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About COPD
Should I See A Dr? (A Checklist)
COPD - Latest Web Info & Research (links)
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NEWPulmonary Function 101 (Understanding How Your Lungs Work) |
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Talking To Your Dr
What is a COPD Action Plan? NEW
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Ask the RRT
Ask The Respiratory Therapist YOUR Question
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Medicines
Know Your Meds - A Reference Guide for Canadians
Drug Names/Equivalents in Different Countries
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Are You Newly Diagnosed?
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Breathing
Anxiety & Pursed Lip Breathing (PLB) (Part 1)
NEWPursed Lip Breathing (Part 2)
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Breathing Tests (Understanding Them)
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Finger Pulse Oximeters
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Exercise
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Nutrition
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For COPD Caregivers & Support People
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Lung Transplant
Lung Transplant Ctrs in Canada
Meet Melody (pre transplant ) The Waiting
Post Transplant Q's &A's of Melody
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Recent Questions for the RRT as it relates to COPD
Mark Mangus, Sr. BSRC, RRT, RPFT, FAARC
(please be patient while the page loads)
Note: The weekly cut-off day is Wednesday evening. If your questions are received "after" that day, they will appear in the following week's postings. Questions and answers are usually uploaded to this site by Sunday evening.
Previous Questions & Answers (2010) of Mark Mangus, BSRC, RRT, RPFT, FAARC
archived by topic, alphabetically
Previous Questions and answers
of RRT Tracy Cushing, covering 2008 and 2009, have been archived by topic alphabetically.
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.
Current Questions & Answers
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January 29th, 2012 Spirometry Results Reviewed
Spirometry test: I
had this test today at work. I took the test twice. First set of results
were FVC 5.90 FEV1 1.97 FEV1% .33 . 2nd set of results were FVC 6.08 FEV1
2.13 FEV1% .35.
Hi Rick,
First, it sounds like you had a ‘screening test’ to identify those who
should be evaluated further for “potential” problems with lung disease. The
veracity of that test you underwent is dependent upon the skill of the
person who conducted it, the integrity of the spirometer they used and its
calibration and the quality of your effort. Missing in your information
that is key for my ability to interpret your numbers is your height. If you
are 6’4” (193 cm) tall, then 223 lbs (101.3Kg) is not bad. But, if you are
5’6” (167.6 cm), then your weight could play a significant role in reducing
your FEV-1. It is your FEV-1 that appears, on first glance, to be
significantly reduced and presenting suggestion that you may have airways
disease of some kind. But, not knowing how tall you are makes such
assessment impossible, from where I sit. As well, that you say you snore is
in itself a worrisome problem and can lead to reactive airways disease among
other problems if indeed a clinically significant problem – like having the
presence of obstructive sleep apnea.
In any case, you SHOULD follow up with your doctor. Have a more controlled and better quality PFT (pulmonary functions test) done that repeats those measurements (3 times, each) after inhaling some bronchodilator medicine. If you produce the same results AND have reversibility, then you have some degree of ‘asthma’ which can likely be treated and controlled. You should also request a sleep study to determine if you have sleep apnea. If you do, then getting that treated and controlled is imperative as it can cause high blood pressure, heart disease, diabetes and obesity, in and of itself!
Best Wishes,
Mark
Condensation when Nebulizing
Dear Mark, Hi Madeline,
Most often, those drops are condensation of the nebulized fluid. Because they are mixed with a lot of air bubbles (too small to see with the naked eye), they make the fluid appear to be white in color. The solution turns white for the same reason. As solution is taken up into the nebulizing mechanisms and “smashed” against the ‘baffle’ to break drops up into minute droplets which can then travel to the depths of your lungs, they fall back into the solution and make it appear to be a white color.
Now, if the solution were to change consistency (become thicker or ‘slimy’) that could be due to mucus flowing back into the nebulizer. While I would say it is unlikely, it’s not impossible.
In any case, the effectiveness of the solution shouldn’t be changed by what you observe. Be sure to clean your nebulizer (rinse with water and air dry) after each treatment and thoroughly wash it at least once a week with soap and water and a disinfecting agent (dilute vinegar or very dilute bleach or commercial disinfecting product made specifically for inhaled medication devices [quaternary ammonia, for instance]).
Best Wishes,
Mark
Hi Mark, Desaturation & Oxygen Needs Hi Philip, No apology needed! I think you’ll likely beat that horse for some time to come as you think of yet new and different – or just different angles of consideration to approach it with questions. And, who knows, there are likely other folks who might be wondering the same things that you wonder about. So, let’s go for it! What you have discovered about PLB is precisely what we say is one of the potential benefits of using the technique. And, you are absolutely correct, when it doesn’t work to improve your oxygen, you are indeed in “a bit of trouble”! At that point, you need to use oxygen to raise your saturation – IF it has dropped to or below qualifying levels. I suspect you are correct in your assessment that you probably don’t need to worry about needing oxygen on a daily or continuous basis for a long time to come. With the desaturation you have reported under ONLY extreme exertional conditions, it may be sooner than you might think. But, I would be surprised if it is any sooner than two years. And even then, it would likely be only for sleep and exercise/exertion where you must get pretty vigorous/intense. Best Regards, Mark COPD - General Information & Understanding Hi Mark,
I have written to you a couple of times now about my mild COPD. I am on Seretide 500 powder inhaler. What type inhaler is this? I was on a purple spray one last year. Does it take a few weeks to get in your system? I am breathing a lot better, now. Was the shock of being told I have mild COPD (that) sent me a bit over the edge as I have never smoked. Am blowing regular 450 on peak flow. Am 56. But, now I have started a treadmill, running about a mile and a half with ease. Can this COPD ever get better, or am I doomed to go downhill? Also, I have Herpes. Been told this gives you flu-like symptoms. Can my spirometry test be wrong? I hear someone got told they had COPD then went for a second opinion which said they never had asthma. I also have been doing breathing exercises, breathing in ‘til I can’t breathe in no more, hold for a second, then breathe out with pursed lips and get every drop of air out my lungs. I feel a bit light-headed at the very end of breathing out. Is this normal? Also, sometimes I sneeze when I do exercises, getting a bit of sputum up. Is this sputum badness out of my lungs getting’ spat out good for your lungs? Do you think there will ever be a cure for COPD or anything to stop it getting worse? With better medication? Also, I was getting over a chest infection when I had spirometry test. I was diagnosed with asthma when I was 21. I had a lot of chest infections. Then I worked out all my life, Karate, weights. I never have too much fatty stuff. I eat fruit. My doctor said don’t worry, we got it in time. Is he just trying to make me feel better. When you tell people they have emphysema, they say, oh that’s bad. My nan died of that. So, you can see my concern. Thanks for your answers. Paul
Hi Paul,
You continue to be very concerned about your possible lung disease, though you don’t seem to appreciate that if you can “run” on the treadmill, especially for a mile and a half, that you are in pretty darned good shape DESPITE your COPD. Now you didn’t say if you ‘actually’ RUN. So, if you are walking very slowly for that mile and a half, that is a different story. If you are doing that mile and a half in less than 30 minutes, then you are walking briskly. If you actually run, then you should be covering that mile and a half in about 10 minutes or less.
Once one had COPD, the NEVER get rid of it. If they take good care of themselves – and it sounds like you are doing just that AND doing it well – then they usually see very little progression of their disease even over many years in the future. So, you should expect to stay in good shape and be able to do most anything you want to do for many years to come. Just because a loved one died from COPD doesn’t mean that you will automatically do the same thing! Many people have mild COPD for the last half of their life and die of OTHER causes, not from the COPD. It seems like you should be able to expect to do the same! So, I don’t think your doctor is just trying to make you feel better and is not telling you the truth. He is right – you SHOULD b e fine for many years to come if you keep doing all the right things.
A cure for COPD is something we all dream about. But, I suspect it is a long way in the future. In the mean time, we need to work hard to prevent it and to treat it with the best tools we have until a cure is found. In ANY case, I would urge you to stop worrying! You should be in good shape for a long time to come!
Best Wishes,
Mark
Exercise Concerns, Longevity and Hope
Hi Mark, Hi Sue, There's ALWAYS hope! That is the one thing you should NOT give up on! Have you been tested for Alpha-1-Antitrypsin-Deficiency Emphysema? You are too young, comparatively speaking to have developed COPD so severe - even with a significant smoking history. So you should ask your doctor to help you get tested. I don't know about Canada, but, here in the USA, it is a "free" test! And it is easy to do, in terms of collecting the necessary specimen. When one has COPD severe enough to cause hypoxia AND they become significantly limited in their level of activity, they get "out of shape", though it might come on slowly and insidiously. When they DO get up and move, beyond their oxygen dropping if not adequately supplemented, their heart rate will expectedly increase in the manner which you describe. That, in itself, is not a problem If you continue to exercise, despite the high heart rate, keeping your exercise "intensity" appropriately low enough not to invoke problematic consequences, yet high enough to allow for conditioning to occur, then you will see that over time, it will come down to much lower levels AND will not jump as high with increasingly more intense exercise. If you are walking too fast on the treadmill or if you have it on ANY incline, it is not surprising that you play out so soon. You should be sticking to a low speed that allows you to go up to 30 minutes, NON-STOP, before increasing the speed. Then you should NOT add any grade until you can walk for at least 30 minutes at a speed of about 3 mph. That may take you months to achieve. It is good that you are getting started in Pulmonary Rehab. Hopefully that will set you on a better path of regaining conditioning and health. I doubt the EKG will show anything that isn't already known. But, you should be getting one annually, if not more often, anyway, as part of your routine health screening. You didn't mention any inhaled medications you use. Hopefully, you are on a combination of inhalers that fits your very low FEV1 (17 %). At that low a level, you are in serious shape, but, again, NOT without hope to improve a LOT. Is lung transplant something you would consider - or available as an option for you? In the end, no one can say that you will or will not see 60. There is much you can do that you are on track to get under way. That and time will tell. Work on living - NOT on avoiding dying! Best wishes, Mark |
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January 22nd, 2012 Quitting Smoking & Will the Numbers Improve
Hello, Hi Sandra, Yes, you ARE in the "mild" range of COPD. Congrats on quitting smoking! Don't expect much change in your FEV1 - at least not this soon - if any change will be forthcoming. At 78 % you are still very high in pulmonary mechanics and shouldn't have any significant symptoms from your COPD. Over time, you should notice even better breathing. Keep active! Eat healthy! Get plenty of rest for your needs. And you should be in great shape for a long time to come! Best Wishes, Mark What is Atrovent? What is Atrovent
hfa Spray q i d Wht is it for ? Atrovent is one of the two primarily administered "bronchodilator" medications. They relax your bronchial tubes and improve your ability to move air into and out from your lungs with less work. It is from the class of medications called "anticholinergics". Atrovent is usually paired with another complimentary - but different-acting - bronchodilator from the "beta-agonist" class. Each does what it does through a different mechanism or "pathway". So, one is not necessarily a 'replacement' or 'substitute' for the other. But, together they work better than each one can alone to produce an overall improvement in your breathing. The most common beta agonist used/prescribed is 'albuterol'. You may likely be prescribed BOTH medications to be taken close together for best effect. Best Regards, Mark Low Iron, Tight Chest Hi Mark; I wrote
to you a week ago about my mild copd. This week my chest was a bit
tight and I have
been having panic attacks thinking about it. I don't want to be on
oxygen in
a wheelchair; cant stop thinking about it. I went to the
hospital on Saturday because my
chest was tight, had x-ray, came up clear. Had blood tests said my
iron count
was 9 and a bit should be 13 in a man. I was diagnosed as a anemic last
year my
count was a 7; felt terrible couldn't really work or do much with out
getting
tired. I went on iron tablets in August and they worked; felt good, doc said
come of them and I did but when I had a blood test in the hospital it was a 9 so
I am losing iron. Also I was told I had a hiatus hernia. I use to get heart burn;
don't get it much now but hospital said its probably my worrying about copd
that's making my chest tight. It's not too bad this week; after
x-ray was clear. I got copd mild; never smoked. Can my working as a tree surgeon caused it
with the pollen as I did have asthma when I started job. Was in job for 20
year; s just want to breath easy. Also I blow 450 to 500 on meter
blower may b 400 when I get up when my chest is easy and clear I blow a 500
am 56 years old, always watched what I eat, and work out with weights. Could it
b because my iron is low that I am chesty? Hi Paul,
No one can tell you "why" you develop COPD when you are not a
smoker. Most likely, 'we believe' it is related to heredity and triggered
by histories like you seem to have - your asthma and working with the trees,
though they likely are not the source of a significant factor or problem any
more than having had asthma for some years. BUT, with the peak flows you
report, you don't seem to have any 'clinically significant' affect from it -
500 ml being an excellent peak flow. Even 400 is very good! Asthmatics
who have problems are down around 250 and less! You should actually be most concerned about your iron deficiency and get that corrected. It is of much more immediate concern than ANY concern you have about lung disease. And it can do more to make you feel bad - AND contribute to any difficulty breathing and/or chest tightness you are feeling! Realize that iron carries oxygen in our body. If your body senses that it is not getting enough oxygen, it will signal to you to do more work to bring in more oxygen. THAT more than any COPD you might have can be the cause of any breathing symptoms you now have, including the tight chest, though worry and panic can easily play a big part, too. Above all, keep foremost in your mind the fact that folks with half the lung function you have - who have MUCH MORE advanced lung disease/COPD than you now have or are likely to progress to in the next MANY years - are able to be VERY active, don't yet require oxygen and are far from needing a wheelchair. You need to read more about the disease to learn where your fears can be misplaced. Until folks' FV-1 drops to less than 30 % of what it should normally be - a LONG time off in your future - they don't have limitations that present significant difficulties in their lives. If you live each day worrying about what is predictably many years - even decades - off in the future, you will miss so much of living and everything that is good in life. Don't WASTE your life living like that! You likely don't have enough lung disease to worry about what you are spending lots of time and emotion worrying about NOW. You may likely NEVER reach a point where COPD becomes a primary ailment and limitation in your life. As I said in an earlier response, STAY ACTIVE! Eat well and get the rest you need - and QUIT WORRYING - and you'll live a long and happy life without problems with lung disease! If you have a little bit of asthma along the way, keep it controlled and at bay and you shouldn't have any significant difficulties. Best Wishes, Mark Can a Person Tell if They're Retaining CO2? Assuming a person isn’t a usual retainer, Is there any way for a patient to know, or tell that they’re starting to retain CO2. (Not as an on-going issue but something that can crop up) If there is a way to tell, is there anything a person can do to minimize or avert it? Thanks Scott Hi Scott, The only way to know if you retain CO2 is to directly measure it. That can be done with a device that measure the air you exhale. It measures how much CO2 is in your exhaled gas at the END of your exhalation. A blood gas is an "invasive" but the most accurate means to measure your CO2. Not unless other clinical information suggests that you 'might' be at risk for CO2-retention, would we/I recommend getting one done. Folks rarely begin retaining CO2 before their FEV1 drops below 30 % of predicted. Even then, many don't begin retaining until it drops progressively below 20 % of predicted. If one develops pulmonary hypertension, their tendency to retain CO2 will be enhanced at the high FEV-1's, but, still most often below the 30 % line. CO2-retention doesn't "crop up" as a usual and/or 'short-lived' problem. In advanced COPD it is a response/result of the physical damage to the lungs that results in chronic hyperinflation, as we see it in advanced emphysema. So, you are thinking off the mark if you think that you can develop it as a short-lived or passing ailment. Once there, it is there for the duration. There is NOTHING you can do to "avert it" or "prevent it" or "minimize it" or "make it go away", once it's there. CO2 can "acutely" increase because of sudden respiratory compromise. That is an emergency and it is obvious that those who experiences it are very ill and in trouble. We call that occurrence "Acute Respiratory Failure" and jump on with rapid intervention to resolve it. That is not something you should spend time worrying about as it is rare. Again, the only way to "know" that you retain CO2 is to measure it. You should NOT worry if you might be entering the realm of chronic CO2-retention until and unless your lung disease is WELL-advanced and you are struggling to do simple daily activities. Even when CO2-retention DOES occur, it is not a problem that needs resolution! It is actually a 'positive' adjustment that the body makes to contend with the poor ventilation that goes with well-advanced COPD. Once there, to try to make it go away or be less would actually mess up bodily functions rather than provide any positive effect or improvement. Best Wishes, Mark
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January 15th, 2012 COPD or a Fungal Infection
My father came in contact with some serious fungus
two years ago while helping a friend clean out the basement of a flooded
cottage. Doctors won't acknowledge or entertain the fact that it's a fungus
in the lungs and sinuses they keep saying and treating him like he has
asthma or COPD. I have read many things and he has become his own doctor
for approx.2 years now. He has been in and out of hospitals half a dozen
times due to not being able to breathe. Doctors fill him up with
Prednisone, Antibiotics and symbicort or Advair. He had severe allergic
reactions to symbicort and advair while in hospital so Doctors finally
realized these two medications could not be used to assist him in his
breathing. The breathing difficulty subsides after approx.two weeks stay in
the hospital because the prednisone and antibiotics are only suppressing the
symptoms (which are asthma like) of the fungus. I have read many forums and
all the people discussing their symptoms are exactly like my
Father...sinuses fill up with mucous, nose drips clear liquid, lungs fill up
with mucous, when he is able to clear his lungs, it's clear, frothy mucous
that's being expelled occasionally with little "fungus plug like
substances". He even went as far as purchasing his own monitor to track his
oxygen level and heart rate. This week, he is fighting for breath, oxygen
level staying mid to low 80's up to 90 or 91. He is petrified to go back to
the hospital because they just want to fill him up with drugs to cover up
the symptoms and get him home. He has limited his diet extremely, no
sugars, anti fungal products galore, he is doing everything possible as I
said he has researched a lot and has become his own "doctor". I am at a
loss! We don't know what to do...my Father has asked me to type up his Will
and Power of Attorney to prepare for the worst. My Father feels that if he
had oxygen at home, he might be able to fight this fungus naturally, (oxygen
gives him the strength to expel the mucous) but no Doctor will agree to
prescribe oxygen Hi Cindy, I'm sorry to read of your father's difficulties and frustrations. But, my first impression is that he is on the wrong track with his insistence that he is suffering from a fungus. While I can't say one way or another, from where I sit, that he "doesn't" suffer from a long-term fungal infection, I 'can' say that from a clinical standpoint that the likelihood is remote, at best. Had it been a fungal infection, evidence more than what you have related - and much more meaningful - would long ago have become apparent. Much of his problems can be argued to result from a combination of his rejection of appropriate treatment for his breathing difficulties and - perhaps even more so - from self-treatment with substances that can easily be worsening, if not outright causing his symptoms. I am very curious to know what his "severer allergic reactions" were to Advair and Symbicort. Can you describe them more specifically for me? I am further suspicious of the potential for a fungus to be at fault since prednisone suppresses immunity such that fungi and other opportunistic pathogens have an "easier" time causing symptoms. Were the prednisone simply temporarily suppressing any fungal influences, they should come back with a vengeance within 72 hours after his last dose at the hospital. Then again, if he takes long-term/maintenance prednisone, his symptoms could (and should) be continually suppressed, so the notion of a fungal infection - especially lasting this long without being more readily detectable by now - is highly unlikely. The worst part of his situation is that by rejecting the assessment and interventions of the medical team he is entrusted to AND by self-medicating with all manner of anti-fungal supplements, he is fostering the more rapid worsening of his COPD. If he is truly observing desaturation with his pulse oximeter, he should take it with him to the doctor and demonstrate his observations. You don't say if he has had pulmonary functions tests or what any of his measurements might be. So I have no 'objective' information upon which to determine where he is in his lung disease process. Oxygen, or use of oxygen will lend "NO" 'specific' assistance to fighting a fungal infection - naturally or otherwise. His thoughts on that are misplaced. BUT, with the desaturation you describe, it suggests he is in an advanced state of his COPD and would definitely benefit both from a health and a functional standpoint, from the use of oxygen. In most locations in Canada, the requirements for needing supplemental oxygen are the same as here in the US. By those means, he seems to qualify without question. So, push for it - and push HARD! That is about all I can tell you at this point. There is one other test that 'might' settle the question of the presence of fungus. If he has not had his sputum 'cultured' for the presence of fungal organisms, that is a simple enough test to do and won't break the health care system bank. If he has suspicious or inconclusive results, a bronchoscopy to obtain deeper-residing specimens can often provide the definitive answer. You might ask his doctor about those two possibilities. In any case, you simply CANNOT say that you are seeing "fungus plug-like substances" in expelled secretions. Mucus plugs are mucus plugs, regardless of contents or origin. There is nothing beyond specific colours or odors that can indicate the presence of one kind of bacteria or another. And those colours and odors are VERY specific to each pathogen that produces or emits them. I fear that his rejection of qualified medical assessment and opinions and insistence upon his problem being a fungal infection AND the rejection of interventions that can certainly provide significant benefit in favor of those his is concocting from his lay resources are both responsible for his rocky course (several exacerbations and admissions) over these past two years AND his inability to get satisfactory collaboration from his medical professionals. At some point, they too become frustrated and take on an attitude of "What's the use? He won't listen to what we have to say or suggest." Perhaps you all need to sit down together and sort out all the questions, suspicions and frustrations that are interfering with your ability to find effective relief and improvement in his condition. Otherwise, I fear that sadly, you may be giving attention to his will sooner than is necessary. Please step back and give thought to the possibility that he is wrong and that his medical team have a better idea of what is going on and what should be done. But, also push for oxygen in the meantime, as I described. Best Wishes, Mark How Bad is my COPD? Hi
Mark; I live in the uk am a very
young 56 kept in shape all my life when I left school at 15 worked at a car
components grinding the left over asbestos of the car brake shoe to glue a
new one on no mask on was only in the job 1 week was not doing the grinding
of shoes all day just now and again then in 1977 started work as a tree
surgeon and developed a cold that lasted 4 a year had breathing problems was
told I had asthma I have never smoked done this job 4 20 years then after
that got finished up done a bit of car spraying on off as hobby was on
ventolin inhalers then in sep this year had breathing teats done in my local
hospital test said I have mild copd am very worried thinking am going to die
soon I have been around smokers 4 years passive do u think the asbestos has
caused this or passive smoking I am on a powdered inhaler now they r very
good keep my lungs easy to breath I can walk up 10 floors my legs do get bit
tired round the 6 floor when I get to the tenth floor my lungs sort of burn
will I get all the stages of copd then die at the last stage I feel ok on
the inhalers my doc says I don't have asthma now but mild copd and not to
worry Hi Paul, I suspect that you are worrying way too much about the disease and your future, as well as a lot of things in your past that have little if anything to do with any COPD you might now have or the course you can expect it to take in many years of your future. The simple fact that you can climb those many flights of stairs tells me that ANY lung disease you may 'now' have is not "clinically significant"> Your asbestos exposure was not enough to present concern for that type of lung disease. Your other activities - including exposure to second hand smoke - are not significant enough to play a meaningful role in development of "problematic COPD" or other lung disease. My bet is that you have a better chance of meeting your demise in any number of other accidental ways LONG before you'll succumb to lung disease. Just keep active and as vigorous as you are now and I'll look forward to reading your posts to COPD-Canada 20, 30 and more years down the road - that is IF "I" can still read and pay attention! Best Wishes, Mark Follow Up From Last Week (January 8th Q's & A's) First of all thank you so much for answering my previous questions.
Susan
Hi Mark, Hi Susan, I'm going to respond to this question and the one that follows since they were apparently duplicate posts from you, sent at different times, this one with more detailed information. Your PA is correct that the HbgCO you reported should not be responsible for your complaints. It's GREAT that you have quit smoking. THAT should go far towards allowing your CO levels to return to normal for a non-smoker. Have you considered that it is a frequent response for someone to experience symptoms of depression when quitting smoking? One of the advantages of Welbutrin and Chantix are their anti-depressive action which helps combat the problem when quitting tobacco consumption. Your complaints are suspicious for mild depression, though I can only offer that as a possibility and speculation from where I sit. While it seems that your doctor wants only to address your pulmonary problems - and seems to be addressing them in a reasonable manner as best I can ascertain, perhaps you should see a cardiologist for an EKG, if you are concerned there might be a cardiac problem - and in view of your MVP problem. It is possible you have reached a point in your life when you need a medication to assist in correction of difficulties that might be developing in relation to that problem. It wouldn't hurt to rule it out, anyway, even if all it does is set your mind better at ease. It is possible you are overly concerned about your condition at this point. Yet, if there is something going on that needs attention, you would do well to learn that sooner than later, too. Think about seeking further opinion from others. Best Wishes, Mark As COPD Progresses, is Oxygen Inevitable?
Hi Mark. As always, thanks for all your help, and my personal best to you and your family Philip Hi Philip, While we have had the "no two cases are alike" discussion before - in which I have contended that while there may be individual quirks much of the time, the pattern and progression, as well as the symptoms and defects have MUCH in common among individuals, the notion of the condition "exactly alike" does not speak much to the issue as a whole. The answer to your question about the inevitability of need for supplemental oxygen therapy is essentially: "Yes." Most all folks whose COPD continues to advance to the more severe side of the disease end up requiring supplemental oxygen therapy. You, yourself, might be in need of it down the line as evidenced by your mild, but nevertheless persistent decreases in oxygen. All you can do is do your best to stay in the best shape and pay close attention to optimizing your lifestyle to keep progression on a slow pace. Who knows, you might even succumb to something else - many years down the road - and long before you reach a point of needing LTOT. That would be my hope for you, any way! Best wishes, Mark Lung Scarring
Hi , my husband was told my the specialist that he
has some old scars in his lungs and if she were to write a diagnosis it
would be pulmonary fibrosis. My husband is 33 years old... He was never
exposed to anything and was never a smoker. He doesn't have any symptoms and
has normal pulmonary function test. I am wondering if you can help. Hi Dahlia, I would go out on a limb, based upon what you have told me, and say that your young hubby has nothing to worry about with regard to lung disease. Folks are often found to have scarring in their lungs that plays no part in their health picture. If he feels fine and has normal pulmonary function, then that should be all you need to know to feel confident that he is OK and has a bright future in terms of lung function. You didn't say why or how the finding of the scarring came about. So, I don't know if he was having problems that resulted in the test being done that found the scarring. But, if it was an incidental finding, then he should chalk it up to just that - an incidental finding. If his follow-up in 6 months finds nothing new or of concern, and he continues to be without symptoms of concern, then I would think that further interval follow-up should not require more than a look at him and maybe an x-ray every several years. Best wishes, Mark
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January 8th, 2012 Exercise (Treadmill) Goal and Oxygen Question
Hi Mark.....This is
my first time to ask a question so I should give some background.....I was
diagnosed with COPD in 2000 and was able to do most hings in my life for
quite a few years....in the past couple of years though my life has become
more restricted.....I use Spiriva and Advair and also take recently turned
it up to 3l.....I now live in an area where there is no respiratory
therapist so have a question... I walk on the treadmill at a pace of 2mph
for 30 minutes a day....usually....I find if the air pressure is low I
struggle to do 20 or 25 minutes.....I am wondering if I should strive to go
further faster and what should my goal be? I should add that I am 71 years
old.....please let me know if you have ideas.. Thank you! and Happy New
year!! Hi Heather, You are doing well and on the right track to maximize what lung function you retain. Indeed, you should strive to go further faster. If 30 minutes is going to be your choice of maximum duration, you should work to increase toward 3 - 3.5 mph. Ad 'interval' walking at some point, wherein you jump the speed be 0.5 - 0.7 mph - abruptly - and maintain the increased speed until you become as winded as you can stand. sustain that windedness for a minute or two at which point you will drop the speed - again, abruptly - back to the lower level to 'recover' while continuing to walk - RATHER THAN stopping, altogether to rest. You may have to drop your lower speed in order to maximize the approach. So, say, for instance, you start at 2.0 mph and jump to 2.7 for your fast interval. The drop back to 2.0 for recovery. It will seem slower when you drop back down to it - a good thing, as you want to keep moving while allowing yourself to regain more comfortable breathing. As you do that more and more, you will see your fast interval increase. When you get to where your fast interval is 20 of the 30 minutes (approximately) increase both speeds and work to increase the fast interval. Over time (perhaps as much as a couple of months, you will see your overall speed increase to where maybe, 2.8 is your low speed, while 3.5 is your fast speed. At that point, you can maintain those speed differences and add o1 or 2 % grade for the fast intervals, dropping the grade back to 0 for the recovery periods. The most important factor in the mix will be to maintain the best oxygenation you can during your walking exercise. You say you now use 3 L. You may find you need 5 liters for exercise and to stay above 90 % saturation. Be sure you have enough oxygen to supply your needs AND monitor your oxygen saturation with a personal oximeter. If you don't currently have one, you can get a good one for $100 or a bit less. Check out the Nonin line of oximeters Look them up on-line) (I have no financial interest in Nonin. I just think it's about the best available.) Let us know how you do over time. Best Wishes, Mark (Note: You can also purchase a finger pulse oximeter from FaCT Canada in British Columbia starting at $59.95 if you're a COPD Canada Patient Network Member. This also includes the carrying case and free shipping Finger Pulse Oximeters) Lung Volume Increase Question(s)
Hi Mark, I had
childhood allergies and Asthma. Nothing really significant that I didn't
live with. I worked a as a Firefighter of 30 years and retired 2 and 1/2
years ago. One of the reasons I retired is because I couldn't t do the
physical demands anymore. my breathing was getting worse and I had a few
scary moments. I took in a lot of smoke over the years. I never smoked
cigarettes. I see a Pulmonologists every 6months. My AM regimen is Spiriva,
Advair, 1 81 mg aspirin, and 1 , 10 mg Loretadine, with about 16 ounces of
water. I'm on 2 lpm of oxygen at night time for sleep hypoxia. Obviously I
have COPD. my blood work has been good. I stay active as I can. Sometimes I
have to work every breath to keep breathing. I use albuterol 2 or 3 x's a
month as needed. I use a nebulizer every few months or so as needed. My PFT
says I have the lungs of an 80 year old. OH yea, I'm 58 years old. I use a
Netty pot every am with a baking soda and canning salt solution to cleanse
my sinuses. I gat a bad cold and or flu every year at least a couple of
times that require antibiotics. My PFT 2'xs ago showed that I lost 700 cc's
of lung volume, however through hard work, and following my orders I gained
back 200 cc's of volume. My question is there anything I' missing? Can I
increase my lung volume through any specific exercises . How about breathing
exercises. Are there any food supplements or herbs that are recommended?
Thank You Bill Hi Bill, There is nothing you can do to increase your lung volumes, per se. They will fluctuate up and down in accordance with your exacerbations (colds, bronchitis events, etc). Walking exercise is very good to maintain your best pulmonary function within the limitations you now have. You are a tough guy as exemplified by the difficulty breathing that your report during activity. While it's not fun or comfortable to sustain hard breathing work, if is a MUST to survive and thrive. AND, breathing hard, while it may 'seem' like it will 'do you in' is not a bad thing and WON'T hurt you AS LONG AS your oxygen saturation is > or = 90 % during those periods of activity. So, if you don't have an oximeter, it would be a great idea to purchase one. I have recommended Nonin as a source for a choice of several that are very good. See my response to Heather for more information. Staying on top of your condition - with attention to exacerbations as soon as possible is a must for continued good management of your disease. You are a young guy, at 58, to have such severe COPD. But, with your fire-fighter history, it unfortunately, is no great surprise. It is sad that you suffer these consequences for your many years of saving lives and property. I hope your community is appropriately appreciative and supportive of your sacrifice! Many folks are finding additional benefit from adding NAC (N-Acetyl Cysteine) to their medication regimen. It has anti-inflammatory and mucus thinning benefit. It can be purchased over the counter and should be taken 1200 mg once a day, up to 2400 mg (1200 mg, twice a day) during bouts of bronchitis and colds) Taks an addition 1000 - 2000 mg of vitamin C with the NAC which helps thwart the formation of kidney stones in some folks who take NAC (very rare occurrence/complication). Other than those suggestions, the key to survival and staying in the best shape possible is to KEEP MOVING! Exercise is of critical importance. With that, adequate oxygenations a must to prevent damage to your heart over time. You now use oxygen at night for sleep hypoxia. I would wager that if you desaturate during sleep, you also desaturate with exertion. And it may not take much exertion to produce dangerous drops in your oxygen level. So, be sure to check out that factor as soon as possible so you can address and correct it as soon as possible, too. Best Wishes, Mark Breathing Test Explanations & COPD Understanding (2 parts) I was diagnosed with severe COPD/Emphysema in October of this year. On my 1st pulmonary doctor visit on December 8th, 2011, my ABG's were :pH 7.49, PCO2 36.0, PO2 79.0, HCO3 27.2, BE 4.2, Hb 13.7, SaO2 97.5, HbCO 6.9. FIO2 21.00. I was diagnosed with Acute Pleurisy & Chronic Bronchitis, Dyspnea, COPD w/ALE (don't know what ALE means), COPD severe, Emphysema, nicotine addiction, cigarette abuse. The physician stated that I was to return on the following Monday (5 days later) & if HbCO values remained the same he would admit me to the hospital. He started me on Bactrin DS BID, Prednisone 40 mg 4 x day, Tessalone Pearls PRN, Musinex BID, hold Advair and use DuoNebs QID, continue with Xanax and Trazadone..
Hi Mark, Answer to part 1 - Susan, I hope you have quit smoking. The CO will remain elevated in folks who continue to smoke. The only other cause of chronically elevated CO is exposure to heavy traffic, as in the city where lots of care exhaust is breathed in, or in jobs where CO is infused into the air from combustion or other chemical reactions that emit CO. Your blood gas actually shows modest "hyperventilation", often seen with various lung disease conditions and in response to low oxygen. But, your oxygen level isn't significantly decreased to explain why that phenomenon is occurring in you. Yet, if you are continuing to smoke, it could be from your body's response to the elevated CO. In any case, the 8.2 CO and the question of continued tobacco use remain a question for me as you didn't include that in your information. I don't know what the ALE means, either, unless it's your doctor's abbreviation for "Acute Lung Exacerbation". Ask him what it means. I don't think your necessarily need a second opinion. You need to know from your doctor what you should be doing to reduce your symptoms and improve your health and function within the limitations you cannot change. If you are not confident with your current doctor's care or skills, that would be an indication to seek a second opinion. But, you didn't allude to any concerns of that type. So, it is up to you to decide. Even then, you need to have a specific objective in seeking another assessment and opinion. If you don't fully know what your current doctor wants you to do, then another doctor won't be in any better position to second guess the first one. Part 2 answer - Your PFT's show a combination of obstructive (COPD) and possibly restrictive elements to your lung disease. Your ability to diffuse oxygen is reduced at 33 % which, when combined with the elevated CO adds up to explain your low paCO2 on your blood gas. It doesn't help much with advising you on what to do. Again, the question still hangs about the tobacco use and the cause for the 8.2 CO level. Answer that and we may have better direction to go in terms of advice. Best Wishes, Mark
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December 25th, 2011 Medicines - Crossover/Mix
I am taking
Roflumilast tablets for copd is it still safe for me to take my symbicort
inhaler my spriva inhaler and my uniphyllin tablets....thank you Hi Margaret, Most surely the answer to your question is: "YES!" Keep taking all of those inhalers and the theophylline. The Roflumilast is NOT a 'substitute' for the others. Rather, it is yet another type of drug having a quite different action in your body. You still need the specific actions of those other drugs. None of the other drugs does what each other does, or what Roflumilast does. It is quite safe to take them all. Best Regards, Mark
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Dear Mark, Hi Nora,
It is 'typical' to find that folks develop COPD many years after they have quit smoking. If smoking history was significant during practice of the habit AND/OR if there are familial tendencies for one to develop COPD, the chances of it rearing its ugly head are greatly increased down the road, typically 20 to 30 years after they smoked. But, all that said, you now have it and must deal with it - as it seems you are - as effectively as you can to keep it from worsening faster than it has to and from making your life more difficult than age and other conditions might make it as you go along through the balance of your life. While we don't like to have to use prednisone if it can be avoided, sometimes it's the best and only choice at given moments. You can rest assured that it will predictably work, as it is a very effective tool to relieve the symptoms and inflammation that occurs with exacerbations. It is a VERY rare occasion, indeed where - even for folks who have taken a lot of it over a long period of time don't find rapid and significant reduction in their breathing difficulties. I would encourage you to consider a consult to an ENT doctor to see if you might have 'fixable' sinus problems. When antibiotics don't make you feel better after sufficient days of dosing, the problem can often be considered NOT caused by bacterial infection. Sometimes anti-viral medications can knock out the problem. Sometimes they're not indicated or available for the particular virus that hits a person. BUT, in almost every instance, prednisone WILL make you feel infinitely better. As long as you only need short courses of the drug, your worries about long term effects are unwarranted, in most cases, especially if you only need them at long intervals between use. At 59 % FEV1, you would expectedly NOT have significant symptoms. Some folks don't even need the inhaled medications at that level and find little benefit from using them. But, I'm thinking that you know by now how well they work for you and if they are worth taking. At present, they are definitely indicated and likely of great help. Be sure NOT to take the Ventolin within two hours before taking your Advair as it will interfere with the action of the Advair (same type of drug in both, though there is a long-acting form of the Ventolin in the Advair that you want to allow the opportunity for maximum effect. Since they both go to the same receptors in your lungs, if the Ventolin is tying up the receptors, the Advair has no where to bind and will be shed from your body, unused.). If you need Ventolin any time 30 minutes or more after taking the Advair, go ahead and use it. By then the Adviar will have occupied all of the sites it is able to bind with. Ventolin will then serve as a 'mop-up' to any sites not occupied by the Advair and can enhance the effect of the Advair. BTW, understand that there is an inhaled corticosteroid (same class of medications as prednisone) in the Adviar. So you are taking a long-term steroid medication with the use of Advair. The evidence shows that inhaled steroids have only a small percent of the effect on the whole body as compared to taking oral, "whole-body-affecting" steroids, like prednisone. Folks can take inhaled steroids for years without showing significant, if any side effects associated with taking oral steroids. If after you finally get your current ailment cleared, you find you have had a significant change for the worse in your 'stable-level' breathing, ask your doctor about repeating your PFT's. You can see a permanent change (reduction in airflow) with the residual lung damage that can occur during successive exacerbations. It should be monitored and accounted for, if it occurs in you. Otherwise, keep exercising as much and as hard as you can - despite any hard-breathing discomfort it might cause. That will ALWAYS be your best medicine and defense against unchecked worsening of your lung disease. Best Wishes, Mark
I have asthma and my youngest child who is 15
experiences tightening of her chest when she plays soccer what test can I have
our doctor do to rule out the possibility of asthma in her?
Hi Yvonne, It sounds like your daughter may develop - or be developing - EIA "Exercise-Induced Asthma". Your doctor can send her to a pulmonologist if (s)he doesn't feel comfortable with or qualified to test her for the condition. EIA is often diagnosed by using a bronchial provocation challenge - a test wherein the subject breathes in varying dilutions of a known irritating/asthma-inducing substance KNOWN to cause airway reactivity. If the subject reacts (with development of 'acute asthma') at what is considered a low dilution of the substance, then the asthma diagnosis is made based upon that information. If such occurrenceance is the result when the subject is being tested, medication to reverse the effect of the asthma-inducing substance is given. Because the test involves a certain amount of risk with the potential to induce acute asthma, many doctors will fell more comfortable sending the patient to a pulmonologist for the testing, as the pulmonologist is most comfortable with doing the test and well-versed in treating any adverse reactions that may occur. That she seems to be OK except when engaged in the intense activity of playing Soccer further points to EIA. Treatment can be as simple as use of a short-acting bronchodilator (SAB) medication before playing soccer. That will relax the airways and inhibit development of the tightness - most often caused by bronchospasm - and allow her to play with plenty of wind and without worry of developing the tight chest. EIA is much more common than most folks realize. AND, there are huge numbers of amateur and professional athletes who suffer from the condition. Yet, with proper diagnosis and treatment, they are able to engage in their preferred sports without developing the acute asthmatic reaction that can occur, as long as they 'pre-treat' themselves with SAB's. In more rare instances, they may need a long-acting form of medication to keep their airways stable and inflammation/irritation at the minimum. In any case, it is rare that one finds it necessary to cease engaging in the sport because of EIA. Best Wishes, Mark
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Posted December 11, 2011 Caregiver Support
Hello Mark Hi Mitch, I'm not quite clear on exactly what about 'a book for caregivers' you are asking. If you are asking for a book that will teach you more about the signs, symptoms and management of COPD that is targeted to caregivers, I would say that there are many, many such resources already available with little effort and search, though they may not all be in book form. As you report, you already know a lot about the disease and have years of experience with caring for Fred. So I doubt that the available resources would tell you much that you don't already know. If you are talking ab out a book that discusses 'support for caregivers', there are a few out there that target the caregiver and the psycho-emotional issues you face, along with helpful information for maintaining your effectiveness as a caregiver - - - AND your sanity, in the process. But, again, I can't tell you much more that this. What I have observed to be the more effective means to sharing information and support is through the formation of caregiver support groups. If there are others in your small town who have significant others who suffer from COPD or even other chronic disease conditions, getting together to vent and have the opportunity to share with each other the difficulties and frustrations - along with suggestions for coping is a popular and effective way to handle some of the 'caregiver' side of living with chronic disease. Sometimes getting a professional to participate - a psychologist or social worker appropriately oriented to caregiver issues - can be of great help. You don't have to necessarily have such a person in the local area. Contact with one in a neighboring community to arrange a visit may be easier than you might imagine. Now, in the event that neither of the above two trains of thought apply to your query to me, let me offer this in response to your discussion of the recent incident with Fred that has sparked you to write with your questions. From what you say, you are already quite an adept caregiver in regard to keeping up with his medical needs, Insofar as his recent event, I don't see how you could do more than you did or detect the problem that occurred with the information you had to go on. If a person doesn't share - at the time of occurrence of the event - the difficulties they are having, you - like us medical professionals - don't have the needed information to be able to detect a problem, let alone determine its nature. I don't think you could have suspected a 'cracked rib' simply from the symptoms, though had he shared his incident with you, the two of you could have sought evaluation and treatment sooner than you did. But, the onus was - and IS - on him to share the problem so that you know what's going on. A cracked rib is a subtle injury and not the first thing that would come to mind in an instance like he experienced. Further, as you learned, there is no direct intervention - beyond pain control and perhaps relaxation (the Ativan) that can be done for such an injury. So, you did the best you could under the circumstances, with what you had to go on. I don't think any amount of additional knowledge would help in unusual circumstances such as those. We all fear that we won't suspect a problem when it occurs and will not intervene effectively. But, we have to realize that there is only so much we can do. And we have to hope for the best when it comes to our role in helping others. I think you are already keenly aware of Fred's issues and are doing the best that can be expected to help him stay on track. What you fear is probably beyond what you should expect to be able to foresee. So, all I can say is 'keep up the good work you have done and are doing'. You shouldn't blame yourself for what you cannot foresee. All you can do is the best you can do. You seem to be doing quite well, as it is. Best Wishes, Mark Expand A Lung Exerciser
Hi Mark Hi Elaine, "Expand-a-lung" is an exerciser that provides resistance to airflow while breathing in AND out against it's restriction. It is a ventilatory muscle exercises and as such, can help strengthen the muscles that help you breathe. If those muscles lack maximum strength, use of the device will help the user get closer to that maximum which, in turn, "can" help relieve/improve upon the symptom of shortness of breath (SOB). But, in my experience, the chief causes of SOB experienced as COPD advances are two: (1) changes in the physical structure of the lungs makes effectively moving air OUT much more difficult than with normal lungs owing to the structural changes and how they impact air movement. The loss of airways results in fewer bronchial tubes - bronchial tubes that are change in structure and other characteristic - such that they cannot accommodate the necessary "rate" of movement of gas out of the lungs. The result is air-trapping. That air-trapping increases as one moves around with increasing intensity. This is called "dynamic hyperinflation" and can be combated to some degree with use of pursed-lips-breathing (PLB). So, the more effectively one can use that technique (especially with regard to the "expiratory" phase of breathing - where PLB does ALL that it does and ONLY what it does to assist in and enhance gas movement - as opposed to the 'Inspiratory" side where many PLB descriptions get crazy - IMO - with instructions that are meaningless and not helpful) the better they will be able to control SOB. (2) Too many folks with COPD spend much energy avoiding SOB. The primary means by which they do this is by remaining sedentary. Face it, SOB is NOT fun! It does NOT feel good. It's about the scariest feeling you can experience among all the symptoms you have with COPD. AND, it can make you feel like it will surely 'do you in' any moment, if you keep up activities in the face of SOB. BUT, exactly the opposite is true! SOB, while scary and feeling terrible, will NOT hurt you. AND, keeping up activity while having even significant SOB will NOT harm you, though it might feel like it will. By living a sedentary life to avoid SOB, one becomes physically deconditioned. It is well known that a deconditioned muscle requires more oxygen and produces more carbon dioxide 'per-unit-of-work' done, which taxes breathing and INCREASES SOB all the more. So, exercise and keeping active - and breathing hard all the while you are maintaining your active life - are essential - no, "imperative" - to being able to keep muscle strength as high as possible AND therefore, the highest efficiency of oxygen use and lowest possible carbon dioxide production possible. So, getting back to the issue of respiratory muscle strength and the use of exercises like the one you inquired about is only a small part of the total picture. If you have the strongest respiratory muscles, yet have weak muscles of propulsion and work (limb muscles, to be exact) then to continue to exercise the respiratory muscles will have little effect, if any, to reduce SOB. So, you can certainly try the device. But, without the other components to enhance the total picture, it will be of limited, if any benefit in helping to reduce SOB. Best Wishes, Mark Oxygen (Cannulas) & Face Creams
I use 2 ml of oxygen at for hypoxia. I have severe
emphysema. I use a concentrator with a nasal cannula. Can I use commercial
night creams that don't have petroleum specifically in them? Is there any
type of cream with certain oils that are okay to rub into my face? I get
extremely dry skin in the winter. Hi Moe, Use of petroleum-based creams and/or ointments is a specific action recommended against when one is using oxygen. Petroleum ointments provide one of the three components for combustion - fuel (the other two being oxygen and source of ignition) - that increases danger of mishap and injury in the presence of higher oxygen environments. There are plenty of non-petroleum based creams and ointments that can effectively provide the moisturizing action you need for your dry skin. Talk to your pharmacist about what products they stock that can meet your needs, if you are unsure of your own knowledge to choose such products. You should always try to avoid use of anything with a petroleum base when you are an oxygen user. Best Wishes, Mark Light Headed
I
have been light headed and actually passed out at one point, splitting my
head open and requiring staples. Will this continue to occur once I go on
the meds. Hi Nancy, Your question leaves me at a loss to give you a meaningful or pertinent answer. I do not know what your condition is. I do not know why you pass out. I do not know what "meds" you are referring to. So, I simply cannot give you an answer. A question like you ask is not unreasonable, on your part. But, the answer is dependent upon a WHOLE LOT more information than you have provided. I would, however, strongly recommend that you put your question to your doctor(s) who, knowing your condition and the meds in question could give you a much better answer than I likely could.
Best Wishes, Mark |
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December 4th, 2011 Azithromycin (Antibiotic) Therapy
Hi Mark. Hope you
and the family are well. Hello Philip, There is continuingly increased evidence coming to light that Azithromycin, taken daily, may be beneficial to reduce inflammation and bacterial counts within the lungs of those with COPD. It is currently in widespread use for those who undergo lung transplantation and is showing to be effective WITHOUT development of resistance of the bacteria to its effects. In some instances it is given a month at a time with a month break - and at other select intervals - for those concerned about the possibility of development of resistance. Yet, in those who have now been on it for years without interruption, it still seems NOT to become a problem with regard to resistance. Now, the caveat is in selection of patients in whom to use it. That is where the research is still not adequate or complete. We just don't know yet if it should be applied across the board to all who exhibit your kinds and degree of symptoms. But, with that said, I would suggest you inquire of your doctor if he thinks you would be a candidate for a trial of Azithromycin therapy, both to see if it has a reasonable and sufficient effect upon your symptoms and your incidence of infection. And I would reassure you that the likelihood of developing resistance to it is smaller than you might think and really unlikely, as it seems. Best Wishes,Mark Very Severe COPD with Additional Co-Morbidities
Hi Mark, Hi Cindy, You hit the nail on the head with your final comment: "A sad case for sure!" I am at a loss for positive and reasonable suggestions that could predictably correct your father's downward spiral. He certainly has the cards stacked against him. With his orthopedic limitations, his insistence that walking is not a reasonable possibility is certainly true. And with his vascular problems with his legs and especially the sores that plague him, one of my favorite alternatives to walking is possibly not an option. That is, I recommend water exercise - even just walking laps in a lap pool or at the shallow end of a swimming pool. But, he cannot use a public pool with his sores. Add to his orthopedic limitations the hypoxia that undoubtedly is a complication of the blood clots in his lungs and you add a 500-pound (or kilogram, if you prefer) weight upon his shoulders! His breathing difficulties are likely caused in great part by that ailment which is a long-term-resolution problem, despite being on the anticoagulants. If he is not using oxygen - and worse yet - has not been evaluated for hypoxia and it's pattern in his daily life, then a BIG part of his therapeutic puzzle is missing. Blood clots in the lungs virtually ALWAYS result in hypoxia that MUST be treated with oxygen therapy. If he is not using oxygen AND is exhibiting hypoxia, then he has yet MORE good reason to remain sedentary AND will not be able to tolerate ANY significant activity without sufficient correction. So, that piece of the puzzle needs to be illuminated and if present, properly addressed. With his difficulties being what they are, it is easy to understand how frustrated he must feel and how hopeless his future may appear to him. He 'might' find better relief using the nebulizer for delivering his medications. With that "potential" being the case, you could approach him about using it at least, for a trial period. Yet, at the same time, with his blood clots in the lungs, his medications are very limited in the effectiveness they can exert. So, even his insistence that the medications will take care of his needs is not true. Hopefully, the sores on his legs will improve making the possibility of getting into a pool a reality - IF you can convince him to try it. But, even then he may not do well with ANY kind of movement without oxygen therapy. And, since you didn't mention that at all in your post, it remains a variable that I cannot account for in my explanation and recommendations. I am also suspicious of the possibility that he may have a 'deep vein thrombosis' and hope that he has been evaluated for that and this it has been ruled out. Deep vein thromboses are notoriously responsible for pulmonary emboli (blood clots in the lungs) AND for the type of condition he is suffering in his legs. If that is the case, the anticoagulants should be doing what is needed to treat that condition. Yet another cause of blood clots in the lungs is primary pulmonary hypertension. Hopefully, that has also been investigated and ruled out. In the end, much as I hate to bring this up, you may be facing a situation where all you can do is appreciate the remaining time you have with him and try to make the best of a bad situation. If you have hospice services available, they might be worth looking into - NOT because I suggest that his time is 'very' limited, but rather because, many times, with folks who have COPD, a stint in hospice actually brings them back to better health and attitude such that after the average allotted 6 months, they are ready to be discharged to 'regular' care because demise is so much less imminent. So, while hospice may seem to some the 'throwing in ' of the towel and 'giving up' to the inevitable, it can ALSO and OFTEN be the bridge to and spark of a better life, down the road. I wish you all the best, Mark Med Question.... Brovana and Pulmicort
Mark, I was told
to take Brovana with Pulmicort Q12 ( 7am and 7pm) . is this correct? I was
told that Brovana should be taken by itself and not mixed. thanks for your
website. its been a great help. Hi Eric, While some folks don't have a problem with mixing Brovana and Pulmicort, the evidence I have seen regarding the 'nebulizing properties' of each shows them to be sufficiently different AND significantly altered during combined nebulization that I recommend using either two separate nebulizers or taking the Brovana first and then the Pulmocort AFTER rinsing the nebulizer well between treatments. But, in any case, I recommend taking the time and putting forth the effort to do each as a separate treatment, though one immediately following the other. Both are intended to be taken at 12-hour intervals, under usual circumstances. However, it is not out of the ordinary or uncommon for Pulmicort to be taken up to 6 times a day (every four hours), for those with especially difficult symptoms that respond well to increased doses/usage of inhaled corticosteroids. Best Wishes, Mark
Dear Mark, Hi Vanessa, While I will say at the onset that WAAAAAY too many health care providers are 'obsessed' with the phenomenon of "CO2-retention" and that it is to the avoidable determent of more than 90 % of the patients they impose their concerns upon, their concerns are - according to the 'preponderance of the evidence' - unfounded AND poorly understood. Education they receive mis-represents and mischaracterizes the effects and incidence of difficulties related to CO2-retention. But, more than that, it causes them to practice interventions that actually FORCE advancement of one's disease severity AND hastens deterioration and therefore death from COPD! How does it hasten worsening of COPD and earlier death than would otherwise happen? It is because they restrict use of oxygen - the single most effective therapy PROVEN to both improve function and quality of life and the ONLY therapy shown to prolong life - to doses that are far too little to do any appreciable good OR to thwart changes for the worse in condition and physical function that occur in the face of inadequate oxygen use as COPD advances. Medications are ONLY effective to relieve symptoms. But, NONE are shown to prolong life or slow progression of COPD. When one fails to use sufficient oxygen to keep their oxygen saturation above about 85% at ALL TIMES, as much as is possible, they develop increased blood pressure in their lungs. (This is NOT to be confused with 'systemic hypertension" which is high blood pressure in the body, 'exclusive' of the lungs which have their own blood pressure and 'separate' circulation.) The increased blood pressure in the lungs is called "secondary pulmonary hypertension" and puts great strain on the right side of the heart. Over time, the right heart fails to adequately pump blood through the lungs (That is the purposed function of the right side of the heart, by the way.) Blood literally backs up into the right heart, causing it to strain and change its physical properties. Over time, with the increased strain, the heart falls into a pattern of failure - called congestive heart failure or "cor pulmonale". Once the changes occur, they are difficult, if not impossible to reverse and the downward spiral is set into motion. Survival of folks who reach that point of deterioration is predictably less than two years. Worse yet, for the four or so years it takes to reach that point, the person is progressively suffering loss of function, increased breathlessness, especially with exertion and severe loss of quality of life. So, they are miserable AND getting worse for a LONG time before the effect hits them hard and kills them in a relatively short period of time. The culprit is the notion and practice - completely unfounded insofar as supportive research evidence is concerned, BUT, nevertheless, still taught in many medical professional educational programs - of prescribing 2 liters oxygen use AND NO MORE and even, as in the case of your friend decreasing that prescription to 1 liter. Clearly, the result is low oxygen levels which are NOT always evident with "resting" measurements of oxygen saturation. Indeed, when the oxygen falls most predictably AND "severely", is when the individual gets up and moves around. Their oxygen saturation can fall into the low 80's to mid 70's very quickly. This repetitious fall and the continued deficiency in oxygen saturation is what causes the damage to the heart over time. In all this, clinicians will sternly warn the user that "IF they turn up the oxygen - and therefore 'use too much' - they will cause their CO2 to increase to dangerous levels which will cause them to STOP BREATHING and DIE!" That is balderdash! Even among the sources of 'research' cited and subscribed to by those who believe in this theory, the evidence does not suggest that using too much oxygen will raise CO2 levels in any significant amount and not to such a degree as to be dangerous - unless one is already in trouble, like heading into an exacerbation in which they develop "acute respiratory failure". Moreover, some warn that using too much oxygen can "make one BECOME a CO2-retainer". That is simply NOT true or even a part of the fallacious theory to which I refer. So, the warnings about using too much oxygen are 'more appropriately' restricted to a VERY FEW individuals who are "really bad" AND in trouble with an exacerbation, if they are to be applied to anyone at all. But, again, insanely, too many clinicians insist that you just don't know "who" will be "the one" who will fall victim to the risk they forewarn. SO, you must treat ALL people as if they are "the one". In doing so, they are directly responsible for the hastened demise of those they care for AND the root of their lousy living experience while they are sliding down that dastardly slope to disaster and demise! Now, two strategies are generally recommended for observed 'desaturation' with activity. Those obsessed with CO2 -retention actually can practice two versions of one strategy. That is, they tell the user to stop all activity each and every time their saturation drops below 85 % to allow it to come back up to more acceptable levels. This is nuts, IMO, in that they 'start-stop-start-stop' with activities every minute of the day and it takes a huge toll on their energy, their psyche and the tasks they are trying to accomplish. Some would say: "If you can't keep your saturation up high enough, you simply must stop doing those activities that cause it to drop so drastically!" - hardly a practical or desirable solution for those who MUST do certain activities to live and function each day. The other tack they will take is to tell the person that: "Their body is "used" to the low oxygen level and will tolerate it just fine. So, don't turn up the oxygen for ANY reason or it will harm you!" That is also balderdash! The heart NEVER adjusts to the low oxygen because when the oxygen level drops too low, the blood vessels in the lungs constrict and cause the flow of blood through the lungs to decrease OR require more right heart pressure to push it through against the increased vascular resistance. (Oxygen is a POWERFUL dilator of the blood vessels in the lungs!) So, this is simply NOT an acceptable method of oxygen therapy. The other and more appropriate strategy is for the user to increase their oxygen to maintain their oxygen saturation at least 88 % - 90 % during activities, if possible. They can turn it down for resting and sleep, though sleeping oxygen flows would most often be one or two liters higher than that required for resting saturations, when awake. That is because one tends to drop their saturation during sleep, often, comparably to the drops seen during activity. Having laid all that groundwork/background, we can now talk specifically about your friend. It is GREAT that he has his own pulse oximeter! And, YES! He SHOULD use it as much as needed to discern his pattern of oxygenation - and to detect those times when his saturation falls. When he detects falls in saturation below 90 %, he should TURN UP his oxygen to thwart those decreases and try to keep his saturation at or above 90 %. He should also know that it may take a large increase in oxygen flow to accomplish that goal. He might find that he needs 5 or 6 liters to keep even above 85 %. And, he could find that he simply can't keep his saturation above 85 % even with 5 or 6 liters which may be the maximum his system can provide. So, he would need to use as much as he can to get his saturation as high as possible and THEN stop his activities when/if it drops below 85 % to allow it time to return to a safer level before resuming his activities. That's the best he can do with the limitations of the technology of today. So, in light of all this, were I in the shoes of your friend, I'd be pushing back against the doctor and nurse, if necessary, to use more oxygen - most certainly more than the paltry 1 liter your friend is using. I'd use the pulse oximeter regularly to assess that the oxygen flow is high enough to keep the safest oxygen saturation possible, especially during activities. If he can't keep it above 85 % (90 % is really the more preferable level) then, he will have to figure out how to accomplish activities in the best fashion to accommodate the low oxygen levels and minimize the effect of the low levels on how he feels. When the nurse comes to measure his pulse oximetry, he should INSIST that she tell him what she records for his measurement. That way, he can compare her results with his own to se if she (or he, for that matter) is maintaining accuracy in those measurements. IF his saturation is 94 % (especially if it is measured while he is NOT using his oxygen) or less while at rest, then her SURELY desaturated significantly with exertion. He should ALSO get up and, while using the oxygen flow he normally uses during activities, walk around for at least 90 seconds, non-stop and have her IMMEDIATELY take another reading. That is because taking ONLY resting measurements is NOT reflective of the most dangerous and frequent times when oxygen saturation tends to drop. She should be reporting to his doctor BOTH measurements. If 'exertional' measurements are not done, then the greatest part of the story is NOT being told AND the health care providers are NOT getting a true picture of your friend's disease severity! As well, they are NOT addressing his treatment needs as a result. I hope this long, but necessary explanation is helpful to you and your friend to better address his needs AND to make significant improvement in his life with such advanced COPD! Failure to adequately address his oxygen needs WILL 'predictably' put him in the ground within two years! Best Wishes, Mark |
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November 27,
2011 Enhanced CT (contrast dye)
Hi Mark, Hi Scott,
CT scans are the best way to "see" the details of
the lungs. Either a high-resolution CT or a CT with contrast are both good
tests and should reveal much detail about what is and isn't right about
one's lungs. That test should tell your doctor what, if anything, is wrong
with your lungs. Best Wishes, Mark Oxygen Saturation
Vic has been diagnosed with
COPD 7 yrs ago. Still smokes; his oxygen level in his artery
left hand read @72 % blood stream but if he exerts himself he huffs and
puffs like a steam engine. Why is this happening? He
walked 5 times around small perimeter and he needs a break. Hi Cynthia, It seems you have some of your terms confused or at least mixed up. So, I can't tell you anything about Vic's condition at this point. Oxygen "saturation" is expressed as a 'percentage'. If Vic's oxygen saturation on blood gas is 72 %, then he is in BIG, BIG trouble, especially if he continues to smoke. A person who runs oxygen levels that low while at rest qualified for oxygen long ago and should have been started on the therapy quite some time ago in the past. But, judging from other comments you made, I doubt seriously his oxygen saturation is anywhere near that low. Partial pressure of oxygen in the blood, if running at 72 "mmHg", is not bad at all and more likely what is actually the case. Folks who continue to smoke while having significant COPD will have trouble when walking as you describe Vic as having, I can tell you that one of the most common problems of folks with COPD is that because of breathless with exertion/walking, they tend to avoid moving too much in order to avoid the breathing difficulties. In doing so, they become deconditioned such that when they HAVE to get up and move, they experience more and more difficulty breathing. With Vic being sedentary (if that applies to him) AND still smoking, I'll bet that he is indeed out of shape. That is likely the major cause of his breathing problems when he gets up to move. I need not tell you what Vic should do the help his situation. But, without spelling it out, I can tell you that there are TWO very important things he MUST do in order to improve his situation and decrease his breathing problems. One of those two things is to get up and move and exercise - simple walking will do what needs to be done. I'll leave the second for you two to figure out. If Vic is unwilling or unable to do those two things, then you can expect that he will continue to deteriorate, possibly at a more rapid pace, as there simply is NO other way to stop the deterioration under current conditions. Best Wishes,Mark Lung Transplant "Cut Off" Age
What age is
eligible for lung transplant Hi Barry, There are no "official" age limits for lung transplant. Generally, folks over the age of 65 have greater obstacles to being good candidates for transplant. In the US, folks as old as 74 (that I know of, personally) have received transplants. I do not know of any child younger than 3 years of age who has received a lung transplant - anywhere in the world. With children, the smaller they are the less likely they can tolerate lung transplantation since there are such significant differences in lung tissue, maturity and function with even as little as 6 months difference in age, up to about 6 years old. The lungs do not stop growing - or more accurately - reach maturity until one is about 12 years old. So, lungs from a 10 year old would not do well in a four year old, even if they were the same size. Yet, they would do better in that four year old than would the lungs of a four-year old transplanted into a 10 year old! The bottom line is that except at the extreme ends of the age spectrum, age itself is NOT a determining factor to eligibility for lung transplant. Nor is it necessary to transplant lungs from one person to another based upon trying to match the age of the donor to the age of the recipient. I know of transplants from a 60 year old to a 30 year old and vice, versa. My daughter at the age of 26 received the lungs of a 12 year old. Best wishes,Mark |
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November 20,
2011 Alcohol Consumption & Home Oxygen
What could be the
effects of using home oxygen when a person is drinking alcohol? A. Hello A. M. I must say, I am a bit curious to know why you ask this question. But, the answer is that there would be no expected interaction or contraindication, much less harmful effects resulting from consumption of alcoholic beverages when one is using oxygen, insofar as any direct correlation between the two. Using oxygen has no special or specific implications with regard to any effect from the influence of alcohol upon your body. So, it amounts really, to a non-effect, if you will, or a non-relationship. Drinking alcoholic beverages could/would instead have greater implications with regard to one's overall health and condition if they have a lung disease that is severe enough to require oxygen. Still, those implications would be dependent upon how severe their lung disease, how much is consumed and what medications one might be taking that could be affected by alcohol in their system, to name a few considerations. Best Wishes, Mark
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November 13,
2011 Bronchiectasis - Meds/Treatments/Devices to Help Loosen Mucus
Hi Mark, I am writing to you about my
Mother...She is 76 and was born with bronchiectasis, (back in 1935) they had
no idea at the time what the problem was until she was in her late teenage
years that she was finally diagnosed...Sooo, 76 Female, her parents both
smoked during and after she was born....When she was young she would bring
up mucus like clock work with any percussion about 1/2 a cup twice a
day..(and no she does not have (CF). At age 40, she had one of her lungs
removed from scar tissue and it was partially not functioning...they
sawed thru her back and opened up the rib and took it out.....She takes the
following drugs; A. Hi Lori, What a great post. Thanks for the thorough run-down and all the good information. I would suggest a couple of things for y'all to consider. first, while your mother is taking Mucomyst (N-Acetylcysteine) by nebulizer with her "cocktail", she might find benefit from dosing it orally, as well. The supplement "NAC" is a powder form of that the Mucomyst liquid is. BUT, it does more than just help thin mucus. It stimulates production of glutathione in the lungs, a substance that decreases inflammation (and therefore mucus production), so has a two-fold benefit for the mucus problem. As well, it is an excellent antioxidant! The usual dose is 1200 mg once or twice a day. Some folk take 1800 mg (1200 in am and 600 in pm) for a moderate doses between the extremes. One should also take at least 2000 mg of vitamin C with 1200mg or more of NAC. The vitamin C reacts with the byproducts of metabolism of NAC - a salt that can aid in formation of kidney stones. She can take the oral NAC without consequence to the inhaled Mucomyst. Another consideration is hydration. Now, while I'm NOT one who touts oral fluid intake in regards to any link to helping to thin mucus (no evidence, though touted a LOT in the literature), the elderly are prone to dehydration which can, in the long term, insidiously lead to drying of mucus throughout the body. So be sure your mom is drinking plenty of fluids during the day. A caution/caveat to this recommendation is if she is taking a diuretic and/or has compromised heart function that would put her at risk for fluid overload, even with consumption of normal amounts of fluids. So, consider that when evaluating the adequacy of her fluid intake and hydration status. Another means of hydrating the mucus is inhaling moisture. A steamy bathroom is good, if tolerated. Cool mist from a room humidifier (at close range to the airway) is another effective measure. Hypertonic saline (3 % to 7 %) is being used with very good results in CF and other conditions where mucus is abundant and tenacious. That could be added to her cocktail for inhalation. Ask her doctor if it might be a desirable addition to her regimen. Yet another thought is the use of a mucus clearance device. There are positive pressure breathing devices, like Acapella, Resistex and a new one I just saw this week called "Quake" (Thayer Medical - a great little device that is very easy to use and very effective to loosen mucus). Then there are devices like the 'Metaneb' (Hill Rom) "Intrapulmonary Percussive Ventilator" (IPV - Percussionaire) and the various vest - high frequency vibration devices (I like "Smart Vest" the best) that she might inquire about. These are at least as effective as the old standard percussion and postural drainage and serve as great additions to that therapy to increase mucus mobilization and clearance. So, those are some suggestions for you to consider and inquire about. I hope your mother is able to try one or several of those and find the combination that will work better for her. Best wishes, Mark |
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October 23rd,
2011 Emphysema Patients - Thin/Lacking Muscle Mass vs Overweight - Differences Hello Mark; Why is it that some people with COPD are overweight while others are very very thin with no muscle mass? Does it have anything to do with how their body frame was even before they developed emphysema? Thanks, Cleo Hi Cleo,
Your observation is astute, indeed! Because
"COPD" entails several different specific obstructive lung diseases, you
will find different body types and physical characteristics and
disease-related changes among the COPD population. Those with more
predominantly emphysema, 'tend' to be on the slender side, while those who
have more predominantly chronic bronchitis 'tend' to be at or above their
ideal body mass. If one has tended towards obesity or been on the slender
side of body mass for their height, age and gender, they will tend to
exaggerate towards those extremes as their lung disease advances. For those
on the slender side, losing too much body mass directly affects prospects
for survival AND how well they are able to live with COPD. Those on the
high end of body mass tend to have much less risk of early demise owing to
nutrition than those who are severely malnourished. Best Regards, Mark Oxygen - Continuous Flow vs Pulse - Differences & Nocturnal Oxygen Settings
Hi Mark;
Hi LJ, You ask some very good questions! And your suspicions are closer to the truth than you might realize. So, let me compliment you saying: "Good thinking!" There IS a difference between continuous flow (CF) and pulsed oxygen, no matter the source. To make matters yet more confusing, the difference is variable between particular POC's and conserving devices. But, we can't stop with just the device types and their individual differences. When you add rest vs sleep vs activity/exertion into the mix, you throw yet another variable into the blender that increases the magnitude of the other differences and explains why - at comparable settings between devices and CF - you see such disparate results. Each POC has a maximum capacity for how much oxygen it can produce per unit of time. For example, small POC's - in the 5 pound range - can produce between 750 mls and 1 L of about 90 % pure oxygen per minute. They are calibrated to dispense that oxygen up to so many mls-per-breath and to a maximum rate of ('X') number of breaths-per-minute below which they can guarantee the advertised purity. Often, the maximum number of breaths is below the number to which folks respiratory rate will increase to during exercise/exertion. So, they end up either generating breaths that do not receive oxygen, or more often, a breathing rate that exceeds the maximum for purity of oxygen dispensed which results in decreased purity of delivered oxygen. Conserving devices tend to operate as advertised up to some maximum response rate, above which they simply don't respond. Further "where" in the inspiratory phase the oxygen is delivered will further determine how much oxygen actually reaches the gas-exchanging units in the lungs and how much stays in the bronchial tubes where it has no opportunity to participate in exchange (That is what we call "dead-space" ventilation.) If the pulse is delivered during the first 2/3 of each inspiratory cycle, it has a better chance of being 'used' than if the pulse is delivered over the whole duration of the inspiration. As well, when you increase your activity and respiratory rate, the volume you take in per-breath can also increase. With CF and pulsed oxygen, the resultant concentration - portion of the total volume of gas taken into the lungs - during each breath varies and becomes lower when larger volumes are taken in against a fixed volume of oxygen delivered during each breath. In comparing CF to pulsed oxygen changes in respiratory rate and volume actually favor pulsed oxygen with regard to which delivers MORE oxygen volume-per-breath, when we look across the spectrum of the many pulsed oxygen devices. Some fall short in comparison, while other will always beat CF. (This is not well understood by MANY doctors, nurses, RT's and consequently, oxygen users who tend to think that CF is ALWAYS better than pulsed, without exception. That is just not true for MANY pulsed devices. So, the overall result is less oxygen received from the pulsed systems and POC's under conditions of exertion than for CF WHEN IT IS INCREASED appropriately. Therein lies the crux of the matter. No one should assume that the same CF setting is fine for activity - or sleep. It is not in the least unusual to find that one needs several more liters flow to maintain comparable saturations during activity than when they are at rest. It is not surprising to find someone who saturates just fine with, say, 2 L while at rest, but who needs 5, 6, 8 or more liters to stay comparably saturated with exertion. Yet, the common practice is to prescribe only 1 or 2 additional liters flow for activity - clearly NOT enough, as your measurements/observations have borne out. As well, among conservers ("OCD's", hereafter) and POC's are significant differences in what constitutes equivalencies. Our saying for that is that "2 is NOT equal to 2", to nut-shell it. POC's vary in how much they deliver with each pulse AND how much they deliver with each pulse as settings change. In some cases, as demand increases, the same 'total' volume of oxygen is simply cut up into smaller pieces, since each POC as a maximum production rate capacity. So, even though a setting may be increased, it can either become reduced in pulsed volume as demand increases, or, worse yet, while the volume may stay the same, demand beyond a POC's capacity can cause dilution of purity so that the pulses are of decreasing concentration, effectively lowering oxygen support by lost purity of the delivered oxygen volume. With conserving devices, some will respond to a maximum breathing rate (20 or 30 or 40 breaths per minute, for instance) if respiratory rate exceeds the maximum rate capability of a device, it simply fails to deliver oxygen on some breaths. Additionally, while each manufacturer sets an "assumed volume of air taken in per breath in determining the volume of each pulse, if the user's actual inspired volume exceeds the 'assumed volume for a certain setting, then the "effective" concentration delivered will be lower than what the manufacturer states. It is well known by those who understand the 'foibles' of POC's and OCD's and advanced COPD, in particular, that while the user's respiratory 'rate' and 'per-breath volume' may increase as demand for breathing during activity increases, we also know that factors like dynamic hyperinflation, changes in blood flow through the lungs and change in matching of blood flow to areas being ventilated occur, even though more volume may be taken into the lungs at higher demand, less "effective ventilation" often - almost always, and very predictably - DECREASES. Too often, those who have poor understanding of this critical process will attribute decreasing saturation during exertion to a simple explanation that the muscles are demanding more oxygen than the diseased lungs can provide and building up CO2 in the process. While blood gas measurements may seem to suggest that to be the case, the truth is that it is more owing to increased ventilatory disturbances than to significant increase in oxygen demand that cause the observation of decreasing exertional saturations, than to much increase in muscle demand or oxygen. All that said, CF is not always or inherently better than pulsed flow. Which is true depends upon the individual device in use and what it's capacity to produce oxygen and meet ventilatory demand are AND to what setting the device is being used at. How to know or determine the difference is a complicated process and beyond the scope of what I am trying to explain, here. The rule of thumb for folks who CAN'T ascertain those exact parameters is to acquire a pulse oximeter and closely and frequently monitor their saturation under the various conditions of their lives and adjust the setting to best meet the objective of a minimum allowable saturation where and when possible. AND, if the POC or OCD they have is NOT meeting the challenge, they should do everything in their power to change to another device that CAN meet their needs. If they cannot change devices, then they need to learn how to pace themselves so as to minimize drops in oxygen levels and to avoid the discomfort and potential organ damage that goes with repeated and prolonged inadequacy of blood oxygen levels. Finally, you are correct to be concerned about your friend's decrease in her oxygen flow at night. AND you surmised correctly that while asleep one does NOT demand as much oxygen based upon less activity, because of changes in breathing pattern (shallower and slower) less 'molecules' of oxygen enter the lungs and therefore less oxygen is available. Sleep studies of oxygen saturation patterns show that one should almost always use a flow setting that is similar to the setting they need for exercise/exertion. At the least, they should arbitrarily use one liter more for sleep than they use for resting conditions while awake. We do NOT tend to sense dangerous drops in oxygen when we sleep. What we usually observe is decreased energy, changes in thinking/judgment and progressive organ dysfunction, especially where the right side of the heart is concerned. Nocturnal hypoxia can lead to secondary pulmonary hypertension, right heart failure, edema, often seen in the lower extremities and/or weight gain that fluctuates a couple of pounds over the course of a day as one sheds the excess water through urination. Best Regards, Mark
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October 16th,
2011 Oxygen & CO2 Retention
Hi Mark The first comment I have to make is that your nurse is unequivocally WRONG. Not “all” COPD’ers are CO2-retainers. ONLY those whose FEV-1 has dropped severely – most prevalently, those whose FEV-1 is below 25 % of predicted and often, not until it drops below 20 % of predicted – are seen to retain CO2. She is misconstruing the long-standing notion about CO2-retention and its impact upon those who use supplemental oxygen, that if they use too much oxygen, they will somehow be inhibited from breathing effectively, even losing their drive to breathe and potentially facing consequences that can be as severe as to include death. I have written about this extensively and fairly recently on COPD Canada in an effort to try to alleviate concern while dispelling the often professed dangers of using what is ACTUALLY ‘enough’ oxygen to keep organ health in a safe range AND to avoid earlier demise that predictably results from inadequate use of oxygen to keep saturation in a safe range. Only a blood gas test can determine if one is a CO2-retainer. Unless you have had such a test, neither you nor she can say that you are indeed retaining CO2. Even then, it depends upon how much you retain. Mild retainers are NOT at risk for any problems or danger. Only those who retain significant amounts of CO2 would be included in the risk population according to the long-standing (but, unproven) theory. As well, as proponents who understand the theory well will tell you, we would ONLY see the purported effects in a VERY FEW of those who are considered most at risk. So, even if it were true, the number of folks at risk is few and far between. AND, it is not enough folks, in the end, to warrant or justify the practice of withholding adequate oxygen from EVERYONE, as she suggests. So, unless your doctor has measured your CO2 AND determined that you not only retain CO2, but also retain it in significantly, you are NOT at risk for any problems or danger. The bottom line Is that folks like you are much more at risk for ill effects from not using enough oxygen than you will EVER be from using too much. And, in reference to your question, there aren’t folks who can use high flows while others can only use low flows. How much oxygen one uses should be dependent STRICTLY upon the results of measurements under the conditions of rest, exertion/exercise and sleep, all of which most often require different flows, sometimes QUITE different from the low flow at rest that will adequately correct one’s hypoxia (low oxygen level) You should ALWAYS, try to keep your oxygen saturation above 90 %, if at all possible, using whatever flow is necessary to get it up there. Best Wishes, Mark
I am on oxygen
concentrator. I was told by respiratory therapist to keep my no @ 4. I
guess my question is . Why when I am on it and I am busy around the house,
or if I walk. does my oximeter read at 84/85 and sometimes even lower.. I am
receiving oxygen but still feel SOB. When at rest oximeter reads 91/92. Why
does it go up and down like that. A. Hi Ann, The flow of 4L/min is NOT enough for you when up and moving around! It is barely enough to meet our needs while at rest. You need to consult with your doctor and let him/her know that your oxygen saturation is dropping to that 84 – 85 % when you get up and move. DO NOT let him/her respond by telling you not to move so much. COPD and other lung diseases are ALWAYS “move-it-or-lose-it” situations such that if you cannot keep moving and stay in the best physical shape possible then you WILL lose it sooner than later (that is, die from the disease). You did not say what your diagnosis is. But, it is apparent that your disease is severe if 4 L/min corrects you only to 91 – 92 % while at rest. AND, it is no surprise that you drop like you do – and experience such difficulty breathing along with the drop – when you get up and move around! You need a system that will be able to give you probably 8 liters or more when you are up and moving. At the very least, you need to turn it up to 6L/min and see how well that corrects your saturation. If 6 pushes you back up to 91 – 92%, then you are good with that. If not, you need more. Best wishes, Mark
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October 9th,
2011 Follow up from October 2nd Query & Suggestion Hello Mark, and thanks for your help. I took off the oxygen for half an hour and at the end of this time I was 84 sats and 77 pulse. Then I started to breath deeply,still no oxygen, and using PLB and in less than 2 mins I got my sats to 90. I could have carried on but my pulse was going up to 94 too with the extra effort, so I put the oxygen back on. I have tried this before but with better results, I did it to know how long I could last out if one day for any reason by portable packed up on me in the street. Best wishes, Val. A. Hi Val, It's interesting that you were able to push your saturation up as you did. I asked you to do the controlled breathing as you did to determine if you had a 'ventilatory' component to your hypoxia that could be corrected to some degree with deep-breathing and to help you discover how much you could influence it - as you saw - to increase it in times that you find it low and as a supportive measure, as you also discovered, in times if/when you were short on supplemental oxygen and needed the help of more deliberate breathing. An increase from 77/min to 94/min is not bad, though maybe a bit disconcerting. But, you know now that you CAN push it up. And coupled with pursed lips, it might go up even higher, as you also note from that and previous instances, as you said have occurred. Best Wishes, Mark Emphysema & Chemotherapy Exposure Why
shouldn't someone with emphysema be around a person receiving chemotherapy?
What are the risks for the emphysema carrier? A. Hi Fle, I am not aware that there are or would necessarily be any risks or restrictions with regard to someone with COPD/emphysema "being around" someone who is receiving chemotherapy. Now, speaking generally, when one is undergoing chemotherapy that suppresses their immune system such that THEY are susceptible to 'opportunistic' infection, THEY should steer clear of other folks, especially those who are fighting infections, flus, colds and other communicable illnesses. It is the recipient of the chemotherapy who is at risk for difficulties. So someone who has COPD/emphysema may be one to potentially share a lung infection, if present, with such a person. The only other condition where all, including those with COPD/emphysema would want to stay clear of one who is receiving a treatment for cancer is when radioactive seeds (as used in treatment of prostate cancer) have been implanted. But, whenever that is employed, all concerned strongly cautioned and instructed in safety measures to avoid exposure. Can you be more specific about why you ask your question, or about what your are concerned? Best Wishes, Mark
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October 2nd,
2011 Blood Gasses Interpretation Follow Up From Sept. 22, 2011 Hello Mark, and thanks for reply last week. I use 1 and a half lpm oxygen at night and 2 lpm in the day prescribed by the pulmonologist now over 5 years ago, but then he told me 1 lpm at night, I upped it to 1 and a half, because on 1 lpm I used to wake up with a high pulse over 90 rpm. He also agreed. The reason he gave me for having less when sleeping was CO2 retention and not needing 2 when sleeping, I use a BiPAP too. When I take off my oxygen sitting I get low sats of 87 in 30mins. I use my oximeter. That's why I can't understand high PO2 of 126. regards Val. A. Hi Val, While to be concerned about the possibility of you retaining CO2 because of using a higher liter flow is a commonly voiced concern among many health care professionals, it is not a well-thought-out notion in your particular case. If you are using BiPAP, you are receiving ventilatory support that not only will PREVENT any possibility of CO2-retention, it will actually be lowering your baseline CO2 in the process, while using it. So, as you can surmise, it is a ‘non-issue’. At the same time, BiPAP also tends to ‘raise’ oxygen levels because of the constant positive pressure which puts more oxygen molecules per volume of gas in your lungs, so, for that reason alone, you might not need the additional oxygen flow during the time you are using the BiPAP. A heart rate of 90, while somewhat elevated at rest, relatively speaking, is not significantly elevated, all things considered. Factors other than low oxygen can be the case. But, to be safe, the 1.5 L/min flow is a good idea when on the BiPAP. Were it not for the use of the BiPAP, the argument – supported by the preponderance of evidence – that one’s oxygen saturation is comparable to that which they hold during exercise is still the prevailing premise and should warrant the use of the same flow during sleep as that used during exercise until and unless proven otherwise (through sleep saturation monitoring, for instance). The 126 still is reasonable and not significantly high, much less a point of concern and may simply have been reflective of a ‘good day’ for you when it was measured. I am curious to know if when you take your oxygen off, then measure your saturation 30 minutes later, as you reported doing when you found that it was 87 %, if you THEN continue to monitor it for another couple of minutes while taking in many deliberate and slow, deep breaths will increase. If so, how much does it increase? In other words, can you force your oxygen level to increase with very controlled and deep breathing for several minutes while breathing ‘room air’ (a.k.a., using no supplemental oxygen)? Try doing that and write back and let me know what you find. Best wishes, Mark Mold Problem Hi Mark..spoke to u some time ago. I am a copd patient who operates at about 23 %. was 30: about 4 yrs ago and slowly decreasing but totally functioning.
A. Hi Barb, Wow! Mold as you found is not a good thing for healthy lungs, let alone those diseased with COPD or other chronic lung ailments! First, while “most” molds found in homes are NOT toxic, or of the species of toxic molds that can cause serious problems, to expose one’s self to them for prolonged periods of time or in significant concentration is what is required for most health problems to occur. You didn’t say “how much” mold you found. But, speed and severity of reaction to molds is “dose-related” and depends upon one’s immune system response and adequacy of integrity. It is likely that you have been inhaling spores for quite some time, even though it was lurking covered up by your carpet, though certainly not in significant concentration/numbers of spores. It is possible that you have developed antibodies to the species you have growing in your home through exposure in low concentration for however long it has been growing. So, you may not have any adverse response to it at all. On the other hand, if a lot of spores were kicked up when the carpet was removed and the mold exposed without barrier containment, then you could experience a reaction to the sudden increase in spores in the air within your home. The best advice I could give you or anyone facing your scenario is to LEAVE the premises! Remaining in the environment with the mold spores free to circulate in the air invites trouble that is avoidable. You should NOT be around when the mold is cleaned up as that will also kick up spores into the air and make them available to be inhaled. Wearing a mask – even an N-95 or other high-efficiency mask - would not be enough protection to ensure you wouldn’t inhale potentially high enough numbers of spores to cause trouble IF the mold you have turns out to be of one of the toxic species. As for how long it would take for you to react, if that is in the cards, I can’t tell you that for reasons already discussed. But, the likelihood of a reaction being significantly delayed from the point of exposure is not likely. So, if you haven’t begun to exhibit symptoms – increased breathing difficult and sputum production, for instance – then you likely are OK and shouldn’t expect to have any difficulties. If you start having problems, don’t delay getting to your doctor for treatment. Best Wishes, Mark Bronchospasm Clarification
Hi Mark; A. Hi Jackie, A-c-t-u-a-l-l-y, “both” descriptions hold some degree of truth! While the ‘parenchymal’ tissue of the lungs – that is the tissues that form the alveoli, connective/structural support network and blood vessels – are devoid of pain nerves, so don’t ‘sense’ pain, the bronchial tubes and “parietal pleura” – that is, the membranous lining of the chest wall that with the “visceral pleura”, combine to enclose the lungs, provide a negative pressure hold that keeps the lungs inflated AND contains a slippery fluid that allows the lungs to ‘slide’ during the inflation and deflation of breathing – are very sensitive and DO sense pain. Folks who have had pleurisy know well about the pain that occurs when the pleura become inflamed. That pain is the result of insufficient fluid to allow the pleura to properly ‘slide’ against one another, acting more like sand-paper than the thin slippery membrane they are. But, it is the pleural lining that is attached to the chest wall (the parietal pleura) that ‘feels’/senses the pain, NOT the membrane that is attached to the surface of the lung (the visceral pleura). Bronchial pain can be sensed due to a variety of causes. Acute Bronchitis causes inflammation which can be accompanied by pain – often a burning and/or aching sensation – that subsides as the inflammation decreases and the cause of the condition resolves. Insofar as bronchospasm is concerned, pain is possible, more in the form of aching, but, certainly not characteristic of the classic pain of a “Charlie horse”. A Charlie horse is classically limited to “striated” skeletal muscles during spasms. As such, one can have a Charlie horse occur in the intercostal muscles – those which attach the ribs to each other. But, because the muscles of the bronchial tubes are comprised of “smooth” muscle which is not striated and not of the same type as are skeletal muscles, when they spasm, the pain potentially associated with their spasmodic activity will be more of an aching-type pain, if anything. Cough, wheezing, increased mucus production and difficulty breathing are also symptoms of bronchospasm, though not of the type of discomfort that would be considered or labeled as “pain”. I hope this clarifies the issue and questions to which you refer. Best Regards, Mark |
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September 25th, 2011 My doctor gave me inhaler twice the last time I had a nagging cough got a new doctor should I ask for refills my family has a history of asthma, its seem to me that my cough happens late winter or early spring and I cough like a seal and smokers cough I do not smoke or around smokers, when going to the new doctors should I say anything about the medication I am on, I have not taking an about three months, it seems like the only time I get the inhaler is when I am coughing how can I get the doctor refills prescriptions, I am tired of sucking on cough drops and cough syrup like water or candy. can you give me any ideas thank you. Eric Hi Eric, If the inhaled medications have helped reduce or eliminate your symptoms in the past AND you think they will likely reduce your use of cough suppressant medications of all kinds, then by all means ask your new doctor for a prescription. It seems to me you should undergo pulmonary functions testing to determine, if possible, the cause for your symptoms. It could be that you have asthma, especially since it seems to come on in a seasonal fashion. But, you should fully discuss your difficulties with your new doctor and pursue answers to the “why” and “what” about their cause. Best Wishes, Mark Marijuana & COPD
What is the prognosis for someone like myself, diagnosed with COPD? A. Hi Mary, Prognosis does indeed depend heavily upon what stage one is in. But, even more so, what determines rate of progression and is a matter over which you have control is what you do to care for yourself. Exercise and being as vigorous and robust as you can in lifestyle go extremely far in not only increasing survival with COPD, but also to influence the quality of life you enjoy while contending with COPD. Smoking cessation – of all kinds of materials – and good nutrition are very important components, as well. While some hype about marijuana’s ability to effect bronchodilation has been published in the past, the prevailing consideration is that smoking of ANY kind – for those with Asthma AND COPD, along with other lung diseases – is much more harmful that any possible help it could impart. There’s just nothing good or helpful about smoking marijuana when you consider imbibing in the interest of helping with lung disease symptoms. And the evidence we have shows that it causes further damage and deterioration in one’s lungs and their function. So, to stay away from it is the best and most appropriate advice I can give you. Best Wishes, Mark Blood Gases Interpretation Dear Mark, I am worried about the blood test I did at my 6 months revision with the pulmonologist on 15th Sept because it shows a high Oxygen reading. The results are ph 7.47, pCO2 47.00 pO2 126.00, HC03 34.20, TC02 35.00, excess at base (Beb) 9.30, So2 saturation of oxygen 99.00. I feel that the p02 is very high of 126.00, when the pCO2 is quite low. Six months ago the same happened, my oxygen pO2 was 108.oo. Before these last two tests, my pO2 never went over the 80's. Do these high levels of oxygen mean that my lungs can't cope with oxygen now, I only use 2lpm resting and 1 and a half lpm sleeping with Bipap. I usually use 3 lpm when walking. Can you throw some light on why I now get much higher pO2 than before. Thank you Mark. regards Valerie A. Hi Valerie, Actually, it is no big mystery that your oxygen has fluctuated as it has. It is NOT a sign of ANY problem, instead actually being a good thing. I am curious to know if when you had the 80 pO2 measurements that your oxygen was turned off. If not, it could easily have been a bit off from the 2 L/min you try to set it to. But, if you were not in similar condition back then to what you are now, it’s certainly possible that you have improved to some degree and are able to get more oxygen into your lungs than when the previous tests were done. Finally, simple small but significant differences in how exactly the flow was set could easily account for the differences you see between the tests. In any case, the changes are positive, NOT negative as you characterize them to potentially be. Higher measurements of oxygen in your blood do NOT indicate your body’s inability to “cope” with oxygen! If anything what it may indicate is that you do NOT need to use 2 L/min at rest as it is pushing your oxygen level up to that 126. I am also puzzled as to why you use more flow when awake and at rest than when you sleep. Your flow “should” be comparable during sleep to when you are exerting, or at least equal to your waking/resting flow. Lastly, I want to thank you for including the entire blood gas results. Because you told me both the pCO2 and pH, I am able to tell you that your carbon dioxide is NOT “low’ let alone “too low” as you said. Normal blood CO2 ranges from 35 to 45. With yours being 47, it is actually a bit elevated, meaning, when considered with the pH, which is also elevated (normal range 7.35 – 7.45) at 7.47, you are mildly retaining CO2, a sign of the advancement of your COPD and its current state. While you need do nothing with any urgency, I would suggest you ask your doctor if you can use less oxygen while at rest OR to remove it when you are sitting. It would be nice to see what your pO2 is while OFF oxygen, breathing only the air in the room. While I do not believe that the 126 oxygen level poses any potential danger to you, it is not necessary or specifically helpful in any way to keep it that high. Best Wishes, Mark
Sensitivity to Smells & Infrared Sauna Issues
Hi Mark, A. Hi Moe, Your sensitivity to odors of the nature you describe is not at all unusual. Many folks who have Asthma and COPD become increasingly intolerant of odors, especially scents used to add fragrance to every day materials we use, like Kleenex and toilet tissues, soaps and laundry and cleaning products. Perfumes, colognes and other hygienic products can wreak havoc with one’s breathing. It is specifically because of these tendencies among those with lung diseases that we RT’s are careful not to wear scents or clean ourselves with products that emit significant fragrances when we work with our patients. So, your husband and son really do need to heed your complaints and try to keep from aggravating your breathing with unpleasant odors and/or those that trigger breathing difficulties for you. Insofar as the question of pollution you ask about, while all folks who have COPD should avoid breathing polluted air, because fragrances are present that bother you does not make them constitute pollutants. As for the bowling alley, it is common knowledge that the lanes are coated with oil. That oil has no significant fragrance or odor to it. As well, that oil has never been shown to become ‘airborne’ or to pose a threat to one’s health. You may be overly sensitive to that particular presence more because you ‘know’ it is there, rather than because it emits any significant fragrance or odor. One other possibility would be to see if there is a concession that fries a lot of foods. That oil can become airborne, but predictably not in sufficient quantity to place anyone at risk for harm, even those who work there, in close contact with it, every day (unless they are exposed to it for a matter of years on a daily basis). In any case, wearing a mask of the type you suggest – or that would be necessary for the type of filtration you suggest, were airborne pollutants actually present because of the oil used at bowling alleys – would be not only impractical, but a visual distraction and potential embarrassment since there is no known or suspected danger posed by breathing the air within that environment. If, as in many areas here in the USA, smoking has been banned from bowling alleys, then the greatest source of actual air pollution has been removed. And the remaining air may be safer than it has ever been. I have to agree with your pulmonologist’s nurse that on the whole, saunas are high-risk environments for those with lung disease. It is curious and quite incongruous that you would be so highly sensitive to odors and fragrances as you are and still able to tolerate the high-humidity of a sauna (at lower temperatures or not!). Beyond the assault of the humidity on your breathing, they tend to support growth of molds if not maintained at an impeccable level of cleanliness. Are you prepared to or able to assure that strict condition in your home sauna? As well, I don’t know what benefit a cooler sauna would potentially have for the aches you describe. Even a hot sauna wouldn’t significantly benefit achy muscles and joints. Better to get in a whirlpool tub or a hot tub (also risky) for that kind of benefit. I have concerns about your oxygen needs. What we see a lot of the time in folks who have extreme sensitivities of the nature that you describe, BUT whose lung disease is not so severe as to prohibit their ability to work full time and maintain an active lifestyle is "hypoxia" (decreased blood oxygen levels), especially during exertion. You note that you use oxygen only at night. Do you have an oximeter to monitor your oxygen during waking hours and especially with exertion? You could be desaturating (dropping your oxygen level) during exertion, in which case you may need to increase your oxygen use to more than just while sleeping. Further, it is fairly well documented that folks who desaturate during sleep most often desaturate similarly during exertion. So if you have not had a walk test with oxygen monitoring performed as you walk for at least three minutes, non-stop AND you do not own or use a pulse oximeter, then you should have that test and/or consider purchasing an oximeter and adjusting your oxygen use accordingly. It is certainly an issue you should discuss with your doctor. One other concern is that you’re using ONLY Spiriva. While there may be a few folks out there who need only an “anticholinergic” medication to maintain their airway tone, with your apparent sensitivities and symptoms related to odors and fragrances, I would be that you also need to be using a beta-agonist medication along with the Spiriva. You may also specifically benefit from an inhaled corticosteroid which would help reduce your sensitivity to fragrances/odors. Ask your doctor about the advisability and potential benefit of adding something like Symbicort or one of the other combination inhalers that contain each of the types of drugs I suggest. What you may see is not only overall improvement in your breathing, but a significant reduction in your sensitivity to some of the offending odors. Part of your underlying propensity for intolerance may simply be airway reactivity of the type that those two medications specifically resolve and/or prevent. Best Wishes, Mark
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September 18, 2011 Symbicort, Spiriva Dosing and Emphysema Progression Questions
Dear Mark: A. Hi Mary Ann, It is safe and appropriate – actually, ‘recommended’ – that you take the Symbicort and Spiriva together – or close to each other in interval. COPD is NEVER “allergy-related”. Allergies cause asthmatic symptoms of inflammation and constriction that are reversible with bronchodilators, anti-inflammatory medications and others, without necessarily having continued reduction in FEV-1 when reversal is successful and/or complete. COPD represents specific and permanent structural changes that do NOT respond to ‘reversal’ interventions. COPD/Emphysema progresses at a variable pace among individuals that is dependent upon a lot of factors. As such one cannot simply say “Your will get worse (this much) every year.” Or anything like that. Because you have a LOT of control over how fast you progress, you can also expect your rate of progression to vary according to what and how much action you take to slow its progression. Exercise, good nutrition, smoking cessation and the rest that goes into an overall healthy life style are key elements of successful intervention to slow progression. Despite difficulty breathing and windedness that comes on when you exert/exercise, it is absolutely imperative that you get moving again and keep moving, especially to return to a regular and as vigorous an exercise program as you can manage. Your breathing symptoms will be controlled but, NOT likely eliminated with use of the medications you now take. They are not able or intended to completely stop all breathing symptoms/difficulties. Further, the person who is successful in achieving control and long term slowing of their COPD progression is one who through exercise and breathing control learns to function at a high level DESPITE working hard to breathe. While breathing hard may “feel” like it is “bad for you”, it will NOT hurt you to force yourself to work hard physically and breathe hard – and uncomfortably – while doing so. Those who cannot manage to push on in the face of difficulty breathing during exertion progress faster and succumb sooner than those who do succeed against breathing difficulties. Asking what stage of COPD you are in is simply not enough information. You should ask what your FEV-1 is (as a percent of predicted), your lung volumes (TLC & RV, especially – Total Lung Volume and Residual Volume) and Diffusion Capacity ( how easily oxygen gets from the air in your lungs into your blood). For these numbers, you need to undergo a “complete pulmonary functions test” which includes, “spirometry”, lung volume measurement and measurement of diffusion capacity – three different groups of tests measurements. If your test includes these, you can come back and let me know what they are – or contact me directly through the help of this forum/Jackie Whitaker) and I will help you make sense of them. At 47 and with what seems likely a modest smoking history, you should ask to be tested for the genetic form of COPD – Alpha-1 Antitrypsin Deficiency Emphysema. If you have that form, you need very specific treatment that is different and beyond the usual treatment for COPD of other forms. Best Wishes, Mark Can an Asthma Action Plan Be Used for COPD
Will my action
asthma plan work for copd?(just recently diagnosed) A. Hi Terry, Your asthma action plan is strictly for management of your asthma to keep it stable and under control from the perspective of active constriction of your bronchial tubes that is caused by asthma. COPD, while often having a feature or component of asthma to some degree, in some individuals is not commonly or very effectively managed with medication administered according to measurement of daily or multiple measurements of peak flow within a day as is asthma, according to the standard asthma action plan. So, you continue to monitor and treat your asthma while adding the arbitrary treatment for COPD as prescribed by your doctor. Both conditions will be most stable with such an approach. Keep moving, exercising, eating and resting well and you should do fine for a long time to come. Best Wishes, Mark Getting Back Into Walking After Foot Injury
Hi Mark. The very
best to you and your family. A. Hi Philip, I cannot give you any hard and fast recommendation, as there is no hard and fast standard. Additionally, not knowing about your condition beyond what you’ve told me I am not in a position to be specific with any recommendations. You are the one experiencing the pain and who has sat out for the last 6 weeks. You should feel free to use your own judgment to determine what will be the best settings in terms of duration and intensity. Generally speaking, I would say remove ALL grade from your treadmill. Find a speed that challenges your breathing and allows you to go at least 30 minutes, if not the full 45, right from the gitgo. Add speed and grade over the next couple of weeks to return to your previous duration and load. Let your foot pain be your guide in terms of how much and how long or even IF it is wise to return to a walking program before you let all pain resolve completely. You don’t want to aggravate the condition and cause a return of acute inflammation. I do have a curiosity. Do you have a pool nearby that you can access to do water aerobics or even lap-walking? If one can use a pool, there should be no need for totally stopping exercise because of conditions like you suffer. The buoyancy of water and the almost complete removal of pressure related to weight-bearing of walking on land make it ideal for continuing exercise during episodes of orthopedic difficulties. Hang in there and push carefully, but not too cautiously and you should be back in the saddle shortly. Best Wishes, Mark |
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September 4th,
2011 Q. Chest Pain & Dizzy Spells
My chest hurts a lot of the time. It seems to be
between my lungs and near the end of my ribs. is this something to be more
concerned about as I also have dizzy or light headed spells a lot. A. Hi Leo, I'm afraid my crystal ball was knocked unceremoniously off it's pedestal, the other day and I simply cannot tell you a single thing from the information you've given me. I would strongly suggest you see your doctor as soon as possible as there are many possible causes of your symptoms, several of which are nothing to mess around with in terms of delaying evaluation and possible treatment. Let us know what you learn and how you do. Best wishes, Mark Several Issues (additional info is required)
I gave up smoking in Dec.1999. as I was diagnosed
having Lung cancer. In Feb 2001 a surgery was performed and 3 lobes effected
were removed A. Hi Sami, You have certainly been through the ringer, it seems, with your cancer woes. With the treatment you've had, there is certainly plenty of reason to have difficulty. AND, I'm betting that you are not getting much if any benefit from the Symbicort and Spiriva. I'm afraid I have more questions than answers for you as you have not told me any key information that would give me basis upon which to assess your condition and situation, let alone provide any recommendations or advice. So, if you will kindly indulge me and get back with the following information: What do your pulmonary functions measurements report? Specifically, I need to know what your FEV-1, FVC, TLC, RV and DLCO measurements currently are. If you have not had them, then you need to seek a "complete PFT" with "spirometry", "lung volumes" and "diffusion capacity" measurements. You didn't say how many years you smoked. You don't indicate how much total lung was resected - i, e; complete or partial lobectomies, and total lung volume removed. You cannot know that too much radiation was used, regardless of what it may 'seem' to you. How much is fairly easily ascertained before hand with a small margin of "too much" or "too little" included in the prescription. BUT, radiation virtually ALWAYS results in some degree and quantity of "radiation fibrosis" in the treated AND surrounding tissues. So, that can further reduce the function of yet more of your remaining lung tissue. You didn't say anything about oxygen use. Do you use oxygen? If so, how much and with what usage pattern. Do you measure your oxygen saturation and adjust the oxygen flow to match what you need to maintain a satisfactory oxygen saturation under different conditions? (at rest, with sleep, with exertion/exercise) I suggested that the medications likely don't do anything for you because with your surgically reduced lung volumes, your PFT's would necessarily suggest that you have significant obstructive lung disease - much more than would actually be there from the smoking - simply because reduced lung volume translates to reduced measurements and the suggestion of disease severity that is much greater than is possible, when one considers that your lung volume has been artificially reduced by resection and removal of lung tissue. Again, this is why I need to know what your current PFT measurements are - and in particular, those that I named. Insofar as the advice from your family doctor, I don't necessarily think it is good with regard to the water intake. Do you have ANY ankle swelling? Do you have heart trouble or have to take diuretic medications to help you shed water? You say you're following the recommendations of your family doctor when in fact, you are doing so only selectively. You are drinking lots o water but NOT exercising, claiming that it is not possible. That simply is not true! While trying to do any exercise is no doubt V-E-R-Y uncomfortable because of what it does to your breathing, breathing hard is NOT harmful (despite the fact that it may 'feel' like it will most surely 'do you in'!). But, the absolute hardest thing folks in your shoes must do is to find a way to overcome the horrible breathing difficulties you have and not only get moving, but continue to move and to increase your movement as you exercise, gain strength, improve the way your remaining lung function meets your body's needs AND become increasingly "desensitized" to the sensations and limitations of breathing difficulties. I know well that it is a tall order I present to you. But, if you continue to refuse to get moving and move more, despite the difficulties, then you MUST understand that - no matter what else you do to help yourself - you will continue to decline and to decline rapidly, with no likelihood of improving your survival or remaining quality of life. Please gather the information I have asked for and write again. I will be happy to try to help figure out what's going on, where you're at in your lung disease journey and what likely to be of specific help. Best wishes, Mark
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August 28th, 2011 Post Fall, Now Experiencing Difficulty Breathing; Reduced Oxygen Levels
Can you tell me if or why the fall I had last
weekend would affect my SATS? I fell on Sun. and broke my collar bone and
severely pulled my rib and chest wall muscles. On Mon. I started getting
really SOB and having to wear my O2 most of the day and night. Now I have
to wear it constantly. I don't know why I didn't check my SATS earlier in
the week, not like me to forget, but I finally remembered last night and
found out just how bad I am. Since I started checking at about midnight, I
have been running at about 82 to a high of 85 when not on my O2. I can get
it up to 94 with the O2 but within less than a minute of taking it off it's
dropped right back down again. All of the testing times have been at rest
since I'm in too much pain to do much of anything more than walking to
bathroom, kitchen, or nebulizer and back to chair. A. Hi Sue, Some initial thoughts that come to mind are that you likely have a pulmonary contusion and other difficulties that accompany that kind of injury. Have you had a chest x-ray? If not, you should definitely get one. You may have cracked a rib or two. You probably have some pleuritic inflammation in response to the injury which is ALSO decreasing your ability to effectively ventilate and oxygenate. If you have some inflammatory response in that area of your lung, it could also be affecting your ventilation and blood flow to that area and consequently your oxygen uptake. A fall wherein one who has significant chronic lung disease AND especially one who has taken any amount of steroid treatment injures their chest/rib cage should NEVER be taken lightly and should ALWAYS warrant a chest x-ray and maybe a CT scan, also. With your history, that should have been first on your list after you picked yourself up and got back into a semblance of stability. So, if this happens again in the future, do NOT wait to see if something worse will develop. Nip it in the bud and get checked out. I suspect that your doctor will order at least an x-ray, but may go straight to a scan to see if you have lung tissue damage that only a CT can best 'see'. Best Wishes, Mark COPD Info Clarification Request
hi i am 33 years old yesterday i had a spriometry
w graphic recc w glow rat and a peak fl test done. they told me i had lung
of a 83 year old then ordered a ekg 12 lead. copd and lung cancer run in my
family do these 3 test have anything to do with that. i also have asthma and
get bronchitus very often sometimes it has to be treated 2 to 3 times before
it goes away. what does this mean A. Hi Jennifer, Your message was extremely difficult to read and decipher between the lack of punctuation and your abbreviations. It's apparent that you're indeed a young lady (at 33) and are deep into the texting and messaging techniques and language/vernacular of young folks today. With a couple of children of my own who are about your age, reading your message and scratching my head a bit made me smile. Unfortunately, your brevity did more to hinder any information I might glean from your question than to provide the helpful information I would need to answer your very appropriate question. I am concerned that what you HAVE told me gives rise to concern for a few possibilities. First, to say that you have the lungs of an 83 year old tells clinicians like me NOTHING! What I would need to know is specific measurements from your PFT. I do not know what you mean with your shortened terms of "glow rat". Maybe you refer to some kind of "ratio"? Spirometry will yield measurements of FVC and FEV1 as well as peak flow, as you indicated. What is most consequential is knowing what the FVC and FEV1 are. And, I would want to know both your measured values (in liters) and the "percent of predicted" or "reference percent". I'm wondering if you smoke? Have you or any of your relatives been tested for hereditary lung disease, specifically Alpha-1-anti-trypsin deficiency emphysema? If not, with the history you did relate, you should at least be tested for that. You could also have Cystic Fibrosis, with the history you've stated.. CF hits folks over a broad range of severity and organ dysfunction combinations. We are diagnosing more and more CF in adults today than ever before. It is a hereditary disease, as well. Until the ECG is read, we don't know what impact it may have on your clinical picture. So, you may want to come back and let us know more of the details as I have mentioned above so that we can better understand what is going on, and, "what it all means". Best Wishes, Mark Oxygen Increased, Potentially Poor Clinical Outcomes (An Abstract Question)
Dear Mr Mangus; A. Hi Beth, I am most happy to tackle your question in light of the study you site - ONLY insofar as I can ascertain the details of the study from the abstract alone. Abstracts do not contain details of theory, target purpose, method, conclusions or discussion, though they are present in a truncated abstract. So, a rush to judgment is easily possible if one doesn't remain mindful of those considerations. And, at a price of $48.00 (and I don't know if that's USD or other currency), I am not about to spend that kind of money to review an article that appears to start with a very skewed/biased premise, targets the method and analysis to that notion and then proceeds to prove the theory while ignoring other considerations/causes. This appears to be yet another study that, on first glance, starts out from a point of cause and effect for the use of oxygen and its effects, declaring oxygen culpable without regard to other more prominent and glaringly obvious influences. As the study is published in an internal medicine journal and not in a pulmonary medicine journal and because among the medical community, it is well known that non-pulmonary-specialty internal medicine physicians often march to a different drummer, so to speak, I would place little credibility in the veracity of the findings of this study. \
One last point I would make is that this appears
yet again, to be a retrospective study which inherently if less than
tenacious in theory, method and conclusions because the studies from which
data collected are not initially or prospectively conducted to answer the
questions now being presumptuously answered by the investigators of this
study. So, for many reasons the study, its method and findings and especially any take-away message derived or claimed from the results must be considered suspect to foster and promote the investigators bias. Unfortunately, the literature is rife with this kind of publication and conspicuously from New Zealand and often the UK, as well, where promotion of the notion that using too much oxygen for ANYONE with COPD is taboo, bad and can "surely" lead to horrible consequences. At the same time, one needs to consider that those same advocates of using less oxygen are also those who collaborate with other who or, themselves foster the criticism that more liberal use of oxygen would impose an economic burden upon the health care resources such that they'd be at risk to approach the declared exorbitance of the US, an unsustainable use and waste of limited and precious resources. So, motives are always in question among those of us who continue to review and consider their studies and publications. As to some points about what is contained in the abstract alone, while I would be loathe to argue with the correlation between those seen requiring increasing levels of oxygen support and mortality, that oxygen use or, as they are trying to convince, "excessive and unnecessary oxygen use" can be even mildly convincingly argued as "causing" the increase in mortality is not only ludicrous, but it is bad theory and science. In the abstract, higher correlations to things like severity of disease, previous exacerbations and episodes of mechanical ventilation are specifically cited. No time line between current and previous episodes is mentioned (or likely considered) as is also conspicuously missing information about co-morbidity and carbon dioxide measurements of the study population. And, that, is initially fro where they are coming in their quest to discredit the "adequate and safe use of oxygen. Typically, in studies for these theoretical objectives, blood pH is ignored, not reported and even hidden from those who would question. CO2 is considered a cornerstone of susceptibility for mishap. In certain locations, not only has the theory been altered and stretched to accommodate biased contentions of investigators, but, it often strays from any originality of the initial and well-defined theory as presented by the very investigators they like to cite in support of their current notions. One case in point is that while theory says that those who retain CO2 are at risk for having their respiratory drive blunted by using too much oxygen, many clinicians have morphed that condition into the warning that for those "at risk" for CO2-retention, using too much oxygen can "initiate and worsen" retention of CO2, clearly NEVER a part of the theory, but nevertheless a current pillar of recommendations for administration of oxygen to those with COPD as a diagnosis. Yet others will extrapolate the so-called dangers and risks to those with other lung diseases NOT of an obstructive nature and which have no condition where CO2 is retained, not even the possibility of such a condition. Idiopathic Pulmonary Fibrosis is often a common target of those who misunderstand the theory, or just simply don't know what the theory says in the first place. All that said, your concern is and should be: "What does it mean for those of us who have COPD and use oxygen? What should we be concerned about? What should we do to safely and effectively use oxygen?" To those questions, I would opine that few would argue the following: (1) If you are not in a severe state of exacerbation - I mean severe enough that getting emergent and significant medical intervention will result in your demise from respiratory system collapse and failure - then you are not even close to being in the population of concern of which this and similar studies speak. (2) If you are stable - EVEN IF you retain CO2, and you increase your oxygen flow for exertion, you are absolutely NOT in ANY danger off compromising your breathing! Why do I say that? It is simply a no-brainer that if you are alert, moving and able to exert, then you are going to be observed to INCREASE your ventilatory effort in accordance with the activity. (3) You can use extremely high amounts of oxygen under exertional conditions - even enough to push your paO2 (as mentioned in this study) above 90 or 100 mmHg and not exhibit a measurable change in effective or other types of ventilation, except to the greater, rather than to the lesser. So, again, that is confirmation that you are not one of those who is at risk as delineated in the study. (4) Even those who caution against the "excessive" use of oxygen during emergent respiratory failure events will agree that no one has EVER seen or encountered a moving, fountaining, awake individual who retains even a LOT of CO2 to actually be "put to sleep" or made somnolent and increasingly unable to support their ventilator needs when their oxygen dose has been excessively increased, along with their paO2. I will close with the point I always make about the need to consider pH in determining what is going on with a patient, especially one in respiratory distress and who is losing the battle to remain able to independently ventilate themselves. If the pH is normal and the CO is elevated, then any concern is much ado about NOTHING! That doesn't happen in these situations. If the pH is severely low, the diagnosis is acute respiratory failure. It is caused by forces/factors other than induction by oxygen treatment. And, while severely restricting oxygen administration so as to keep oxygen levels forcefully reduced in an effort to stimulate breathing IS one clinical option, it is far from being the treatment of choice or any manner of an imperative, as proponents would argue. When that strategy is employed just as many sink or swim as do those who receive plenty of oxygen and subsequently are supported with mechanical ventilation. But, again, that is a point that is so often - deliberately - omitted/.hidden from the conversation in the zeal to push one's biased and theoretically/evidentially unsupportable notions. I hope this provides a bit more understanding of from where these studies arise. But, moreso, I hope that you will NEVER be afraid to raise your oxygen when the need and indicators are there. Lastly, I will advise you to look into yourself and answer the question: "Do I feel better after turning up the oxygen? Or do I feel worse?" If you feel worse and cessation of activity doesn't resolve your difficulties, then it's time to seek the care and advice of your physician. Something might be brewing that has NOTHING to do with the question of how much oxygen you are using. Best wishes, Mark
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Posted August 20th, 2011 Prednisone Tapering Problems
Good Afternoon Mark
Hi Mitch, My thoughts are that Fred may be experiencing the infamous "prednisone let-down', or rebounding of his symptoms as he tries to come off the prednisone. That he has been using it 2.5 weeks per month tells me that he does indeed stop it altogether for short periods - an action that can amplify the rebound effect. I don't remember if Fred is using an inhaled corticosteroid medication. But, using one may help him slide off the prednisone more easily. He needs to understand that coming off the prednisone will likely entail some return of symptoms that he will need to consider 'overcoming' through perseverance through the post-prednisone period. He might try a longer more gentle tape of the prednisone. rather than stopping it altogether for those short periods, he could consider dropping it 5 mg at a time on a weekly basis until he reaches 15 mg after which he would cut his dose by 2.5 mg per week until he is completely off the medication. At the same time, if he is not using an inhaled steroid, that would be something to ask his doctors for. It might turn out to be that he will require prednisone for long term use in which case, finding the lowest tolerable dose will be of advantage. See if his doctors will agree with a slow taper as I have described to see if he can truly come off it or if he can at least get down to where a maintenance dose of 2.5 to 5 mg might give him a balance of enough benefit to be comfortable and as highly functional as possible, yet not on significant doses of prednisone. It is apparent that for him to try to do without it as he has been trying to do is not working for him. I would also consider going ahead and trying to write to his Respirologist in Toronto, anyway, if for no more than to run my suggestions by him and get some affirmation. If he answers, you're good. If not, you tried. But, in any case, I would give it a try. Best regards, Mark How Much is Too Much When Exercising Hi Mark,
A. Hi Philip, Congrats on the weight loss! I would recommend pushing yourself as much as you can. Your body.lungs will let you know if you re pushing too hard. Age is not a necessary dictator of how hard one can push themselves,physically. So don't set age as a limiting variable for your effort. As far as the heel pain, I would suggest seeing a podiatrist as it can be from any number of causes which I cannot suggest from where I sit. Keep up the good effort! Best Regards, Mark Corticosteroid Inhaler or Presnisone (Steroid) Hello Mark, Back in May of this year you provided me with your expert comments and answers based on the various reports I sent to you. You stated that I did not have COPD but Asthma. Indeed this was good news! A few months have gone by and I can say that I have not used any Puffers whatsoever. Question #1. Should I be using Puffers and if so, which kind would you suggest? Overall, I would consider my breathing as fair. My doctor put me on Prednisone approximately 5 weeks ago. The first few days, I felt some improvement. I was using one dose of 50 mg per day. Since then and as a Bonus, the Psoriasis that I have had for 11 years is now gone from my upper torso. Psoriasis still exists on my legs and only show a slight improvement. I don't believe my breathing has improved. I do understand the pros and cons of Prednisone. I have now reduced this drug to a weaker strength of 25 mg per day. My doctor tells me that as a big man, (260 pounds)( 6' 5") it won't hurt for me to continue with the Prednisone. I am overweight by 20 pounds. In addition to the Prednisone, I am taking Vitamin A & D3 as well as Calcium, 600 mg. I am told that Calcium is a must when using Prednisone. As a matter of interest, I still have been unable to establish why I'm still having excessive trouble breathing when showering. Mark, you did address this problem before as a mystery and one that you did not have an answer for; Question #2. Do you detect anything here that could pose problems with my ability to improve breathing? As above, I would repeat the question, Should I be using a Puffer and if so, which kind would you suggest? Mark, what kind of doctor would you suggest would be able to diagnose the shower problems. Thank you very much Mark for tending once again to my problems. Best Regards,Roger A. Hi Roger, If you continue to require prednisone to maintain some level of stability, it would seam reasonable that you should be using at least a corticosteroid inhaler to try to replace the prednisone, over time. At the same time, a long-acting beta-agonist inhaler would also be reasonable to consider. If you have a significant improvement in airflow (as indicated by a large increase in FEV-1 on before and after testing with a short-acting beta-agonist), then a long-acting beta agonist would be in order. Asthma is a disease that is most effectively kept at bay with effective control through the use of "maintenance medications" like inhaled corticosteroids and beta agonists. If you can find a drug regimen and effective pattern of use, you might also find that your shortness of breath during showering might improve, as well. It is likely that you have enough airway reactivity and inflammation that the water vapor that increases in the shower and increases the amount of moisture you inhale during showering is a primary cause of your difficulty. Maintaining the best airway tone with proper medication use is the first step in reducing your response to the moisture in the shower. At this point, with you not using any inhalers, you have a big piece of the puzzle missing. Talk to your doctor about a change in your regimen and medications and see if he/she doesn't agree that a trial of treatment similar to what I have suggested would be worth trying. Best Regards,Mark
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Posted August 12th, 2011 CO2 Retention & Bi-Pap
I am in stage 4
emphysema. I am a co2 retainer. I wear a bipap at night to blow off the co2
.Is it ok to use a pillow nose piece with this machine? I am
claustrophobic. I really need your ok on this because my daughter and I
don't agree on using it. At least I will wear it willingly. Thanks A. Hi Nedra, I'm happy to be able to reassure you and your daughter that you can receive the same benefit from use of nasal pillows as you can from other appliances like full face mask, nasal mask or nasal CPAP cannula. Indeed, for claustrophobic folks and for simply better comfort, the "Nasal Aire" CPAP cannula works even better then the pillows, as with the pillows, you still have a head gear and bulky apparatus holding the tubing and pillows in place. With the Nasal Aire CPAP cannula, there is no bulky head gear AND the cannula fits nicely in place even allowing more ability to sleep 'other than' on your back. Check out this website. I don't endorse the proprietor of the site as where to purchase one. I include it only because they have a great picture of it in use. http://www.cpapxchange.com/cpap-masks-bipap-masks/nasalaire-ii-cannula-cpap-mask-bipap.html . From a personal point of view I can tell you that my daughter, who require the use of ventilatory support during sleep before each of her double lung transplants used all the available appliances, settling on the Nasal Aire as her appliance of choice. So, for her, it worked best among the choices ALL of which produced equal benefit in terms of delivering the pressure. But, if you have the pillows and like them better than the nasal mask or full face mask, then you should use what feels/works best for you. All that said, while there has been a lot of enthusiasm for the use of CPAP/Bi-level pressure therapy for "blowing off CO2" for those who retain it, the evidence is sketchy at best and - IMO - very 'underwhelming'! CO2 -retention becomes a compensated metabolic process that "normalizes" the body and its tolerance to chronically elevated CO2 such that it need NOT try to adjust CO2 downward. While anecdotal evidence from the studies done to date "suggests" that some folks "feel better and have more energy when incorporating positive pressure ventilatory support to their sleep periods, the consequential evidence -what does it ACTUALLY and MEANINGFULLY do to CO2 levels and pH - is just NOT there. We know well from decades of data and observation that "during" the time positive pressure is used to assist ventilation, CO2 can be 'acutely' driven down. But, when you remove the positive pressure support - as you do every morning when you arise and hang up the tubing and mask/pillows - your CO2 rapidly returns to its compensated level. The pushing of the use of night-time ventilatory support in an effort to alter/reduce compensated CO2 reminds me of the Russian efforts back in the mid-20th century to produce wheat that would grow in the harsh winter climate of Siberia and similar regions. Scientists placed generation after generation of wheat seeds in the freezer predicting to be able to acclimatize them to germinate under winter conditions. Needless to say, results were completely disappointing when none of those efforts produced seeds subsequently hardy enough to conform to the Russian scientists 'imposed' theory. There is another analogy of Russian scientific efforts that is similar and entails the same resultant failure (recall the experiments wherein they tried to produce rats/mice with no tails, forcing the Chang by cutting off the tails of offspring and measuring successive generations for shrinking tail size in response to the removed tails). I offer the preceding explanation NOT to discourage you from continuing to use the positive pressure therapy while you sleep. But, given that regardless of choice of appliance you make, as long as the modality is correctly used, you WILL achieve predictable benefit "only while wearing it" and may NOT achieve any permanent change in your CO2 level or benefit in how you feel or your energy level as a result of using the modality. So, if you do not achieve significant changes, understand that it is not because of you or anything you did, as long as all was done correctly. Rather, it will be because the theory of what it should do and how it should do it is extremely flawed and a set-up for failure, with regard to achieving the intended, even declared benefits. BUT, while we have much reason to doubt its ability to help, we have no evidence - theoretical or measured that it will cause any harm or negative result. Best Wishes,Mark |
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Posted August 7th, 2011 Oxygen Saturation Levels While Swimming
Hi Mark A. Hi Shelley,
While studies show folks tend to desaturate much
more modestly during water activities, thanks to buoyancy and reduced oxygen
consumption, owing to the water medium, one cannot predict what your
saturation might be while you are swimming. You didn't say if you're swimming in a lake or a pool. But, if in a pool, try placing a towel and your oximeter at the edge of the pool. Swim a couple laps - or what ever interval you go between rest periods and stop by the oximeter. Quickly dry your finger off and place the oximeter on it and see what it measures. You can measure your oxygen with your finger still a bit damp. So just remove the excess water and get the device in place as soon as possible. Provided not more than 30 seconds has elapsed since you stopped swimming to measure your saturation, you can figure that the measurement represents at least 90 % of your "decrease" experienced during swimming FOR THAT TIME INTERVAL. See how that works for estimating what's happening to your saturation while you swim. If you have further questions or difficulties, write back to the forum and I'll try to help with further suggestions. Best Regards, Mark Low FEV 1- Seeking Ideas/Suggestion on How To Manage/Cope Better Hi Mark; Thank you for joining us; you are very much needed here it will be wonderful having you with us. Question: I am copd stage 4 since diagnosis on first pumonary visit in 2005. I have been on advair and spriva since then and also albuterol as needed Of course I have lost some function since then; been real sick a couple times. Last time my pft was 13 for first one and 20 for the next one. 20 took longer and was given albuterol. Ok I want to know what I can add to make me breathe a little better. Can I add a steroid inhaler? I have recently started taking 5mg pred by mouth 1 time a day but ir doesn't help that much. I have actually gotten on hospice but I am very active. I still take care of my housework and shopping and take care of my animals but it is very hard sometime and I am thinking there got to be something else I can do . My hospice nurse will write a prescription for whatever I need but I don't know what I need so maybe you can help.. Thank you for your time. I look forward to hearing from you and again welcome!! Georgia A. Hi Georgia, Thanks for the welcome - though I've been here for perhaps more than a year. But, I'm glad to be able to help where I can with questions and problems COPD-Canada members (and others) have. Unfortunately, when one's FEV-1 drops down into the teens or low 20's, as has yours, there's nothing significant that you can do to push it back up to any appreciable degree, short of lung volume reduction surgery or transplant, for those who are good candidates. You are kind of 'stuck' with what you have to work with. So, your work to breathe will always be increased, though not necessarily unmanageable or unbearable. What folks who are successful at remaining functional and mobile do under your circumstances and conditions is to work to "desensitize" themselves to the difficulties associated with working hard to breathe. The ONLY way to do that is to get up and move, use pursed lips breathing and keep coaching yourself to accept the "FACT" that while, at times it 'may' feel like it's harmful to you or might 'do you in' at any moment, IT WON'T! That's the single most difficult thing to do (IMO), but certainly possible. Ultimately, the more you move and "push through" breathing difficulties, the better your physical condition will become and the less oxygen you'll require, per unit of physical work and the less carbon dioxide you'll produce which, in turn, reduces load on your lungs to breathe and therefore your overall work and discomfort. This is easier said than done, needless to say. But, you MUST master it if you are to see appreciable improvement and to continue survive with reasonable ability to enjoy life. I can't comment on your being in hospice, as that is 'usually' entered for the purpose of keeping comfortable during the 'predictably short life expectancy' that remains. But, you sound like you're actually far from that point. So, hopefully, while the services of hospice may be helpful for the time being, you will improve sufficiently such that you'll need to be discharged from hospice care because you are doing too well to need it. As to the question of adding steroids to your medication regimen, you can certainly try adding an 'additional inhaled steroid, maybe 2 times a day to your Advair and Spiriva. You already have a steroid in your Advair, so what I'm talking about would be in addition to that - IF - your doctor thinks it would be helpful and not contraindicated, for any reason. I would suggest you consider trying a course of using an additional inhaled steroid instead of the oral prednisone, if it works adequately. That way, you will reduce your chances of side effects of steroids which tend to be greater with oral (total body) dosing than with topical treatment, such as inhaling the medication. So, if you decide to try more inhaled steroid, try also to discontinue the oral prednisone. If in doing so you find that you feel worse after a couple of weeks, you may need to resume the prednisone. Remember that initially, you might feel the 'steroid let-down' which often causes folks to jump back on the steroids, thinking they are getting sick or heading for an exacerbation. So, you have to give yourself a couple of weeks to get past the initial 'slump' in how you feel. Another point to consider and ask about is the pattern and dose at which you take prednisone. For perhaps most folks, an initial course of higher dose prednisone for a few days, tapering off to the lower dose - and even off it completely, as time passes - works more effectively than simpl starting to take a low dose without a 'loading' regimen. To do that, you would start with 30 or 40 mg and decrease the dose by 5 or 10 mg every two or three days. Dose packs for this pattern also come with one to three days of loading dose, say, 40 mg, then a daily taper until the pack is gone, which may cover five days or more. So, a change in your oral steroid pattern would likley impart greater effectiveness/symptom improvement, if you were to change to that pattern. At present, you could increase your daily dose to, say, 30 mg for 3 to 5 days and then reduce to 20 mg for another 3 days, then to 10 mg for another 3 days and then to 5mg for 3 to 5 days and then stop it altogether and see how you do. If you also add an 'additional' inhaled steroid for between the steroid doses provided by your Advair, you should at that when you reach 10 mg, so that you have gradually bridged the transition off the prednisone. The choice of steroid to use could be more of the Fluticasone that is in the Adviar, or a different one, like Pulmicort, which is Budesonide, another steroid version. Best wishes, Mark |
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Posted July 31st, 2011 High Altitude Simulation Test (HAST) What is a 17% oxygen test? And how is it performed? Lil A. Hi Lil', What you refer to is called the HAST test - High Altitude Simulation Test - used to estimate the potential for one to desaturate while at altitude, as in air flight at normal cabin pressures of 8000 feet (2.44 Km), average and if visiting locations that are at elevations greater than a mile (1.61 Km).
A mixture of gas that has been 'reduced' to 17 % oxygen content from the 21 % oxygen content of normal atmospheric air, at sea level, is breathed by the subject for several minutes. During that time, oximetry may be used to monitor changes in the subject's oxygen saturation. An arterial sample of blood may be obtained for measurement of blood gases to more definitively determine the effect of breathing the low oxygen containing gas mixture after several minutes of breathing it either in addition to the saturation measurements or instead of oximetry measurements alone.
If the subject can maintain an acceptable oxygen saturation - usually equal to or above 88 %, then they are deemed adequately oxygenating to be able to travel to altitude without need to use supplemental oxygen.
17 % is selected as the likeliest lowest 'equivalent' concentration of oxygen the subject might be exposed to if they travel to no greater than 10,000 feet (or a little over 3 Km) elevation. While we understand that the atmosphere is comprised of 21 % oxygen at ALL elevations, the partial pressure of oxygen at the altitudes simulated by the 17 % concentration is very close to equivalent at sea level or modest elevation, where the test is performed.
If the subject cannot sustain an adequate/safe oxygen saturation under HAST conditions, most doctors will then recommend and prescribe oxygen for in-flight use and for use during the high-altitude travel period. Or, as happens all too often, the doctor will simply forbid the subject to be able to travel under those conditions, or will divest responsibility for consequences if the subject decides to travel against the doctor's recommendations/instructions.
Best Regards, Mark
Sequence of Medicines (Inhalers) Chart Explanation
Hi Mark!
A. Hi Sue, If there were such references, I would gladly share them with you. But, alas, there are none, as that table was developed as the product of several years of observations, collecting evidence and data from hundreds of patients and significant investigation into the theory and practices which continue to be the mainstream because of common practice, misunderstanding and lack evidence for what has become the "standard". The best I can do is to give you the history and explanation of how the chart came about and more importantly, the theory and basis upon which it was devised. Click here for a detailed explanation...... Webmistress Note: We hope to include a Canadian Meds version of Mr. Magus's sequence chart here on our site soon. |
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Posted
July 24th, 2011 COPD Action Plan-Does Not Include Fever Symptom I recall reading that it’s suspected that 50% of COPD exacerbations is caused by bacteria. I would think that might mean (at least sometimes) that a person might run a fever. BUT, on the COPD action plans for both the United States and the one from Canada, a fever is not included in the yellow/caution zones (symptoms area). Any idea why it’s not included? Thanks, Dell A. Hi Dell, While some sources suspect and even estimate based upon some measure of data that exacerbations are caused by 'bacterial infections', the use of the term 'bacteria' is broad and encompasses viruses as one of those 'bacterial' sources. Some of the culpable viruses do not produce fever as a symptoms, at least not initially and in many cases, even as infection advances to pneumonias. Some bacteria that often produce fever in those who don't have COPD will fail to manifest the symptom in those who DO have COPD, again, at least not as an early warning sign. Strange as it may seem, fever is NOT an obligatory symptom of infection - for those with COPD OR for even other ailments. And, in COPD, when it becomes a feature it may be well into the manifestation of an episode/exacerbation. Folks who are taking immunosuppressives, like prednisone, whose ability to develop fever is blunted, would not manifest fever on a predictable basis. Ultimately, fever is simply not a prominent feature of much of the infection seen in COPD. That's the main reason why it is not one of the listed warning signs, as you note. Best regards, Mark What Medicines Are Available for COPD?
Hi Mark,
Thank - you A. Hi Dorothy, Your question is very difficult to answer without knowing a whole lot more about the 'details' of your mothers illness and most importantly her level of severity at this time. Generally speaking, COPD symptoms are what's treated with the various medications available. Those medications include a group called bronchodilators - medicines that relax the bronchial tubes to improve the ease with which air moves through them. There are two classes of inhaled bronchodilators from which 'usually' one of each class is prescribed. Another class of medications often used is inhaled corticosteroids - medications that reduce and inhibit inflammation and swelling of the tissues that make up the bronchial tubes. Reducing that swelling also 'opens' up the bronchial tubes and helps ease movement of air into and out from the lungs (using less energy to breathe). Inhaled steroids also reduce irritation that causes increased mucus production which further makes breathing difficult as well as serving to foster the development of infections that can lead to pneumonias. Corticosteroids are also administered as a medication taken by mouth, in pill form, when it is deemed necessary and appropriate, at times. When COPD becomes well advanced, the use of oxygen becomes increasingly necessary as more and more lung tissue and function is lost and one's ability to get enough oxygen into their blood from what is contained in the atmosphere becomes insufficient as a result of their impairment. So, oxygen becomes a 'medication' that plays an important role in treatment of COPD in later stages. There are other medications that have been introduced more recently that can address specific features of the disease for some individuals. Leukotriene and phosphodiesterase inhibitor medications have more recently been introduced to treat patients in whom their use is found to be advantageous and appropriate. The COPD-Canada website has a list of medications commonly used in COPD, if you wish to learn more about specific drugs and what they do. Go to the website and look for " a guide for Canadians' which contains the following link to that list. http://copdcanada.ca/Know_Your_COPD_Meds.htm Beyond this information, I cannot be specific to tell you what your mother should ask her doctor about as I don't know which medications she now takes or has taken to this point. Her doctor likely will know best if there are medications available of which he/she has not given trial. Best wishes, Mark |
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Posted
July 17th, 2011 Concern re: COPD, Coughing & Catching the Patient's Germs
I work with
an annoying woman who says she has COPD and she coughs like crazy and she
does not cover her mouth. She is rude and obnoxious. Is this a danger to
my health being in the same room as her because of the COPD and the
coughing? A. Hi Robyn, That is a tough one to answer. If the 'room' is of sufficient size, any danger is commensurate with the air volume and exchange ratio of the room. If she is coughing toward you, the less the distance between you the more you will be exposed to any germs in her expelled air and 'fomites' (particles expelled during her cough). If she is actively infected, the danger increases commensurately with the two above factors. The presence of cough in COPD (likely mainly Chronic Bronchitis, if cough is a prevalent and frequent feature) in and of itself is not the primary risk/problem. It is when there is active infection that risk increases to those exposed to such a situation. And the mere presence of her persistent cough is not necessarily and indication that she has an active infection Thereafter, as with anyone - COPD sufferer or not - your own susceptibility to bacteria spread with a cough plays the key role in your susceptibility to contracted ailments. COPD is not a 'contagious' disease. So, there is no danger of you 'coming down' with it as a result of exposure to the consequences of her cough. If you are a smoker or have other predisposition to developing COPD, yourself, then that would become a risk factor for you, specifically. Generally speaking, the bacteria usually found in the airways of those with COPD will not necessarily be those for which you have the same degree of susceptibility, as folks with COPD tend to have poorer immunity to 'opportunistic' bacteria and infections (that is, bacteria which do not normally produce infection in healthy individuals). Are you able to diplomatically make her aware of her unprotected coughing and to let her know how annoying it is to you that, while you realize she can't help coughing so much, she CAN help the situation by covering her mouth and being diligent to keep her hands clean, so she doesn't spread her germs about when she handles things that others must touch. Try keeping a bottle of hand sanitizing gel in plain sight and offer it to her, while using it yourself as often as you feel advantageous. Perhaps she'll get the message and begin using her own source of hand gel to help ease your concerns and those of others. Best Wishes, Mark
Chronic Bronchitis & The Lungs
Mark,
Jim A. Hi Jim, Chronic Bronchitis and Emphysema are the two 'biggies' under the COPD umbrella. For smokers, chronic bronchitis tends to be the predominant COPD component, though for the majority of those with COPD, it is rarely a stand-alone affliction and is in observed in combination with emphysema, as you correctly understand, which develops later as the result of loss of airways to 'remodeling' and destruction from inflammation and infection. Airway remodeling in chronic bronchitis is a process wherein normal tissue components of the airways are damaged or destroyed, being replaced by scar tissue and other abnormal cell types. Airways have underlying structural cells upon/to which the (predominant) surface cells are connected - cells like the primary 'ciliated columnar epithelium' (CCE) - cells that bear the cilia that move the mucus blanket as they beat rhythmically, 'sweeping' secretions toward the larger airways for expulsion (coughing, etc). Interspersed at intervals are ducts connected to 'mucin' and 'goblet' cells that produce the components of mucus that blend to create the end/resulting substance that is in liquid form coating the airway surface and the cilia and transitions to the gel form as it is exposed to the air passing through the airways which removes water from the mucus. What we cough up is the transitioned liquid form that has become the gel form and is abundant enough to reach the larger airways, rather than being absorbed back into the bronchial tissue (as is most mucus produced, under 'normal' - non-diseased- conditions). In the normal lung model, CCE are observed to be very uniform in size and placement relative to each other along the inside surface of the bronchial tubes. Number of cilia and their beating action is very uniform, as well. To see them in action is actually quite an impressive 'dance' with perfect rhythm and sequence. That action is the result of the uniformity of size, placement and proper function of the CCE. Ciliated cells tend to become abnormal in size and number, with loss of and derangement in size and number of cilia. As a result, if one observes the beating action in the airways of those with chronic bronchitis, they would see 'dysrhythm' resulting from loss of uniformity in size, number and placement of cilia, as well as loss of the uniformity and number of CCE due to abnormal growth and invasion of inflammatory and scar tissues among the remaining CCE. One would also observe increased Numbers of mucin and goblet cells which as well, would be variable in size and placement. Instead of fairly uniform sized cells, some would be normal and some would be increased in size, even to a degree that they are described as 'giant goblet cells', because they are so relatively large. It is the proliferation of mucin and goblet cells (in response to inflammation and need to increase mucus production in the effort to more effectively flush the airways of debris and irritating substances) that is responsible for the increase in production of mucus that we see in Chronic Bronchitis. Combine that proliferation and the increased 'amount' of mucus with the physical and functional derangement of CCE and you have the process that presents the conditions for the pathological variants we contend with in those with Chronic Bronchitis - infection, pneumonias and increasing difficulties in adequately clearing mucus from the airways. Increased mucus production and the decreased efficiency of clearance set up the scenario for increased bacterial growth (mucus is made up of sugars, proteins and water and is in a nice warm and wet environment - very inviting to bacteria and their proliferation) which has its additional influences to perpetuate the difficulties and changes seen within the airways. Bacteria release irritants/toxins that invoke inflammation and invasion by immune cell types that engage in war with the bacteria to kill them and thwart the inflammation. Dead cells release yet other irritants and add solid debris to the mucus, further contributing to changes in its volume and character and so on. As irritation destroys normal CCE and underlying structural cells of the airway, fibrotic/scar tissue replaces more and more of the previously normal cells further contributing to 'airway remodeling'. And so, you can see how the process is cyclical and self-perpetuating. There are yet additional changes in inflammatory substances that contribute yet more to the process and so it goes on and on. Variants in the process result in some folks who experience production of large volumes of mucus and some who don't produce so much extra mucus, but in whom if tissue samples are obtained, the abnormal (metaplastic) changes in cell types and numbers can be seen. so, just because one doesn't have abundant.over-production of mucus, does not necessarily mean they don't have Chronic Bronchitis. Treatment, then, is directed at reducing/eliminating irritants (smoking cessation, for one), attention to clearance of mucus to reduce 'stasis' (settling and retention) of mucus and invitation to bacterial growth and infection and treatment with agents to reduce the inflammatory process, as well as to enhance increased diameter of the airways to aid in more normal flow of air through them. Active bronchodilation with the familiar inhaled medications and use of steroids - both inhaled and taken orally, etc. - to reduce inflammation/swelling of the tissues is another tactic employed. That, in a nutshell (though, maybe a large nutshell) is the Chronic Bronchitis in simplified terms. It really is a complicated and multifaceted process - which is why it's so difficult to sort out and create interventions to counter the process. That is also why it take so many different kinds of medications to attack the process and why one or two alone, cannot do much to affect the whole process. And there are still several major components of the process for which we have yet to discover and develop effective interventions. What research continues to provide is yet greater and more detailed information/knowledge of the 'cascade' process that causes and perpetuates Chronic Bronchitis. As time passes, we gain greater understanding of what is going on and what leads to potential points on which to concentrate future treatment efforts. But, it's like lifting a rock and continually uncovering new secrets hiding beneath that rock - - - and the next one under it and the next one and the next one, etc. Best regards, Mark
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Posted
July 10th, 2011 Hydrogen Peroxide Treatments
I suffer from very
severe Emphysema and I have been reading several articles recently on
Hydrogen Peroxide treatments, what are your views A. Hi Tony, Stay far, far away from any of the H2O2 (peroxide) interventions. They will do NOTHING good for you and could easily inflict harm. There is not a shred of empiric evidence that H2O2 does anything beneficial for lung diseases of any kind. It is the proverbial snake oil. There is plenty of mainstream warning regard H2O2 therapies. So, dig deeper and look for the words of warning. As well, consider that if H2O2 truly held any potential benefit, it would be a mainstream treatment and legitimate health care professionals/doctors would be using it commonly. Best Wishes, Mark COPD Caregiver
Dear Mark, A. Hi Sandra, I'm sorry to learn of your predicament. But, you also did not tell me anything about how serious your hubby's disease is at the moment or where in Canada you reside, to know what resources might be readily available. At any rate, COPD is, as you are probably learning, a progressive disease that advances - in most instances - slowly and over a period of several years. Folks can have quite severe changes and loss of lung function and still live lives of good quality with significant and adequate continued physical function. But, exercise, good nutrition, adequate information and education on the disease and a good attitude are a must. One must get past the psychological 'punch' of learning they have the disease and learn how to contend with the symptoms and to overcome the limitations imposed as the disease progresses. We say that COPD is the disease where "move it or lose it" is the key to survival and continuing to thrive in the face of the adversities that arise. Folks with even severe disease and the accompanying breathing symptoms can regain much health and function IF they do the right things and do enough of them. If you have a pulmonary rehabilitation program nearby, that would be an excellent start for your hubby to learn more about the disease and what he (and you) CAN do to contend with it. As well pulmonary rehab programs include a component of exercise that is guided and monitored to maintain safety and to help participants learn to exercise and control shortness of breath. One point I would make is that while severe windedness may be a part of moving around, especially of ambulation AND it may "seem" like it is harmful or will cause harm, it WILL NOT, especially if one learns some breathing control tricks and techniques to help them manage to keep moving and contend with the windedness that accompanies exertion. Proper medications and oxygen therapy, when indicated are a MUST. While they may seem daunting, they are easier than most think to learn, master use of and contend with - especially the use of oxygen which, for MANY folks seems the worst of all prospects to require for continued and productive living. Oxygen use, rather than seeming to portray the worst in the future, is TODAY, the key to living well with COPD when it has reached a severe enough stage. It is like insulin to diabetics. It most certainly is NOT the death nell it has been considered to symbolize in decades past. I cannot stress too greatly the importance of getting him on a proper regimen of medications. They go a long way to helping relieve many of the causes of breathing difficulties AND provide a means to be able to continue to move and function. Oxygen is a MUST if hypoxia (low oxygen levels, especially during exertion and/or sleep) is detected. If your hubby has not been tested for hypoxia during exertion or sleep AND has the onset of shortness of breath during exertion, then he should be tested as soon as possible. Uncorrected hypoxia will not only impede one's ability to get up, move and keep moving, as well as function with advanced COPD, to accomplish even the easier tasks of daily living, but it will cause damage to the heart and lead to more rapid advancement of symptoms and more importantly, much" preventable" misery, not to forget earlier demise. As for support, I have a couple of suggestions to get you started. COPD Canada has a 'Caregivers forum' message board whereat you can communicate with others who are helping their loved ones live with the effects of COPD. You may find that at the following link: COPD Helpmates & Breathing Buddies http://copdhelpmates.proboards.com/ Also, Jackie Whitaker, our COPD Canada Patient Network President has offered to help you find more local resources for help near your home if you will contact her at the following link: Jackie@copdcanada.ca. If you have more specific questions that I might be able to answer for you, feel free to post them to the list and Jackie will see to it that I get them. Best Wishes, Mark |
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Posted July 3rd, 2011 Q. Accuracy of Finger Pulse Oximeter Readings & Exertion
Perhaps this has been addressed but I can't find the answer :) Now
that summer is here and am working in my big yard (425 ft deep on a slight
hill), I find when I walk uphill and come in for a break every 45 min or so,
my SpO2 can be anywhere from 88-91 with a heart rate in the 140-150 range.
I do practice PLB while working, especially if I have been dong a lot of
bending over. Within 60 seconds both numbers start to improve to SaO2
96 and heart rate 120-130. I think you have said that you need to let
the oximeter settle down for 40 seconds or so. Am I right that this
transient reading is of no significance? My last PFT FEV1 pre/post was
48/52 and DLCO remains at 30. Thanks for explaining this again A. Hi Doris, The 40 second stabilization suggestion is a 'general' rule, especially when one sees fluctuation that is significant after initially placing the oximeter at start-up. If no significant fluctuation is observed - saturation and heart rate remain reasonably stable, even with the "gradual" increase in SaO2 measurement and decrease in heart rate, then - looking over your shoulder, you can assume that the initial readings were fairly accurate. What you relate sounds like in your case, the measurements come in accurately almost immediately. So, the 88 - 91 % and 140-150 heart rate are likely the actual case. One trick you can do is to count your pulse as you head for the house and see if your heart rate counts near the same range as you observe when you place the oximeter. If that is the case, you have more information to indicate that your measurements are reasonably accurate from the outstart of placing the oximeter. Another point to consider is that if you are relaxed and still when you take those measurements, then they are more likely to come in accurately sooner than if you were moving around. All in all, it's great that you're working to get your heart rate up and receiving the benefit of the conditioning that working in your yard imparts. At 88 - 91 % as lows, you should not be hurting yourself, as long as you can continue to contend with the added breathing discomfort and still exert. The benefit outweighs the risk, in your case. Keep up the good work! Best Wishes, Mark Q. Serratiopeptidase (as an Anti-Inflammatory)
Have you heard about
Serratiopeptidase
and can it
help to clear the lungs. I have a friend that takes it for back pain and he
thought it might help. Of course I would not try it without consulting my Dr
and pharmacist A. Hi Roly; Serratiopeptidase (Serratia E-15 protease) is a proteolytic enzyme that has been touted for over 40 years as having anti-inflammatory, anti-edemic and fibrinolytic properties that in effect change the viscocity of mucus from the 'nose to the toes', so to speak. There are some pretty wild claims on various easily accessed websites. Wikipedia has a petty good write up on it, conveying skepticism of it's benefit, with one manufacturer of a preparation deciding to pull it from the market for lack of evidence of its claimed benefits. Some claims of benefit that clears out bad tissue allowing the body to 'replace' it with functioning tissue, thereby improving pulmonary function are likely without merit as no drug or substance has been demonstrated to actually accomplish that process in that manner, to date. While it appears to have undetectable negative action and consequences, it lacks proof of effectiveness beyond what have been called poorly controlled trials, anecdotal evidence ('testimonials') and lack of randomized, placebo-controlled trials, in reviews of the literature as recent as 2002. If you think you would like to give it a trial, I would definitely recommend you discuss your plans with your doctor, as you say you would do. If between you two, you decide to try it, that would be up to you and your doctor. There are other better studied approaches to reducing inflammation that accompanies COPD, with NAC continuing to hold a place as a better studied substance with more likely anti-inflammatory benefit. My chief concern about serratiopeptidase is its fibrinolytic effect which causes blood thinning and reduced ability to clot. While none of the easily accessed information suggests bleeding problems as a common or frequent side effect AND state it has been used expressly for that feature, it is a point of concern that should be addressed and monitored by your physician, should you decide to use it, especially if you take other blood-thinning medications or NSAIDS/Aspirin. Best Wishes, Mark Q. Oxygen Therapy - Venturi Mask- Hypoxia & Hypoxic Drive
A doctor asks me to start the oxygen therapy
through venture mask to a patient who is a known case of COPD (Chronic
Obstructive Pulmonary Disease). How do I think the venture mask will help my
patient? A. Hi Rifa, I wish you had revealed in what capacity you function such that you 'treat patients'. But, assuming that you are a medical professional of some sort, the answer to your question is not affected by your 'mystery status'. The "Ventimask", also called the "venturi" mask (which is actually a misnomer, as it is actually a "jet-mixing" device, rather than operating upon the "venturi principle" from which it got its original name) is thought to 'protect' those with advanced COPD AND who have documented CO2-retention, from receiving too much oxygen which, according to long-standing claims that are to this day without convincing evidence and merit and which hold that administration of too much oxygen supposedly would suppress the patient's 'drive to breathe', assuming they are driven to breathe by 'back-up' mechanisms related to 'chronic hypoxia' (the so-called "hypoxic drive"). While the hypoxic drive is a very real and demonstrable mechanism, significant drive to breathe in the face of hypoxia does not occur until and unless the blood oxygen level (paO2) drops to and below 45 mmHg, a level that is arguably undesirably low. As well, part of the theory of the mechanisms of drive to breathe in those with severe/advanced COPD WITH CO2-retention holds that because the CO2 is chronically elevated, the body's (brain's, to be exact) 'normal' mechanisms of control of breathing - namely CO2 changes in the blood, from breath to breath which supposedly stimulate the respiratory centers to send a signal to the diaphragm to breathe (take in a breath/to 'ventilate') are somehow 'dulled' or 'incapacitated' such that CO2 no longer becomes the primary stimulus to breathe. Instead, the presence of elevated levels of CO2 causes the brain to "switch" to the hypoxic drive as the primary stimulus to breathe. Incidentally, not one shred of empiric evidence has been forthcoming to prove that the CO2-drive mechanism stimulating one to breathe has indeed ever changed - even in those ho significantly retain CO2. While the theory has been accepted as mainstream wisdom, evidence to prove it valid and applicable is virtually non-existent AND very much anecdotal, even though almost 50 years of its prevalence has been withstanding and a LOT of studies have been done along the way. The problem is that CO2 as a stimulus to breathe does not take a 'backseat', as it were, to the hypoxic drive. Indeed, proponents of the theory proclaim that oxygen levels of 50 to 55 mmHg are 'necessary' and 'safe' to sustain those with significant CO2-retention in order to keep them safe from losing their drive to breathe in response to having their blood oxygen levels pushed too high. Yet, as I stated earlier, the actual hypoxic drive doesn't contribute significantly to drive to breathe until the paO2 drops to and below 45 mmHg, where it becomes stronger as the paO2 drops further. And, all argue that sustained blood oxygen levels of less than 50 mmHg produce very predictable and demonstrable organ damage - primarily secondary pulmonary hypertension (from hypoxic pulmonary vasoconstriction) and chronic right-sided heart failure. Those who hold to the veracity of this theory claim to 'avoid' "knocking out the patient's 'drive to breathe', the result of pushing their oxygen levels up too high to allow functioning of the hypoxic drive, by administering 'just enough' oxygen to raise blood oxygen levels to an 'organically safe' (paO2's of 50 - 55 mmHg, depending upon the conditions and the patient) level while not giving too much, which could cause the patient to breathe ineffectively or, by some claims, stop breathing, altogether. Lastly, to proclaim that the body goes through what amounts to very contradictory changes away from normal physiology to accommodate chronically elevated CO2 levels - and does so with selective and inconsistent occurrence - imposes a set of conditions that are further very unpredictable, unprovable and contradictory. Several studies using very good methodology have failed to induce apnea (cessation of breathing) or consequential and sustained hypoventilation in those with significant chronic CO2-retention, who are in acute respiratory failure and have been administered enough oxygen to raise their paO2 to above 60 mmHg and their oxygen saturations to 94% and higher. Indeed, when numerous studies are reviewed - in which both withholding of oxygen that would normalize paO2/SaO2 (to > 60 mmHg/94 % or greater) AND administering enough oxygen to normalize paO2, the same results - that is, those who go on to complete their episode of respiratory failure and subsequently require ventilatory augmentation/support - are observed in BOTH groups with comparable frequency. Some sink and some swim and an equal amount do both in each treatment approach. So, no difference according to intervention is observed. This remains the strongest continuing evidence arguing against the veracity of the theory that giving too much oxygen to this group of patients - when in crisis, especially - is broadly applicable and at play across the population. But, still, the theory persists along with its widespread practices. I have said all this to lay out the rationale behind the ordering and use of "low-concentration" oxygen therapy for those with COPD AND chronic CO2-retention. By using a ventimask at 24%, 28%, 31% and 35 % for those who present to the emergency department with COPD and respiratory insufficiency, proponents claim that they will be able to correct harmful hypoxia, while not removing the patient's stimulus to breathe and ultimately allow them the opportunity to pull out of their crisis without need for mechanical support of their ventilatory needs. Most clinicians take the rationale and approach to yet another level, placing EVERY patient with COPD - whether or not they exhibit chronic CO2-retention - on low-concentration oxygen and striving to keep their paO2 below 60 mmHg, claiming that you never know who will be a retainer and/or who will be "one of THOSE" who will decrease their drive to breathe or "stop" breathing if given "too much" oxygen. And yet others take the theory beyond its professed limits claiming that to give ANYONE who has COPD too much oxygen will put them at risk to "begin retaining CO2" - in other words, to "induce" CO2-retention - something that has never been a formal art of the theory OR ever observed in ANY patient! Therein, lies the answer to your question of "how will it help your patient". Those who DO NOT subscribe to the notion that CO2-retaining COPD patients can suffer from administration of too much oxygen hold to the premise that "acute respiratory failure is acute respiratory failure", no matter the underlying diagnosis. Patients treated in EITHER manner will either sink or swim. They will either resolve their respiratory crisis or they will go on to complete their respiratory failure and require ventilatory support. They argue that withholding sufficient oxygen to relieve hypoxia and raise paO2 (and therefore oxygen saturation levels) to near normal or normal (saturation of 94% and above) is more important to resolving the crisis while preserving organ function and avoiding hypoxic pulmonary vasoconstriction and secondary pulmonary hypertension. Neither side has presented sufficient convincing evidence to cause widespread change in theory or approach to treatment, even after these many years of what may be a wrong-headed and counter-beneficial practice. Today's texts and recommendations have shifted towards favoring more complete correction of hypoxia while closely observing the patient for worse respiratory insufficiency. The wisdom is that it is more important to provide adequate oxygen than to worry about hose very few and widely scattered patients who might lose their drive to breathe. The evidence suggests that much more harm has been done through too conservative an approach to oxygen treatment than through a more aggressive effort to normalize oxygen levels. The jury will remain out on the matter until and unless much more quality study is done to resolve arguments for each side. I apologize for the lengthy response to what you may have thought to be a short and easily answered question - AND for the lengthy and technical response which may be more than our readers care to know and even a bit confusing to those without significant respiratory physiology and respiratory professional education/training/experience. I hope this is helpful to you and others who understand what I have explained. Best Regards, Mark
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Posted June 26th, 2011 Order of Meds & Frequency of Ventolin Hi Mark,
I am stage 3 A. Hi Elaine, I would suggest you take your morning Spiriva between 10 and 20 minutes after taking the "Foradil", so that you get the little bit of synergistic effect that taking them close together provides and that is missing when you now take them two hours apart. You certainly may use the Ventolin more than once a day, if needed. Be sure that you don't take any Ventolin within two hours BEFORE you are scheduled to take the Foradil. That way you can maximize the effect and benefit of the Foradil. Understand that Ventolin is not a cure all for ALL SOB. If the Ventolin doesn't work when you use it three times between Foradil doses, then you should call your doctor and seek evaluation. Something acute might be trying to brew. Best Wishes,Mark |
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Posted June 19th, 2011 CO2 Reduction Exercise Hello Mark, I have emphysema and on oxygen for 5 years now all day and at night with a BiPAP. In 2006 I had my last hospital stay, 2 days in the intensive care and 7 days in ward after having an infection and Acidosis. When I was in hospital my CO2 was not lowering and so I was given a plastic bottle two thirds full of water and a piece of oxygen tubing stuck through a hole in the top of the bottle. The pulmonologist told me too blow all I could during the day through the bottle as this would help reduce the high CO2. I did this religiously in hospital and at nights used the BiPAP. I was told to continue with the bottle 15 minutes every hour when I went home. Well five years later I still do this exercise, always in the afternoon when I'm more relaxed watching TV. My FEV1 was 4 years ago 2.8, but now it's 2.4 to 2.2., It seems to be going down quickly. Could this blowing into the bottle now not be beneficial to me. I have not been in hospital since then, and had infections which have been cured at home. The action of blowing through the tube into bottle seems to be the same as pursed lipped breathing, perhaps a bit stronger. Could this action repeated many times every day be destroying the aveloi more. I already have bullus one of which is 10 to 11cm in diameter. I have asked my pulmonologist here (who is not the same doctor who set me this exercise in hospital,) but I get no concrete answer. I would be grateful if you could help me know whether continuing with this is not such a good idea, I've been doing it for 5years. I do not have any mucus problem. Thank you, Joan A. Hi Joan, Wow, you have worked hard to keep in the shape you have managed to maintain. What dedication! First, you told me how your FEV-1 measurement has declined, BUT, not the percentage of predicted it represents. While I'm pretty sure you've lost some ground on the percentage of predicted consideration, I suspect that it is not terribly significant considering that you have significant bullus formation that is likely increasing. You've lost approximately 100 ml of FEV-1-per-year over the four years which is fairly close to what might be expected under relatively normal circumstances (though you did not mention your age to put it into better perspective). 2.2 L for FEV-1 is still pretty good, all things considered, though, again, without knowing your age and height, I don't have anything to compare it with to know what 'normal' would be for you. That you are on oxygen for this long period AND using BiPAP for ventilatory support interjects a bit of mystery, since I suspect that most folks with your FEV-1 would not normally require oxygen at this point in their disease. So, I suspect there is more to your condition than simply emphysema with a bullus disease component. Yet, a bullus of 10 - 11 cm is huge and can account for much in your current condition. So, it may not be such a surprise after all that you require supplemental oxygen. I wonder if you might be a candidate for bullus reduction/removal or wedge resection lung volume reduction surgery, if it is even an option for you where you live and under your health coverage. Have you asked about that possibility? It might be worth investigating as it could improve your FEV-1 and overall ventilation and perfusion matching, ultimately improving your gas exchange, even reducing your need for oxygen, if not eliminating it, altogether. Insofar as your question about the resistance breathing exercises, I seriously doubt that any harm may be occurring, at least not that outweighs the benefit you derive. Between the gentle pressure you are blowing out against, which should be maintaining as much of your lung that can be kept expanded and functioning, the simple act of the vigorous breathing that goes with the exercise has to have contributed to the decent lung function you have been able to maintain. While I doubt the device and the expiratory resistance you exhale against are doing much if anything to alter your CO2, again, the action of the breathing that goes with the exercise certainly lowers your CO2, acutely, for some period off time associated with doing the exercise. So, I wouldn't recommend ceasing it without considerable discussion with your doctor and his agreement that it would be a reasonable course of action. All in all, it seems you are doing the right things to help yourself maintain the best lung function you can with what you have to work with. I would again mention checking into bullus reduction or wedge-resection lung volume reduction surgery, which ever might be appropriate for your particular condition to see if it has potential for improvement for you at some point. It is not a procedure without risk. But, if/when the potential benefit becomes greater than the risk of any complications, you might want to consider having it done. Keep up the good work, in the meantime! Best Wishes, Mark SPO2 Reading of 93, Short of Breath, Potential CO2 Retention
Mark; A. Hi Dan, I would change your "would" to "could" and tend to agree with you. Elevation of CO2 can certainly be responsible for the 93 % saturation you suggest, though, as you stated, only a blood gas can confirm that it is indeed the cause. And, I would say that , "Yes," a blood gas test should be done and likely would be done if one presented to the ER with breathing troubles and a saturation of 93 % while at rest. Best Wishes, Mark |
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Posted June 12th, 2011 Q. Multiple: End Stage COPD, Lung Transplant, Living With One Lung
Dear Mr Magnus, Sincerely Sandy A. Hi Sandy, I'm not sure what you are asking when you say "final stages" of COPD. The Global Initiative on Obstructive Lung Disease has classified COPD into dour stages of severity according to measurements of pulmonary function. You can read more about the staging and definitions of severity at: http://www.goldcopd.org/ People who are evaluated and found to be suitable candidates for lung transplantation include those with very severe COPD, especially if they are considered unable to survive for more than a year or two without undergoing transplantation. It is certainly an option for those with very severe COPD, should they choose that treatment path. People can live quite nicely with one lung and many do. While some folks who have had a lung removed do have 'maximum' exertional breathing limitations, they function and breathe quite comfortably while doing normal daily activities - as long as the remaining lung is healthy and functions reasonably normally. Best Regards, Mark Q. Dramatic Variations in Breathing & Decreased SPO2 & BiPAP
Mark A. Hi Mitch, Without a blood gas test, no one can tell if elevated CO2 is a problem or the cause of Fred's difficulties. It is no surprise that BiPAP will raise his saturation to normal within a few minutes, regardless of what causes the drop in saturation.. Whether or not it was decreased due to elevated CO2 levels can only be determined by doing a blood gas test under very specific conditions. As you are seeing with Fred, for some folks, COPD presents a lot of difficult to explain circumstances. All you can do is roll with the punches and appreciate the time you DO have with loved ones. Best Wishes, Mark Q. PFT Review/Analysis
Hi Mark,
Thanks in advance, A. Hi Mike, While you might be having some difficulties with acute bronchitis and perhaps some component of asthma which may be showing some air-trapping on x-ray, the prednisone and other treatment which you have undergone seem to be effective to resolve your difficulties. Your PFT's are within normal limits and are the most important measure of whether or not you have any significant problems with lung disease. with such a brief smoking history AND at your tender age, I would not worry about COPD for many years to come, if at all. If you continue to have recurrent bouts of bronchitis and/or asthma, you might look for further evidence of developing lung disease. But, at this point, you are doing well. Why you were told that your lungs did not fully develop is beyond me and, IMO, simply not true. If that were indeed the case, it would be reflected in abnormal PFT measurements, which you simply don't have. Continue to live a healthy and active life and you should be fine for many years to come. Best Wishes, Mark Q. COPD & Multiple Health Issues (Comorbidities)
My
son-in-law is 51 he has sleep apnea, copd. He is on a trach and
humidified oxygen and a Biped machine at home. He is obese and he
won't leave the house. He feels he doesn't breath as well leaving the
house or he may quit breathing. He is depressed not being able to
leave and about his weight. He was in the hospital and we almost lost
him 3 times, they put him on a vent and was planning to move him to a
different hospital in a different state that can handle long term vents and
that can work on getting him off. His Co2 was so high. As God
chose to bless us and him he was determined to get off the vent. The
drs. were shocked, but pleased. He also is diabetic. A. Hi Vicki, Your son in law is in a difficult predicament, the resolution of which you stated in your information and story about his plight. As I do not live in Canada and am not familiar with what resources may be available to him, I'm at a loss as to what to suggest. But, from where I sit, there is nothing I can suggest, specifically, that you haven't already said is necessary. All I can suggest is to talk with his doctors and see what you can do to get him the help he needs to move toward a healthier situation. You are right. If he doesn't get help and get moving, he will continue to deteriorate and likely lose his life at a much younger age than is avoidable. Best Wishes, Mark
Hi Mark
John A. Hi John, Tiotropium is a very good medication. However, because of the way it acts, you cannot "feel" it working like you can your Salbutemol. The Salbutemol works on a 'nervous' pathway that makes one 'feel' it working. Spiriva does not work on that same pathway. Instead, what folks notice is that they find they can do tasks that were more difficult to do before taking Spiriva, much easier once they've been taking Spiriva for a few weeks and months. We can also measure improvement in pulmonary functions tests that may not necessarily be 'felt'.
If I made any suggestion it would be that you should ask for
a "long-acting" form of the medication Salbutemol. Salbutemol is a
short-acting drug, which explains why you must take it every 4 hours.
Medications like Salmeterol and Formoterol will last 12 hours and might
offer you greater benefit, especially when combined with the Spiriva. With an FEV-1 of 23 %, I am surprised that you say you do not need oxygen, especially when flying. Your FEV-1 is awfully low and in a range when most folks have at least some amount of exertional desaturation. I suspect you need further more careful testing to determine if that is indeed the case. I'm wondering what kind of test was done to determine if you need oxygen for flying or not. If you are interested to see if LVRS might be an option for you, you should go to a center that does the procedure and be evaluated to see if you're a good candidate. Stem cell research for application to humans is still in very early stages, but shows potential promise. It will be several years before we see clinical trials, though. So, it is not something I would encourage you to hold out for. Best regards, Mark Q. Respimat Availability
When will Spiriva Respimat Soft Mist Inhaler be available in Canada? Thanks. A. To whom . . . I wish I had an answer to your question. Only your drug approval authority knows that answer to that one. Best Wishes, Mark
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Posted June 5th, 2011 Why "NON" Exercise Before a Breathing Test?
Mark; A. Hello Felix, The caution for one not to exercise strenuously prior to undergoing PFT testing is two-fold in purpose: (1) Exercise can bring on asthma - EIA = Exercise-Induced Asthma - in those at risk for this problem. The purpose of the PFT testing for these individuals is to determine if they have EIA and how severe it might be, as well as how well and to what it responds, in terms of reversal. If they exercise before having a PFT and bring on EIA, they will likely have to treat it with a bronchodilator, skewing the subsequent testing, both for presence and severity determination and for response to reversal. (2) In view of the above, it is a safety concern. Those individuals who are suspected of having EIA and who have not received bronchodilator medications before undergoing PFT's could put themselves in serious trouble by exercising hard before having a PFT - and that may be from the time the test is ordered until it is actually performed. So, the caution could pertain to days or weeks of duration until testing is done and intervention, if found necessary, can be put into place. When EIA is the reason for testing, exercise is a part of the PFT and bronchodilators are part of the intervention to test response. So, the PFT, itself, will entail exercise as part of the testing process. Beyond that, for others who are known to be ventilatory-limited, the fatigue factor of exercising to a point that is, for them, considered strenuous can cause under-performance on their PFT's, again, skewing the results. Another reason, though not often the case, considers that if a blood gas is done as part of the PFT, they may also measure blood lactate as part of the process. Blood lactate levels can remain elevated from baseline for hours after exercise. So, that might throw off measures of what is supposed to be baseline. The most prevalent cautions we almost always give is for folks to hold off use of inhaled bronchidilator and sometimes steroid medications. We usually will do measurements of some of the tests before and after administering a bronchodilator, in which case, we want as little medication/influence from what is the 'usual' routine in the system so as to better measure the true response of the airways to broncodilators. Best Regards, Mark |
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Posted May 30th 2011 Ongoing Infection
I live in the Uk, in the country and am retired,
my COPD was diagnosed in 2000, I have had an infection since the beginning
of April spent 8 days in hospital been out a week and coughing up plugs now
back on LEXOFLAXIN 1000 MG A DAY how long would expect this to start to make
a difference, I am beginning to give up, I have done rehab and have managed
my condition well but since this infection I am really getting more and more
depressed. A. Hi Marian, Your frustration is understandable and not unique. While all seems never-ending at this point, rest assured, that virtually all infections DO come to a resolution. Generally speaking, when multiple courses of antibiotics do not seem to clear up and infection, one can surmise that the infection is likely caused by a virus. Viruses do not respond to antibiotics. And only those for which there are effective anti-viral medications will respond to treatment. Instead, they must run their course with treatment confined to symptom control and reduction where possible. It may be that this is the scenario you are faced with at this time. Another possibility is that while you have felt rotten for several weeks AND it certainly may have begun as an infectious process, what you continue to contend with is 'not' infection-related, but rather, is an ongoing exacerbation of your symptoms triggered by the initial infection and continuing to plague you these several weeks later. You could be more deconditioned now than you were when this episode onset, owing to the imposed sedentary life style you likely have experienced due to your sickly condition. In any case, if 'any' antibiotic doesn't effect improvement within 5 to 7 days, then it is likely that the infection, if indeed present, is not susceptible to it. In that case, changing antibiotics would be a course of action to consider. What does your doctor think? Are you also on oral steroid therapy? While steroids will not thwart an infection, they can help to reduce your breathing symptoms. Ultimately, I have to say that for having been diagnosed 11 years ago and having done well for these many years, you are doing well to have done so for this extended period of time. It could be that your disease has progressed significantly over this time and that your symptoms may be related to that advancement, rather than solely to a current infection. As you do not indicate what your FEV-1 is, I cannot tell more than what I have suggested, at this point. That is little consolation, I realize. But, this is the frustrating territory that folks with COPD traverse as their disease progresses. Hopefully, it will resolve soon and you'll be back up to par, as much as your disease severity will allow. In the meantime, as difficult as it is, your best course of action is to try to keep moving - even exercise - as working through the difficulties and gaining conditioning will go a long way towards helping you fight this current battle. Best Wishes, Mark |
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Overuse of Oxygen Q.
Can anyone overuse
home oxygen? A. Hello A.M., The 'nut shell' answer to your question is an emphatic "No!" What we see more often is folks NOT using their oxygen enough! That said, there are those who would argue contrary to what I've said, for a number of reasons which I could dispell. Some believe - without any empiric evidence to support their contention - that avoiding using oxygen or using enough oxygen to 'normalize' one's saturation will somehow 'toughen' them to the throes of hypoxia. To that I would argue that plenty of empiric evidence shows that failure to use oxygen in the face of desaturation hastens the development of right heart compromise and failure and indeed, as statistically well demonstrated, shortens survival. Some go on to suggest that you should only use enough oxygen to raise your saturation to 88 - 90 % and that raising it any further is both unnecessary and by some arguments, dangerous, leading to negative consequences. Neither argument has strong support from the body of evidence we have gathered to date. As such, they represent notions based in unproven and questionably accurate theory. After that, strong argument can be made regarding the issue of "comfort" with regard to breathing symptoms. It is well documented that the difference in comfort level and therefore, the ability to sustain and better tolerate activity of increasing intensity is greater when oxygen saturations are closer to normal levels than when they are raised only marginally to 'safe' levels with regard to sustaining organ health and function (the heart, in particular and also the brain). Richard Casaburi and others have nicely demonstrated that fact in several well-designed studies reported since 2003. Some argue that "over-use" of oxygen - which, by the way, is defined by them in many different and incongruous ways - will lead to "addiction" to oxygen, meaning that the addicted user will then use oxygen when they can be defined as not needing it. Yet, such addiction is NOT considered a physical phenomenon. Rather, they define it as purely psychological, again with inconsistent criteria as to what that psychological addiction condition entails or by what it is identified. Again, I suggest, as does the available empiric evidence, that this notion is falacious and unsupportable. The bottom line is that if you desaturate significantly under various conditions and are prescribed oxygen, then you should use it appropriately to avoid those instances when your saturation would otherwise drop to unsafe levels. If you own an oximeter and can monitor your saturation so as to adjust your oxygen to meet your needs, all the better. I hope this answers your question and your curiosity, as you did not attach any qualifications or conditions to your initial and short question. If you have more specific concerns, come back with a question (questions) addressing them. I'll be happy to explain further. Best Regards, Mark BiPAP's & Co2
Loved the explanation ( Understanding your
Lungs.) Can you explain to me what a BiPap does in getting rid of the CO2? I
have noticed over the last four years, that when my husband seems to be
short of breath or just not feeling good he puts on his BiPap and he does
feel better. I am not saying his BiPap is saving his life but I am saying it
helps him feel much better. Do you know if the BiPap is getting rid of all
the CO2 or is this something that can only be told thru a Blood Gas. I just
love reading all the letters ppl send in. The questions help me understand
COPD more and it helps me understand how to make my husband feel as
comfortable as possible. A. Hi again, Mitch, The BiPAP does indeed "blow off" CO2 ONLY during the time it is in use. Whether or not that CO2 is excessive - that is, greater than normal levels - can indeed ONLY be determined by doing a blood gas test. Insofar as BiPAP or any other ventilatory supportive maneuver getting rid of "all of the CO2", I would caution you and everyone else to understand that NOTHING ever gets rid of "all" one's CO2. Even under normal circumstances, we breathe/ventilate a given amount per unit of time in order to keep CO2 levels at a fairly constant level/partial pressure in the blood - specifically 35 - 45 mmHg - when measured on a blood gas. CO2 is a by product of metabolism. As such, as long as metabolism is going on, CO2 will be produced. Without this condition one would not be living/alive! Your hubby uses the BiPAP because it augments his respiratory efforts and reduces his work to breathe. That is has any appreciable effect on his CO2 may be arguable and again, cannot be ascertained without doing a blood gas. Even if it momentarily shifts his CO2 to a lower level, the effect occurs ONLY during the time that he is using the BiPAP. Once he stops using it, his CO2 level will return to it's pre-BiPAP level within minutes and remain there, though he may "feel" more comfortable and feel better for having used it. Yet, that is not a bad thing. If he has the ability to use the BiPAP and it helps him feel better - especially if that feeling is sustained for significant duration after its use, then one would be hard-pressed to argue against its use. So I would encourage him to continue, especially if its use will help him be more active. Best Regards, Mark Daxas, PFT's Causing Black-Outs, Lung Sounds (or not)
Hi Mark, A. Hi Philip, I didn't find a question within your missive, so I'll make a couple of comments on your points, if that's OK. Roflumilast does have some nasty side-effects for may who use it. It has a more limited application than I think it has been prescribed for. While I don't like to see physicians swear off its use completely, I would like to se more of them learn more about for whom it is more specifically targeted. When folks who use it DO realize benefit, it is dramatic in many instances making it a drug of value for some. It just needs better help in finding its appropriate audience, so to speak. In regards to your problems with passing out while performing the maximal exhalation maneuver during a pulmonary function test, I would point out that the vagus nerve is NOT in your 'neck' as you stated. It is in your chest. But, while part of your problem may indeed relate to the "vaso-vagal" response, it is reduction in blood flow to your brain that ultimately causes your blackout. That is a function also of increased pressure within the chest that slows blood flow to and from the brain. It is unfortunate that you cannot tolerate the procedures required to produce a quality PFT as without it, ALL assessment and treatment is speculative. But, there ARE folks who, like you have that very reaction to performing the maximal exhalation maneuver making them more difficult to manage without the PFT data to guide us. Lastly, while having clear lungs on auscultation is always a good thing, I would caution that in and of themselves, negative findings on auscultation are not uncommon in COPD as with airflow being progressively reduced and breath sounds dependant upon sufficient movement of air so as to create the 'noises' we listen for, the reduction or absence of those 'noises' can have both negative and positive implications. It is apparent that you are doing well, at the moment. So, for that we should be very appreciative. Thanks for your kind thoughts for my family and my Kimmy. She is doing well, working at her job in respiratory care at the affiliated children's hospital at Vanderbilt University, in Nashville, Tennessee. Best regards, Mark |
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Posted May 15th, 2011 Daxas - Right Decision? I saw my doctor recently and she had a sample of "DAXAS".And asked if I wanted to try it . I had read about it Roflumilast and knew it had been used in Europe for some time ,so even though she (my doctor) told me about all the possible side effects I decided to try it !! Was my decision right or not ?? Thanks !!
Ken A. Hi Ken, I wouldn't characterize your decision to try Daxas as "right" or "wrong". It 'shouldn't' hurt to try it. You will either find that it helps or does nothing or that you have side effects that make it not worth continuing. If your doctor felt it was worth a try and gave you samples, that should say a lot about what she thinks of the potential for it to benefit you. Best Wishes and I hope you find it beneficial! Mark Supplements
Have had COPD for officially 10 years now.
Recently I have spent some time looking into using MSM 1000 mg caps for
improving my breathing. A. Hi John, Dietary supplements used for medicinal purposes entail many potentially slippery slopes for those who look for much in that regard. While I am versed to some degree in a number of dietary supplements and indeed use some myself, I caution others that I can only share "non-professional" or "un-official" information with them in regards to dietary supplements and hesitate to recommend their use as a general rule. Having said that, it is my understanding that MSM is touted for improved joint and connective tissue health and would have nothing specifically to offer for lung health. At the same time, NAC (N-Acetyl Cysteine) has received a fair amount of controlled study by mainstream scientists and facilities and has been shown to be beneficial for a couple of different aspects of lung function. First, we know it is a powerful antioxidant. Secondly, for those with lung disease, it seems to help loosen/liquefy and mobilize mucus for easier clearance from the lungs. Thirdly, NAC stimulates the increased production of glutathione in the lungs, a substance that has several beneficial actions among which are anti-inflammatory action. So, it would seem to me that if you wish to take a supplement that has some known benefit for the lungs, then NAC would be the better choice as I am aware of no empiric study of MSM in regard to lung health or function. If you are interested, consider taking 1200 mg NAC per day along with 2000 mg of Vitamin C which counteracts the body's tendency to metabolize NAC and form kidney stones in the process. The Vitamin C reacts with the byproducts of NAC metabolism and prevents formation of kidney stones while imparting yet other benefit. I will close with strong admonishment for you to check with your doctor to be sure it is safe for you to take ANY supplements and for you to specifically take NAC and increased doses of Vitamin C, BEFORE you embark on any trial of either. MSM, shouldn't hurt you to take, even with NAC and Vitamin C. But, again be sure it's OK and that you collaborate with your doctor on your course of treatment - even if he or she doesn't fully support or approve of your choice of intervention. Best Wishes, Mark Infrared Saunas - Safe to Use?
Is it safe to have Infrared saunas if you have COPD? The gym
I attend allows a 10 minute session. If so, what is a safe
temperature? Thank you. A. Hi Marilyn, Having COPD, in and of itself is not a contraindication to being able to use a sauna. And, I don't know of any specific safety issues with infrared saunas in regard to lung function and health. I cannot tell you what would be a good or safe temperature for you as that depends upon your type and severity of lung disease and how you respond to breathing hot air and high humidity. Only you can be the judge of that. Ask your doctor if he/she sees any contraindications to your using a sauna of that type. Best Wishes, Mark |
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Posted May 8th, 2011 Stem Cells ..... To Do or Not
Hi Mr. Mangus, A. Hi Judy, MD or not in the US, there's something more to be said and concerned about than the restrictions on stem cell therapeutic applications as a reason why he is doing his interventions in Tijuana! All of the reliable and official sources here i9n the US caution against virtually ALL therapeutic applications of stem cells that are not currently approved by the FDA or under legitimate clinical investigation. Your concern is well-placed. I would recommend against your father wasting time and money on it NOW and until specific benefit has been discerned and substantiated! Best wishes, Mark Patient Follow Up........
Mark; you explain a theory/opinion you support - paraphrased A. Hi Gregory, The answer to your question should go without saying. AND, you assume that the theory as I explained is much more finite and limited and black and white and all or none than would be reasonable to suggest. Theory rarely is so specific. I did not state it as such. You are asking for more than the intent of my explanation AND imposing conditions according to your own notions. Only hard research to quantify and specifically explain THEORY can answer the questions you demand answers for. And, nothing I stated sets such conditions or suggestions. Nor does anything I said in my explanation preclude the fact that more dosing will provide greater effect - at least until a point of saturation or overdose occurs. Clinical trials of all approved drugs that fit into this category and application show that increasing the dose - either through multi-dosing a specific strength or increasing the dose of each administration - will increase effect until saturation or lack of additional effect is reached. That said, as I said what should go without saying, let me state outright simply that the more particles taken in - with multi-dosing - the more sites made contact with in the process, the less the effect will have to rely on transmission of benefit to non-directly-contacted sites. Insofar as timeline is concerned, my explanation required no "timeline" as it was NOT a specific recommendation or instruction for dosing or anything like that, at all. It was simply a general explanation of one train of thought on how the pharmacokinetics of the applicable bronchodilators works. I'd suggest that you not make more of it than it represents or was intended to represent. AND, if you want specific theory to match the conditions you demand, I'd have to refer your to a pharmacokinetecist for that kind of information as it is beyond the scope of my knowledge or desire to know and of my explanation as you quoted it, at this point. Best Regards,Mark PFT's/Breathing Tests & Concern
hola doctor Gracias, Jose A. hola Jose, Your PFT's reflect essentially normal lung function. If you have quit smoking, then you did the best thing you could. If you DID have COPD, you would still be years away from any chance of need for oxygen. So quit worrying about that for a long time to come! You may NEVER need it! Continue to take good care of yourself and life a healthy lifestyle with plenty of exercise. You'll likely live to be an old man and die of something else, altogether. Best Regards,Mark
'Sus puebas
de funcionamiento del pulmon (espirometiria) reflejan esencialmente una
funcion normal del pulmon. Si ha dejado de fumar ha hecho lo mejor que
podia hacer. Si existiera la remota posibilidad de que tuviera EPOC (COPD)
faltarian muchos años hasta que tuviera necesidad de oxigeno. Asi que
no se preocupe, usted probablemente nunca lo necesitará. Continue
cuidandose, viva una vida sana con mucho ejercicio, Es muy probable
que viva hasta una edad avanzada y muera de cualquier otra cosa'. |
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Posted May 1st, 2011 Breathing Tests Are Within Normal Range; But Still Having Symptoms I have been
trying for a very long time to find out what is causing my shortness of
breath on exertion and dry cough. Elevated pulmonary pressures of 51(3
months ago) seem not to be the problem as I had a right heart
catheterization two years ago for a pressure of 48. It was normal. Lori A. Hi Lori, Hmmmmmmm. You present an interesting and possibly perplexing scenario. Your complaint is SOB on exertion and dry cough. Your FVC and FEV-1 are indeed within normal limits as are your VC and DLCO. However, normal as they may be individually, when considered with your at least, two-year history of elevated pulmonary artery (PA) pressure - now having reached clinical significance, at 51 - your reduced RV and TLC (the TLC still being within normal limits) and the overall picture presented by the combination of complaints and abnormal proportions to your PFT, there is reason for concern and further investigation, IMO. So, you are correct to question the significance of the reduced RV, as you do. Your reduced TLC and RV in the face of normal RV/TLC can lead one to believe that all is well and that you are just one of those who falls into the lower end of the predicted normals for lung volumes. BUT, generally speaking, when one falls into the lower end of normal predicted, ALL volumes tend to be more equally reduced, which is not the case in your scenario. Your TLC and RV have fallen by 8 % and 7 %, respectively while your timed-volumes (FVC and FEV-1) have remained disproportionately high. As well, your FEV-1/FVC's, an important ratio to consider, have been 99 % over the period of the two PFT's. I suggest that is NOT normal! While we consider FEV-1/FVC ratio to be normal when it is > 70 %, when it exceeds 90 %, one should ask "Why?" That yours is 99 %, should send up a red flag in the face of your elevated PA pressure, disproportionately reduced TLC & RV and dry cough and exertional SOB complaints. Dry cough is a common complaint in the presence of both pulmonary artery hypertension (PAH) syndromes and restrictive lung diseases of both interstitial (within or between the lung tissues) and fibrotic types. I wonder if you have had a CT scan of your lungs, preferably a high-resolution CT. If not, that would be the next test I would recommend requesting. Your abnormalities within your 'normal' numbers suggest that you might have a restrictive process at play, though I would expect that your DLCO would be somewhat more reduced than it is. Still, your TLC and RV are not reduced enough at this point - even if a fibrotic or interstitial process is in progress - to suggest that it is significant, or that hypoxia is necessarily a part of the process, at this point. And the question of the likelihood of a fibrotic or interstitial lung disease process is confounded by your PAH, which could be the cause of all of the abnormalities. As well, PAH is a 'dynamic' process such that if while laying on the cath lab table, your PA pressure is now 51, it can be increasing further during exertion, again, a common cause of your SOB and cough complaints. And, it is possible that your reduction in TLC and RV are related solely to the PAH as it has developed to this point. So, you can see how the picture becomes confounded and unclear as to cause. In any case, at 47 years of age, I disagree that you should have changes like you exhibit AND elevated PA pressure on top of those changes attributable simply to "age". Elevation of PA pressures does NOT occur as a process of lung aging. Elevated PA pressures, alterations in lung volumes as you exhibit and SOB and dry cough, especially with exertion are NOT a normal age-related, lung-change-caused combination. I would suggest seeking another opinion, perhaps at an academic facility, if one is reasonably close by AND you have the ability to make that happen. While you may find that you have either or both an interstitial/fibrotic lung disease and/or PAH, neither has progressed significantly to suggest that treatment is as yet or imminently necessary. So while a more definitive diagnosis may prove your pulmonologist's impression to be inaccurate, it may not alter the suggested course of action at this time - that is, to do nothing interventive and to continue to monitor your PA pressure and PFT's aty intervals, looking for more significant changes to trigger intervention. On the other hand, a more comprehensive evaluation and 'sorting out' of your situation may lead those perhaps more expert in those disease processes to suggest intervention sooner than later. Those remain the questions to be answered at this time, as best I can surmise. I think that in the meantime, your immediate challenge is to continue to function as normally as you can, contending with the COB and cough as best you can to keep moving and stay in the best physical condition you can. Exercise as much as you can (walking for cardiovascular benefit) without letting the SOB and cough inhibit your effort any more than you can prevent them from doing so. And, if you do indeed get a diagnosis that is different from that which you already have, double-check to be sure that you can continue to work safely and fairly vigorously in the face of the SOB and cough. Best Wishes, Mark |
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Posted April 24th, 2011 Prednisone Withdrawl
Please
explain to me when my husband is finished a two week course of prednisone,
what are some of the withdrawals I can expect. He has been on prednisone
before when he had pneumonia but this time the Dr put him on because he
thought it would do him some good. He did not have an infection nor a fever
but he breathing was laboured but not all the time. Anyway he is ready to
come off and for some reason he is concerned taking prednisone so many times
what can he expect. Once again I hope I able to explain well enough for you
to comment. A. Hi Mitch, Typical withdrawal symptoms from taking prednisone are feeling worse. Prednisone, among its other effects "masks" how bad one feels. So, when coming off it, they can feel like they are 'relapsing', when they are just seeing a decrease in the therapeutic effect of the drug. He should be sure to taper the dose as he comes off, especially if he has taken it for more than a week or two. If he can, he should weather the worse feelings, as they will ALSO subside with time. Best Wishes,Mark Potential Sleep Apnea Hi;
I was diagnosed
with copd 3 years ago but have not been sent to a specialist for a confirmed
diagnosis or taken an air flow test. I do trust the diagnosis however.
I am going to ask my new doctor to send me in for the test and possibly to a
specialist. A. Hi Mary, I'm glad you are going to ask for a PFT! There is no excuse (IMO) for someone to be diagnosed and treated for COPD for three years without having had a PFT! It sounds to me like you may have sleep apnea - either obstructive or central. Your complaints are classic for the problem. You should insist on having a sleep study done and SOON! Folks who have obstructive sleep apnea gain weight, develop high blood pressure, diabetes and sleep enormous numbers of hours while feeling like they haven't had enough sleep and complain of somnolence, lack of energy. They can also develop heart disease. So get checked out, soon, please. With treatment (CPAP - positive pressure breathing support, during sleep) many of the symptoms can be reversed. But, the greatest benefit is improved quality of sleep and energy, as well as normalization of blood pressure and weight. Best Wishes, Mark Longevity Expectancy
I need some straight-talk. My husband of 47 yrs just had a PFT
after saying A. Hi Patricia, First, an FEV-1 of 18 % is very reduced and good reason for why your hubby struggles so much. Is he using oxygen? If not, has he been tested for low oxygen - especially during activity and sleep - for hypoxia? I suspect he should very likely need oxygen with an FEV-1 of 18 %. And, using it can go a LONG way to help him in many respects. Second, only fools will try to predict how much time someone has with COPD of ANY severity. So much depends upon what the person does. Getting in the best shape possible, receiving the best medical management, achieving the best medical condition possible can help someone with even as severe COPD as your hubby has survive for a matter of years. Even so, all it takes is one severe infection/pneumonia and it can be all over. Your best option is to encourage him to work hard to get in and stay in the best physical shape possible. He needs to work hard 'against' the breathing difficulty her experiences, especially when he moves. His breathing may be VERY difficult AND may seem potentially harmful, but indeed, the opposite is true. Sure, it is NO fun struggling to breathe AND to keep moving. BUT, in doing so, he WILL reduce his difficulties, over time AND acclimate to those difficulties he cannot reduce. It is a process that is NOT easy, but is certainly possible. So, the best help you can give him is to encourage him and NOT "do for him" in an effort to make life easy. With COPD, especially so severe, kindness and codling kills! If there is help in the form of a pulmonary rehab program, see about getting him into it. Best Wishes, Mark Good Oxygen Saturation, Short of Breath (SOB)
This problem started 4 years ago when they put me on Metformin. I couldn't walk and breathe and my sugar test went all over the place. Been off of it 5 weeks, have lost all the swelling in my legs, muscles still a little weak but coming back with therapy. My A1C is good, breathing is improving. Can this cause that problem? Thank You, Dave A. Hi Dave, I do not think that the Metformin could be blamed for your difficulties/symptoms. I cannot say with any confidence what might be the cause of your problem aside from perhaps being very deconditioned. If you are rotund, bending over can be hampered by body mass. The only other thing that comes to mind is the possibility of pulmonary hypertension (PH) which 'can' occur and be clinically significant without observing desaturation. Does the oxygen help your breathing, despite the normal, measurements you report? If so, that could be a suspicious sign of PH. Best Wishes,Mark
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Posted April 17th, 2011 More Short of Breath (SOB) After Exercising
Why is it that I have a tougher time breathing after exercising and
also the following day . I am am on 02 when exercising 2 liters and my
oximeter says 98 on 2liters , but that night I am sob and the same thing the
next day .I do weight lifting one day and 30 minutes on the treadmill the
next what am I doing wrong? A. Hi Paul, There are several possible explanations/reasons for your pattern of difficulty. You don't provide enough information for me to speculate with any confidence, as the possibilities are varied and rather specific to potential causes. I'm left wondering "when" and "how" (under what conditions) you are measuring your saturation associated with exercise. Is that DURING exercise? or do you place the oximeter on your finger after you have stopped exercising? If enough time has passed since stopping exercise (say, more than 15 or 20 seconds), the measurement you observe is not reflective of your exercise saturation. Are you taking appropriate and sufficient inhaled medications as a habit and in an effort to help your breathing during exercise? You see, it could be that you're not doing anything "wrong" per se. It could be that you just aren't doing enough things right, at this point. In any case, don't let it discourage you. Work with your doctor to be sure that you are doing everything to optimize your breathing, especially to cover your exercise needs. Keep exercising. Maintain good nutrition and even try using more oxygen than the 2 L/min during exercise and see if you have less negative after-effects. Best Wishes,Mark Disease Progression
Thank You in Advance for your time Mark. Is it possible for a
patient to worsen very quickly? I had gotten a flu bug and of course
it went straight to my chest. I was sick for 2 weeks. Took my
anti biotics but unfortunately had to travel while still sick. It was
already booked and cancellation was just not possible. Since then I
seem to be struggling more and I noticed that I have a 'bruised' feeling on
my left side just under my arm pit and another area on the front just below
the breast.......I think more on the rib cage. The bruised feeling has
sub-sided in the front now but I seem to be worse with the sob. A. Hi Merry, Unfortunately, it is all too easy for one to experience a raqpid decline in their condition, though, while exacerbations can happen a lot, a significant and permanent decline is NOT always or even often the result. It sounds to me like you are still in the throes of an acute exacerbation from which you won't be able to determine if there are permanent changes until more time has passed AND you have had a chance to return to your steady-state and see how you are after yet more time. Your chest/rib pain 'could' be from pleuresy, if you have a significant infeciton in that area of your lungs. An x-ray miight help to clarify that. But, at this stage, it might not prove helpful with regard to input to guide or alter treatment. I would see if an anti-inflammatory, like Ibuprofen, would help IF it is not contraindicated by any other medications you might be taking. Your doctor should be able to adivse you best in that regard. And, in case you haven't reported your current symptoms to your new doctor, I would urge you to do so! If the 43 % is - as I suspect - your measurement from your FEV-1, then I would say that you are in better shape than many others AND maybe even than you think you are! In any case, exercise and proper lifestyle should go a long way toward improving your situation. Best Wishes, Mark |
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Posted April 10th, 2011 Unchanged FEV1/ Disease Progression
Hello Mark A. Hi Mitch,
After reducing or removing the negative/progressive causes of COPD, like smoking, for instance, the rate of progression returns to what would be normal loss of lung function as one ages. Each year, the predicted values are subsequently slightly decreased according to gender, age and height. So, the PFT’s can appear to remain unchanged in terms of worsening at a more rapid rate because of the COPD. But, indeed, they are stabilized in their natural rate of decline.
Also, consider that while we speak ‘generally’ about the progressive nature of COPD, it is not a hard and fast ‘given’. AND, while one can remain stable without significantly more rapid decline, get a severe infection and you can see a sudden and significant drop as a result. So the otherwise smooth progression can become stair-step, in fashion.
After only a year of being diagnosed AND depending upon where your hubby is in terms of severity, it is not unusual for him to see no significant worsening of his disease. Be happy in that fact and continue to work toward maintaining the best condition and state of health possible for him as long as is possible.
Best Regards, Mark
Short of Breath/Oxygen Level & Death from Chronic Bronchitis
When I work outside
cutting wood for about an hour I get very short of breath. Does this make my
oxygen level low and can this damage my lungs more than they are. If your
oxygen level is low and you don't know it can this do more damage to your
lungs when you have emphysema. Can you die from chronic bronchitis if you
don't have emphysema. Thanks John A. Hi John, I can’t answer your question about your oxygen level as ONLY a measurement of it at those times when you feel short of breath will provide the answer. I CAN tell you that, contrary to what many folks think, shortness of breath does NOT mean one’s oxygen is necessarily low. LOTS of folks experience shortness of breath while their oxygen level is perfectly normal. There are MANY influences on breathing that can cause shortness of breath, besides low oxygen levels.
As to your second question, Low oxygen levels that go undetected AND are significant CAN over time cause further damage to organs – but NOT to your “lungs”. Instead, low oxygen levels put stress on your heart, especially on the right side of your heart. Such changes must occur over a period of years to result in significant compromise. If you are worried about the possibility that you might be experiencing low oxygen levels, talk to your doctor. There are some simple and painless tests he/she can do to determine if there is a problem.
To your third question the answer is not as cut and dried as you present the question to be. Chronic Bronchitis and Emphysema are both components of COPD, among other types of obstructive lung disease processes. One most often does not have “just” one or the other. Indeed, most who have smoked, has a combination of both, though one may be worse than the other in their total picture. Also, we are careful to point out that one doesn’t “die from” COPD, like they would die from a heart attack or similar ‘other’ ailment. They tend to die from the “complications of” the disease process, since it affects so many ‘other’ systems as it progresses. So the question as you put it is not answerable, as presented.
Best Wishes,
Mark
Dry Mouth Contributing Factors & What Can be Done?
Hi Mark - hope all is well
with you, A. Hi Lynn, You (like me) are probably a mouth-breather when you sleep, allowing the opportunity for the problem of dry mouth to give you trouble. While it is a nuisance, keeping that water next to you and sipping throughout the night if/when you awaken is about as good as you can do. Certainly the Chantix and Spiriva can be contributing to the effect. AND there aren’t any good alternatives for those, let alone those that wouldn’t ALSO contribute to the problem. You ‘could’ try taking the Spiriva at night and see if there is any difference. But, I don’t have a good alternative to suggest. Best Wishes, Mark NAC, Vitamin C & Kidney Stones
Hi Mark : A. Hi Gregory, I cannot answer your first question as there is no common definition for what constitutes an “incapacitatingly low FEV-1”. And, what incapacitates folks with very severe COPD is due to much more than ‘just’ the FEV-1. As well, trying to treat ONLY the FEV-1 would not be effective to address the scope of changes that accompany drops in FEV-1 and worsening of one’s disease. Even then, treatment would not necessarily be confined to simply taking more of any given drug, especially not bronchodilators in and of themselves. So, I would have to refer you to your doctor and the long term assessment and care he/she provides and trust that he/she will know what, if anything will need to be adjusted along the way as you age with your COPD and experience whatever progression pattern it ends up taking. The best evidence recommendation we have to this point is that one should take 1000 mg of vitamin C with every 600 mg NAC to “avoid” formation of kidney stones. I don’t know what you mean with your mention of the source that says to “match doses”. What do you mean by “match doses”? In any case, I have given you the evidence-based recommendation for what comparative dose to take. So, that should answer your subsequent question.
If you don’t develop kidney stones, then you shouldn’t need to look for a
remedy or preventive, especially if you are already taking
precautions/preventive action as in the case of NAC and Vitamin C.
In any case, I would imagine that if consuming lemon juice indeed DID
dissolve kidney stones, then a
I doubt that you will succeed in getting a prescription for oxygen – portable or otherwise – on a ‘just in case’ basis for the purpose you suggest, OR to somehow avoid incurring the expense of an ambulance ride, should you fall ill, as you suggest – that is, unless you are looking to pay for it out of your own pocket. I would further suspect that a cabby - faced with a person truly in need of a trip to the hospital AND one that would rightfully/appropriately involve oxygen therapy – would refuse to take on the responsibility of transporting you, especially to simply avoid the expense of the ambulance. Indeed, you should expect that cabby to call 911 and request an ambulance and trained medical personnel to help you!
I’m betting that while “Mucinex” may not be a brand of mucolytic offered in
Best Wishes, Mark
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Posted April 3rd, 2011 Follow Up Re: Tony & Meds Sequence
Hi Mark,
Initially after the operation I use to catch any
virus that was in the air, hence, I claimed our little hospital as my second
home. |