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Recent COPD Questions for the RRT

 

Mark Mangus, Sr. BSRC, RRT, RPFT, FAARC

 

Note: The weekly cut-off day is Wednesday evening. If your questions are received "after" that day, they will usually appear in the following week's postings. Questions and answers are usually uploaded to this site by Sunday evening.

Disclaimer:  The responses supplied by Mr. Mangus to your question is intended solely as  "general information"  only and  NOT  diagnostic in any fashion.  Mr. Mangus's  answers are based on his understanding of your query and on his personal knowledge and training.   As with anything of a medical nature you should ALWAYS check with your physician. 

Previous RRT Questions and Answers, archived by topic alphabetically (see L side Border)

Do you have a question for Mark?

For Q & A's Submitted  the Week Ending.......

 

June 28th, 2914

O2 sats recovery time and 6 min walk test distances

Hi Mark

I don't recall if I read it here in one of your answers, or read it elsewhere but believe I read that the accuracy of a pulse oximeter is effected by movement, as well as other things. I just started walking again after several months of being a couch potato and took my PO along. I put it on my finger but didn't look at it until I had walked 6 or 7 minutes at a reasonably brisk pace. I had to stop and cover it a little in order to read it as it was bright enough out that I couldn't read it otherwise. When I looked at it is was 88 and within 5 seconds of stopping it went to 92 and within 15 seconds was at 95. When I have walked or used a treadmill previously I would usually be 96-97 when first starting, and 95-96 after a period of time occasionally dipping to 94, so have to say seeing the 88 was a little unsettling considering I had had the PO on my finger for quite some time. I appreciate it may not be possible to give me a definitive answer without having a better quality PO, as mine was pretty inexpensive. I just wondered if in fact it is dropping to 88 would it recover back to 95 that quickly (15-20 seconds)?

One other question. I have tried to find what distance a normal person (one without lung disease) would do in a six minute walk test to compare to my distance but was not able to find what is considered normal. I know several variables need to be considered but wondered if you are aware of a chart I could refer to.

Thank you.

Don


Hi Don
,

Pulse oximeters are subject to "movement" and "circulatory" artifact.  In the scenario you describe, if your hand was fairly steady and you were not gripping anything during the time you cite the changes having occurred, then it is likely that the measurements were indeed accurate.  Whenever you are unsure about what you are seeing, be sure to steady your hand and that you are not gripping anything with that hand while walking.  It is possible to see changes like you relate, as correction occurs pretty quickly in that regard.

With regard to your 6MW question, we do NOT have "norms" for healthy people for that test.  Because it is a walk test, it is not sensitive to predict anything for healthy folks.  we use much more vigorous standardized exercise tests for those who are more robust in condition.  The 6MW test has been 'standardized' to some degree for various ailments for which it is used as a diagnostic tool.  For lung disease, it is graded in meters, with so many meters indicating poor, moderately poor and good condition.  Survival is even graded according to 6MW results, for COPD.  Those statistics can be found if you search more specifically for them and pull up the publications that deal with that aspect.

Generally speaking, if you are achieving greater than abou
t 750 meters, you are in pretty good shape, functionally.

Best Wishes,

Mark

 

June 14th, 2014

Q.    With air trapping, how can I have high oximeter reading with supplemental air

Sir;
Thank you for your last response.
I have COPD with severe S.O.B. upon exertion. My Lung Dr. tells me it's caused by the air trapped in my lungs upon exhalation. I am on
supplemental O2 at 1 1/2l, 24/7. I am 87, male, and live at an altitude of 6,000 feet for 23 years. I'm a former smoker off them for past 15
months when I was diagnosed with COPD. The pulse oximeter reads 97/98 when I'm on supplemental air. When I do go off the air concentrator my
oximeter drops to 84 within 10 minutes. My question is: If I have air trapped in my lungs how can I get such a high reading when I'm on
supplemental air.
Thank you.
Tom

A.    Hi Tom,

First, at 87, it sounds like you're doing quite well, all things considered, including your health difficulties.

You're NOT getting "supplemental air" from the concentrator.  You're getting about 93 % 'pure oxygen'.  That being the case AND if it takes only 1-1/2 Liters to boost you from 84 % to 97/98 %, then I'd have to opine that your COPD is not terribly severe AND that 'air-trapping' is not as bad as you might be led to believe.  What I WOULD be curious about is what your saturation is when you're up and about AND short of breath during activity.  Also, do I presume correctly that you are using your oxygen when you are up and about and exerting?

At 6000 feet, your saturation with 'normal function would run only about 94 % at best and likely around 90 - 91 % during exertion.  That's because the air is thinner and the partial pressure of oxygen is much lower than at sea level.  So, 84 % is not all that bad when your diseased lungs are considered.  But how much air-trapping is playing a part, I can't tell, exactly.  I suspect it is not all that much.   And, it is likely to be a more 'dynamic' kind of trapping that is worse when you're up and exerting than when you're sitting at rest.  AND, under those conditions, such air-trapping quickly reduces when you STOP exerting. All that makes your observed changes in saturation not surprising, at all.

In any event, just be sure to keep moving, exerting and enjoying life WITH oxygen.  Be sure you are getting enough during exertion by checking your pulse oximetry during exertion and adjusting your oxygen as you need to (with your doctor's permission, of course).

Best Wishes,

Mark

June 7th, 2014

Q.     What percentage of patients cannot perform spirometry

Hi Mark,

In your opinion, what is the percentage of patients unable to perform spirometry according to the ATS/ERS guidelines? I know there are contraindications, incapacity for severely sick patients and young children, but what percentage of all patients?

Thanks

Francois

A.   Hi Francois, 

Well, the kind of statistics you ask aboutdo not exist.  But, if I had to speculate, I'd say it's probably 5 % or less of those who 'should' be capable or are not deemed to have limitations that would preclude being able to adequately perform the tests.

So much more than simply patient factors go into producing a quality test.  The tech doing the test matters perhaps as much as the patient, since maximum effort is so critical and coaching is so much a part of eliciting that effort.  As well, for those who don't end up putting forth their absolute maximum, the range for normal being > 80 % of predicted allows for a good margin of error.  We can also tell - as those who run the tests - when a patient might not b e giving their best effort - whatever the reason.  And we can note as much in our comments on the report.  That way, the doctor can take that information into account.

I'm curious to know why you ask this question.

Best wishes,

Mark


Q.
  Are there any home remedies for thrush

Hi there. I have been using Advair 250 disc and Spiriva daily for over 2 years, and have been told that I have asthma and not COPD as first diagnosed. I know you can get thrush if you don't rinse after Advair. I recently got 1 sore on my tongue near the middle back, and wonder if there are any home remedies I can do if it is thrush. I am on an island for the summer and am  not close to any Dr.

Thanks Cynthia

A.   Hi Cynthia,

first, I find it interesting that you say you were 'told' that you have Asthma instead of COPD.  Does the conflicting informatin come from different doctors?  What does your PFT say you really have?  If your lung volumes are increased (TLC, FRC, RV) and your FEV1 is less than 80 % with the FEV1/FVC ratio less than 70 %, then you have not just asthma, but some additional COPD - which is most often the case.  Also, if you had 'only' asthma, then Advair would NOT be the recommended maintenance drug for you according to international asthma management guidelines.  It is rather unusual that someone would be steered from a diagnosis of COPd towards Asthma.  It is usually the other way around.

In any case, IF you get Thrush, you won't have to guess about it.  It does not strike as a single isolated 'sore' in the tongue.  Rather, it breaks out in the posterior oral cavity, tongue and all.  It presents as creamy white, cottage cheese-like lesions on the tongue and cheeks as well as the rest of the oral cavity.  It is VERY painful and does not go away without treatment.

Insofar as home remedies, I know of none that have been shown to be effective, though over he years, I've heard of many!  The tried and true remedy for Thurs is a benign drug called Nystatin.  It is simple to use and most effective.  Diflucan has become very popular, though it is a bit harsher than Nystatin.  As for what to do while away from home and close medical help, yogurt can sometimes be helpful to ward off Thrush.

Best wishes,

Mark

 

May 25, 2014

Medication to help chronic cough and is azithromycin helpful in an action plan

Q.  Sent in a rqst for information regarding Advair..but now my husband has two questions  and has asked me to send to you…  Dawna

Bill is asking….

1) Is there any medication (inhaler or otherwise) that responds to those COPD’ers  , like myself who suffer from chronic cough and the resulting poor quality of life,  that we should be discussing with our Respiratory Dr as a possible remedy?

2) Some folks in my Pulmonary Rehab prg. have an action plan that includes Azithromycin Therapy. Do you see this inclusion as being beneficial? Resp. Dr. has not brought up action plan development (we will at next opportunity) or Azithromycin therapy. 

THANKS…Bill

A.   Hi Bill,

If your cough is more nuisance and irritation than productive and moving secretions out of your lungs - in other words, is it mostly a dry, hacky cough - then you should ask your doctor about a suppressant medication.  Now, I'm not talking about simple over the counter cough suppressants - which will not do ANYTHING for your particular cough.  I'm talking about codeine syrup.  Maybe a lidocaine solution to nebulizer might help numb your upper airway and reduce the stimulus to cough.

It is not uncommon for folks to develop a hacky, dry cough after receiving radiation therapy for lung cancer. Sometimes it goes away.  Sometimes it doesn't.  Only time tells.

Insofar as Azithromycin is concerned, it is more targeted to those with a predominant component of chronic bronchitis AND who tend to have infection problems more than a couple of times a year.  I am still not even sure if you have COPD, whether or not it is clinically significant and how severe it is, much less if you would even be a candidate to ask your doctor about Azithromycin treatment.  Let's get your PFT's and look them over before considering further treatment options.  AND, for comfort you should try to get that cough addressed as soon and best as you can.

Best Wishes,

Mark

How to help oneself and stem cell therapy in Canada

QHi Dr. Mark, I wonder if you could tell me if there is anyway for me to truly help myself, having been diagnosed with mild emphysema. Is there stem cell research being done in Canada, that one could volunteer for? thank you so much, Darlene

A.  Hi Darlene,

The BEST way you can help yourself with mild - early stage - COPD/emphysema is NOT to look for 'magic bullet', pie in the sky 'fixes'.  While you don't relate anything that tells me anything about your disease state (other than the term 'mild'), I would say that if you are fully functional and able-bodied, the "truly best" thing you can do for yourself is quit smoking, of you currently smoke, get up and get moving - especially with exercise (a walking program and some strengthening exercises for limbs) and keep yourself as healthy as you can.  Those simple things will go infinitely farther than anything available today towards thwarting advancement of existing disease.

While some stem cell study is definitely going on, none of the serious investigation is using human subjects, as yet.  And, I suspect that when they do, they may likely start with those who have nothing to lose and are seriously advanced.  I could be wrong on that, though.  In any case, the LAST thing you should want to do at THIS time is go looking for unorthodox cures when tried and true AND SIMPLE means are at your immediate disposal!

Best Wishes,

Mark

May 17, 2014

Could IV sedation cause lowered oxygen sats?

Q.   I had dental surgery last week and I was told it would be under a GA however it appeared to be only IV sedation instead. After waking up they got me up to walk to a recovery room of sorts to monitor me for about 45 minutes before letting me go home. Upon standing they asked me to take a few deep breaths as my O2 had dropped to 88, which has never happened  before, at least not that I know of. I do have a pulse oximeter and periodically check my O2 when exercising and usually stay in the 94-96 range and if I do drop as a result of the exercising it is usually only by 1%. I have moderate COPD (I believe the last PFT was FEV1 OF 63%) and just wondered if the drop to 88 is something that would happen as a result of the IV sedation or if it is totally attributable to my COPD? A couple of times when I was laying in the recovery room you could hear the tone on the monitor change and they would ask me to take a few deep breaths and then my O2 immediately went back up.

My question, is the drop of O2 a result of the IV sedation, my COPD or a combination of both, or would you see a similar drop in someone’s O2 if they did not have COPD?

Thank you

Jack
A  Hi Jack,

While I can't say for sure that your observed desaturation during the time you were under the influence of the sedation was real or artifact  - or at least when you had the 88 % when moving - it is certainly possible.  BUT, that your "oxygen level" was the culprit may be doubtful.  You see, BOTH oxygen level and ventilation factors produce the saturation we see with pulse oximetry.  Since you relate that the folks caring for you during recovery had to tell you to take some deep breaths AND assuming that they pushed your saturation back up towards normal suggests that you were 'hypoventilating', a common phenomenon when one is sedated.  Folks with normal lung can exhibit 'lazy breathing' when sedated under conditions that you were - i, e; 'conscious sedation anesthesia' - and similar decreases in saturation as a result.  The drugs most often used depress respiratory drive while in effect.  Once cleared from one's system, breathing dynamics and blood gases return to the person's 'steady state'.  So, I suspect that you are back to your reported normal which, by the way, demonstrates very adequate gas exchange and normal saturations - especially if you maintain saturations as you report during exercise.  I think if you use your personal oximeter, you'll likely confirm that you are in good shape, now.  Chalk up the desaturation to the sedation and don't worry about residual or other potential adversity.

Best Wishes,

Mark

 

Reaction to Advair and timing of meds.

Q.   Hi Mark..perhaps like many others this site and your counsel have really been a god send..particularly in those early a.m hrs. when fears, questions and anxiety flood the mind and prevent sleep. So thank you for your service.

We finally got an appt. with a respiratory Dr. (after sending you an earlier msg. on my husbands case and your suggesting that we seek an appt. )

My husband has lung cancer, had  2 lobes removed  (Rl/RM), radiation and chemo which ended in Oct. He is doing well at this point but had/had a chronic cough for a very long time. So this  still is the main issue. N-AC which I learned about on this site, is doing wonders for his phlegm issues however.

After we asked for referral to Respiratory clinic, we finally got our appt. At our first meeting with Resp. Dr. the news was  conveyed to us that not only does my husband have lung cancer but he has COPD as well… I guess the cancer trumped COPD issues/concerns and no one thought to tell us . Husband put on salbutamol and flovent. 

After PFT taken off flovent and put on Advair powder (was unsuccessful with this as coughing increased and he could not hold breath past count of 3 if that ..tried for a week and then put on Advair aerosol inhaler…had many issues, including increased phlegm production, increased coughing, sob and during rest …chest sounds that were just different. Leg muscle tenderness and he couldn’t sleep..he also developed a fever. So, we stopped after 7 days and because I couldn’t get a hold of the Dr. I put him back on flovent. In two days he was doing so much better, more energy, vigor. Got a call into resp. Dr to advise what has been going on. Waiting for return call. 

What do you make of his reaction to  Advair  and why can’t be just stay on flovent..or does he need something stronger, such as Advair but not Advair???? 

One last question..we are attending the Pulm. Rehab prg and it is wonderful.  We were advised that when a COPD’er gets up in am they should take their ventolin first…to clear their lungs of the phlegm/mucus and then follow up  immediately with  flovent or (whatever long lasting med they are on.) Do you concur?

thank you for your counsel…Dawna

A.   Hi Dawna,

It's difficult for me to make much of hubby's difficulties without knowing some numbers from the PFT.  That said, it sounds to me like he doesn't need the long-acting Advair.  The increased coughing and phlegm along with fever could have been an infection and nothing to do with starting the meds.  Then again, maybe it could have been in part, at least, to do with the Advair.  But, since he got better when you stopped the Advair, I suspect he may only need the Salbutemol and Flovent, after all. 

Do you have the PFT results that you could relay to me?  That would really help.

A couple of things come to mind.  when folks have radiation to the lungs, it is not unusual for them to develop a cough.  Sometimes it is self-limiting and subsides as time goes by.  Sometimes it doesn't go away.  That remains to be seen.  I'm glad the NAC is helping.


I'm concerned that his lobectomies may not have been fully considered when interpreting his PFT's.  Removal of that much lung would reduce his spirometry, mimicking COPD and potentially making it appear significant.  But, if lung volumes were done as part of the testing, they should have shown the reduction, as well steering interpretations away from COPD.  If his expiratory 'flows' were reduced commensurately with the reduced timed volumes (FEV1 and FVC) then that would suggest COPD.  If his lung volumes were disproportionately reduced, with Residual volume (RV) increased relative to TLC (total lung volume), that, too would tend towards COPD as a diagnosis.  Another measurement - actually a calculated ratio - the FEV1/FVC ratio - might also shed light on if he has COPD and how bad it might be.  So, as you can surmise, the PFT results are very important to sort out and figure out what is really going on with him.

You said he had the "RI"and "RM" lobes removed.  I can surmise that the RM is his middle lobe.  But, I don't know which lobe you refer to with the "RI" initials, unless you meant to type "RU" for 'right upper' lobe, whic would make sense.  That brings up another possibility for misinterpreting the PFT's.  Depending upon how his airways were severed and configured after removing the lobes, it's possible that his remaining lobe is showing obstruction because of the change in airway configuration - large bronchial tubes, to be specific.

S
o, as you can see there are too many variables to speculate with any confidence just what might be the case.  The PFT result would be infinitely helpful, as I said earlier.

Insofar as the order of medications, as long as the meds he is taking are the bronchodilator (salbutemol) and Flovent, the order he is taking them is fine and doesn't really matter.  If the folks at rehab meant he should take the salbutemol and then immediately follow it with Advair, I would strongly disagree as the Salbutemol taken so shortly before the Advair would cancel any benefit from the bronchodilator in the Advair (Salmeterol).  But, with him taking Salbutemol and Flovent or Flovent by itself, there's no problem with a question of which to take first.  We generally recommend taking the Salbutemol and follow with Flovent soon after.  There's no conflict between those two.


One last thought on medications - if he truly has COPD AND Advair doesn't agree with him, but Salbutemol and Flovent do, he might ask about trying Spiriva - yet a completely different class of medication, but one much more specific for those with COPD.

Best Wishes,

Mark

May 10th, 2014

Thank You

Hi Mark

Just wanted to say another thank you for the detailed responses to my rather lengthy questions of the past few weeks, as it is very much appreciated. Most often you don’t have the time to ask your doctor all of the questions you may have and often don’t seem to get a direct answer.

Thank you

Wayne

Hi Wayne,

Most gracious thanks for your kind words.  I have enjoyed responding to your questions and hope we have helped others learn something in the process.  Don't be too hard on your doctors.  when you think about the detailed explanations, you need to consider that the time it would take for the doctor to go into that much detail you can understand why it's so difficult to do in a short office visit.  And doctors aren't always easily able to bring the accuracy of details to the language of patients so that they don't talk over their heads, dumb down too much and make the effort to explain technical terms that can't easily be related to layman's  vocabulary.  That's why folks like me do what we do - to help the doctors and patients alike.

Best wishes!

Mark

May 3rd, 2014

Pneumonia/ Fungus – Acute respiratory Distress Syndrome

Hello.

Q.  My name is Billy. My mom passed away back in 2009 due to a fungus that got in her lungs. On her death certificate it says she had pneumonia which caused Acute Respiratory Distress Syndrome. I remember she got a cold before she was hospitalized like 7 to 12 days after. She also had stage 2 of COPD. Her doctors told the family she had a 10% of survival because they "couldn't find a way to get rid of the fungus". Would you think that surgery would had help her breath better? If you can give me any information that would be appreciated!

Thank You

A.  Hi Billy,

From the scant information you relate, I would have to opine that surgery would not have either been indicate or helpful.  You can't simply cut fungus out of the lungs.  What kind of fungus it was matters much to explain her unfortunate clinical course and ultimate demise.  It would help to know what 'kind' of pneumonia she might have had.  If it was Mycobacterium Avium Complex - sometimes described as a fungus - that would explain why it 'could not be cleared' from her lungs.  Again, there is no surgical procedure that would have been helpful.

In any case, I suspect that while her chronic lung fungus might have lead to her acute pneumonia, pneumonia from most any cause can lead to ARDS.  And ARDS, itself is deadly for many folks - fungus or not.  I'm afraid I can't tell you anymore than this.  But, I hope this makes you feel a bit better knowing that there was likely nothing you or the doctors could have done any differently to change to outcome.
 

Best Wishes,

Mark

Can Lungs Burst from Pneumonia?

Q.  Hello Mark

I really appreciate this opportunity to ask a question that has been plaguing me since my brother's death 7 weeks ago.

The day my brother died, he was vomiting all day long.  But it was vomit like I had never seen before.  It was dark, almost chocolate brown in colour, thick liquid with gelatinous blobs in it and a very strong smell.  He defecated similar material, but with great difficulty.  His abdomen was extremely bloated, painful and tight.  He died after about 12 hours of this.

We were in Mexico, and I do not speak very much Spanish.  What I think they told me was that his lungs had burst.  The cause of death was listed as pneumonia, as a consequence of long-term copd. 

If you can explain to me what happened, it will be a great comfort. 

For a few days previously, he had been very tired and was not eliminating much either in urine or feces.  But he had enough energy to walk outside on his own and sit in the sun for 20 minutes or so.  He had asked for paper and pencils so he could start drawing cartoons again.  I do not think he knew he was dying on that day, expected to feel better the next day.  Well, I guess he did.

Thank you so much for this kind service.

Jenny


A.  Hi Jenny,

First, let me express my condolences for your loss.  It sounds like a harrowing experience for you - and your brother.

Let me get this out of the way, to begin with - lungs do not "burst".  So, such a characterization was probably not the best or most appropriate way to describe what happened to him.  From what you relate, it sounds like he was bleeding AND that it was a gastrointestinal problem, rather than a pulmonary one, though I can't say he didn't have pneumonia.  But, the brown malodorous vomitus, the bloated, tight and painful belly and the stools that were like what he was throwing up all 'scream' "GI Bleed".  He may have had a ruptured colon or intestine. It could have been a bowel obstruction.  Those are three possibilities that jump out for me.   In any case, the GI problem was likely the cause of his demise from the sounds of it.  Was an autopsy done to determine the exact cause(s) of death? 

Best Wishes,

Mark
 

Follow Up’s from Wayne’s Q’s Last Week

Q.  Hi Mark

I think I understood your reply to my post last week but thought I would give you what I took from it so if I am wrong please let me know.

While for the most part exercise will not decrease shortness of breath or allow more exertion before becoming out of breath, I may in fact be able to improve my SOB through exercise as a component of my SOB is from being out of shape rather than all of it being from COPD.

Also when I inquired about taking Serevent without a steroid you mentioned that usually a steroid is included as part of a three pronged approach to treating COPD. I just wondered if you feel there is a downside to me not talking a steroid as from my limited understanding a steroid has many side effects that is best to avoid if at all possible. I appreciate an inhaled steroid is probably less of a concern than a steroid taken orally like prednisone.

Also had a question about pulse oximeters and if their immediate reading is generally accurate? I have several times when I put it on and it may show 92 or 93 for 20 seconds or so and then step up to 94, 95, 96 quite rapidly and sometimes it will stay on 95 or 96 for a few seconds and then step up to 97 and occasionally 98 and then often back to 96. This will happen just sitting on the couch so am not sure if one’s O2 changes that often or that rapidly when one is not doing anything. It is a cheaper unit so whether that has a bearing on it or not I don’t know. When I go on the elliptical it is often 95 or 96 when I start and usually stays around the same area throughout my workout although I have times where it will increase by 1 to 97 if it is on 96. If I do a one minute sprint occasionally it will drop by 1, so am not sure how much of a change one would expect when exerting or if for a normal person it would just stay constant.

Thank you.

Wayne

A.  Hi Wayne,

'Decreasing shortness of breath' is a fair bit different from what I was trying to get across.  I would call your characterization of 'shortness of breath' "windedness" - an expected response to exertion plus some component of difficult breathing from your moderate COPD, rather than being completely SOB as a symptom.  One of the pitfalls of having a disease like COPD is that what was formerly considered a completely normal phenomenon - getting winded with intense exertion - suddenly becomes a symptom and the line between normal expectation and problematic symptom becomes blurred.  Granted, your heart rate topping out at near 160 DOES suggest either you are out of shape OR something in the cardiac realm might be going on.  It might be worth asking your doctor about.   With an FEV1 of 60 %, you really shouldn't be having so much limitation by windedness until you are really exerting quite intensely.  But, the more I think about it, it is increasingly suspicious that you are having such significant windedness AND the high heart rate.  At the same time, it could simply be, as I've suggested before, that you are really out of shape.  Only time and steady exercise of significant duration and intensity will tell if that is the case, since the expectation would be that your heart rate will ultimately drift downward as your core condition improves.

One last thought in regards to heart rate and windedness vs SOB - a heart rate of 160 during exercise contributes significantly to windedness/SOB/breathlessness.  So, you should be able to expect that your breathing 'should' improve as your heart rate decreases in response to exercise.

Insofar as the inhaled steroid is concerned, the only way to tell if it would be of help or not is to give it a trial - perhaps for 30 days.  Then stop it for another couple of weeks to a month and see if you feel worse without it.  That is essentially the way we determine the need for steroids in COPD.  Yes, it is part of the three-pronged approach.  But, just as there are folks who do fine with Spiriva alone, there are folks who can get along fine with Spiriva and Serevent without the inhaled steroids.  And, yes there IS a chance that even though dose is lower when inhaled, side effects are possible, though slower to onset and not always near as severe.  The question is does the inhaled steroid make a difference?  AND, does it make enough of a difference to outweigh potential risks.  Only you can answer that after giving it a try.  BUT, yet another thought - with an FEV1 of 60 %, you may simply want to wait for a time when your FEV1 drops to 40 % or less - IF it even does.

As for the pulse oximetry, we never pay any attention to the first numbers - good or bad.  Pulse oximeters require an average of 30 seconds to reach a stable signal and measurement.  Insofar as as the 'drift' between 95 and 97, that is perfectly normal and does not represent any kind of significant change in oxygenation.  Any saturation of 95 and above is considered within normal limits.  Under normal conditions, oxygen will remain within normal range during exercise, as yours seems to do.

Best wishes,

Mark


 

April 26th, 2014

Is FEV1 the best indicator of COPD?

QHi Mark

I read something the other day that I was not aware of and am not sure whether it is accurate or not. According to this article FEV1 is a poor indicator of emphysema. Even if your COPD appears to be stable and your FEV1 remaining at roughly the same value your emphysema may well be continuing to progress and you getting be getting much worse. If that is the case how does one monitor your severity of COPD aside from going for a PFT more often than most of us would want to go? I have a handheld meter that measures PEF and FEV1. It seems reasonably accurate but even if it is not completely accurate I can still compare my readings to what it showed last month and last year etc. as I am comparing to the readings from the same device so know what change there may be in my condition, however if these readings are not representative of ones state of their emphysema than is there any way to monitor it on an ongoing basis?

I guess the other question is how does one know whether an individuals COPD is bronchitis or emphysema or the percentage of each when both are present which I would presume is the norm?

Thank you

Wayne

A.  Hi Wayne,

PFT measurements - and FEV1 in particular - measure lung 'mechanics'.  As such they give us definitive - and accurate - information about the state of air movement in one's lungs.  We have decades of data from millions of folks with COPD that attest to the veracity and validity of FEV1 and FVC and their ratio to tell us the severity of airflow obstruction.  This is only one component of monitoring and assessing severity of disease.  Symptoms, though more subjective are another very important piece of the puzzle that is determining severity and progression.  As well, FEV1 and FVC and their ratio correlate very well with survival statistics to 'indicate' - not 'dictate' - severity of disease and likely mortality predictors.

While they are accurate and important indicators, they are NOT the 'be all' and 'end all' of determining 'clinical' severity of ones COPD.  That is better indicated by 'how well' one lives and functions with whatever numbers they generate.  Some folks with relatively better numbers function poorly and live with great difficulty.  Others have horrible numbers and yet somehow function remarkably well and live a higher quality of life than their counterparts with the same or better numbers.  So, you can see that the numbers only tell part of the "clinical" picture.

You are doing well to monitor as you say you are.  You just need to bear in mind that the numbers are only part of your story.  How you feel and function are another part.  And yet another part includes what you do each day and over time to improve and maintain your health and condition - to optimize what you DO have.  Those comprise perhaps the greatest part of the picture of living with COPD.  Eat well.  Avoid exacerbations. Keep moving!  Those are three goals to effective management of COPD.

In regards to the question of how much is due to which component of COPD, it is virtually impossible to tell.  Generally speaking, smokers have a combination of Chronic Bronchitis (CB) and Emphysema (E), the CB being the condition of prevalence.  While there are slightly different clinical courses and progression characteristics for each component, determining which one is more prominent would not help much in determining progression in a meaningful and predictive way.  Again, so much depends upon the individual and how they fair according to how they manage themselves.  When we look at the total COPD population, we find that about 5 % have mostly and purely E, while about 90 % have mostly CB.  But within those numbers, perhaps 80 % have a mix of the two with no way to specifically identify which contributes what amount to the overall condition.  Even if we could, treatment and management would not be particularly affected.

Best Wishes,

Mark

 

Help in explaining PFT results

Q.    Mark: I'm an 87 year old man Diagnosed a year ago with Whatever??? The doctors [4] Don't seem able to get a confirmed Diagnosis. My O2 stats are in the high 80s, low 90s when resting, but on exertion can drop into the 70s. On Symbiotic, and Tudzora, [powder] Inhalers with albuterol as a rescuer. No coughing except maybe two three times a week a total time of no more than five minutes. In the past year I've had seven stents placed in right leg [.4], and three around my heart arteries.
Had a PFA done on 09/18/13: No doctor explained the test results, though I suspect they didn't know how.

SPIROMETRY

FVC                   3.55             2.37          67%
FEV1                 2.77             1.01           37
FEV1/FVC  %       78                43
FEF25-75%       2.74             0.36          13
FEF50%              3.51            0.42          12
PEF                      7.58            3.56         47
MVV                    113 

LUNG VOLUMES

TLC                     5.94             9.41        158
RV                       2.51             6.60        1.58
RWTLC                %                    43             70
FRC N2               3.65              7.74         2.12

DIFFUSION

DLCO                     .16.8          5.7              34
DLADJ                     16.8          5.7              34
DLCO/VA                 3.01         1.87
DL/VA ADJ                                 1.87
VA                                                3.05

MAXIMAL RESPIRATORY PRESSURES

cmH20                     101

Thanking you in advance,
Thomas

A Hi Thomas,

I think your doctors likely know very well what your tests indicate.  I suspect that their dilemma is what to say and how to say it, as well as what to do, if anything.  At 87, you have done well to live this long simply in general terms!  That said, you obviously have some significant cardio-vascular disease, as evidenced by the need for the stents in multiple locations.  Add to that COPD with hypoxia and the picture doesn't get any better.  You didn't indicate how well you're getting along.  But, judging from no more than your post, you seem to have your faculties in pretty sharp shape, despite your difficulties.

So, in regards to your PFT, it shows you have pretty severe COPD - a reason to explain any significant breathing difficulties you live with every day and that may slow you down in terms of function.  The medicines you are taking - provided you are compliant with their use and using them properly - are good coverage from a medical treatment standpoint.  The only other thing I would say you absolutely should be using is OXYGEN!  You are significantly hypoxic and should be using oxygen 24/7/365 AND probably at 3 to 4 liters or more much of the time (at least when moving and sleeping) to keep your saturation above at least 85 %, but preferably in the 90's as much of the time as possible.  So, if you are not using oxygen now, you need to push your doctors hard to get you started.  Oxygen can go fairly far to improve your life and ease your breathing difficulties with your disease - especially since you also have significant heart disease.

If you have further specific questions, don't hesitate to post them and I'll try to answer.

Best Wishes,

Mark
 

April 19, 2014

Timing of drugs, inhaled steroid required with Serevent?, and how long after starting exercise program for breathing to improve.

Hi Mark

I am in my early 60s with an FEV1 of about 60% of predicted. I have been taking Spiriva and now have also been prescribed Serevent. First I wondered does it matter which of the two i take first, and secondly I read the information sheet that came with the Serevent, and perhaps I misunderstood but believe it said if you are taking Serevent you should also be taking a corticosteroid, which I am not taking so would appreciate knowing if I have misread or misunderstood this?

My last question relates to exercise and may be out of your area of expertise. I smoked for roughly 40 years a pack a day. During the majority of this time I had a desk job and seldom exercised so was not what you would call fit. I am not overweight,but am at the upper end of the range of normal, and have started walking and/or using our elliptical. I get out of breath quite quickly although I push on and keep going. My heart rate also gets into the 160-170 range quite often which i know is well above the target heart rate I should be trying to achieve. I have had heart tests (stress test and angiogram) and it checks out fine and from at least some of the reading I have done being out of “shape” can account for the higher heart rate and at least part of the shortness of breath, however also know, or at least assume, that the COPD accounts for much of the shortness of breath. My question is how long should it take before I start noticing an improvement in my breathing if I am either walking for a half hour a day or going on the elliptical for half hour a day, and also how long should it take for me to start getting in shape to the point that my heart rate does not climb so high when basically just walking at a reasonable pace. Just for reference as to the speed I try to maintain when walking my 6 minute walk test was 545 meters although I tend to slow down at least a little as the walk progresses.


Thank you very much
Wayne


Hi Wayne,

There's nothing that says one should always be taking a corticosteroid if they are using Serevent, though it IS part of the recommended 3-pronged approach to treatment of COPD.  As well, while some will insist that the Serevent should be taken first, there's no hard and fact, evidence-supported rule to that effect.  Generally, I advise my patients to take he Serevent and wait about 5 or 10 minutes to follow with the Spiriva.  If one takes a corticosteroid, I advise them to follow the Spiriva in about 10 minutes with the corticosteroid inhaler then rinse/gargle to clear the oral cavity of residual steroid medication to avoid developing thrush.

Insofar as your breathing complaints, what you ask about is my bailiwick of over 30 years, as I spent that time running a pulmonary rehab program and engaged in disease management of COPD.   I would suggest that you may have your expectations misplaced to some degree.  While getting back in shape should indeed reduce the severity of your symptoms, it will NOT result in elimination, or possibly even all that significant of a reduction of your huffing and puffing, especially during exercise.  Exercise in COPD does primarily two things, among others: (1) It reconditions muscles so they use less oxygen per unit of work and produce less carbon dioxide per unit of work.  Those changes reduce load on the lungs and result in reduced severity/intensity of difficult breathing through reduced demand for ventilation.  (2) Perhaps more importantly, exercise helps the individual to 'desensitize' to the limitations of breathing hard.  Over time, the ability to tolerate the increased work to breathe becomes the resultant benefit of vigorous exercise and improved conditioning.  The breathing doesn't really change a lot.  What changes is the individual's ability to shrug off and deal with the discomfort of breathing hard and continue to tackle activities that challenge breathing.


Keep in mind that when folks with normal lung function exercise, they, too become 'winded' and think nothing of it, as it is the expected normal response to physically working hard.  Unfortunately, when folks develop lung disease, much of what 'used to be' normal takes on the abnormality of becoming a 'symptom'.  It is easy to lose sight of what is normal and expected and what is a problematic symptom.  
Indeed, exercise, especially in COPD, should target "achieving" significant windedness.  If you're not breathing hard and having to use significant psychological and physical energy to keep doing so and to overcome difficult breathing and ultimately advance in exercise load and intensity, then you're not working hard enough!  That's the rule of thumb.  Another point that must be learned along the way is that breathing hard - very hard - no matter how bad it feels and may seem, will not harm you!  That is a difficult point to learn and understand, since the discomfort of breathing so hard seems to most folks as if it MUST be bad for them.  It goes to the very core of our survival instincts.  AND, along the way, many well-meaning folks will often tell the person who is breathing hard and looking rather distressed that they should STOP and rest and avoid working so hard to breathe, or stop pushing themselves so hard, etc.  Nothing could be farther from the truth.  Indeed, it is those folks who take the easy route and stop too soon who lose ground with regard to breathing, eventually becoming invalids and succumbing to COPD much sooner than necessary AND having a miserable time during their final months because of it.

Lastly, if your FEV1 is 60 % of predicted, then while you DO have reason for discomfort, not as much of your hard breathing difficulty with exercise
may be coming from your COPD as from simply being out of shape.  And it is certainly not enough to prohibit you from exercising very vigorously.  At 60 % FEV1, not as much of that decrease as you may suspect may actually be producing symptoms - - - in MOST folks.  But, with your heart rate going so high, that in itself influences breathing.  160 - 170 may be a bit above the predicted maximum, by formula.  But, if you have had a cardiac cath and it shows normal heart function then you should not be in any predictable danger for exercising very vigorously.  If your doctor say it's OK, then exercise as much as you can.  Over time, and with an exercise pattern of extreme intensity you should be able to reduce much about how you react to your symptoms.  If you can tolerate the elevated heart rate, it should start coming down within a period of weeks to a month or two.  Remember, you didn't get this way over night.  So, it won't get better overnight, either.  But, it CAN get better with enough effort and committment. 

One more suggestion may help you much to deal with control of breathing during exertion and exercise.  That is the use of "pursed-lips breathing"  (PLB).  When you "exhale" during exertion, purse your lips like you're going to whistle and create a restriction to the air coming out of your lungs.  Increase and decrease that restriction to match what 'feels' effective to 'splint' your airways and slow your rate of exhalation to some degree, again to what feels better.  Of all the 'tricks' I've taught folks over the years, PLB is the single-most helpful among them, according to the feedback I've always received.  One last caution on PLB: a lot of sources and folks will tell you to breathe in through your nose in order to do PLB correctly.  I will tell you categorically that ANY way you get the air into your lungs is FINE, as long as it is comfortable and effective.  It is NOT the problem of getting the air INTO one's lungs that gives folks with COPD fits.   It is getting the air OUT that is part and parcel of the problem.  Any manipulation of the breathing "IN" phase is superfluous AND counterproductive.  Indeed, it can thwart the whole effort of achieving effective PLB in the end.

I hope this covers all of your areas of concern and questions.  If not, write back and post your additional questions.  I will certainly try my best to answer them.

Best Wishes,

Mark

 

 

March 29, 2014

COPD diagnosis by X-ray, do I need PFT

 Q.  My name is Lisa.  53 years old.  Was a smoker for close to 40 yrs.

In May 2013 my family doctor told me I have very early stage COPD.  This diagnosis was the result of an x-ray taken as part of follow up to a possible kidney issue.  He told me I needed to quit smoking and offered to prescribe an NRT.

I thought I would be able to quit cold turkey just because of the diagnosis alone.  I was not able to until just now.  I am now six days smoke free.

In viewing the COPD site I cannot say yes to most of the questions no coughing, no phlegm, no wheezing, do not get short of breath easily.  Do not get a lot of chest colds.

The only symptom I have had is a lingering feeling of mild upper respiratory congestion.  This has been on again and off again.  I have it now.

Since receiving the diagnosis I have been terrified and avoided reading about COPD because I was too scared.  I have only recently started to face this head on.  I want to do the right thing and develop my action plan.  Stay smoke free and exercise for sure.

Should I be pursuing a Pulmonary Function Test?

Thank you for your time.

And Thank you for this site.

Regards,

Lisa

A.  Hi Lisa,

Congratulations on your six (and hopefully more, by the time you read this) days smoke-free!  First - I would recommend you r-e-l-a-x!  If you have no symptoms AND all you have is signs of COPD on x-ray, then you are FAR from any clinical significance, at this point.  Your action plan is most reasonable for the time being!  You can do NOTHING better than those two things!

At "some" point, you may want to get a PFT done - at least to establish a 'baseline' of where you are in the disease.  Understand that folks do not develop symptoms (like those you related having read about COPD) until pulmonary function has decreased significantly - to less than 60 % of most predicted volumes on the PFT.  My bet is that you're far from that.

Read about COPD and keep in mind that you are stocking your mental/educational 'tool box' for 'some day' in the future - maybe.  Many folks who do 'the right things' early in the process don't end up progressing significantly.  In other words, it may be more likely that 'something else' will be the cause of your demise long before COPD plays any significant role.

If you run into problems along the way, give us a holler and we'll help you navigate the difficulties and manage your situation.  But, in truth, I wouldn't expect to hear from you any time soon!

Best wishes!

Mark

Follow up question on NAC and Cancer

(see last week's q...     Are there any contra-indications for the use of NAC

 Q.   Hi Mark..sorry didn't provide  my name in last msg /question regarding NAC and concerns  for those with COPD and /or those with lung cancer. The site that I was referred to regarding cons of taking NAC is  http://www.the-scientist.com/?articles.view/articleNo/39022/title/Antioxidants-Speed-Up-Lung-Cancer

Your opinion please…

Regards..Dawna
 

A.   Hi Dawna,

The article is very interesting.  I cannot say that it is not raising a valid concern.  BUT, that it is the first of any 'hard looks' at NAC, for instance AND that, while many correlates were identified between 'mice and men', I can't get too excited - at this point - about the findings.  I will follow future investigation of these possibilities and adjust my recommendations accordingly as time passes.

For the time being, I have to fall back to my usual stance and modus where these kinds of questions arise.  first, we tend to favor the approach of weighing benefit versus risk.  And as NAC is undergoing study for use in Pulmonary Fibrosis and COPD - as anti-inflammatory, antioxidant and mucolytic benefits, I would defer to what those studies find.  Secondly, as no mention of effect on stimulation of glutathione production was mentioned or seemingly investigated AND that only the ROS and P53 markers were investigated, important questions of the interplay between those factors need to be addressed and answered.  for instance, If glutathione production defers activity 'away' from the cancer-fostering activity, then, again, the benefit needs to be weighed against the potential for harm.  As with so much in science, finding a relationship between isolated factors and harmful effects cannot be considered the 'whole story' until the entire - or at least significantly more of the - process becomes illuminated.  We don't know, for instance, if humans might have a mitigating factor that ends up making us different from the mouse-model, despite the striking similarities in the isolated relationship(s).

For now, I would have to advise you to go with what you are comfortable with.  If you feel NAC can potentially benefit you AND you can accept the potential risk as may be identified to this point in time, then you have your recommendation.  If you cannot accept the risk, you also have your recommendation.

Best Wishes,

Mark
   

What to expect in ‘last stage of COPD’

Q.     Mark, my Dad has entered the last stage of COPD according to the emergency room Dr. What can we expect to face in this stage of the disease? My Dad, Mom and I all feel it would be easier to face known hurdles than to face imagined ones due to ignorance, but none of the medical personnel we deal with are giving us any information. Sometimes when facing a new problem with the COPD the Dr's reaction is along the lines of "oh, you didn't know that?". This adds to the frustration of not knowing in the first place. Please help. Thank you.
Carol

A.   Hi Carol,

First, I 'hate' when doctors characterize COPD (or many other conditions, for that matter) as "end-stage" or, worse yet, as you have been told "last stage".  I would recommend that you peruse the internet and gain knowledge of the COPD process.  Pay special attention to 'pulmonary functions tests' (PFT's).  Then, get a copy of your dad's PFT's and find out where he stands in the process.  The Global Initiative on Obstructive Lung disease is a good reference for understanding PfT's and how they fit into the COPD picture.   I can tell you that there are innumerable folks who fit into the most severe stage of COPD as per PFT's who are quite functional and lead productive and decent quality lives.  But, COPD is NOT a disease where one can 'rest on their laurels' and let it have its way with them. 

Things like 'pulmonary rehab' - which can be undertaken in a formal program or on an individual basis - can make a world of difference.  Getting the right amount of treatment for symptoms - inhaled medications to control symptoms and oxygen, if and when it becomes necessary - are CRITICAL to living well and managing COPD.  Learn more about what medications are available and when they are helpful.  Be sure your dad is getting the appropriate care for his disease state.  And get him MOVING!  Movement is so critical to doing well with COPD that I cannot stress it enough.  Check out the EFFORTS website and its wealth of information - from and by people who deal with COPD every day AND by professionals, like me who have contributed much to that body of information. (You can also visit this site's forum/ message board and learn, share, interact with peers)

I expect that you could be pleasantly surprised at what CAN be done for and with your dad to better his lot in life with this disease.  And, as you learn more and more questions arise - POST THEM!  We are here to help answer what we can.  In any event, you should NOT have to continue to feel helpless and ignorant about COPD.  There is much available to help you know better and do better with your dad.

Best Wishes,

Mark
 

Review of PFT results

Q.  Hi Mark, I am a 56 year old female. I got a throat infection Jan 3rd 2014 which developed into a chesty cough. Treated with antibiotics Jan 6th and Jan 29th. I still have some phlegm. Referred for respiratory tests and I have attached the results. My Dr thinks I have moderate COPD. I am not breathless and able to 2-3 miles daily.

Chest X-Ray is clear.

I would be grateful if you could review the test results and forward your opinion. I am not taking any medication even though my Dr and I have talk about a few puffers.

Thank you

Lorna

(PFT's were received but not posted on this page)

A.  Hi Lorna,

Your PFT's suggest only the very mildest of obstructive defect.  But, looking at the  tests, overall - especially the lung volumes -  and putting all the numbers into perspective with each other -  I'd say that even the "mild" obstructive defect (a.k.a.- COPD) is questionable as you have "NO" increase in resting lung volumes.  Indeed, they are below predicted. AND with normal DLCO, you have absolutely no clinical suggestion of meaningful disease, at this point.  So, I would opine that you need NO medical treatment at this point.  And, you are doing the right things to preserve your good lung function.

In any case, I disagree that you have much to be concerned about any time soon.  Save the 'ouffers' for when (and IF) you actually need them.  NOW is not that time, IMO.

Best wishes,

Mark

 

March 22, 2014

Questioning Doctor's Diagnosis

(Note:  This is a follow up from a March 8th question (below)  "Querying COPD Diagnosis"  )

Q.  Hi Mark:

I've made a copy of my spirometry test for you.  Just want to also mention that most of my breathing is done through my mouth  as I cannot get much air in through my nose.

Pat

A.  Hi Pat,

Well, I'm inclined to agree with you that your doctor has mis-diagnosed you.  BUT, in fairness, I think that the two measurements that sparked the error are not wholly misdirected.   Your RV - on the lung volumes - and FEV1/FVC ratio - on the spirometry are elevated and reduced, respectively, which - when ignoring ALL of the other numbers could lead one to a diagnosis of COPD, albeit extremely mild! 

However, that said, I would argue that your PFT's are grossly normal and that the two values that are out of range are consistent with a person who, when compared to the standard deviation-driven statistics for your age, gender and height, is simply one who lies outside the predictors. 

Another possibility is that the machine was miscalibrated, though the comparability between predicted is too consistent for me to suspect that.  One other possibility would be that your age, height and/or weight may have been mischaracterized or recorded erroneously, which would affect the predicted values and push them out of range.  In other words, if you are taller, or younger than what the recorded height and age are, those woud throw off the predictions and therefore, the comparisons.

Insofar as your question of another test better measuring the presence or absence of any disease, the PFT - when accurate - is the most sensitive and accurate test for making the diagnosis AND for assessing severity in accordance with the measurements *though NOT clinically).  In any case, keep doing the healthy things you are doing.  And don't worry about what the doctor has said!

My curiosity is WHY you had the test in the first place? ? ? ? ? 

Best Wishes,

Mark

(Note:  The  actual PDF accompanied the above query but was omitted on this page.)

 

Are there any contra-indications for the use of NAC

Q.  Hi Mark.. do you know of any reason why NAC (N-Acetyl cysteine) should NOT be given to someone who has COPD and suffers from lung  cancer. I have been reading the posts of many COPD patients who suggest that NAC has made a significant improvement in thinning out their mucous/phlegm.  Then someone sent me some research information which suggests that NAC can stimulate tumour growth in those who have cancer. What if anything have you heard about this?

A Hi (???) You gave no name!'

I have not seen ANY evidence/research/warnings of carcinogenic action or influence exerted by NAC.  Tghat doesn't mean it's not out there.  HOWEVER, considering the chemistry of NAC and the fact that it is an antioxidant AND an anti-inflammatory my suspicion of the informaiton claiming it can foster cancer growth in those who have cancers meets with extreme skepticism.   Anti-oxidants and anti-inflammatories necessarily are cancer-protective.

So, my inclination would be to suggest that the information about carcinogenics is erroneous.  If you come across anything that supports the negative effects of NAC, I would appreciate receiving it so that I could evaluate it for its integrity and accuracy. 

In the mean time, if you are taking NAC - - - AND have mucus issues that NAC can or is helping with - - - AND you have cancer, then barring strong evidence-based advice from your doctor, I would say that you should NOT discontinue its use, especially if you feel it is providing positive benefit.

Best Wishes,

Mark

Mach 15th, 2014

Best indoor air quality for COPD

 Q.  What are the "ideal" range of indoor conditions for someone with COPD?
Are any air filtering and/or tempering equipment recommended?
Thank you, Brian

A Hi Brian,

This question comes up again and again among those with COPD.  It is very difficult to answer with much of a helpful response.  Indoor air quality is an ongoing and difficult issue that affects folks very individually and differently.  Where one lives, the local and immediate pollutants, allergens and weather seem to contribute much to the difficulties - and resolutions - that end up being effective.  There is no 'blanket' recommendation for what folks should do with regard to conditioning the air within the home, aside from restricting smoking of any kind within the home and being careful with cooking and the smoke and odors, etc., that can be attendant with that activity..

Generally, it is always recommended that, say, during the winter, you should try to keep the humidity of indoor air higher than the weather will usually supply.  Around 40 % seems to be a good level.  But, most folks don't have suitable equipment to measure humidity.  So, comfort has to be the litmus.  On cold days, steamy windows indicate that the humidity is usually at least 40 %, if not higher.

Some folks find it helpful to use an air filter of some sort - whether a HEPA placed in a central air/heat unit or a free-standing device.  But, adequately filtering the large volume of air within one's home is a daunting and difficult task.  So, one can spend considerable $$$ for less than stellar return.  Also, with many air filters producing ozone as a by-product, it can be a challenge to find a device that will not ADD that pollutant to the environment and counter efforts to improve air quality.  So, I make no recommendations in that regard.

With doors and windows open during nice weather, if that is what folks like to do, any filtering or conditioning is negated.  at the same time, keeping a home tightly closed and 'sealed' can render the air within the home less than ideal, simply because of indoor pollutants that accumulate and may not be easily removed by purifying systems.

About the best I've seen folks do is to ascertain what their individual preferences and difficulties are and try to accommodate them with the most cost and energy-efficient mechanisms they can conjure up.  That means trying different tactics to see if they make a positive difference.  If they seem to help, stick with them.

Best Wishes,

Mark

March 8th, 2014

Querying diagnosis of COPD

 Q.  I've just been told by my Dr. that I have COPD.  I'm questioning this diagnosis.   I am a 63-year old female in good shape.  I exercise regularly (5 times a week for an hour) and often do over 500 stairs at a time (counting the up stairs only) during lunch break.  (I used to do 1000 but it was hard on my knees.)  I would say I've never had problems with my breathing.  I have been exposed to smokers as my husband used to smoke (quit 20 years ago) as did our friends. Last year I tried running again and was able to run for 30 minutes without stopping.  I do, however, have problems with my nose/nasal passages.  I have a double deviated septum (one nostril was opened up surgically when I was 27) and I experience a lot of post nasal drip.  When I went for the spirometry test, I told the technician that I felt my throat was not clear because of the drip, but he thought that would not be a problem.  Is there another test I can take that would confirm this diagnosis? 

Pat

A.  Hi Pat, 

I'm afraid I can't tell you much of anything about the veracity of your diagnosis without actual numbers from your pulmonary functions test.  Your characterizations are nice - and suggest that perhaps you don't have COPD as bad as maybe you were led to believe.  But, just because you feel good and can do what you can do doesn't mean you don't have at least mild COPD.  But, again, only the PFT numbers can tell me what is the case.

IInsofar as your question about another test - - - a PFT is really the best and most definitive test to detect AND quantify severity of COPD.  BUT, it cannot always do a good job of characterizing how well one is living and functioning with the disease - - - especially in those who have very mild cases - as it seems you might have.

So, if you'd like me to tell you more, can you get your PFT results to me?  In the meantime, don't let the diagnosis slow you down or stop you from continuing to do all that you're doing.  The more you move, the better you'll do for the years to come - - - with or without COPD!

Best Wishes,

Mark

Is Advair the right medication for me

Q.  I'm 71 stopped smoking around 40. I take the advair discus inhaler as prescribed by my medico but after 4 months it burns my lungs when I inhale the stuff. I take it at night because that's when I get the phlegm problem which forces me to sleep just about sitting up. they have done the stress tests on my resp. system here at the Medicine Hat hospital but I am not any wiser about my actual condition. I am wondering if this product is doing more harm now than good. My chest feels permanently squashed up as if someone is sitting on it. my medico here in Medicine Hat is Dr.  Mei and I will be seeing him tomorrow. he prescribed this advair before I left for Nicaragua 4 months ago so I have been inhaling this stuff all this time as he told me.

Thanks.

Fred

A.  Hi Fred;

It certainly is possible that Advair is not the right medicine for you.  But, in taking it only at night you are not taking it as you should.  Those medications are supposed to be taken twice a day AND as close to 12 hours apart as possible.  They are NOT supposed to be taken for "phlegm control", per se, though they should help reduce phlegm over time.  Their affect can ONLY be established and sustained when they are taken every 12 hours.  So, there is a possibility that part of your difficulty with them is because of the  once-a-day dosing pattern.

Ask your doctor if you can try Symbicort.  See if that helps.  Also, it would be worth asking about taking Spiriva, another very COPD-specific medication that could help with your phlegm.

You didn't say if you use oxygen.  But, it sounds like you should be tested to see if your oxygen level drops when you are walking for more than a minuite or so.   If you are, then that could be contributing to your "cruched chest" sensation.  In any case, more informaiton needs to be gathered.  But, you can ask your doctor about changing the Advair to Symbicort, immediately.

Best Wishes,

Mark

March 1, 2014

Bronchiectasis followed by chemical trauma resulted in some blood in phlegm. Help please

Q.  Live in Manhattan NY, youthful 76, have had bronchiectasis 20 years, was stable enough, but this past year I flew when oughtn't have, was hospitalized 2 weeks May with pseudomonas pneumonia (my 4th hospitalization since end 2002 & 14th pneumonia),  had almost fatal "run-in" with an industrial-strength chemical end Sept. & over-exhausted myself in Oct. - leaving me with deep-pink & occasionally litely blood-streaked deep phlegm for 1st time & it persists.  Biaxin & Augmentin, always worked for me & were gentle on my system but  didn't work this time (Augmentin a little). I have alternative/complementary medicine bias & have taken no other drugs but antibiotics & only when necessary. Have conservative but indecisive pulmonologist at good NYC hospital, getting conflicting counsel, told if no improvement by mid-March or so need another C-scan & probably 3 antibiotic cocktail for 18 months.  Want to avoid that, taking lots oral C, NAC, started (oral) serrapeptase, 5-6K D3, 20k IU Vit. A, B complex 100, Co-Q10.  Am at 6s & 7s about going outside &  exercising. Don't take flu vaccine. I have strong spirit but badly in need of direction. Was impressed by your response to  Lori on Breathing Better, Living Well website. Thank you for any help!

Diane

A.  Hi Diane,

You gave what seemed to be very detailed information with regard to what you take in terms of medications and supplements.  But, you generalized so much of the history information that you have left me at a loss to be specific about anything, much less to be able to form a reasonable idea of what might be going on with you.  So, I will ask some more questions and offer a few general suggestions, at this point.

What does your CT scan currently show?  What do you mean by "stable enough" with regard to the past 20 years of having bronchiectasis?  Are you sure your pneumonia was indeed caused by pseudomonas infection?  Was a good quality sputum specimen obtained that was not contaminated by external elements/influences?  With what "industrial strength" chemical did you have your "run-in"?  Was it an inhalational exposure/injury?  Did it require allopathic (conventional, interventional) treatment?  By what standard or measurement or qualification do you suggest that you "oughtn't have flown" last year?  When and where did you fly?  What happened tgo cause you to characterize that trip as you did?   How do you define "over-exhausted my self"?   What do you mean - "am at 6's & 7's about going outside & exercising"?  What kind of 'breathing" symptoms do you experience and under what conditions do you experience them?

I don't see anything in the supplements you listed that impresses me as being viable or effective options to antibiotic therapy.  NAC, depending upon how much you take, may be helpful as a mucolytic.  But, with bronchiectasis, the mucus "rheology" (character and consistency) and virulence (infectiousness) of secretions is quite different from chronic bronchitis and other non-bronchiectasis infectious lung diseases.So, the NAC might easily need to be 1800 - 2400mg/day./  But, there is no substitute for the antibiotics.  And with bronchiectasis, antibiotics are a critical component acute and crhonic treatment - components for which there are no reasonable or effective non-tratidional alternative or supplements.  Augmentin is penicillin and will become l;ess effective over time.  Biaxin is a macrolide which has a bit more staying power - IF it works, which it seems not to be doing at this point.  Another possibility is that you have a virus caused infection, which wouldn't be expected to respond to antibiotics.

You are in a very unenviable situation with your aversion to conventional medical interventions and owning a diagnosis like bronchiectasis which is notoriously responsive to conventional interventions and without suitable alternative remedies.  At 76 - regardless of how "young" you may think and feel, you are at a stage in life where things can go wrong very quickly and severely.  I am concerned that what you may have been able to deal with well for the last 20 years could be fading/ending. 

As I said earlier, I can offer you nothing specific at this point as I would need much more pertinent and specific information as requested above.  If you are able and willing, please provide that and I'll take another stab at a helpful response.

Best Wishes,

Mark

Feb. 22, 2014

Oxygen and anemia

Q.   Recently a patient  had this question.. Could you please explain the correlation or association  between COPD and anemia.   It show  “2yrs in a row I am low on iron although I take an iron pill daily and eat spinach and all the iron rich foods.”   Thanks,  JW

A. Hi J

Folks who suffer from anemia have a precarious relationship with regard to oxygenation.  As hemoglobin carries 97 % of our oxygen, when we have anemia to the tune of a deficit of 10 % and more, getting sufficient quantities of oxygen to the tissues becomes a challenge - one that increases, the more severe one's anemia happens to be.  Now, for women, whose hemoglobin should be about 12 gm%, being at 10 or 11 is not too big a deal, as long as thy are
otherwise healthy.  For someone with COPD, 10 and under becomes of increasing concern.  Most doctors will determine if either transfusions or medication to stimulate the bone marrow to produce more red blood cells(RBC's)/hemoglobin is in order.  Some will elect to administer EPO - (Erythropoetin) which may help to increase hemoglobin.  A lot depends upon the 'morphology' (departure from normal shape, size and other characteristics) of RBC's when examined under the microscope.  If they are particularly distorted from normal, then action would be in order.

Bottom line:  many folks reside in the range of borderline adequacy for RBC's and hemoglobin and do just fine - even with COPD.  The more advanced one's COPD - especially if they require oxygen supplementation - the more consideration must be given to anemia and its consequences.  If one's doctor is satisfied with the patient consuming increased iron and other vitamins (especially the B's and C), then they should be able to rest assured that their anemia is not severe enough to require intervention.  Those who are anemic should be very sure to discuss their concerns with their doctor and get an adequate explanation and assurances that they are doing what can be done to either remedy the condition OR keep it stable and exerting the least negative influence possible.

And then there's grandma's remedy - a sizable dose of Liver and onions at regular intervals!  Seriously, red meat is a good source of iron, enzymes and vitamins that help with anemia even more so than do supplements.

Best Wishes,

Mark

 

Cervical lung hernia

Q Hi Mark,

I appear to have developed a cervical lung hernia – my diagnosis as I haven’t yet got to see a doctor. It only started on Monday afternoon but when I cough the swelling increases on the left side, from behind the collar bone. Painful but a little less so if I keep hand pressure on the area when I cough. I don’t recollect seeing this discussed anywhere and would be grateful for any advice or information from an RT perscective.

Chris

A.  Hi Chris,

I think what you may be referring to is an "apical" hernia, rather than a 'cervical' hernia.  In any case, the likelihood of that being the case is low, if possible, at all.  Two things that can cause the observation you relate include pneumothorax and a large bleb, or 'bullus'.  If you are feeling or 'seeing' a bulge when you cough, then you should see your doctor and get an x-ray to be sure it is not something that can expand or rupture or cause serious trouble.  Insofar as the hernia possiblility is concerned, the lungs are contained within the pleural sack,.  It is not subject to 'herniation' under most scenarios that I can imagine.  BUT, blebs can rupture and send air 'outside' the lungs and 'into' the pleural space causing collapse of part of the lungs in the area.

Another possibility is simply that the displacement of the surrounding muscles by emphysematous lungs is causing the pain when that part of them expands with air-trapping during coughing.  That you can keep the "swelling and pain" at bay by holding pressure over the area during coughing suggests that it might just be ornery muscles that don't like being compressed.  In any case, I'd suggest you bring it up with your doctor and get his/her assessment on the issue.

Best Wishes,

Mark

 

Feb 15th, 2014

Reaction to industrial chemicals, how to get tested for COPD

Q.  Mark :

I work at General Motors Cami assembly plant. I have been in the paint dept. for 3 years.

I am having some breathing problems, and I know it is from paint solvents and 3M polishing compounds.

Every time I am exposed to paint solvents I get a severe pain in my chest and feel like vomiting.

There is always a fine cloud of 3M polishing compound in the air.  I have been coughing a lot the past year and my chest, lungs get sore at work.

My breathing has been short, and when I exert myself I get out of breath easily.

 

I am not in A-1 shape but pretty good. My wife and I do a lot of walking and outdoor things.

 

I went to my friend's auto shop a while ago and they were painting a car.  As soon as I smelled the paint fumes I had to get out.

Pain in my chest and almost instant headache nausea.

 

I have been off work for 4 weeks because of ulcerated colitis.

 

As time has gone by coughing almost has stopped.

My chest and lungs still hurt if I sneeze, cough or large yawn.

 

So anyway how do you get tested for COPD.

I complained to health and safety about this, everybody started to give me a hard time saying I was going to cause trouble.

John

A.  Hi John,

It is hard to say - from where I sit - that you have any specific lung disease, though your symptoms are not unreasonable for the conditions you relate that you work in and you may indeed be at risk for development of lung disease.  If indeed you are developing lung disease, it would be more likely to show up as one of the 'restrictive' lung diseases, as opposed to COPD (obstructive).  And that, too, is dependent upon whether or not you are a smoker - which would put at risk for COPD AND possibly a combined restrictive disorder.

In any case, you should make an appointment to be seen by your doctor and request "pulmonary functions testing"  That is the first and best test to begin to see if there is anything clinically significant going on with your lungs.  As well, for the kinds of lung limitations your are at risk for, a CT scan might be in order.  Often, doctors will order a simple chest x-ray.  But, that is not sensitive enough to detect the kinds of changes one would develop from inhaling toxic or caustic agents that can damage the lungs - at least not until the damage has progressed to such significance that it causes significant changes that can be seen on x-ray.  So, don't settle for a simple chest x-ray if your pulmonary functions turn out to show abnormalities.

At this point, you need testing to determine IF there is anything to your concerns and then to determine 'how' significant the problem is. with that information in hand, of you have further questions, please come back and post them.  I'll be happy to try to answer them for you.

Best wishes,

Mark

 

Feb 1st, 2014

PEP Therapy (Product) Question

Q.  Could you please give your opinion regarding Aerobika® Oscillating PEP Therapy System .

Thanking you in advance,

Michael

A.  Hi Michael,

I have no experience with the Aerobika.  I don't recall seeing it at the recent AARC International Congress, either, or I would have snagged a sample to check out.  But, from what the website reveals, if it truly is as much better than Aeroeclipse , then I would certainly add it to the list of options recommended to those for whom it would benefit.  PEP therapy with vibration has proven itself to be of great help in airway clearance efforts.  Aside from the "Lung Flute" and "Flutter Valve", most all the others seem effective and easy/convenient to carry and use for those who need them.  I'll keep my eyes open for this device in the future so I can give it a test run, myself to form a more educated opinion.

Best Wishes,

Mark


January 25, 2014

PFT near normal but short of breath - additional post from  week of Jan. 18th

Q.  Hi Mark ... I would like to add to my previous post as I am now confused.. below is your reply to my first post.. I am wondering why I have the following symptoms.. Shortness of breath, chest tightness if I repeatedly go up and down the stairs... difficulty with humidity (feel like someone is sitting on my chest).. clearing of sometimes green sputum, sometimes just clear but thick and on a daily  basis this did not start until after I quit smoking.. I did have that happen last spring but thought that I had a sinus infection and after antibiotics it went away,  I have shortness of breath while sweeping the barn floor or walking up hill.. Pulling the waste can out to the end of the driveway makes me puff.   I thought I was a fairly fit person, not over weight and have always engaged in regular exercise.  I hate to bother you but it confuses me.. wondering why I have these symptoms I am certainly not imagining them.. I am not limited in what I am doing but I do notice it.  The summer humidity was the hardest part for me.  Is there something else that should be looked at ?  I am going to include some other numbers just in case I missed something.  I do not  want to be taking medication that I do not need.   They say that this testing shows that I do not have asthma or allergies. 

Sharon

Your Reply:

You have extremely early/mild COPD.  The fact that your FVC and FEV1 remain within normal limits makes your COPD sub-clinical, for all intents and purposes.  I would suggest that at this point "no" medications are indicated or appropriate.  Nor would I expect you to demonstrate or report any significant, even noticeable benefit from taking the inhaled medications.  The FEF 25 - 75 % tells us about airflow in the mid to small airways - the first place we see changed from normal in COPD.  That your is reduced is not surprising. 

Pulmonary rehab is indeed an inappropriate intervention for you at this stage.  You should be able to exercise quite normally, without ANY restrictions. 

Your chest tightness is likely anxiety and can be easily invoked through being overly concerned about your diagnosis at this point.  But, from a mechanical and clinical standpoint, you do not nave enough loss of lung function to be the cause of ANY respiratory limitations.  Therefore, any breathing difficulties you have are from some source and cause other than your early COPD.

You have taken the single most important step in helping yourself - that is, quitting smoking.  Going forward, exercise, eat right, get appropriate rest, flu and (when the time cones) pneumonia shots and keep moving as vigorously as you can.   You should remain in good shape for many years to come

(Webmistress Note:  Patient's additional Spirometry numbers are not shown here due to space)

A.  Hi Sharon,

I affirm my response above, once again.  It IS possible that you indeed DO have sinus infection causing the green sputum as opposed to any infection in your lungs.  Let me add that when some folks quit smoking, they go through a period of 'adjustment' of their daily lung function with regard to very subtle 'un-measurable' activities of the bronchial tissue.  Think of it as a 'cleansing adjustment' of sorts as your lungs are 'learning' to function without the assault of tobacco smoke which used to invoke defensive action within your lungs to mitigate the influence of the irritants of smoking.  Your lungs don't simply 'turn off' those defenses.  Instead, they must gradually subside over time - as much as a year after quitting. 

As I said before, your FEF 25-75 is reduced - a common and expected change due to smoking.  at 42 % of predicted, AND without improvement after bronchodilator, it is likely a "fixed" change that may or may not improve the farther out from smoking you go.  BUT, while it may cause you some degree of increased 'work to breathe', it should not be the cause of significant symptoms in terms of breathlessness or shortness of breath.

I don't recall you telling me if you exercise regularly or how vigorously you exercise.  But, my experience has been that the vast majority of folks experience "windedness" that they often perceive as "shortness of breath" or as 'abnormal', that windedness being easily attributable to poor conditioning - a.k.a.- simply being 'out of shape', relative to the breathing demands of many of the activities they cite as bringing on the shortness of breath.  What they invariably experience is a reduction in the discomfort and work as they engage in exercise of the right 'type' and 'intensity' and 'duration' to produce the conditioning in terms of 'wind power' to sustain them through the activities that are physically demanding.

Another phenomenon that I see with great frequency is that when folks quit smoking, they develop a set of expectations that are inappropriate with regard to "normal" physical responses to activity involving increased breathing work.  They expect "NO" windedness, or much less than 'normal' windedness for many activities and consider ANY increase in breathing to be a "symptom".  I have spent much effort with those folks to help them understand and allow themselves to become winded AND to understand that it is NOT a "symptoms".  Rather it is an expected and 'normal' response to the activity based upon many factors 'outside' the lungs that are contributory.  Again, another thing that recent 'quitters' experience is the heightened awareness of their body and breathing - to the point that many little sensations that they used to ignore AND were able to deal with quite nicely NOW become points of concern, often having increased emphasis placed upon them.

As I said in my earlier response, get moving and keep moving.  I would expect that the post-quitting changes you now experience will subside over time.  Give yourself 'permission' to breathe hard and become winded. Exercise with the specific GOAL to make yourself breathe VERY hard and become VERY winded.  It WILL NOT harm you!  AND you WILL recover after stopping AND in reasonable time, as well.  If you continue to have daily sputum, especially if it is in the morning, continue to monitor your sinuses, as such is usually due to post-nasal drainage during sleep.  Lastly, the medications have been shown to be ineffective, according to your PFT's from pre- and post-bronchodilator measurements.  So, the medications really are not likely to be of significant benefit as we don't have any reasonable evidence at this point that there is any preventive effect in using them this early in the COPD process.  Barring unforeseen difficulties you SHOULD continue to enjoy good lung function and health for a very long time to come.

Best wishes,

Mark

When to be concerned about reduced diffusion capacity

Q.  I don't have a diagnosis yet but my recent PFT's show that everything was within normal limits excepted the Diffusion Capacity which was 69% down from high 80's a year ago. Could this still be okay or is something brewing? Normal chest X-ray by the way. What could lower it? I have been short of breath for years. Thanks, Loren

A.  Hi Loren,

If your PFT's are normal in terms of spirometry and lung volumes, then I would expect that the variation in DLCO is due to what we often see which is momentary variation in that measurement.  It is one of the most volatile measurements and can be changed (in terms of measurement) with simple factors like effort, machine variation and technique variation, all that can be VERY subtle in nature, yet result in wide variation in measurement.  It is not unreasonable to expect that your next measurement of DLCO could well be back above 80 % again, simply due to variation in measurement dynamics.

It is very possible that your "shortness of breath" (SOB) is simply normal windedness associated with deconditioning relative to the intensity of activities that seem to bring on the sensation of SOB. 

Please understand that you must take my collective remarks with the understanding that not having seen your actual measurements, I can only base them upon your statement that they are WNL.  If there are one or two key values that are reduced (FEF 25 - 75%, TLC, for instance) then my impressions could be different than what I express here and now.  In any case, I cannot account for your complaint of being "SOB for years" through anything you have provided with your post.  In any case, I doubt that you have anything to be specifically concerned about at this point.

Best Wishes,

Mark

January 18th, 2014

Spirometry Interpretation

QHello Mark

I have recently been diagnosed with COPD , I obtained a copy of my spirometry testing and have a question. I would like to know where the FEF25-75% factors in on overall diagnosis and what the numbers mean. The final diagnosis on the bottom of the testing states the following:   

These are optimal studies.  The pre and post bronchodilator measurements of the FEV1 and the FVC are normal.  Pre and post bronchodilator ratio of FEV1 to FEVC mildly reduced.  FEF25-75% severely reduced. Impression : Mild obstructive ventilatory impairment suggestive of early COPD.

FEV1 85%        FEV/FVC 68%

FEF25-75%  Base – 1..13    %Pred - 42    Min - 1.58    PRED - 2.66     MAX -  3.75    Post 1 – 1,10     % Pred – 41   

I am using Spiriva in the am and also have a Ventolin inhaler which I do not find makes a lot of difference and I do not use this very often.   I am finding that stress really makes my chest tighten more than anything and right now stress is a big factor I am trying to educate myself as much as possible in hopes to keep this disease from worsening.  I was a long term smoker quit two months ago. I went to what they call a Rehab Clinic I did not find it really helpful for my age group and fitness level.  I am struggling right now with cardio from a physical problem of “ bursitis” in my hip.  I can send more numbers if you need them.   Thank you for your input.   Sharon

A.  Hi Sharon,

You have extremely early/mild COPD.  The fact that your FVC and FEV1 remain within normal limits makes your COPD sub-clinical, for all intents and purposes.  I would suggest that at this point "no" medications are indicated or appropriate.  Nor would I expect you to demonstrate or report any significant, even noticeable benefit from taking the inhaled medications.  The FEF 25 - 75 % tells us about airflow in the mid to small airways - the first place we see changed from normal in COPD.  That your is reduced is not surprising. 

Pulmonary rehab is indeed an inappropriate intervention for you at this stage.  You should be able to exercise quite normally, without ANY restrictions. 

Your chest tightness is likely anxiety and can be easily invoked through being overly concerned about your diagnosis at this point.  But, from a mechanical and clinical standpoint, you do not nave enough loss of lung function to be the cause of ANY respiratory limitations.  Therefore, any breathing difficulties you have are from some source and cause other than your early COPD.

You have taken the single most important step in helping yourself - that is, quitting smoking.  Going forward, exercise, eat right, get appropriate rest, flu and (when the time cones) pneumonia shots and keep moving as vigorously as you can.   You should remain in good shape for many years to come!
 

Best wishes,

Mark

Unusual Drops in Oxygen Saturation (Levels)

Q.  Hi Mark, 

Can you explain why during a exacerbation (like currently) I need to increase my supplemental O2 (from 2.5 to 3.5 l/m) and have significant drops in sat  (96/7 with O2 to 87-88) when going from sitting/laying to standing up even when done slowly?  This doesn't happen when feeling fine/baseline nor have I experienced this degree of sustained drops during previous illnesses.

 I had an AECOPD/ICU admission in September.  Echo showed PA press at 46.2 (up from 37 two years ago), mild mitral regurg (no change) and mild/mod tricuspid regurg (new finding.)  PCP blew it all off as a none issue since EF is 55-65%.  Even though in hosp for 7 days, I was back in our rehab maint. exercise class in 6 days and felt better than I had in many months.  But over past few months not doing quite as well as I have had to increase O2 to 3-4 l/m when on the treadmill, sometimes having to stop for 2 minutes to get sats back up from sudden drops to 89-90.

While I understand this is just progression of the disease, I don't understand the drops this current time.  Could  you give me a mini-refresher course on the etiology a related to COPD.  Thanks.  Doris

A.  Hi Doris

While you may have thought that 3 to 4 liters oxygen during exercise (as in walking on the treadmill) was a lot of oxygen, it is actually not all that much.  "Typically", what we see is that folks can maintain fine saturations while sitting at rest with say, 0 - 2 L/min flow.  Get them up and moving and their demand can jump to 6, 7, 8L/min and more - - - exacerbation or no exacerbation.  The reasons have more to do with changes in the mechanics of breathing than they do with any special or different 'malfunction' beyond the disease state.  The phenomenon is called dynamic hyperinflation.  Also, as one's respiratory rate increases, the amount of oxygen inhaled each breath decreases as a function of the shortened "inspiratory time" associates with the increase in respiratory rate. 

The bottom line is that you should not be afraid to increase your oxygen during exercise.  In fact, your absolutely should because of the beneficial effect it will have to dilate your pulmonary blood vessels.  Having a PAP of 46 by echo suggests that it is likely higher, since echo notoriously underestimates PAP.  Further, with the regurgitation, and regardless of the fact that you maintain normal EF, you STILL have retrograde flow that is increasing your PAP even more.  Add that to the changes during exercise AND hypoxia and your PAP could easily be jumping to 60 and higher.  We see that not so uncommonly in those with your set of physical changes.  There might not be anything that needs to be done at this time for the Mitral and pulmonic valve regurgitation.  But, at the very least oxygen is one of the most effective drugs to combat the combined effects.  AND you should AVOID desaturation - especially during exercise - if you can possibly do so.  That means using enough oxygen -  which may be 8 or more liters.  With patients who demanded more than 6 liters and still couldn't keep saturated, I used a high flow venti-mask at anywhere from 28 to 50 % and very high driving flows (15 25, even 45 to 50)  It is delivered with a mask so it's just a strong breeze in the face of the user.  BUT, it must be applied in a clinic where high flow is available, as home respiratory equipment puts out neither the flow or the pressure required to use the system in the home.

I disagree that what you are experiencing is simple progression of the disease OR necessarily exacerbation related.  Indeed, it is very possible that the added load which becomes much worse during exercise is causing your "exacerbations".  AND it might be that use of more oxygen at strategic times would reduce or eliminate future episodes and symptoms.  In any case, to continue to struggle with the saturation pattern your describe will predictably shorten your survival while making you a lot sicker lot sooner.  Oxygen is a critical drug for you and should e used with much more deliberacy and strategy.  To not do so will result in  very unpleasant consequences! 

Best Wishes,

Mark 

Shortness of Breath, Coughing,  After Lobectomies – Follow up

Q.  Hi Mark, I am responding to your rqst for more detail/information following my initial email to you. I hope you won’t get this msg. twice as I was having some pc difficulties...so here is my 2nd attempt to get this to you.I realize that my question is not specific to COPD but I do see some areas where there might be some benefit of your expertise to my husband’s situation. And I am trying to do whatever I can to bring issues/concerns/ suggestions/recommendations to my husband’s health care team.

My husband has had 2 lung lobectomies ..first surgery was to remove a lower right lobe due to cancer. He sailed through the surgery w/o any problems..very little pain and breathing was excellent.  Life returned to normal. Nine months later, after a routine follow up, another growth (cancer)was discovered and 2nd lobectomy took place..right lung, middle lobe. His recuperation from this surgery took a little longer but he experienced little pain and seemed to be recovering well. A couple of mths. into this recuperation he developed a cough which turned chronic and which he still has. But everyone was concentrating on the lobectomy and the cough was just something that was there. 

However, no matter how much we hoped and prayed that this was the end of surgeries, appts. etc. AND specifically the end of the cancer,  my husband was told in 2013 that the cancer was back and radiation and/or chemo were now  warranted. He started radiation in January of 2013 and followed that up with chemo which ended in October 2013. The cough has been persistent and unrelenting throughout. But shortness of breath more evident after radiation. Now, more often than not the cough is accompanied by shortness of breath-this is especially true when the cough comes in waves/spasms. (Oh, mucous production was a big concern after radiation..white, thick, stringy.) This however has minimized over time and seems to be more evident in the a.m. upon rising or after a diary rich diet.

We notice that the cough is generally worse in the evening hours and interestingly right have the supper hour and can continue for some time (nocturnal). The wheezing was recently treated with a 7 day amoxicillin  treatment and is no longer an issue for the most part. However, on January 8th at our Onc visit I played a recording of how my husband’s cough sounded and Onc thought it could be asthma related! So, we are now awaiting an appt. with allergist. My husband is on Fentanyl path, Fentanyl nasal spray, Flovent, Sabutamol..ALL FOR CONTROLLING THE COUGH AND SHORTNESS OF BREATH. He has no cancer related pain .  At this point, he feels that they are just ‘throwing’ things at him to see what sticks and what doesn’t to control the cough. Although we appreciate their efforts we wonder if they/we are missing something. We are realists and understand that the cough /sob can be attributed to the cancer, to scar tissue, to movement of organs in his chest cavity. We just want to be sure we have explored every avenue and then some!!! Throughout all this no one has suggested/recommended that he visit a Pulmonary clinic...I have asked that this be considered and we are awaiting an assessment appt. and placement on enrolment list for 8 week rehab program. 

Our last CT scan in late Oct was described by the Onc as remarkable in how well my husband has responded to treatment. Again no pain..just an unrelenting cough/shortness of breath that impacts his quality of life.  He is my hero, he has a lot of life left and he has demonstrated time and time again what a fighter he is.  If there is anything that you think we should be exploring with our medical team we would be so happy to bring it to their attention or investigate ourselves. Again, if my request for information is beyond the scope of your mandate I understand and just wish to thank you for sharing your expertise with those who so very often feel disconnected from their medical team or Dr.   Regards....  Dawna

A.  Hi Dawna,

Thanks for the additional information.  It is indeed difficult to pinpoint any specific change of the many your hubby has undergone that would by itself, account for his two primary symptoms of SOB and cough.  In some instances where a person undergoes lung resection of significant portions of lung, a subsequent symptoms is cough - dry, hacky cough, and sometimes with mucus production, as well.  As your hubby has undergone resection of his middle and lower lobes on the right, he has lost a significant portion of total lung capacity  as the result.  Were the rest of his lung capacity normal, he would expectedly have minimal limitation in breathing which would predictably manifest during significant levels of exertion.  

Another consideration is the effect of radiation and perhaps also the chemo and their influence on his cough.  While there is debate about the question of radiation fibrosis in those who receive radiation treatment to the lungs, this could be a factor in his ongoing and worsening cough.  I am concerned that he is being sent to an allergist rather than or instead of a pulmonologist.  I agree with you that he should be all means be evaluated by a pulmonologist.  If he has not had a pulmonary functions teat (PFT), you should push hard for one to be done.  Allergists often do them.  BUT, they generally do only spirometry as that is what rules out asthma. He should have a complete PFT with lung volumes and diffusion capacity.  while I would fully expect his 'numbers' to be down - especially his volumes, taking into consideration the lobectomies, they ARE interpretable and should also be helpful to determine potential causes for his symptoms.  If he has not had an oxygenation evaluation, that should also be done. His diffusion tests would also illuminate any problems he has with getting enough oxygen into his blood.

If he has not previously been an 'allergic person', there's no reason to expect that he would be now.  So a lot of testing for allergies, IMO, would be of little help, if any, in finding the cause of his cough.  His CT scan, if done with contrast or high resolution, should show if he has any interstitial infiltrates suggestive of any fibrosis formation.

In the end, if his cough is serving no mucus management purpose, it should be quelled.  Codeine might be a better cough suppressant than Fentanyl - a pretty drastic approach.  But, it has its drawbacks, as well.

I would be interested in hearing from you as you get more assessments and information AND to learn of his progress.  I'm sorry I can't offer much more than I have.  His is an interesting challenge and case.  Please let me know what you learn and how he does.

Best Wishes,

Mark

January 11th, 2014

Several Questions from a recently diagnosed COPDer

Q.  Dear Mark

COPD Website – Canada

Thank you for your website, which I have recently discovered and have found to be extraordinarily helpful and informative.

Well, this is me:

I am a 54 year old Aussie male.  I was diagnosed as having early stage emphysema in about April 2013 following a CT scan for an unrelated lung condition [a check-up on a nodule which had been detected a few years earlier, but had remained unchanged so the diagnosis was that it was stable/benign].  The result from the CT scan however, also stated:  “multiple imperceptible upper lobular cysts, consistent with early stage emphysema”.

Prior to the CT scan I had been a fairly heavy smoker for about 35 years [about a 25 pack per day] but hadn’t had any particular smoking associated symptoms that I can recall, save perhaps for some occasional morning ‘smokers cough’.  So even up to diagnosis I thought of myself as a fairly regular fit aussie bloke.

After diagnosis I started to significantly cut down on the smoking to about 6 – 8 a day up to about the end of September 2013, and then on 3 October 2013 I stopped smoking completely and haven’t had a cigarette since.  What a disaster this has turned out to be.  Since stopping smoking I can hardly breathe, and I have had increasing chest, neck and back pains, and have started to cough up mucus continually [which never happened before].

I have a number of questions for you, which mainly arise out of the results of a number of different consultations I have had with various professionals here in Australia over the last few months, which seem to be at odds with each other.  For that reason, I wondered if I gave you a bit of history whether you might be able to at least consider some of the questions I have?  The history is as follows:

-          Following the initial CT scan which showed early emphysema in April 2013 I saw my GP, who said the results [ie early stage emphysema] were not good, but she then gave me some sort of single blow tube test [which I now know to be a standard hand-held FVC instrument] which showed a result of 95%.  That surprised my GP a bit, and from that she then said that everything was OK, but that I needed to stop smoking.  My GP however didn’t tell me any more than that – ie as to the stage or progression of the disease – and at that stage I didn’t know anything about it myself, so I didn’t even know what to ask in any event.

-          I then started to do a bit of internet research about the condition [as you do] and I saw a clinical trial for moderate COPD offered by one of our local hospitals here in Melbourne.  I traveled out there and was given a spirometry test to see if I fitted the criteria for their trial.  My results were FEV1/FVC < 70%, and FEV1 pre-bronchodilator of 63% and post-bronchodilator of 70% of predicted.  On that basis they said that I had moderate COPD, which fitted with their trial criterion, and so they joined me up to it.  In my post-test interview the lung specialist said I had significant lung damage as a result of the smoking.  This was in about late August 2013.

-          I gave up smoking fully on 3 October 2013, and I have not had a cigarette since [though, like most Aussie males, I still tend to drink far too much beer].

-          Following quitting smoking I started within weeks to experience really very unpleasant things.  I started to find it increasingly difficult to breathe [which is not something which had ever happened to me while I was smoking] and I started to get increasing tightness and burning pain in the chest, and I started to experience other rather unpleasant things related to bodily functions, which I don’t want to go into here.  These things continue to persist to date, and seem to be worsening, rather than improving.

-          I then went back to my GP.  She seemed nonplussed that I should be having negative side effects of giving up smoking, as if I was trying to kid her that there might actually be some [at least initial] negative effects of quitting smoking after long term use.  She referred me to a lung specialist.  I went to see him before Christmas.  I had spirometry tests again – though in this case the tests were clearly far more extensive than I had had at the earlier hospital appointment.  The tests took about 40 minutes or so, administered into a breathing tube with multiple stops and starts and all monitored by computer, pre and post bronchodilator.  This was on 19 December 2013.  The results were:

Ref                         Pre Meas                             Pre % Ref                            Post Meas                                Post % Ref                          Post % Change

FEV1      Liters                                                     3.43                        2.59                                        76                                           2.92                                        85                                           13

FVC        Liters                                                     4.27                        4.61                                        108                                         4.72                                        111                                         3

FEV/FVC %                                                          78                           (56)                                                                                        (62)                                       

Following those tests I saw my lung specialist.  He said from the results that I had mild COPD [in his terms, Stage 1] and that seeing as how I had now given up smoking that the disease should not progress so long as I did not start smoking again.  He didn’t seem particularly concerned about the results at all [which was quite a different attitude to the first lung specialist I saw].

My questions are as follows:

1              As I understand it, in diagnosing the stage of COPD, the FEV1 measurement is used, but is the measurement the one taken pre or post bronchodilator?

2              I am confused as to whether I am at the ‘mild’ or ‘moderate’ stage, because I have been told two different things from two different lung specialists.  On the figures referred to above, what would your assessment be?

3              Also, would the fact that I had given up smoking for nearly three months before taking the second set of spirometry tests have anything to do with the difference in prognosis from moderate initially, to mild 3 months later?  Is it normal for the result to actually improve with time? 

4              I was told by the second lung specialist that there was a small element of ‘reversibility’ in my test results, which he seemed to think was a positive thing.  Is it possible do you think to get back to a position of having few if any symptoms of COPD on the measurements referred to above, if I continue not to smoke?

5              Is it usual to have really very unpleasant symptoms following cessation of smoking, such as shortness of breath/chest pains and aches/infections and coughing?  If so, is it something that will eventually settle down and, if so, how long do these types of things generally take to settle down a bit?

Sorry this is such a long-winded request, but I thought it better to at least set out some detail first before asking you my questions.

Any information you might provide would be gratefully received, and if you felt like posting this email on your website for the assistance of any others, that would be fine by me.

Regards

Brett

A.  Hi Brett, 

You do indeed have very mild COPD.  You also have some airway reactivity as demonstrated by the 13 % improvement in FEV1 after bronchodilator.  Your current symptoms are likely from an infection - though it may simply be viral in nature - no need for antibiotics unless your sputum is significantly colored or green.  Your doctor can advise your on that point.

To answer your questions in order that you asked them: 

(1) measurements to ascertain "base-line" or "Steady state" are those which follow bronchodilator.  In your case, though, you are having an exacerbation, so your post-bronchodilator measurements do not represent your baseline OR steady state, at this time.  You would do well to have them repeated in a couple of months at a time when you are not having symptoms.

(2) Your disease would be classified as mild/Stage I.  You can look up the "GOLD" guidelines for classifying COPD and learn more about what constitutes the different stages.  In any case, when you are nor having a flare up/exacerbation, you should NOT be symptomatic with the FEV-1 and FVC you have even now while experiencing symptoms.  Most folks do not experience COPD related breathing difficulties until their FEV1 drops to and or below 60 %.  Even then, symptoms are not significant until below 50 to 40 % FEV-1.  So, your current lung specialist is giving you a valid assessment and prognosis - that barring contributory behaviors, you should do well and not have difficulties with progression of symptoms for years to come. 

(3)  PFT's reflect lung function and health "at the moment".  As well, they are effort-dependent.  Another factor to consider is that depending upon the values used by any given physician or lab, as well as the instrumentation used to measure PFT's wild variation between measurements can easily occur. I would suggest that the differences between the first and second PFT's are owing more to external influences than to any real change in you.  Symptoms will alter measurements. When you had both tests, you were having symptoms motors, as I understand your information.  So, were I you, I would not hang my hat on any measurements up to this point.  Wait until you see a set of "steady state" measurements.  In addition to the FEV1, FVC and FEV1/FVC ratio, look at your FEF 25 - 75 %.  If it is significantly reduced (even though the volumes may be good and/or within normal limits) a reduction to less than 60 % indicates small airways obstruction - TYPICALLY seen with COPD and especially with early COPD.  It is not significantly consequential IF/WHEN the FEV-1 and FVC remain high (> 60 % of predicted).  Also the fact that your FEV1/FVC ratio is so reduced reflects more on current airway reactivity than on any suggestion that your COPD is any worse (> 70% being normal).  At this point, there is NO reason for you to jump on getting more PFT's any time real soon.  even waiting a year or so wouldn't provide much more useful information than what you have now with these two tests.  Were your COPD more advanced, then the need for more frequent PFT's to better quantify your condition might be needed.  But, at this point, it is not necessary.  Lastly, without certain significant circumstances at play, once a "good" steady-state, base line PFT is obtained, on will rarely see improvement of any significance.  That is because the PFT measures the "mechanics of breathing.  And mechanics are dependent upon the physical structures and their influence on airflow.  The physical damage does not improve once disturbed.  It might not get significantly worse - or it would do so over significant time passage.  But, it will not get better.  Small variations from PFT to PFT over time are normal based upon effort and other usual factors from one testing moment to another.  So, if you see a 2 or 3 % change from one test to another (steady state, base line tests, that is) don't get excited.  The variations are more likely due to momentary influences than to real change. 

(4) Again, when we speak of "reversibility" demonstrated by post-bronchodilator improvement, we are speaking of reversibility of airflow obstruction.  It does NOT mean or apply to "reversibility of underlying disease or physical changes.  To illustrate what this means, we call "asthma" - "reversible airways obstruction, as we can reverse the obstruction by administering bronchodilator medications which reduce airway narrowing, inflammation and "momentary" obstruction.

(5)  Many folks report experiencing unpleasant symptoms after quitting smoking.  The evidence is unclear on just what the causes might be.  In some, the symptoms are more "perceived" than measurable.  In others, they don't actually exhibit heightened symptoms as much as they experienced heightened awareness of their body.  After all you have done a great thing for yourself in quitting smoking.  You expect to feel better.  You DON'T expect to fell worse.  And, even though you might not "be" worse, you still feel that 'any' symptom shouldn't be occurring, since you've done the most significant thing you can to prevent additional or increased symptoms as time goes by.  Finally, in those who DO experience actual amplification of symptoms or onset of new symptoms that may be attributable to changes in airway physiology after cessation of the irritation of smoking, those symptoms MOST OFTEN "DO" subside as time passes.  So, you should reasonably expect them to settle down.  AND, what you currently contend with may - as I suggested earlier - simply be a coincidental cold, infection or some other such acute episode.

Hang in there and keep trying to do the right thing.  If you need medications for your symptoms (inhalers, etc.) for a current episode, be sure to ask your doctor about them.  You may only need to use them for the immediate period, rather than worry about having to use them in the long term.  I suspect that you are some years away from needing to use regular dosing of medications for your COPD.

Best Wishes,

Mark

Order for taking inhaled drugs

Q.  Good Morning,

I was curious if you could tell me what order you would tell patients to take MDI’s for example Sprivia, Advair, Ventolin

Thank-you 

Michelle, RN

A. Hi Michelle,

I would recommend - as seems to be the standard recommendation, though there is no incontrovertible evidence  to support the 'standard' recommendation - the beta-agonist should precede the anticholinergic.  In the case of those medications you listed, you have two beta-agonists and one anticholinergic.  As well the beta-agonists differ in that one is short-acting and the other is long-acting.  As well, the long-acting beta-agonist is coupled with an inhaled corticosteroid (Advair).

Now that much explained, my recommendation would be that the Advair should be taken (first thing in the morning and again "12" hours later.  The Advair would then be followed by the Spiriva.  The Ventolin should NOT be taken routinely or on a set/arbitrary schedule.  The Advair should be sufficient to handle all symptoms, unless the individual has more severe COPD, in which case they would dose with Ventolin PRN "between" doses of Advair.  In ANY case, the Ventolin SHOULD NOT BE TAKEN within TWO HOURS before taking the Advair.  The reason for that is because both drugs go to occupy the SAME receptor sites within the airways.  If the Ventolin is taken too soon before taking the Advair, too many receptor sites will still be occupied by the Ventolin preventing the Advair (specifically the Salmeterol) from binding with the receptors.  In that event, the Advair is shed as waste without having had the opportunity to do any work.  When folks "prime" the airways with Ventolin and then take a long-acting beta-agonist shortly thereafter, they will almost always experience a much reduced or poor response to the long-acting beta-agonist demonstrated by the need to use the short-acting beta agonist at frequent intervals throughout the day.  It is not unusual to see folks require 4 to 6 doses of Ventolin IF they are taking it too close before taking their Salmeterol.

I hope this answers your question and gives you the rationale behind my recommendation.  I can tell you that in many thousands of patients now, over 15 or so years, having them NOT take their Albuterol within two hours before taking their Salmeterol or Formoterol has made a tremendous difference in both symptom control AND need for 'a boost', or 'pick me up ' (rescue dose, some call it) with Albuterol in between the long-acting beta-agonist doses.

Best Wishes,

Mark

January 4th, 2014

More wheezing and SOB – ? due to recent Rx for Spiriva?

Q.  Greetings Mark...my husband is on Flovent (twice a day), Salbutamol (as needed) and recently put on Spiriva. He has a chronic cough due in part to having undergone 2 lung lobectomies..but we have noticed that the cough has changed in recent weeks..more wheezing and SOB. Would the effects of being on Spiriva show up about 10 days after starting this new med?

Thanks..Dawna

A.  Hi Dawna,

There are a few different reasons why your hubby could be having the increased SOB.   The wheezing is potentially linked to those reasons or could be something altogether different.   You didn't mention which lobes he had removed, nor the reason(s) for their removal.  Nor did you tell me his diagnosis.   So, it is impossible for me to ascertain much about his lung function with any confidence at all at this time.   If I know how much lung volume he has had removed compared to what he had before 'any' surgeries were done, that would help.  His disgnosis would be important, as well.  If enough lung has been removed AND depending upon where from and how they 'tied off' the airways serving the removed areas, his SOB and wheezing could be related to the re-configuration of airflow within his lungs.  If he has pulmonary fibrosis, the cough could be caused be that.  Does he have much phlegm production?  Has he had recent scans to be sure there are no growths (like tumors) pressing on his airways.  Such things could cause wheezing.

He is only on a "as needed" beta agaonist bronchodilator (Salbutemol).  Perhaps he needs a long-acting version to take every day.  If the wheezing stops or reduces significantly with the Salbutemol, then he should likely use it more frequently and ask his doctor about using a long-acting version of it.

Anyway, if you could tell me more about his condition and the surgeries, as well as the cough and what, if anything he may be spitting up and out, that would certainly help me a lot to try to give you a more meaningful and pertinent response.

Best Wishes,

Mark

 

 

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