND may seem potentially harmful, but indeed, the opposite is true.  Sure, it is NO fun struggling to breathe AND to keep moving.  BUT, in doing so, he WILL reduce his difficulties, over time AND acclimate to those difficulties he cannot reduce.  It is a process that is NOT easy, but is certainly possible.  So, the best help you can give him is to encourage him and NOT "do for him" in an effort to make life easy.  With COPD, especially so severe, kindness and codling kills!

If there is help in the form of a pulmonary rehab program, see about getting him into it.

Best Wishes, Mark


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More Short of Breath (SOB) After Exercising

 Why is it that I have a tougher time breathing after exercising and also the following day . I am am on 02 when exercising 2 liters and my oximeter says 98 on 2liters , but that night I am sob and the same thing the next day .I do weight lifting one day and 30 minutes on the treadmill the next  what am I doing wrong?     


A. Hi Paul,

There are several possible explanations/reasons for your pattern of difficulty. You don't provide enough information for me to speculate with any confidence, as the possibilities are varied and rather specific to potential causes.

I'm left wondering "when" and "how" (under what conditions) you are measuring your saturation associated with exercise. Is that DURING exercise?  or do you place the oximeter on your finger after you have stopped exercising?   If enough time has passed since stopping exercise (say, more than 15 or 20 seconds), the measurement you observe is not reflective of your exercise saturation.

Are you taking appropriate and sufficient inhaled medications as a habit and in an effort to help your breathing during exercise?

You see, it could be that  you're not doing anything "wrong" per se.  It could be that you just aren't doing enough things right, at this point.  In any case, don't let it discourage you.  Work with your doctor to be sure that you are doing everything to optimize your breathing, especially to cover your exercise needs.  Keep exercising.  Maintain good  nutrition and even try using more oxygen than the 2 L/min during exercise and see if you have less negative after-effects.

Best Wishes,Mark

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Disease Progression

Thank You in Advance for your time Mark.  Is it possible for a patient to worsen very quickly?  I had gotten a flu bug and of course it went straight to my chest.  I was sick for 2 weeks.  Took my anti biotics but unfortunately had to travel while still sick.  It was already booked and cancellation was just not possible.  Since then I seem to be struggling more and I noticed that I have a 'bruised' feeling on my left side just under my arm pit and another area on the front just below the breast.......I think more on the rib cage.  The bruised feeling has sub-sided in the front now but I seem to be worse with the sob. 

Unfortunately for me, my Dr. just dismisses the COPD as not being anything to worry about.  He said lots of people have this and live with it and it is not a death sentence.  Asking questions was not something I felt comfortable doing after hearing this.  I now have a new Dr. and he seems to be a little more considerate.  I really knew nothing or very little about this disease until I found this website, so for that I am grateful.  The new Dr. sent me for some breathing tests and all I know is I am at 43%..........lung capacity? or breathing functionality? .  She (the therapist doing the test) was recommending the Dr. increase my dosage of symbicort. 

I just received the exercise DVD today so hoping that will help. 


Hi Merry, 

Unfortunately, it is all too easy for one to experience a raqpid decline in their condition, though, while exacerbations can happen a lot, a significant and permanent decline is NOT always or even often the result.  It sounds to me like you are still in the throes of an acute exacerbation from which you won't be able to determine if there are permanent changes until more time has passed AND you have had a chance to return to your steady-state and see how you are after yet more time. 

Your chest/rib pain 'could' be from pleuresy, if you have a significant infeciton in that area of your lungs.  An x-ray miight help to clarify that.  But, at this stage, it might not prove helpful with regard to input to guide or alter treatment.  I would see if an anti-inflammatory, like Ibuprofen, would help IF it is not contraindicated by any other medications you might be taking.  Your doctor should be able to adivse you best in that regard.   And, in case you haven't reported your current symptoms to your new doctor, I would urge you to do so!

If the 43 % is - as I suspect - your measurement from your FEV-1, then I would say that you are in better shape than many others AND maybe even than you think you are!  In any case, exercise and proper lifestyle should go a long way toward improving your situation.

Best Wishes, Mark  


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Unchanged FEV1/ Disease Progression

Hello Mark

How is it possible that my husband Fred just had his PFT's done( he gets them twice a year) and they have not changed in a year?? How long can you slow down COPD. I am always confused. I know his disease is progressive. Well I know I should be happy but confused at the same time.


A. Hi Mitch,


After reducing or removing the negative/progressive causes of COPD, like smoking, for instance, the rate of progression returns to what would be normal loss of lung function as one ages.  Each year, the predicted values are subsequently slightly decreased according to gender, age and height.  So, the PFT’s can appear to remain unchanged in terms of worsening at a more rapid rate because of the COPD. But, indeed, they are stabilized in their natural rate of decline.


Also, consider that while we speak ‘generally’ about the progressive nature of COPD, it is not a hard and fast ‘given’. AND, while one can remain stable without significantly more rapid decline, get a severe infection and you can see a sudden and significant drop as a result.  So the otherwise smooth progression can become stair-step, in fashion.


After only a year of being diagnosed AND depending upon where your hubby is in terms of severity, it is not unusual for him to see no significant worsening of his disease.  Be happy in that fact and continue to work toward maintaining the best condition and state of health possible for him as long as is possible.


Best Regards,



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Short of Breath/Oxygen Level & Death from Chronic Bronchitis

When I work outside cutting wood for about an hour I get very short of breath. Does this make my oxygen level low and can this damage my lungs more than they are. If your oxygen level is low and you don't know it can this do more damage to your lungs when you have emphysema. Can you die from chronic bronchitis if you don't have emphysema. Thanks John


A. Hi John,

I can’t answer your question about your oxygen level as ONLY a measurement of it at those times when you feel short of breath will provide the answer.  I CAN tell you that, contrary to what many folks think, shortness of breath does NOT mean one’s oxygen is necessarily low.  LOTS of folks experience shortness of breath while their oxygen level is perfectly normal.  There are MANY influences on breathing that can cause shortness of breath, besides low oxygen levels.


As to your second question, Low oxygen levels that go undetected AND are significant CAN over time cause further damage to organs – but NOT to your “lungs”. Instead, low oxygen levels put stress on your heart, especially on the right side of your heart.  Such changes must occur over a period of years to result in significant compromise.  If you are worried about the possibility that you might be experiencing low oxygen levels, talk to your doctor.  There are some simple and painless tests he/she can do to determine if there is a problem.


To your third question the answer is not as cut and dried as you present the question to be.  Chronic Bronchitis and Emphysema are both components of COPD, among other types of obstructive lung disease processes.  One most often does not have “just” one or the other.  Indeed, most who have smoked, has a combination of both, though one may be worse than the other in their total picture.  Also, we are careful to point out that one doesn’t “die from” COPD, like they would die from a heart attack or similar ‘other’ ailment.  They tend to die from the “complications of” the disease process, since it affects so many ‘other’ systems as it progresses.  So the question as you put it is not answerable, as presented.


Best Wishes,



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Dry Mouth Contributing Factors & What Can be  Done?

Hi Mark - hope all is well with you,

My question is kind of small, but not to me.  I have been on Spiriva, Advair and Ventolin for almost three years now with severe COPD.  I had mentioned to my doctor some time ago, although at the time I thought it was the Champix, that my mouth is sooo dry in the morning it is scary.  She suggested it was probably a side-effect of the Spiriva.  I also drink almost a whole large glass of water while I am sleeping.  It still feels like someone has sandblasted my entire mouth in the a.m. when I wake up.  Too dry to even swallow sometimes.  I am not a gum-chewer or candy sucker so I was wondering if I took my Spiriva at night if this might help.  I am sure that there is probably not another drug similar to Spiriva so what do you suggest?  I get a dry mouth during the day also but can usually solve it quickly.  Thanks for any suggestions.


Hi Lynn,

You (like me) are probably a mouth-breather when you sleep, allowing the opportunity for the problem of dry mouth to give you trouble.   While it is a nuisance, keeping that water next to you and sipping throughout the night if/when you awaken is about as good as you can do.  Certainly the Chantix and Spiriva can be contributing to the effect.  AND there aren’t any good alternatives for those, let alone those that wouldn’t ALSO contribute to the problem.  You ‘could’ try taking the Spiriva at night and see if there is any difference.  But, I don’t have a good alternative to suggest.

Best Wishes, Mark

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Q.  Stem Cell Treatments, Meds - When to Take

Hi Mark,
I am 68 years young, I was diagnosed with COPD 10 years ago. I had LVRS in 2004.
For a short period I did Smoke maybe 10 years, however, My choice of employment was not the best. I was a metallurgist (10 years) working first in foundries and then mines having to put up with fumes and dust and then for 40 years firstly as a developer and then builder mainly restoring of historic buildings. Dust, asbestos etc. 

Just recently with the humidity in the area (sorry, I should have told you that I live in NSW, Australia), either hot or rain my breathing goes haywire.
By doing lots of exercises in air conditioning using O2, I seem to temporarily feel better. I also use the traditional COPD medicines that is Ventolin, Seretide, Spiriva. I also use a nasal spray which I make myself, 1/4 teaspoon salt, a dash of bi sodium of carbonate and 2 drops each of eucalyptus oil and tea tree oil in a cup of boiling water.

My question is:
What do you think about stem cell treatment for COPD?
What I have heard is a lot of contradictory information, from at least is you will not do you any further harm, to nearly jumping out of your skin.
My biggest concern is that stem cell treatment is not carried out in Australia, hence I have to travel to Germany or some other location for it and it is a long way to go if there are NO Benefits.
Yours truly

Hi Tony,

So, do I assume correctly that the LVRS has run its course of benefit for you, after these 7 years since the procedure?  I’m curious to know what your initial improvement was from the LVRS, as with as much interstitial lung disease as you should have AND in view of only a 10-year smoking history, I find it difficult to believe that your COPD was significantly worse than your restrictive component likely was AND of questionable severity that LVRS was necessarily the best approach for your treatment.  The NETT was just finishing up at the time and there were a LOT of folks getting LVRS whom ultimately were NOT ideal candidates for benefit from the procedure.

In any case, you now ask about stem cell therapy.  First, there is “NO” ‘approved’ version of stem cell therapy, in ANY country, that I am aware of.  There are some very limited studies being conducted to ascertain if it will produce meaningful benefit and in what way it may benefit those with lung disease. There is GREAT interest in the development of stem cell interventions for lung diseases, especially for COPD.  But, there are NON that have reached any conclusive results so as to ready them for approval by the various agencies of different countries.  ANY stem cell therapy being employed at this time is either ‘bogus’ or renegade and highly suspect, regardless of who is doing it and where it is being done.  There have been a few attempts at xenograft therapies – wherein stem cells from animals have been used.  But, again, they are NOT based upon gathered and proven evidence, at this point.  Where non-human agents are being employed, great peril lurks as we don’t have sufficient data to know what to expect.  AND, there is reason to believe that depending upon the animal tissue employed, there may be hazards associated with transfer of animal disease strains to human hosts resulting in a whole new set of infectious troubles in the recipients and possibly to the greater community (AIDS being an example).

So, my best advice is to steer clear of current stem cell therapies and claims until research is done to show benefit and safety.

One last point I would make is to be sure you do NOT take the Ventolin within two hours of when you take your next dose of Seretide!  It is OK to take the Ventolin 30 minutes or more after taking the Seretide.  But, do NOT take it within two hours before the Seretide or the Ventolin will make the Seretide ineffective or at least poorly/less than optimally effective since they both exert their effect through the same receptor sites in the lungs.  If the Ventolin is already occupying the receptors, the Seretide has nowhere to bind with and exert its effect.  So the Ventolin effectively cancels the benefit of the Seretide.

Best wishes, Mark

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A COPD Patient  & Dog Owner, with Recent Allergy Diagnosis  to Dogs & Cats

I have been diagnosed with asthma and COPD, I have also been allergy test and have proved positive to cats and dogs. I have always had dogs and would like to have another. What is your response?


Hi Sheila,

The question of whether or not to continue to keep pets to which one is allergic is an age-old issue about which only you can make the final decision for action.  Innumerable folks are found to have allergies to their pets, the advice from their health care providers of all sorts usually being: "Get rid of them".  That may be easy for them to say.  But, they do not live in your shoes.   As life would expectedly and reasonably dictate, you must decide for yourself what is most appropriate and acceptable course of action for 'you'.  Questions you must consider include:  How much are your pets influencing any allergic symptoms you suffer?  Is life without your pets worse to bear than the symptoms they might be invoking?  Is there a possibility and opportunity for receiving desensitization therapy (allergy shots).  Does your health care benefit plan cover such therapy?  If not, do you have the means and opportunity to pay for it yourself?  What if desensitization therapy doesn't work?  Then  what?

If you determine that you'd rather put up with the symptoms and palliative treatment (medications like inhaled bronchodilators, inhaled cortisteroids and maybe cromolyn sodium or nedocromyl), then keep your pup(s) and ask your health care providers to bear with and support your decision.  If your symptoms are simply to great to treat effectively to reduce with palliative treatment, then you must make your decision about enjoying better/adequate breathing or putting up with the symptoms that cannot be relieved in order to continue having the companionship of your dog(s).  And, you must consider the impact upon your disease course.  Will it hasten your decline?  Will it cause your demise earlier than would be expected without the pet(s) being in the picture? 

Keep in mind that if you decide to divest of the dog(s), then you will need to thoroughly clean your home - furniture, bedding, carpets, drapery even washing walls or painting, maybe even A/C ducts, if you have central air - in order to reasonably reduce the allergens that currently exist in your environment and give yourself a chance to discover what life and breathing without them will be like.  Simply getting rid of the pets will not reduce the allergenic exposure you live with every day in your home, having had them for so long.  Not realizing the continued allergenic environment and its influence on your health could send to you a false signal that being without the dog(s) is no better than being with them, since the existing allergens would continue to produce symptoms for a long time to come.

You are faced with a tough choice, indeed.  Best wishes in whatever you decide to do.


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Questions on Oxygen, Transplant,   Medical Personnel - Misinformation/Knowledge/Actions

Dear Mark,

My husband suffers from emphysema, he was diagnosed over 5 years ago. Two years ago he quit smoking, and his condition has continued to worsen since. He is classified as severe. Since November 2010 he has been admitted to hosp. 4 times with the stays being 5-17 days. He was put on continuous oxygen in late Dec.. He now has developed a lung abscess and is undergoing treatment for that with antibiotics. His respirologist has recommended he very strongly consider a lung transplant. I would appreciate any insight you can give me on the various related problems we can run into from this disease and what reliable sites I can access regarding lung transplants.
One of the problems we have experienced is in the hospital, many of the nursing staff take his blood oxygen and when they see it at his usual resting 94-95% they turn the O2 off or down despite the fact our regular doctor and the respirologist have said a flow rate of 2-2.5l is appropriate for him, even when he is at rest. When he gets up to use the washroom he has run out of breath so much he has had to call for help. We live in a small centre and the respirologist is 3 hrs away. Our doctor communicates with him as much as he can but we still feel lost. I unfortunately am just getting started researching info. I guess I was under the same stupid thought as my hubby, that we would have all kinds of time to check these items out.
Thank-you for any help you can give me.  Hortense

Hi Hortense,

First, you must stop beating yourself up for what you ‘think’ may be “stupid” assumptions when you simply ‘don’t know’ the full situation because you haven’t had the information you now seek.  “Stupid” is the result of knowing what to do and the answers to your still-yet-to-be-discovered questions and THEN not acting appropriately on the information you ‘then’ gather.  You cannot expect to act on what you don’t know to act upon!  So, let’s try to sort out some of your dilemma and come up with some suggestions and actions for you to pursue.

As you may have discovered, COPD/emphysema is a progressive disease that continues to worsen, despite actions like smoking cessation.  While it is GREAT that your hubby quit – quitting being the most significant help to provide opportunity for best health and disease progression reduction AFTER the quit point – his disease was well-advanced when he managed to successfully quit.  As well, consider that even though he was diagnosed five years ago, his disease was well advanced by that point, too.  So, he started out his post-diagnosis life already seriously affected.

It is clear you MUST do something since he has been in the hospital so much during these past several months.  You didn’t share any ‘numbers’, such as his PFT measurements (FEV-1. FVC, DLCO, lung volume measurements) so to know what “severe” means is not possible for me at this point.  BUT, that his oxygen saturation is running at 94 – 95 % while breathing 2 – 2.5 L/min of oxygen is very telling, in terms of judging severity.  He should be using a regimen of inhaled medications, preferably long-acting ones with a short-acting form for those moments when he is distressed or preparing to engage in an activity that habitually takes away his breath.  Among the usual choices would be Symbicort or Advair (or the Canadian equivalents) and Spiriva, at the very least.  So, if he is not currently using those, talk to his doctor about prescribing them.  

It is clear that the nurses are acting inappropriately when turning his oxygen down or off.  While it is considered acceptable to allow oxygen saturations to hover around 90 %, while one is at rest, for them to turn his oxygen flow ‘down’ or ‘off’ is inadvisable, indeed, unacceptable!  They are not thinking about his welfare, with regard to his getting up to use the bathroom.  His saturation no doubt takes a severe ‘dive’ when he gets up and moves around, hence the response he has exhibited with his respiratory difficulties/distress when getting up to move around, to any degree.   Sure, he may be OK while sitting there at rest.  But, unless he has the easy ability to INCREASE his flow AND the opportunity for his saturation to THEN increase in preparation for moving around, they are failing to consider the problem they create when turning the flow down/off by setting him up for severe breathing difficulties with insufficient oxygen support.  That is BAD nursing practice and MUST be stopped.  You may have to have the doctor write an order forbidding the downward adjustment of his oxygen whenever he finds himself in the hospital in the future.  There is absolutely no excuse for concern over a saturation of 95 % while breathing oxygen that should prompt them to continue to lower his flows.  The prevailing practice MUST be “safety first”.  And the likelihood of  oxygen support – left alone at 2 – 2.5 L/min  - causing any problems is simply NOT outweighed by the danger they place him in with the adjustments they are making. 

Another other point to keep in mind is that when he is home, he will not be running back and forth from his home oxygen source to raise and lower his flow, simply to keep his oxygen saturation in the 90 % range!  For them to act any different is misplaced consideration, indeed!  Lastly, while 90 %, even 94 – 95 % is comfortable while sitting at rest, it is NOT going to stay up there with activity.  AND with activity, 90 % saturation for MOST folks simply is NOT comfortable.  To impose that kind of discomfort upon them AND to expect them to become or remain adequately functional is simply not realistic AND forces increased inactivity upon them, further thwarting their ability to remain active and functional.  Over time, it takes its toll with more rapid decline in health and disease severity.  To sum it up, there is simply and absolutely ‘no good’ that can come of messing with his oxygen levels as they have done in his past admissions!

Now, as for the question of transplant, I must assume that he is young enough to qualify for such consideration.  While lung transplant DOES offer potential extension of survival for those who would predictably succumb in 2 years or less of transplant date without transplant, it is NOT a panacea AND constitutes trading one set of conditions (and potentially, problems) for another.  Transplantation imposes life-long requirements for taking medications every 12 hours, day in and day out, without fail – NO other option being acceptable.  Folks who undergo transplant have accepted that conditional requirement before ever traveling to the operating room. 

Transplant offers the opportunity for return of function and elimination of symptoms for the majority who opt for it – at least for some period of time AND when there are no lasting complications.  Complications can entail less than fully restored lung function for many reasons after transplant, acute rejection, chronic rejection and a host of other difficulties. It is truly a ‘mixed bag’ of potentially great and potentially horrible possibilities.  You may or may not know it, but my daughter has undergone TWO double lung transplants, having done well for four years with her first set of transplanted lung, suffered devastating acute rejection and damage to them and then surviving to receive re-transplantation, three years ago.  She currently is doing pretty darned good, having just taken a position as a Respiratory Therapist with the children’s hospital affiliated with Vanderbilt University Medical Center, in Nashville, TN, just a few weeks ago.  She will celebrate her 29th birthday this coming Monday (3/21/2011).  So, I speak about transplant from both personal and professional experience.

Another possibility your hubby may want to look into is LVRS (lung volume reduction surgery).  While it is a BIG operation, as is transplant, it has a somewhat lower-danger set of risks associated with it and can either bridge a person to transplant or serve to avoid transplant, depending upon how they do with the process.  It can ALSO significantly reduce breathing symptoms and restore function for those who undergo the procedure.  Candidate population for LVRS, though, is limited to about 12 % of ALL who have emphysema.  So, not everyone – indeed, only a little more than 1 in 10 – is a candidate for benefit from it

Ultimately, ONLY a transplant center can properly evaluate a person for candidacy for transplant OR LVRS.  I strongly recommend that you travel to the nearest transplant center and that your hubby undergo evaluation for those prospects.  Evaluation provides the opportunity to become fully educated in the process, the difficulties and the benefits as well as to ask ALL the questions you develop along the way.  And, while undergoing evaluation may offer opportunity to become informed and make an informed decision as to course of action that is best for him to take, it doe NOT constitute committing to the process.  If, after learning all he needs to know, he decides it is not for him, he can simply walk away from it and return home to live as best he can for his remaining days.  Evaluation does NOT obligate one to go through the entire process.  I would strongly encourage y’all to schedule the trip and get your referral to a transplant center as soon as possible.  You do NOT want to wait until transplant is direly needed to THEN begin the process.  If he decides to enter the process, it could take two years before he is called for the actual procedure.  Some folks I have corresponded with here in the USA, have waited four and five years to become severe enough to need transplant OR for their blood type in donor organs to become available AND seniority/priority on the list to reach the top. So, delay to enter the process can spell disaster and demise if one waits too long to be evaluated.  Lastly, ONLY the transplant experts are capable of fully and accurately advising folks of where they stand in the process and what the urgency level might be for their individual case.  So, don’t waste time seeking opinions from anyone less than the experts who actually DO the transplants. 

I will close with the following link to “Second Wind” which is an on-line support group of folks who are waiting to undergo lung transplantation, who have already undergone lung transplant and those in between along the path of interest in the process.  I would encourage you to link up with them as you will open up the opportunity for a wealth of information and ‘from the horse’s mouth experience with the process.

If you have more questions that you think I might be able to help with along the way, certainly don’t hesitate to post them to he list and I’ll give them my best shot.

Best Wishes,


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CT Scan Accuracy with a History of Smoking

Hi Mark,

I just turned 50 and smoked for 25 years. I quit during the summer of 2000 and have not smoked since then. I went to my PCP because I was concerned about smoking for all of those years and it had been a very long time since I even had a chest x ray ( probably 15 years ).I have had dull chest pain on and off for 6 months but only on the right side about an inch to the right of the breast bone. My PCP ordered a CT scan after a chest x ray was performed within normal. The CT scan was normal. When I was at the imaging facility I asked the tech what type of cat scan was being performed and she advised it was a helical 16 slice scanner. I also received 100 ml Isovue 300  intravenously. I do not believe it was a high resolution scan

My question is will this type of scan show damage caused by smoking ? Will emphysema or COPD be visible on the scan or evidence of it ? I included the findings of my CT scan with contrast below :

The mediastinal structures are normal with no enlarged lymphadenopathty or vascular legions. The lungs are well expanded and clear. No pulmonary consolidation, mass lesion, or pleural effusion is present. The chest wall is intact.

Thanks for any insight you can provide.


Hi Skip, 

The "enhanced" CT scan you had done was plenty along with the chest x-ray to determine that you do NOT have COPD, despite your smoking history.  That is also tempered with the qualifier "at this time".  It doesn't mean that you won't develop it over the next 20 or 30 years.  BUT, if you were to develop COPD, your age and relative point of onset would be farther down the road than for most folks and therefore, the likelihood of severe disease at the end of your life is relatively and possibly significantly reduced.

Remember, that while COPD is caused by smoking 95 % of the time, as many as 3 of 5 smokers never develop COPD.  You may be one of those. (hopefully).

I would suggest that if your pain continues you seek evaluation for causes other than COPD, of which there are many possibilities.  In the mean time, continue to live as healthy and active a lifestyle as you can and you should b e just fine.

Best Wishes,  Mark

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Reduced Bronchial Irritation & FEV Decline

Hi Mark...thanks for very big expert info help with your last week's post :)

Has there been any correlation study measuring the reduction of bronchial swelling/inflammation with the decline rate of FEV in COPD victims ? Confused as to what I mean....if quitting smoking slows the rate of decline of ones lung functions, measured in FEV rates, and quitting smoking immediately reduces bronchial irritation and swelling/inflammation, then it reasons there would be a direct and clear co-relation between inflammation  and FEV decline.

Putting the money desires of insurance companies or tax-pool funders of prescription drugs aside, it would solidly prove out that earlier rather than later increased dosages of the less dangerous COPD drugs would best defend COPD victims from FEV decline...hence, improve their life expectancies !

Gregory J

A.  Hi Gregory,

If airway inflammation were the only cause of decline in FEV1 among those with COPD, your line of thinking might be applicable, though, the inhaled medications to which you refer have ONLY a palliative action, rather than a preventive one. 

As it is, decline in FEV1 in COPD is the result of a composite of changes the most prevalent of which is loss of conducting airways (from frank destruction and consolidation) and airway remodeling which not only includes inflammation, but also changes in tissue types and make-up which increase resistance to airflow and loss of compliance - involving some increase in compliance (loss of elasticity) and some decrease (higher airflow resistance).

There is no evidence that quitting smoking "immediately" reduces inflammation as inflammation is the result of both irritation from elements of smoking AND changes in inflammatory mediators in the airway that have set-up over time and also must resolve over time.  Again the inflammation is not simply "swelling" as might respond to, say inhaled cortisteroids, but also the histological (tissue-types) changes that occur over years of smoking and even after quitting has occurred - even years later.  Consider that COPD is a disease that, when influenced by smoking, continues to develop and manifest years after one has quit.  If one quits AFTER having established clinically significant COPD, then they start out their post-smoking-cessation period already at a disadvantage over those who might have ceased smoking years before their COPD developed.

Finally, realize that COPD medications - whenever they are taken - have shown "no benefit" in decreasing morbidity or mortality in COPD.  So, even early and preventive use of medications would not confer a longevity/survival benefit.  These facts have indeed been researched and continue to be part of continuing evaluation of survival with COPD and factors that influence survival.  We are still looking to discover medications that might offer that kind of benefit.  Still, at this point in our knowledge, all medications we employ target some single process towards reducing symptoms.  We are still trying to relieve symptoms as a primary goal and looking for agents that may effect some kinds of changes that will actually influence/improve/reverse the histological process of COPD.  That is where perhaps things like stem cell therapy may hold promise.  And, as such they seem to be a long way off from 'market-ready' applications for lung disease.

Best Wishes,Mark

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COPD Medicine Questions & Dosages

Hi Mark :)

After 5 yrs of progressively worsening COPD my lame GP finally referred me to a lung specialist in august. My new Dr. changed my drug regimen, and I'm now using Oxeze 12 mcg, Symbicort 200/6 x 2 twice daily, Spiriva 18 mcg and Salbutamol 100 mcg.

Do you know of any 'receptor' trouble with Oxeze and Spiriva ?  (like the SABA and LABA have)

Also, I recently looked for more drugs and found a very promising medicine named Xopenex (Levalbuterol).

From a submitted formal clinical study;

"Levalbuterol increased forced expiratory volume by nearly 40% compared with racemic albuterol..."

"clinical trials have demonstrated lower mean heart rates in patients using levalbuterol vs racemic albuterol "

Heart failure is the leading cause of death in COPD victims.

(it may be clinically significant in patients with a history of arrhythmias, structural heart disease, or cardiac conditions that could worsen with an episode of tachycardia)

"(S)-albuterol lacks bronchodilator activity and is metabolized 10-fold more slowly than levalbuterol, and some have theorized that it may also have negative effects such as worsening  airway reactivity or proinflammatory effects."

Do you know about this drug ? What do you advise.

1. Because bacteria in the mouth causes bronchia swelling/inflammation, I've started plain water brushing of my teeth and gums and tongue 4-5 times day and the improvement in
my breathing is very noticeable.
2. Virtually all the COPD drugs dry-out the mucous in the mouth and bronchia and sinuses, yet that mucous is a very important 'buffer' to soften and smooth the coarseness and irritation in breathing. I found chewing gum whilst doing physical stuff really really helped me to breath easier. (I use a sugar-based gum as the steroid budesonide has caused an allergy to chemical sweeteners, margarines, etc.)
3. Vitamin C is an important chemical in the processes of the lungs, and I get a very obvious improvement in my breathing rather quickly when taking 1-2g x 3/day.

Gregory J

Hi Gregory,

I'm glad for you that you finally got the work-up you required and deserved to delineate your ailment.  Hopefully, you are feeling improvement with the drug regimen you are now on. 

I am a but concerned with 'duplication' and excess dosing inherent in the regimen you have been prescribed.  You are correct to question the conflict in terms of receptors, that might occur with your regimen.

First, understand that Oxeze (Formoterol Fumarate) and Symbicort (Formoterol Fumarate + Budesonide, a steroid medication) when BOTH are taken twice a day, constitute a double-dosing of the LABA Formoterol.  While that is necessary in some patients, to start one out on the double routine is of questionable necessity or value.  It's like driving a finishing brad into a piece of wood with a sledge hammer, in a manner of speaking AND if I may use a carpentry analogy to illustrate what you're doing when taking both.  

Symbicort, alone 'should be plenty" without doubling up with the Oxeze.  My suggestion would be that "if" your doctor gave you the option and discretion, take ONLY the Symbicort and leave the Oxeze aside for back-up IF after taking only the Symbicort for a couple of weeks, you notice that your breathing is not as good as it was with both Symbicort and Oxeze.  Even then, I might prefer to take the Symbicort at 12-hour intervals and space the Oxeze at 12 hours apart, BUT 6 hours apart from the Symbicort.  That would give you dosing of 12-hour-acting medications at 6 hours and not constitute a double whamy of both at the same time every 12 hours. 

In any case, it is important to space dosing of Formoterol as close to 12 hours apart as possible to get the most consistent ongoing benefit.  Surprisingly, I find that many folks do not do this or understand how important it is.  They take the medication when they get up in the morning and before they go to bed at might, placing it closer to 16 and 8 hour intervals.  So, be sure that you are spacing it properly.   

If I have not correctly understood your regimen and you are taking one or the other of the Symbicort and Oxeze, then that is OK.  You would not be double-dosing on the Formoterol, in that case.

The Spiriva is good and can and should be taken at the same time you dose with the Symbicort. 

The Salbutemol (albuterol Sulfate) should serve strictly as an "as needed", "pick-me-up" medication.  It is a SABA as compared to the Symbicort, which contains the LABA.  Thse two will conflict with regard to receptor competition.  So they should not be taken close together or on a regularly scheduled regimen, again, unless your breathing symptoms are so severe as to require the extra medication to control them.  Taking the Formoterol should be all you need except on days when your breathing is extra difficult and is not responding adequately to the Symbicort, alone.  In any case, if you find need of taking the Salbutemol, DO NOT take it within 2 hours BEFORE taking your Oxeze or Symbicort.  AND, if you are indeed having a bad breathing day and must supplement with the Salbutemol, take it  no less than 30 minutes after taking the Oxeze and/or Symbicort.  If you can, reserve it for four to six hours 'after' the Oxeze/Salbutemol dosing.

There is no conflict between the Salbutemol, Oxeze or symbicort with your Spiriva.  The Spiriva is the only LAAC you are taking, while the other three are SABA/LABA's and "DO" constitute potential conflict.

Insofar as Levalbuterol is concerned, much has been made of the single-isomer preparation.  The study you quote, while portraying the company mantra about why Levalbuterol is superior to Albuterol (the two-isomer version) in subsequent observation, the number of folks who exhibit the benefit touted is not as great as the manufacturer would have us believe.  In the albuterol, the S -isomer albuterol preparation, the isomer removed from Levalbuterol does indeed show effects to inhibit as extensive an action as the uninhibited Levalbuterol with regard to sustained bronchodilation and duration of effect.  BUT, it is not so strong an effect to make it necessary for everyone to take it.  Benefit of significance between the two, in the population on general who use these drugs, simply has not been seen in clinical evaluation OR in pulmonary function measurement when studied.  So, unless one experiences the significant side effects of tachycardia (rapid heart rate) or other clinical signs of the effect of the S-isomer AND those additional effects are NOT eliminated by the test-use of Levalbuterol, then to spend the extra money (whoever is paying for the drug) is not merited by return in benefit.  For these reasons, the FDA in the USA reduced coverage for Levalbuterol to match that of Albuterol so that abuse of the more expensive drug would be curtailed.  As a result, Levalbuterol, while still being widely used, is prescribed with more caution in consideration of the lack of cost benefit, much to the shagrin of the manufacturer.  And no evidence of unnecessary suffering or lack of benefit has been forthcoming in many years of both drugs being available and in use.

While I'm happy for you that you find your oral care routine beneficial, unless you could eliminate the influence of the inhalers you are taking in their beneficial effect on your breathing, I am doubtful that the oral care is responsible for any significant improvement in your breathing.  And, it would seem to me that simple use of antibacterial mouthwash two or three times a day would accomplish the same effect.  While we have a boat load of various bacteria in our mouths, some of which, when aspirated CAN cause respiratory symptoms if unchecked and remedied over time, there is no compelling evidence that beyond usual recommended oral care, symptoms are any different between groups, though I doubt this has been extensively studied.  Yet, with the number of folks suffering COPD, if oral care to the extent that you suggest WERE of such significant benefit, it would seem to me that this fact would long ago have come to light and our treatment and maintenance activities would include more careful and specific additional interventions as you describe.    In any case, I have no recommendation for change, if you are happy with what you are doing at present.

Actually, while Spiriva, an anticholinergic drug does directly dry secretions and to some degree, the anti-inflammatory effect of inhaled corticosteroids will help reduce secretions, beta agonists do not directly cause a drying effect as you suggest and describe.   If chewing gum helps your dry mouth, then that is a good thing and certainly acceptable to use as a countermeasure to the dryness caused by the anticholinergic effect.  I am unconvinced that budesonide has caused allergy, as you suggest, to artificial sweeteners or margarine, much less anything else.  Be aware that you ARE at increased risk (as is anyone who inhales corticosteroids) for developing opportunistic infection from Candida Albicans, the infection commonly called "Thrush".  So oral care is very important in avoiding problems with Thrush.  Your oral care regimen is likely sufficient to do a good job in that regard, as would be using mouthwash after inhaling the Symbicort.  Artificial sweeteners have an ill-effect on a number of people, myself included.  In my case, I get an abominable case of heart burn when I ingest artificial sweeteners as well as artificial creamers, commonly used in coffee.  Fortunately, I drink my coffee black, without sweetening.  But, every once in a while, I like a cup of sweetened coffee with milk or cream after a meal.  If I can't get 'real' milk product, I forego it and the sugar and stick with black coffee.

While Vitamin C is important for many functions and benefits in the body, no evidence has been produced, that I am aware of, for the recommendation to take 4 to 6 grams of it a day, as you say you do.  More side effects are inevitable were the general population to take it, let alone many individuals.  I do not think it a good idea to take that much Vitamin C.  Further, without eliminating the benefit of the inhalers you are taking from the overall equation, that you would feel "noticeable improvement quickly" from the Vitamin C alone is highly doubtful.  It does NOT have any direct effect on improvement of air movement or gas exchange in the lungs, the two causes of breathing difficulties in ALL lung diseases.  Additionally, there is danger in taking excessive amounts of Vitamin C, though not "inevitable".  Kidney stone formation is the most prevalent adverse effect I know of with taking high doses of supplemental Vitamin C.  It is common to read about high incidence of gastric symptoms (nausea, vomiting, diarrhea, heartburn), as well.. 

Folks who take N AC (N-Acetylcysteine) for pulmonary support/benefit should take up to 2 grams of supplemental Vitamin C for 1200 mg or greater daily doses of NAC.  NAC can cause kidney stone formation which is prevented by the availability of Vitamin C to react with it in the metabolic process to form salts that will not collect and form kidney stones.  So, in this instance, there IS good evidence in support of taking large doses of Vitamin C.  While I DO recommend NAC, 1200 - 2400 mg/day for folks with or at significant risk for COPD and pairing it with 1000 mg of Vitamin for each 600 mg taken (up to a maximum of 2000 mg of Vitamin C per day), that is the extent of my recommendations for Vitamin C.    But, beyond that, additional Vitamin C has not been shown to be of benefit - and it HAS been studied extensively.  So one could not make a reasonable case for the "unknown factor" in touting benefits.  I do not think that taking as much as you are taking is a good idea, at all.  Read more about the difficulties of taking too much Vitamin C here:

Best Wishes,


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Lung Function, Sneezing, PFT's, SOB (Shortness of Breath), Exercise

Hello Mark,
I am Male, Age 74. I am now an ex-smoker. having quit some 3 years ago. I was diagnosed just over 2 years ago with COPD. I sleep well, about 9 hours. I do take afternoon naps that range from 20 to 30 minutes. My appetite remains great. I may be overweight. l am 6' 5" and weigh 240 pounds. I do get tired very quickly. Any kind of exercise or even walking is very difficult for me. I have tried several different Puffers. None of these worked. As a matter of fact, they made my COPD conditions worse. 
The strange thing and this has been going on for over 20 years is that on showering. When finished with my shower, I sneeze and
blow my nose on a continual basis. This ordeal will go on for a good 15 minutes. I'm breathing heavily and with much difficulty. Once this scenario is over I'm good to go and have an abundance of energy. It is though nothing our of the ordinary took place. This is now to the point that showering is no longer on my LIKE  list. I would ask you, what may be causing this 20 + year old breathing condition? What can I do to improve this very unpleasant situation? Should you have a Remedy, will this help my current breathing?   
Thanks for your help Mark.

Hi Roger,

I'm sorry to learn of your difficulties.  I'm afraid I also have questions for you before I can give you an answer to your questions.

Have you had a Pulmonary Functions Test (PFT)?  If not, how has your diagnosis been established?  My suspicion is that if you truly have COPD, then at least one or two of the "puffers" should have had a beneficial effect, but certainly, should NOT have made you feel worse.  However, if you have a lung ailment 'other than' one of an obstructive nature, it's possible that the medications could make your breathing worse.

With a PFT, I would first, be expecting more than what we call 'simple spirometry' to have been performed.  You should have a PFT that includes all three types of measurements.  They are, spirometry - how well air moves into and out from your lungs, measurement of lung volumes - how much air your lungs can hold and diffusion of carbon dioxide (DLCO), which is a measure of how well your lungs are able to transfer oxygen into your blood.  As well, if your DLCO is significantly reduced and/or your lung volumes are significantly reduced in the faced of air flow measurements that are near normal, then you should also have at least a measurement of pulse oximetry, especially during walking for at least 2 minutes, without stopping OR an arterial blood gas (ABG).  These tell us what's going on with your lungs when demand is put on them to transfer more oxygen into your blood in order to accommodate increased demand for oxygen during exertion/exercise/activity.

With spirometry, I'm looking for the measurements of "FEV-1" and "FVC".  With lung volume measurements, I am looking to learn what your "TLV" or "TLC" is.  As well, I would be looking to see what your RV and/or FRC is.  DLCO should be greater than 40 % in order to have normal oxygenation.  If it is less AND your oximetry (oxygen saturation) is also dropping below 90 %, especially during exertion, then at least part of your breathing difficulties when you move around can be attributed to lack of adequate oxygen levels.

The remedy for low oxygen levels, as you might expect would be to use supplemental oxygen.  While that may seem an unpleasant, scary and unwelcome prospect, it is actually 'life-enhancing' in terms of both survival and wellness, but more importantly, in terms of function and quality of life.

While your BMI - the measure of 'if' you are overweight/obese and how significant it is - is 28.5, according to the NHLBI calculator for BMI.  That puts you in the overweight category, b but not severely over weight.  Generally speaking, in lung disease, being overweight, without being significantly so, has little effect on severity of one's lung disease symptoms. It is when one is under-weight, especially by more than 10 %, that symptoms, quality of life and survival are negatively influenced to an increasing degree as weight drops lower.

Being out of shape, on the other hand, has great impact on one's symptoms, including survival and quality of life.  And, contrary to what most folks may feel or surmise, breathing hard and experiencing breathing discomfort, even fairly severe breathing work and discomfort do NOT have a detrimental effect on health.  Indeed, as one exercises and gains improved conditioning, breathing difficulty decreases AND tolerance of breathing difficulty that doesn't seem to want to improve certainly improves.  This is why it is so critically important to GET moving and to KEEP moving!

As far as your sneezing is concerned, while it may be unusual to suffer such a pattern AND a  nuisance, especially over such a long period of time, I doubt that it has any relation of significance over your lung disease or symptoms.  AND, the fact that it resolves without any residual difficulties suggests that it is likely nothing to be overly concerned about.  If showers become to difficult to engage in, how about changing to baths?

So, please gather the information I have asked for and provide any further information that comes to your mind and I'll look for your return response in a week in the future.  I hope to be able to give you some helpful answers and suggestions when all is said and done.

Best Wishes,


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CO2 Retainer with  Adequate Saturation but Short of Breath


When a person with COPD has shortness of breath but his saturation is still 93 or 94 with a heart rate of 98 how does this happen. My husband is a CO2 retainer but has a BiPap, could it be his BiPap was not secured right? Or is it just something I can expect with COPD??


Hi Mitch,

One of the great fallacies of understanding and belief held by many medical professionals the world over is that just because a person's saturation is adequate and safe at 93 or 94 %, they should ALSO be "comfortable" and not have any issues with breathing!

Nothing could be farther from the truth.  "Most" folks do NOT achieve a level of breathing comfort under conditions and circumstances like you relate with your husband until and unless their saturation is ABOVE 95 % and even not until is it up around 98 %.  Even then, because of the physical changes in their lungs and especially with moving around, the dynamics of their breathing invite shortness of breath (SOB) and MUCH increased work to breathe. 

His problems probably have nothing to do with the ineffectiveness or improper use of the BiPAP.  But, to be sure, you might call your equipment provider to have it checked out along with observation of his technique of applying it and the care he employs to clean his mask and prep his face for application each time he uses it.  If he has significant sleep apnea, then it is possible that his BiPAP isn't set to help sufficiently. Maybe he needs the pressure adjusted. 

But, being a CO2-retainer, tells me that his COPD is advanced to a very severe point at which SOB is now and unavoidable symptom no matter what his BiPAP does for him and no matter what his oxygen saturation is reading.  Unfortunately, because a modest amount of research data suggested 'some' subjects experienced less daytime SOB and improvement in energy when they used BiPAP at night as a supportive/augmentation to their breathing during sleep, many clinicians have jumped on BiPAP and the notion of nocturnal positive pressure ventilatory support as a magic bullet to greatly affect these symptoms in everyone who presents with them.  Unfortunately, that simply has NOT proven to be the case.  CO2 doesn't change in the vast majority of folks, or it doesn't change sufficiently to relieve associated symptoms.  Most still have significant SOB on exertion, despite effective use of BiPAP.  Many still have way too little energy, also despite effective use of BiPAP. 

So if your hubby is using it under those pretenses, don't blame him or some deficiency for his lack of improvement and continued symptoms, even with a saturation of 93 - 94 %.  AND, if that saturation is being measured while he is at rest, then he has even MORE reason to have problems, as I guarantee that it drops a BUNCH when he gets up and moves around the least little bit! 

Does he use supplemental oxygen?  If so, does he have permission/support to adjust it as needed to achieve greater comfort and better saturations, especially during exertion?  Understand that it is the questionably necessary and counter-productive practice around much of the world of pulmonary medicine to provide only short and barely adequate (for organ function safety) oxygen supplementation to those who retain CO2 for fear that they may be those on-in-a-million who might retain MORE CO2 when given sufficient oxygen to raise their saturation to more normal levels.  So the consequence is sacrificed comfort for what has ALWAYS been documented to be a most rare observation, and one that is at the least controversial in it's validity, as well.

Best Wishes,



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Oxygen Tanks - Types & How Long

Greetings.    I am fairly new to copd and am still struggling to adjust to it and get back my usual positive outlook on things and me.  The recent setbacks which mean I am worse were painful and depressing, though I don't know whether I am overreacting.  The hardest was three weeks ago when I was informed that I had to have oxygen when I went outside. Previously I had been doing fairly well, walking to a neighborhood shopping center, taking the Metro downtown to meet with friends. But with the portable system I quickly discovered that one tank would not be sufficient, and the gearing up and carrying two tanks so I have a spare has made me less inclined to go out.

Approximately how long could I expect one tank to last, and are there things which could make it last longer?

Recently I heard there was such a thing as a portable concentrator and I thought it was possible that this might make things better, especially the smaller machines. However, this is not like when I wanted to buy a Canon camera and I could go to google with "Cannon XYZ reviews" and get a pretty good range of information and recommendations.  There doesn't seem to be anything like this for the portable concentrators, and I need to find reliable information which doesn't come from a dealer, along with opinions from users.

If I go ahead with this, there is quite a bit of money involved which I do not have, and so would probably have to raid my savings. I have spoken to my family who say I should go for it.  At my age, almost 73, such an expenditure, if it adds as much to quality of live, I would seem to be money well spent..

So my second question, I guess, deals with how viable the machines are and whether there are any compelling reasons to avoid such a purchase.

Thank you very much,


A.  Hi Judith,

You asked great questions and well articulated issues that are not unique to you, but shared by many!  Using oxygen has been proven to be the ONLY intervention to not only prolong life with chronic lung disease and hypoxia, but also to greatly improve "quality" of life, though it takes some practical adjustments and a lot of learning to deal with it to your best advantage. 

With regard to portable systems that use tanks of compressed gas as the supply, there are several key considerations.  First, as there are many sizes AND because I don't know what 'flow rate' you are using, it is impossible to tell you how long any given tank will last without that knowledge.  Also, if you are using "continuous flow" from your tanks, they will last much less duration than if you have an "oxygen conserving device" (OCD) on them.  OCD's 'spit out' small bursts of oxygen each time they sense the user making an effort to breathe in.  By delivering only enough oxygen necessary to add to each breath, they do not waste all the oxygen that flows from a continuous flow device during times when you are not breathing in.  Depending upon the device, they can stretch tank duration up to four or five times what it would last with continuous flow, while still giving you enough oxygen to maintain safe blood levels while moving around.  So, while you may still need to devise a way to carry a spare tank or two for extended activities away from home, you can certainly get a lot more out of the supply you DO carry with use of an OCD.  There are MANY OCD's available on the market.  They all deliver different amounts, despite having common setting numbers.  But, as we advise, a setting of "2" on one device does not deliver the same amount of oxygen as "2" on another.  And folks who undertake to use an OCD should ALWAYS have their oxygen saturation measured (with a device called a 'pulse oximeter') while engaging in the activities during which they will use oxygen to insure that they know what setting they need to be on the particular device they are using for each kind of activity they engage in.

Insofar as taking more than one tank out and about, with an OCD, you can stretch each tank to make carrying more than one or two extras necessary.  If you are driving, you can leave them in your car and change them out as necessary with a short trip to the car.  A carrier that will hold a couple of tanks is also helpful, if you can manage the weight.  Some folks use a backpack.  Some use a small luggage cart.   You can be creative and devise one of your own.  The main consideration is safe storage and handling! 

Portable Oxygen Concentrators (POC) are indeed another option.  Like the OCD's for compressed oxygen tanks, there are several devices on the market. Also like the OCD's each delivers a different amount of oxygen at comparable settings.  So, again without being able to have your oxygen saturation measured during activities while using a POC, you cannot know if a given device is suitable for your personal needs.  And because most everyone must purchase POC's from their own resources AND the fact that POC's cost more than $2000 and up to $5000, depending upon from where you purchase them, you don't want to purchase one without FIRST giving it a "test drive"!  That, is the most common problem and complaint about the process of selecting and obtaining a POC.  Because they are so costly, most medical equipment companies do not carry more than one or two models, if they even carry them at all.  Companies who DO sell direct to the public, do not let you give the device a "trial run" before purchase, for many practical reasons.  So, you are left to rely on your home respiratory care professionals to first, have enough knowledge about the devices to help you determine if one is right for you; then to help you select the right one or to obtain one or two that are likely to meet your needs and then assist you in evaluating how well suited it is to your particular needs. 

That point brings out another pitfall: Too many respiratory professionals assume that because your oxygen flow needs are significant with continuous flow that you simply will not find an OCD that will provide what you need.  Additionally. many also lack understanding of the significant differences between the various devices and, when using a device that provides less than another device and finding that 'that particular device' fails to give you enough support, they declare that you simply cannot use an OCD or a POC of ANY kind.  Nothing could be farther from the truth.  When all is said and done, certain OCD's have the potential to give you more oxygen-per-breath than can continuous flow with any reasonable kind of tank duration!

Generally, the smaller the POC, the less oxygen it can produce.  So, while a POC may seem inviting because it is easy to handle and small, it may not likely come close to giving you enough oxygen to meet your needs.  Too many folks go for the small size only to find they have spent lots of money for a device that doesn't help them.  And trying to sell it does not return nearly the money one paid for it.  At the same time, there are POC's that CAN produce enough oxygen for one's portable needs BUT, are not light enough to carry without using a small luggage carrier or cart designed for and provided with the POC, or purchased as an extra adjunct.   

POC's offer portability with almost unlimited supply as long as one has enough battery power when away from stationery power sources like the car battery's D/C power or an A/C outlet.  For more information on POC's (and OCD's for compressed and liquid oxygen systems) you can check out the following website:  My friend and colleague, Bob McCoy has much information about OCD's and POC's as well as being what I like to call the 'Consumer's Union  equivalent" for testing and reporting of preformance of oxygen devices of most any kind.

Best Wishes,   Mark


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Understanding PFT's

I wish I could understand PFT Test a lot better. I have tried  but have not been successful. Can you help me.


A.  Hi Mitch,

Your complaint is shared by MANY, including a lot of health care professionals!  But, short of wanting to understand more than is practically necessary to be able to understand one's disease severity, PFT's are a complicated groups of measurements that require entire courses for those of us who become Respiratory Care Practitioners PLUS years of experience and exposure in the practical setting to grasp the intricacies of their application.  So, what follows can be called "PFT-101 - a fraction of the whole story".

Generally, pulmonary functions consist of three "kinds" of measurements.  We measure "spirometry" which tells us how well air "flows" into and out from the lungs.  As one's COPD worsens, they lose the continuous pathways of the interconnected airways so that there are fewer and more distorted and misshapen pathways for the air to travel as it comes into and goes out from the lungs.  While air is always easier to get "in" even as COPD worsens, what becomes more and more limited is the ability to get air OUT, as the decreasing numbers of airways lose stability and fail to accommodate the additional airflow movement demands placed upon them from the progressive damage to the lungs.  Spirometry measures air movement per-unit-of-time - hence from where we get, for instance, measurements like FEV-1 (the amount of air one can blow out in the first second of a maximal exhalation using maximum effort).  Indeed, when we breathe, we MUST move a certain amount of air per-unit-of-time in order to maintain normal CO2 and oxygen levels.  As it becomes harder and harder to EXHALE sufficiently in the amount of time we take to breathe, from breath to breath, we tend to trap more air and much later in the disease, to fail to clear enough CO2, at which point we become CO2-retainers.  Another very important (timed) volume measured with spirometry is Forced Vital Capacity (FVC), recently changed to FEV-6 in some measurements and interpretations.

The next kind of measurements we obtain on PFT's are lung volumes.  These are static measurements that tell us how much air the lungs hold.  By having the subject breathe in very low concentrations of gases like Helium and oxygen, we can calculate how much air is in the lungs when they are full AND how much of that volume represents the various 'sub-volumes' of air, like Residual Volume (RV) (the amount of air left in your lungs when you have blown out as much as you possibly can) and Expiratory Reserve Volume (ERV) (the amount of air left in your lungs at the end of a "normal" ["tidal"] breath, but that you could forcefully expel if you desired to) and Total Lung Volume (TLV)/ Total Lung Capacity (TLC) (the amount of air the lungs can hold when full).  In COPD, we look for those volumes to change.  In particular, the TLV/TLC increases and can go as high as about 140 % of predicted (though in a few folks, it can reach and exceed 150 %).  It can't really  increase any more than that simply because the limitations of the bones and volume of the chest cavity won't accommodate further increases, even in those whom we note to have "barrel chest" as a feature of their disease.  But, within that maximum increase, RV can increase by a very large percentage to greater than 250 % of predicted.  Increased RV represents the air that is trapped in the lungs with COPD.  Also, as RV "plus" ERV (which add together to represent what we call the Functional Residual Capacity - FRC) increase, they reduce the "Vital Capacity (VC) which is the amount of room we have to inhale to our full lung capacity from a point of maximum exhalation.  Another volume found within the VC is the Inspiratory Reserve Capacity or Volume (IRC or IRV) .  That is how much we can inhale from the end of a normal breath to maximum lung volume (TLV).  So, while the total volumes within the lungs can change only by a total of about 40 % to 50% (increased) within that increase, volumes of air left in the lungs at the end of normal breath increase at the expense of losing more and more ability to bring air into the lungs.  So, while, as I said with COPD, we can get air INTO the lungs easily and exhaling enough air with each breath becomes more difficult, it doesn't help to be able to easily bring air into the lungs if there is not enough room for it in the first place.  And therein lies yet another difficulty with COPD.

The last 'kind' of measurements we can make include "Diffusing Capacity" (DLCO) to assess how readily oxygen is able to cross the barrier from the air space within the lungs (alveoli) into the blood vessels throughout the lungs.  We use carbon monoxide to measure this, though in a very, very small amount, since it is toxic to our body in more concentrated amounts.  But, because single-molecule oxygen (carbon monoxide) has a known rate of speed in crossing that memberane AND we also know the mathematical relationship between single-molecule and double-molecule oxygen, we can 'calculate' the rate of exchange of double-molecule oxygen exchange based upon the rate of exchange of single-molecule oxygen to learn if we are bringing in enough at any given time.  When DLCO drops below a critical minimum (usually somewhere less than 25 % for most folks) we then suspect hypoxia to be an increasing problem with such an individual.

There, in a nut shell is the explanation of what PFT's are and what  we measure with them and why.  For the average person with COPD, it is important for them to know their FEV-1 and, FVC.  Those two values can tell us an enormous amount about the degree of COPD they have and give us information about what we can reasonably expect that OTHER measurements on the PFT might be.

Best Wishes,  Mark

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Symptoms of CO2 Retention & Ridding of Trapped Air

Hi Mark;
Thank you for your response about CO2 retention.  Guess I'm stuck with it.  But; beyond a blood test, am I correct in assuming  there's no way to tell if a person is retaining?  Like, is there any physical symptoms a patient, or caregiver would notice?

Also with emphysema and air trapping (forget about CO2) is there any way to help get rid of that trapped air?

Thank You, Giselle

A.  Hi Giselle,

Because the body is so nicely designed to be able to handle and compensate for the elevated CO2 that comes with advanced obstructive lung disease, it does not cause "symptoms" when one is in their "steady state", that is, their established equilibrium.  Indeed, when they get sick - pneumonia, and/or acute exacerbation from infection or such - AND they experience worsening ventilation, their CO2 - like that of anyone else, including those who do NOT retain - will increase and they will feel commensurately worse, again, as would anyone else, regardless of whether or not they retain.  But, in the steady state, one cannot tell that their CO2 is elevated unless and until, it becomes significantly elevated, even if compensated.  For most folks, that number would need to be greater than 55 mmHg, on their blood gas.  BUT, the symptoms that they would encounter are NOT the result of the presence of CO2, per, se; as much as they would be from simply having COPD serious enough that their CO2 is so elevated in the first place.  We're talking serious breathing issues ALL OF THE TIME, from contributions from ALL of the aspects of the advanced disease state!

So, the patient or caregiver, if anything, should be on the lookout for sudden worsening of breathing and increased mucus production, or changes in mucus color and the like and THEN be aware that as breathing worsens, the person might reach a point that they cannot adequately support their ventilation needs, at which point, they need to seek and receive appropriate medical care.  But, again, in the end, none of this would be any different for anyone with COPD, whether or not they retain CO2.

Insofar as the air-trapping is concerned, it is the result of "structural changes" in the lungs that result from the disease progression.  As such, without changing the structural abnormalities, to improve ventilation so that less gas is trapped is not possible.  Pursed lips breathing gives folks a tool to use to help reduce the additional trapping of air during exertion and times when breathing demands are increased.  That's about as good as it gets.  Beyond that, keeping active, exercising to your maximum and staying in the best shape you can allow you to better deal with what you cannot change about the physical/structural aspects of the disease.

Best Wishes,    Mark

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More on CO2 & Stomach Gas

 My Mother is 65 years old and was recently diagnosed  with COPD the type that she has she does not expel carbon dioxide from her lungs. She is on oxygen
full time. My question to you is recently she has formed a lot  of gas and it makes for difficulty in breathing until she can expel it. Is this normal? And what can
we do to get rid of it so she can breath better?


A.  Hi Kristie,

First of all, if your mother was only recently diagnosed as having COPD, AND she is already prescribed full time oxygen, then her COPD is not a 'recent' development.  It would help to know more about her condition in regards to knowing what her 'numbers' are on 'pulmonary functions testing (PFT).  Has she had such a test?  If not, then she should have one as soon as possible to 'quantify' her disease.  On the PFT, the numbers we are most interested in learning would be her FVC and especially, her FEV-1.  Since she has been prescribed oxygen AND you say she has been told she is not getting rid of CO2 efficiently, do I presume correctly that she has had an arterial blood gas (ABG) measurement test to determine these facts?  If she has not had an ABG, do you know on what basis she is presumed to 'retain CO2'?  I ask these questions because CO2-retention problems cannot be determined by any means short of doing that test.  Low oxygen levels can indeed be determined using a pulse oximeter to measure oxygen saturation.  And, many folks are prescribed oxygen based upon such measurements, without obtaining the more invasive ABG blood test.  But, CO2 retention cannot be determined using pulse oximetry.

Insofar as her problem with gas, I again presume you refer to stomach gas which causes a feeling of bloating and because of the location of the stomach and its physical expansion from the extra volume of the gas, it presses upward on the lungs making breathing more difficult due to the competition for space between the lungs and the stomach.  As she burps the gas out, pressure is released, the stomach becomes smaller and breathing becomes somewhat easier.  So, she first needs to put vanity aside and try to burp as much gas out as she can, when she feels the need. 

Another strategy she can use is to take Gas-X or other anti-gas medication that contains 'simethicone', which causes the gas to dissipate and also to be more easily burped out.  Simethicone is a medication that she can take in any amount needed without fear of taking 'too much' or of any kind of toxicity.  There is a product called Bean-O that prevents formation of gas.  If/When she eats foods that tend to cause her to produce gas she can put a drop or two of that onto the food as she eats.  That will keep her from forming gas or forming as much gas and also make it easier to expel the gas she does form. 

Many websites list foods that can cause gas so that folks can avoid eating those foods.  But, as the list is long and entails so many foods commonly eaten by most folks, I have found it difficult to steer clear of some of those foods without punity.  As well, many folks find that not only do some of those foods on the list NOT bother them, but many foods NOT on the list will cause them difficulties.  So, while it may be worth perusing websites that recommend dietary information for those with COPD, take what you find with only the grain of salt that she may find it applicable to her. 

Yet another recommendation that is fairly universal in application and effectiveness, though often the bain or nemesis of those with severe COPD is to get up and move!  Walking for exercise when one can tolerate continuous walking for at least 15 minutes at a time, for most, will 'mechanically' assist in expulsion of stomach gas as well as aid in digestion so that less gas is formed.  If she can use this strategy, it will yield not only the benefit of helping reduce problems related to the gas, but it will also directly improve her physical condition while also helping to improve her ability to breathe.  

All that said, I can't stress enough how BAD 'immobility' is for folks with COPD, especially when it is significantly advancing/advanced.  it is imperative that she get up and move as much as possible, no matter how rough it becomes for her to breathe.  If she is increasingly sedentary, then you can help encourage her to get up and move.  We recommend that folks who are having a hard time moving around because of breathing difficulties see if there is a pulmonary rehabilitation program nearby that they can get into to get help from respiratory professionals in how to breathe better and to engage in guided exercise to get  them on the road to improved breathing and living.  Lastly, I would recommend she learn 'pursed-lips-breathing', a technique of blowing out through squeezed lips to create back-pressure which helps to reduce windedness and anxiety when up and moving and short of breath.  Again, there is a lot on-line about how to do the technique.  

Best wishes,   Mark

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Q.  High Indoor Temperatures & Breathing


My mother is 83 years old & has severe asthma & severe COPD. She also only weighs 85 pounds and has poor circulation, so is always cold. Because of this, she keeps her house extremely warm (29 degrees).  She takes a number of inhalers & meds for her condition but always has problems breathing.  

When I enter the house, I have a difficulty breathing due to the heat and I am healthy. So my question is - does the warm temperature of her house exacerbate her breathing problems?  One would think that if it were slightly cooler in the house it may be easier to breath, but I don’t know. 

Any information on this would be helpful.  Thank you 


A.  Hello, Nancy,

That your mother, at her age and with her physique keeps her home as warm as you report is not, in and of itself, all that unusual.  That is affects her breathing as you suggest is difficult to say and could only be discerned by trying to have her breathe in a cooler environment, whether that be in her home, with the heat turned down or somewhere else that she could visit for long enough to tell.  I suspect, that the heat plays little part - or at least much less a role - in her breathing difficulties than does simply being deconditioned and elderly while also suffering from advanced COPD.  The tendency of folks to 'hunker down' and stay put in their home is accompanied by the tendency to also move around less and less.  As we well know, the less one moves around, the worse their breathing is affected b y deconditioning so that when they DO try to get up and move around, their difficulties increase.

The difficult question you must answer is: at 83 years of age and 85 pounds, how much can, or even 'should' you push her to correct the obvious causes of much of her breathing difficulties?  What are "her" desires?  Does 'she' want to get up and about more and breathe better?  More important, is 'she' willing to endure the discomfort sure to be encountered in her effort to become more mobile and improve her overall conditioning? 

Your mother sounds very frail, from what you've told me.  One piece of information not given is how tall she is.  If she's 4'10" (147 cm) then 85 pounds isn't bad (about 10 pounds low).  If she is greater than 60 inches, her weight becomes a greater problematic issue.  As well, while 29 degrees C is quite warm, as a winter-time indoor temp it is not all that extreme for one as frail as she.  Keeping the same temp in the summer when the outdoor temperature is comparable presents an issue of concern.  But, as I alluded to earlier, I don't think the environmental temperature is as much of a concern as would be the other aspects of your mother's physical and health concerns and features.  And, I would be very hesitant to suggest any changes, much less simply cooling the environment, as I am not confident doing so would have a significant impact on her breathing difficulties. 

Yet, I would have to leave the question up to you and her.  If she's willing to try cooling her home environment a few degrees to see if there is helpful impact on her breathing, then it might be worth trying.  Keep in mind that the number one illness of the frail and elderly, especially at this time of year, is pneumonia.  So don't have her cool things down and then leaver her unobserved under those conditions for any significant length of time.  Even overnight might not be a safe interval to leave her alone and unobserved.

Best wishes,                    Mark

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Q.  Ridding Ourselves of CO2

Hello Mark,

I hope Kim is doing better and I hope you don't mind one quick question or two for now.
Next to pursed lip breathing, what's the best method of ridding ourselves of CO2? Would blowing up a balloon be effective?  Thank You


A.  Hi Giselle,

Kim is doing OK, all things considered.  Thanks for your concern.

As many folks seem to do, you appear to regard CO2 as some kind of nuisance thing that can simply be "gotten rid of".  Moreover, many folks have asked questions that allude to an understanding that if they just work harder at "something" they can be rid of the stuff, once and for all.  Worse yet, when folks develop worsening COPD, they clamor for magical ways to "get rid of excess CO2" through somehow  "working harder" at doing something better - - - as if they are not currently working hard enough or effectively enough - - - otherwise why would they continue to have a problem with CO2? !

This is all to say a couple of things.  First, CO2 is always produced on a constant basis.  It's a product of metabolism.  If you stop making it, you are no longer wandering among the living.  So, it's a GOOD thing to continue to produce.  Secondly, while there are ways you can improve the comfort of your breathing, stretch your wind and increase the efficiency of your breathing, when enough lung damage has occurred to cause you to become less than "normally effective" at CO2 removal during regular breathing, there's NOTHING you can do to "improve CO2 clearance" or to "get rid" of the stuff any better.  But, beyond PLB, nothing will help you get rid of CO2.  While blowing up a balloon and/or doing a number of other ventilatory maneuvers can make breathing easier, that they contribute to significant improvement in efficiency in terms of gas exchange is highly debatable and without evidence to support them.

Best Regards,



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More on Saturation/Desaturation  & Hypoxia

Mark. Thanks so much for your answer regarding transient desaturation.

The reason I mentioned my pneumonia was that the hospital would not let me get discharged until my 02 level was 95 at rest.

I am SLOWLY learning. Because my COPD has a lot of asthma, my numbers day to day can be all over the place depending on daily conditions.

Am I in a dusty environment. What is the weather ?? Cold damp is the worst. What allergens are in the air? Gas exhaust from cars and buses, what is the barometric pressure??. All who have asthma or a component with their COPD will be effected to a large or small extent.
This is why one day I am SOB tying my shoelaces, and other days it's a breeze.

When ill all these things manifest themselves. Upon recovery hopefully all numbers will adjust themselves to the levels before the illness.

Thanks Mark. Takes a while to get educated.

Regards Philip

A. Hi Philip,

You have said a mouthful, with your post and realizations.  I'm a bit amused and even a little bit surprised that the hospital holds you in-patient awaiting resolution to 95 % saturation.  On the one hand, even achieving a 95 % saturation while at rest, for those with COPD and who are coming off an acute episode where consequential clinical hypoxia while at rest was a symptom may represent a significant improvement, it is still predictable that they would have some degree of exertional hypoxia.  And in some folks, it could take a matter of weeks, if not many days to resolve/normalize hypoxia.  So such a requirement can make for a very long hospital stay, not to forget add potential for hospital-acquired maladies.  Those would be situations where it might indeed be worth sending you home with a month's worth of home oxygen therapy.  The cost would be infinitely less than the cost of continued hospitalization, if resolution of hypoxia is the only objective.   But, they have to do what they feel most comfortable with and what the system will allow.  If that's continued hospitalization, then so be it.

In any event, you see more and more what you are up against, especially in view of your asthma AND especially since it is such a major component of your pulmonary difficulties.  Keep up the learning and you'll always have a better chance of keeping the upper hand on the difficulties.

Best Wishes,


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Q.  Did Anesthesia Hasten Disease Progression?

I live in the States and was diagnosed with severe emphysema while in the hospital recovering from an emergency appendectomy which was done laproscopically  under a general anesthesia.  I am 62 years old female and smoked a pack of cigarettes a day for approximately 38 years.  I last smoked the day of my surgery on 11-6-10.  I was not really aware of much SOB before my surgery; although, I guess I might have experienced some when climbing several flights of stairs which I attributed to being out of shape.  I now know that COPD/emphysema takes years to develop but I can not understand why I went from infrequent SOB to "severe" emphysema so quickly.  Could the anesthesia have hastened the progression?  I am now frequently SOB and take Spiriva and  Advair, and use Albuterol through a nebulizer.  Upon discharge from the hospital I was on home oxygen 24/7, but that was discontinued after one week   I have a 2nd follow-up appointment with my lung Dr. in January and now have learned enough about this disease to want answers to questions!

Thank you.

A.  Hi Elizabeth,

I'm afraid that I have more questions than I do answers at this time.  So, I hope you'll bear with me and humor me with responses in a future posting.  First, by what means were you diagnosed?  Did you have a PFT?  If not, was it based upon an x-ray or CT scan?  If not one of those tests, was it a "stethoscope diagnosis", or one based upon nothing more than clinical information and/or your smoking history?

Your increased SOB, while possibly a contemporaneous development, can be no more than the result of the heightened concern you are experiencing as the result of not only the diagnosis, but all the treatment measures suddenly heaped upon you.

Do you feel you are breathing significantly better in view of your breathing, before the appendectomy as compared to now, under the influence of the inhaled medications you are using?  How much Albuterol are you using (how many times each day)?  Do you take Albuterol within two hours BEFORE taking your Advair?  If so, you might be significantly reducing the potential benefit from one component of the Advair.  despite advice you may be given from a host of pulmonary health care professionals, the Advair should be taken no less than two hours after the most recent dosing of Albuterol OR at least 30 minutes BEFORE taking your next Albuterol dose.

On what evidence was the continuation of the home oxygen based?  And, in the same light, on what basis was its discontinuation based? 

Have you undergone a walking test during which your oxygen saturation was measured for no less than 2 to 3 minutes of continuous walking?  If not, it's possible that you are experiencing exertional oxygen dasaturation, the symptoms and severity of which cannot - under ANY circumstances -  be quantified with resting oxygen measurements of ANY kind. 

In any case, while illness and surgery can result in the expression of symptoms of a condition that theretofore might have been inconspicuous but indeed present, that it would 'trigger a sudden expression or worsening' of a condition that was NOT there before is not likely or a reasonable expectation.  I'll have to defer further opinion until you are able to provide answers to the questions I have posed above.

Best wishes, 



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Q.  Desaturation

Hi Mark. I hear Kim is having a few problems and my prayers are with her. I hope she recovers very soon and please wish her from me a speedy recovery.

I am convinced mark that my transient desaturation was due to illness and not a sudden change in my COPD. For 11 months previous I had NO COUGH at all and felt in general " GREAT ". .

The real puzzle here Mark is that I do NOT desaturate doing the same things. As an example.

In the morning I climb the 14 stairs to my bedroom, get dressed, go back downstairs and the 02 level reading is 91. Doing exactly the same thing when under the weather 86-88, yet the numbers bounce back quickly.
Would you concur the following statement.
I was told by my doctor that transient desaturation is not harmful. He said lets say you desaturate with exercise to say 84 and it stays there quite a while he said to come and see him. If you desaturate to 84 and it bounces back say to 93 within say 5-6 seconds, nothing to worry about. he said just to keep an eye on it.
When I had pneumonia 10 years ago,  I could not walk to the bathroom without my 02 levels going to 83. In the hospital I need 02 just for the duration of my stay ( 11 Days ) After no 02 was needed again, therefore short term use seems to have great benefit especially during illnesses.

Thanks mark for all your help, and again my sincere best to Kim.


 Hi Philip,

Yes, Kim has had some challenges these past few weeks that continue for the moment, though we are hopeful that they will be resolved with some treatment planned over the course of the next few weeks.  Despite the test findings that showed potential for significant problems and did indeed, find some treatable issues, she has continued to feel no differently than she has for the months before this latest (annual) round of testing at the third anniversary of her second episode of double-lung transplantation.  and, we expect that it will not preclude her being able to move to Nashville to take the position offered to her to work in the Respiratory Care department of the affiliated children's hospital to Vanderbilt University, later in February.

I would say that in spirit and intent, I agree with your doctor's assessment, regarding desaturation, its surrounding conditions and circumstances and the need for oxygen therapy, though you attach some specific conditions that I don't think necessarily accurately characterize the scenario or situation, per se. 

It is true that transient hypoxia/desaturation must be considered and interventive action taken according to the momentary factors and conditions.  In the hospital, oxygen therapy is readily and easily available and is a part of the standard of care for MANY conditions, even to go so far as to say "whether or not it is truly needed".   It's inexpensive to provide and, despite some who would argue otherwise, doesn't do any harm if given at the doses it is administered even when not significantly needed.  So, to think that you 'really needed it' or that it "significantly benefited you" simply because it was given to you in the hospital may not be a good or valid summary in every case.  Even the observation that you "felt better", were that the case, is not reliable in view of the potential influence of placebo effect. 

That you also went home without it, doesn't necessarily mean that you didn't need it for longer, either, simply on the basis of it's discontinuation before or at the time of discharge.  Indeed, studies have recently revealed that (at least here in the USA) as many as 68 % of patients with significant measurable hypoxia are discharged to home without ongoing oxygen therapy.  And when we investigate home oxygen use, we still find a number of patients treated who don't exhibit significant hypoxia, at least not after a short interval past discharge. 

Having done some research involving measurement of blood gases with comparison to concurrent pulse oximetry measurements of different types of transducers placed at different sites, all this done on patients who were deliberately made to significantly desaturate during exercise/physical activity, I can tell you that changes and resolution of those changes does NOT occur over intervals as short as 5 or 6 seconds as you suggest.  Indeed, resolution to 80% of baseline or steady-state saturation levels requires an interval of approximately 15 seconds as a minimum and increases according to the magnitude of desaturation.  That is as a result of the factor of duration necessary for blood cells to travel from the lungs to the measurement site, depending upon where the measurement is being made.  We call this 'lag time'. That is not to say that we don't see changes in pulse oximetry measurements such as you describe.  But, owing to several factors inherent in the measurement method a well as artifactual influences, we must consider the potential that changes such as you describe present an erroneous picture of the 'actual' condition. 

That, my friend, is the nature of the imperfect approximation of the technique and technology and also why pulse oximetry measurement, as a method, is only just so useful. To be sure, we take the liberty to interpret measurements we observe towards the side of caution, when those measurements tend to show greater significance in desaturation, preferring to err on the side of prudence.  But, we must still consider that pulse oximetry measurements are ONLY an 'approximation' of the real condition/picture and subject to influences that interject inaccuracy to 'some' degree.It remains true that that data support the notion that transient hypoxia that is accurately reflected in pulse oximetry measurements during acute illness and that resolves sufficiently quickly so as not to be considered "sustained and/or repeatedly sustained" over time do not produce detrimental damage to vital organs or foster conditions that are associated with significant, sustained and uncorrected hypoxia.  Indeed, we have sufficient data to this effect such that in treatment of certain conditions, we employ a technique called permissive hypoxia, or seek only to correct hypoxia to a minimum level (sometimes only to a target of 85 % saturation) because the evidence suggests that fully correcting hypoxia to normal levels has a negative effect on resolution of the condition or on duration of the illness, as well as potential long-term condition after resolution of the acute illness.  The rationale and physiology is very complicated and beyond the scope of what we are trying to answer here in your questions.  But, I bring it up as a point of illustration that transient hypoxia is not a hard and fast condition requiring correction simply by virtue of its presentation AND why each case must be considered upon the conditions at play and the objective of the outcome, all bearing in mind that the primary concern is to "do no harm".

So, this long-winded explanation will hopefully serve to help you and others to understand that while pulse oximetry is certainly an invaluable tool in ascertaining the nature of the situation at any given moment, we still cannot hang our hat on it being so definitively accurate as to dictate the necessity, magnitude or immediacy of action simply on its results, alone.  It is only one factor in the overall picture.   For those who have established long-term hypoxia due to the progression of their chronic lung disease, they should continue to err on the side of caution and increase their oxygen dose according to measurements that are consistent and believable AND with their oxygen prescription as imparted to them by their doctor.  If the prescription they are given does not bring them to an adequate oxygen level under the conditions they must contend with in life, then they must prevail upon their doctor to alter the prescription.   If their oxygen system cannot meet their more extreme requirements, THEN they need to consider a better system, if available, or if not available, modification of activities so as to maintain the safest and most comfortable condition possible.

Best Regards,


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Q.  PFT (Pulmonary Function Test) Results (Interpretation)

Dear Mark
I have been having problems for over a year, sob,heavy chest,lots of mucus and have them almost everyday! some days are worse then others but not a day goes by where I don't have a symptom!  I quit smoking 18 months ago and have gone to see three lung specialist! one says moderate copd, another one says very mild copd. and the last one says that I should not have symptoms at this point at all, and he says he thinks the symptoms are in my head!
I am 49  5'6  120 lbs was a smoker for 30 plus years! all three of these doctors are looking at same pft lung function test. Please help me! which one of these doctors is right? I Just know that these symptoms occur almost daily! thanks in advance for your help! these are pre broncodilator numbers as there was no big change  after the medicine

  PARAMETER        PRED           READING              % PRED
   FVC             3.75            4.13                 109.9
   FEV1            3.08            2.97                  96.5
   PEF             8.03            6.94                  86.4
   FEV6            3.97            3.94                  99.2
   FEV1/FVC%       78.4            72.1                  92.0
   FEV1/VC%        78.4            66.7                  85.1
    FEF25-75%      3.75            2.06                  55.0
   MEF75%          6.99            6.39                  91.5
   MEF50%          4.29            2.69                  62.6
   MEF25%          1.63            0.68                  42.0
   PEFr            481.6           416.2                 86.4
   IVC             3.90            4.46                 114.4
   ERV             1.18            1.29                 109.7
   FRC             3.16            3.32                 105.2
   RV              1.98            2.04                 103.1
   TLC             5.91            6.50                 109.9
  RV/TLC           33.1            31.4                  94.9
  FRC/TLC          54.1            51.1                  94.5
  MVV              115.6          146.2                 126.5


A.  Hi Lou,

I tend to agree with the second and third opinions you have received with the exception that the symptoms you report - SOB and significant mucus production - are anything but "all in your head".  Your PFT's paint a picture of "normal pulmonary function" without taking into consideration your smoking history.  While some numbers suggest the mildest level of obstruction, they all still fall well within the interpretation of "normal". In fact, with exception of a couple of flowrate measurements, they are all within the realm of 'high-end normal' and even exceed normal, according to the predicted values.  Still, there is evidence to suggest that you have a problem that may or may not require treatment, or at least behavioral modification. 


Mucus production that is constant or prolonged is a sign of airway irritation.  As well, the purist definition of 'Chronic Bronchitis' is 'having mucus production that is sustained and prolonged over a period of several months, regardless of the presence of concurrent changes in pulmonary functions measurements'.  So, that gives explanation of, or at least a label to what you may be experiencing/have going on.  At the same time, it doesn't necessarily direct the necessity of treatment, per se, if the mucus is serving a positive (albeit nuisance) action.  The SOB can easily be attributable to simply being out of shape such that when you engage in activities demanding of increased pulmonary response, you experience SOB, OR, perhaps more accurately excessive windedness.  And, you are devoting a heightened attention and awareness to your work of breathing as an understandable response to your underlying concerns.  So, while one doctor may say "it's all in your head", the more accurate characterization, in my opinion, would be that you may be giving your breathing symptoms more concern than you need to, in view of the concerns you carry and your history of smoking and what you may fear results from that part of your life.

In any case, the mucus production bears observation and note of pattern, duration and any changes in character or color, so as to avoid the complication of infection.  You need to continue efforts to clear it as it develops and is expellable.  Inhaled medications short of perhaps, inhaled corticosteroids, are not recommended, as your lung function - and reportedly your PFT testing - show that they are not helpful or necessary.  I hesitate to recommend inhaled corticosteroids, as the risks can be argued to outweigh the benefit at this point in time.  And the desired result - reduction in inflammatory response of your airways in the form of reduced mucus production - may not be observed while you are at the same time exposed to the well-documented side effects of steroid use.  It may be worth considering and asking your chosen pulmonary doctor about at some point in the future, especially if significant mucus production persists.

If you are not currently exercising, I would strongly recommend you start a program that, while not totally wasting you with regard to production and management of windedness, does not shy away from 'achieving' significant breathing effort and work in consideration of intensity and duration.  I would bet that after a couple of months of solid exercise at a level sufficient to impart significant conditioning benefit to you, your perceived 'dyspnea' (difficulty breathing, a.k.a. excessive windedness) will be reduced by a significant margin, if not resolved altogether.  At the same time, I would not look to significant changes in mucus production until or unless a source of airway irritation is discovered and mediated or your airways adapt to and resolve on their own the inflammatory response that has driven the increased mucus production. 

I am not confident that using guaifenesin or other mucus mobility enhancers would offer meaningful benefit.  Yet, taking 1200 mg/day of NAC might help.  Not only would it keep the mucus that IS being produced flowing and more easily raised and expelled, but the anti-inflammatory effect might help reduce or resolve your airway reactivity, as NAC promotes production of Glutathione, a substance that helps reduce inflammation that can be responsible for increased mucus production.

Aside from these suggestions, I would say that you may be worrying more than you need to about COPD and the consequences of your years of smoking.  You are young and have taken the best step you can to roll back your chances of developing significant chronic lung disease.  And, by evidence of your PFT's, you have acted soon enough that you have VERY GOOD lung function and should expect to sustain that for many years to come.  Get a follow-up PFT every five years for the time being to assure that you don't slide insidiously into a treatable disease state without detection.  But, other than that, you shouldn't be overly cautious or hesitant to get out there and 'move with gusto! 

Best Wishes,


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Q.  Exercise - Equivalency

Hi Mark, hope your holidays were enjoyable!

Exercise/equivalents - I realize that there's not much replacement for walking and/or a treadmill.  It would seem, however, that measurement of typical activity could be helpful to understand what one already does on a daily basis.  This might also be encouraging to continue doing typical chores, and then add various beneficial exercises to augment the daily routine.   

Is there a chart or other resource that compares various forms of exercise and the typical types of chores?  As an example, a comparison of X reps of X upper body exercise and the equivalent ... vacuuming carpet (or hard surface floor), or mopping, or making a bed, or doing laundry ... ?

Thank you for your help and have a healthy, happy and successful New Year!


A.  Hi Linda,

Thanks for your holiday greetings and well-wishes!  Despite some challenges and difficulties that have accompanied this year's holiday season for my family, we are looking back and feeling that the holidays, this year, rank among the best in memory for us all. 


You ask an age-old question in your post and one to which the answer is less than rewarding, I'm afraid.  As you allude to in your opening comments about exercise and its equivalents, there really isn't a 'standardized measure of comparability' to household chores with regard to exercise that imparts 'meaningful' conditioning.  It is in the consideration of 'conditioning' that such comparisons fall short.  The reasons are several, among which are these two major considerations.  First, the intensity level of most activities of household chores falls short with regard to providing significant or meaningful strength or endurance benefit.  Secondly, duration of the activities is insufficient to produce a meaningful benefit, as most activities are performed in an interval fashion.  Activities like mopping and vacuuming, even bed-making, come close to becoming 'conditioning exercise', but fall short because they are neither significantly sustained to provide benefit-over-time and are ultimately performed as interval and 'paced' activities, the pacing aspect negatively affecting intensity .  The pace at which they are performed and that negative influence on intensity have as much to do with the lack of conditioning benefit as does the duration and interval nature of their performance.

When we step back and look at the big picture, we can appreciate a prevailing theme that exercise targeted to  strength and endurance training provides the conditioning necessary to be able to more easily perform those activities of daily living and chores that require a minimum level of strength and endurance in order to perform them AND to perform them in a "normal" fashion.  By "normal" -  a word that I always hesitate to use without qualification -  I mean being able to mop four or five rooms, while moving furniture and objects, after having first swept the floors, or vacuuming all the rooms in your house, again, four or five, as examples, in a 'usual' amount of time that reflects a pace that is not reduced from a comparable and reasonable pace AND is done without need for stopping to rest or recover from fatigue or other difficulties.  In considering these activities and equating them with one's general physical and functional condition, we find that if one cannot keep pace and/or must stop to rest or catch their breath during their performance, they are considered to be in less than 'normal' condition.

Indeed, when we look at the data on exercise training and the resultant conditioning that it imparts, we see the undeniable fact that 'how much benefit' gained is inseparably dependant upon the intensity and duration of the exercise.  So, even when we consider treadmill or walking on land, or bike riding of either kind, or weight-lifting and other resistance training exercises, the amount of benefit each imparts varies with intensity and duration.  Getting on a treadmill and walking at 1.5 mph on a level grade for 30 minutes imparts a whole lot less conditioning than does getting on that same treadmill and walking for the same 30 minutes at 3 mph and a grade of a couple of degrees.

In the end, what defines exercise as such is dependant upon "duration" and "intensity".  After that, "sustainability" of the activity is a prevailing part of the equation.  Sustainability is actually a sub-consideration of duration, as it is a factor in determining "duration".  But, when we look at 'constant-level intensity' and' interval training' patterns, duration can become clouded without considering the factor of sustainability as a specific factor.

So, while performing those higher-intensity chores is certainly a necessary component of maintaining a minimum level of functional conditioning, they provide nothing of meaning when it comes to considering one's overall level of conditioning when it comes to the primary components of strength and endurance.  Those can only come from deliberate effort to perform controlled exercise as a separate activity.

Best Regards,                  


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