Posted  September 3rd 2010

Q.  Symbicort & Thin Skin

I've been taking Spirva and Symbicort 200 for 6 years. The Symbicort has made my skin paper thin and tears so easily.  Is there anything at all a person can do for this other than stopping the Symbicort?

Thank You

Terra

A.Hi Terra,

While steroid use is notorious for causing changes as you notice in your skin AND you’ve been using your inhaled steroids for these 6 years, there are also hereditary influences that contribute a large part to changes in skin characteristics.  Rarely do inhaled steroids cause the changes you mention to a significant degree.  But, nothing’s beyond the realm of possibility.  AND I have seen folks who seemed more susceptible than others.  I wonder what your close relatives’ skin characteristics might happen to be.  Do any of them who DON’T use steroids, or at least inhaled steroids have the same skin changes?

In any case, you are correct that there is little you can do short of stopping the inhaled steroid.  Even then, with those changes having already manifested, the likelihood of them subsiding and your skin returning to a more normal is remote, as I’ve never seen a reversal of those kind of changes simply from cessation of the use of steroids.  AND, there IS the consideration that without the steroid, you may see a significant worsening of your breathing.  I’ve seen recommendations for nutritional interventions, most of which have little or no empiric evidence to show their effectiveness.  I know of no direct treatments, like medications, that can stop the changes, much less cause improvement.  Some cite vitamin deficiencies as a cause and potential solution.  Perhaps a dermatologist could give you some insight into your condition and if there may be anything that you could do to alter your present course of changes.

It is interesting to note that as data shows that we prescribe steroids (both oral and inhaled) for many who don’t receive consequential benefit from their use, if you want to trial doing without them, consult your doctor and ask about going a month or so without the inhaled steroid.  You can use Foradil, by itself to continue benefit from the other component of the Symbicort.   Whatever you do, I strongly advise you to do it in collaboration with your doctor.  By successfully stopping the inhaled steroid, you can eliminate that influence on the changes you complain of.  In the end, good breathing HAS to trump vanity, though I do not presume to minimize the difficulties you note, as those skin changes amount to much more than simply appearance.

Best wishes,

Mark

Q. Inconsistent Sats, Clear Lung Scan,  No Heart Disease or Asthma But Short of Breath

I am a 47 year old female with a 3 year history of progressive SOB with exertion. Initially, they thought I had pulmonary hypertension due to an elevated pulmonary pressure of 48 but the RHC was only showing the upper limit of normal. I have been tested for heart disease and asthma but all normal. My last PFT's actually improved because I lost 34 lbs except the DLCO dropped but is still considered normal.  A few weeks ago, I became very irritable after going to the gym and a coworker suggested I do a walking oximetry(I am an RN at a hospital). I desaturated to 85%. I didn't believe it as the "siq scale on the side of the monitor showed red even though the perfusion scale stayed green and my pulse was accurate(between 130 and 150). It is a Massimo oximeter. I tried it several more times over the following weeks and sometimes it would drop and other times it wouldn't or my sats would go up and down during the whole walk. I told my doc who showed up at my office with an oximeter and took me for a walk. My sats dropped to 81% with her so she made me an appointment the following day with a specialist who walked me again and they were normal. He did a lung scan which was normal. I don't feel well and am getting tired of being so SOB. Could these sats be accurate even they are so variable? Any suggestions?


Lori

A.  Hi Lori,

Thank you for the thorough and pertinent presentation of your condition, tests done and results and the other detail that was SO helpful to me in at least drawing some potential conclusions about your situation which I hope will facilitate further investigation, as I don’t think enough information/data has been gathered under the best conditions to identify what’s going on with you.

First, I don’t know what your team considers “upper limit of normal” with regard to resting PA (Pulmonary Artery) pressures on the RHC (Right Heart Catheterization) that was done.  But, I would suggest that anything over 30, even a generous 35 is reason for concern, in view of your collective symptoms.   If your PA pressure was even 40 on the RHC, that should be a red flag.  And if the 49 your report was from the cardiac cath, then you definitely have significant elevation in PA pressure and PAH.  In terms of PA pressure that is marginally within normal levels when resting one can ‘usually’ assume they will observe potentially significant elevation with exertion.  In the cath lab, when we observe marginal saturations, we usually try to create/produce conditions that might allude to or even induce elevation under more dynamic conditions.  With someone who uses oxygen, it is easy.  We simply turn down or turn off their oxygen for enough time to see their saturation drop several percent.  And we will see a commensurate increase in PA pressure IF hypoxia causes their PA pressures to rise. 

Finger oximetry is difficult to use with confidence to quantify exertional changes in saturation.  Motion and circulation artifact contribute greatly to error in measurement that is too often not detected, appreciated or understood by those doing the assessment.  Manufacturers like to brag that their instruments aren’t significantly affected by motion and circulation - - - one in particular - - - and indeed, it is the one that you are using.  But, the fact is that beyond their demonstrations, motion and circulation artifact DO significantly and negatively affect finger saturation measurements.  I have used Masimo for three years now and am not gullible to their highly touted claims. 

I’m a fan of reflectance transducer technology and have studied it in comparison with finger transducers and blood gas measurements under dynamic conditions.   By far, the reflectance sensor is most accurate and will often detect what the finger sensors CANNOT detect OR sort out that questionable measurements from finger sensors are indeed not valid or accurate.  The reflectance transducer measures saturation through the skin of the forehead, just above either eye where vascular conditions are unique compared to EVERYWHERE else in the body AND lend to the MOST accurate potential measurements possible with oximetry.  IF your resources have such technology, I’d strongly recommend repeating the walk test using reflectance sensor technology to measure your saturations.  Another means to double check accuracy of what you’re seeing is simply to QUICKLY obtain an arterial sample (within 15 seconds of stopping your walking) and comparing it to the saturation measurements.  BUT, in any case the ABG will be your “gold test”, since it is a direct measurement.

While we often see a decreased DLCO with PAH, it isn’t ALWAYS the case.  So, that your DLCO is reduced but not abnormal is another one of those points of consideration.   Take several points that are barely within normal limits and add them together and you have potential for an overall influence upon an abnormal condition.  So, those little things shouldn’t be summarily dismissed.

I am disturbed by your pulse rate of 130 – 150/min.  At 47 years young, that is NOT what ANYONE should expect during a 6 minute walk test from one who is not in absolutely horrible shape AND significantly over weight, for instance.  You DID say you lost 34 pounds.  Are you still significantly above your IBM (Ideal Body Mass)?   I wish I knew what your resting pulse - - - truly resting, that is, like upon first awakening from sleep.  Unless it is in the high 90’s to low 100’s, and elevations to 130 – 150 range is NOT normal.  If you were jogging at a fairly brisk pace, 130 – 150 wouldn’t be that unusual; but, NOT during a “walk” test.  SO, a cardiac cause can’t be completely ruled out, “yet”.  Have you been checked for unusual problems like Lupus or other rheumatologic or autoimmune disorders?  How about Thyroid dysfunction?

While it ‘could’ turn out that your lungs are not the primary source of your troubles AND/OR are not significantly affected by what ever IS your ultimate abnormality.  I don’t think you have anywhere near a satisfactory answer to what’s going on.  AND, it certainly COULD be a heart condition that has yet to be identified.  So, don’t give up on your pursuit to find an answer.   I’d like to hear from you as you discover what is going on and to learn how you are getting along.  So, please come back to this list with questions, if I can be of further help or with reports on how you are doing.

Best Wishes,

Mark

Q.  Could it be asthma?

Last year I went to the Emergency room for a cough they diagnosed as pneumonia.  It was like a barking cough.  My sister has asthma.  They gave me a nebulizer treatment and prescribed an inhaler.  I used an inhaler for two weeks and my cough seemed to stop.  Should I get another inhaler because it seems like it was the only thing that subdued my cough after cough syrup and cough drops after one month. So I could I have asthma too?  It was a barking dog cough and I am not a smoker.

I do cough on hot and humid days and my breathing is usually fast when I run.


Eric

A.  Hi Eric,

I cannot tell you much based upon what you’ve told me.  If your pneumonia is resolved, then there is no reason why you should need inhalers, nor to expect continued coughing.  If after not taking the inhaler for a couple of weeks your cough returns, have your doctor check you out to be sure your pneumonia hasn’t relapsed.  You can have a pulmonary function test before and after using the inhaled bronchodilator medication and it will determine if you have a problem with asthma.  That is the only definitive way to diagnose asthma.   Coughing alone is not a defining symptom, though it can often be one of the problems of having asthma.  If you are indeed able to “run”, if you mean that in a literal sense, then the likelihood of you having significant lung problems or disease is less than if you didn’t or couldn’t run.

Best Wishes,                                                 Mark

Q. Lung Collapse & COPD

Good Evening Mark:

I was diagnosed with severe COPD just over a year ago.  I am currently taking Advair and Ventolin and am still very often short of breath.  As straight answers, or even the opportunity to ask the questions are hard to come by, I am hoping you are able to deal with a couple of them for me.  Outside of the breath issue, there are two others that cause me problems.  I have difficulty in walking at times, even when not hugely short of breath.  It's more of a case of the legs just refusing to work, resulting in me stopping dead in the middle of wherever I happen to be.  The second is chest pain, largely across the breastbone area, but as of a month ago or so, is also along my lower left side at the base of the ribcage.  The chest pain is not heart, embolism or collapse.  I have asked on numerous occasions whether this is par for the course with COPD, but never have gotten a straight answer.  Re:  legs,  I have good blood flow to the legs.  Are both of these things par for the course with COPD?

I have also noted that lung collapses seem to be fairly prevalent.  Can you tell me at what stage are these most likely and just how prevalent these are?

Thanks

Laurie

A. Hi Laurie,

I can certainly ‘deal with’ giving you and everyone else “straight answers” to your questions - - - when they are presented in such a way that they can be given a simple and straight answer.  But, as I most often find, folks - - - and I have to count myself among those “folks”, because we are ALL given to some measure of presumption - - - tend to ask ‘leading’ questions and then expect the answers to fit the conditions of the questions as they put them.  When the answer does not fit their expectation or their required conditions, they feel they have been short-changed when the response does not contain the information they wanted or expected.  I say all this to kind of prepare you for my straight forward responses to your questions but responses that will not answer the questions as you asked them because they are NOT as you might think them to be.  Read on to learn what I mean.

You said you were diagnosed with severe COPD.  Because there is such a broad understanding and application of the term “severe”, when speaking of COPD, to say that yours is “severe” means literally ‘nothing’ to me.  I can ascertain what degree of severity you have only by knowing what your FEV-1 and FVC are, as well as perhaps a few other numbers on your pulmonary functions test AND a few pieces of clinical information like breathing symptoms with some specific level of activity (6 minute walk distance, for instance) AND saturation of oxygen to go with the breathing difficulties.

You currently take Advair and Ventolin.  But, you didn’t say how much, what strength and on what schedule you take them.  You don’t say if you use supplemental oxygen or not.  You don’t say if you use Spiriva, or why you don’t if indeed you do not us it.  You tell me of your chest pain AND declare that it is not from problems with your heart, embolism or collapse.  Have you had tests done that specifically rule out those as causes?  Do you understand that they are not the only possible causes of the pain you describe?  Have you brought these complaints to your doctor’s attention?  If so, what does he/she think?  From where I sit and based upon the information you have offered thus far, I cannot tell you anything about potential cause.  You simply haven’t told me enough pertinent information to be able to ascertain anything.

I CAN tell you that neither of those complications you suggest are “par for the course with COPD”, to put it in your characterization.  I can also tell you that the leg problem you describe is NOT a “usual” or common complication or progressive symptom of COPD.  Difficulty breathing can be caused by lack of sufficient oxygen and can be detected by measuring your oxygen saturation while you walk for several minutes.  COPD causes a certain amount of irreversible breathlessness that escalated with exertion/exercise and cannot be relieved, regardless of how much and how many medications one takes.  Those more severe, irreversible symptoms usually are seen in folks whose FEV-1 has fallen to less than 20 % of expected.  But, they are noticeable and can be significant between an FEV-1 of 20 % and 30 % of predicted.

According to the evidence, lung collapse as a general symptom/complication of COPD does not happen.  So there is no answer to your question on how prevalent and at what stage to expect it.  Since we don’t see it as a prevalent phenomenon, according to what we DO know at this point, we cannot go further to suggest when and how many will see it happen to them.  That said, I would also remind you that again, lung collapse covers several quite different kinds of “loss of volume” phenomena that we see in pulmonary disease.  Some kinds are life threatening, like that resulting from pneumothorax.  Some are nuisance or progressively problematic, like those caused by mucus plugging and progressive inflammation.  So, you can’t simply say “lung collapse” and expect that to mean something singularly specific.

If you continue to have questions about this and would be open to being asked for specific information that I or anyone else would require in order to attempt to give you a reasonable explanation, then please write again and provide at least some of the information I asked for and stated was lacking and be ready to give more as requested.  And, please qualify statements like: “It’s not heart or embolism . . .”, etc with how you specifically know them to be true.  I can give you MUCH better answers when provided the pertinent and accurate information.  And I’m happy to give it a try!

Best Regards,                                                                        Mark

Q.  Nose Congestion When Coughing

Could you please explain why my nose gets so plugged  when I cough especially if I'm laying down?  Breathing is hard enough without closing another orifice. TY


Sherri

A.  Hi Sherri,

While I can’t be sure in your particular case, what is a most common cause of your complaint is what we call a ‘vaso-vagal response’ to position and other factors.  That is a phenomenon that is triggered by a nerve impulse to the nerves in that area the control congestion and hormone and other chemical substance release, among other things.   Can I assume it subsides later in the night after you’ve been laying down for some time or sleeping?  Have you tried a Vicks nasal inhaler to see if it helps?

I would say that if it happens every night or very frequently AND doesn’t subside after laying down for a while, you should tell your doctor.  Perhaps you might benefit from a steroid nasal drop or spray solution.

Best Wishes,                                                Mark

Addendum to the post last week titled "Vertigo Caused by COPD or a Neurological Disorder"

To Jorge to whom I suggested inquiring about “spinning” to be done by a PT to see if it would help with her vertigo:  I have since talked with our PT who did the technique on me whereupon I was informed that “Spinning” is kind of a slang term or nickname.  The method is actually called the “Epley Maneuver”.  She says most any PT who is current with their knowledge should know about and how to do the Epley Maneuver.   I can only say it worked great for me and many others whom I’ve seen her apply it to.

Best Wishes,                                                Mark

Q.  The Future of Stem Cells

I always read what you've written here on this website and respect what you have to say.  I DO have a question and although it might appear outside your line of work,  I am curious as to your opinion.

I know lungs are very complex but do you see, at any time soon, stem cells being used to repair or grow lungs or are they just too far away from that?

Thanks, Bonnie

A.  Hi, Bonnie

You ask the million-dollar question(s), indeed!   Yes, the lungs are very complex.  And, it would seem a monumental task to grow the array of tissues that comprise the lungs in the correct cell numbers and configuration.  But, there is so much we still “don’t” know about stem cells and how they work to ‘tell’ cells to differentiate into the myriad of cell types we have in our body that nothing can be discounted in the realm of possibilities.   The fact that, at least in the ‘Petri dish’, we are growing tissues with complex structures suggests that such an end is possible.  The question that we cannot answer is: “How long will it take?”

In the early 80’s, as a speaker for the Cystic Fibrosis Foundation, I shared the CFF developed and endorsed information about how long it would take to expect to discover the CF gene.  At that time, they projected it would be 30 years.  It was less than 5 years later that it was discovered.  And, it was only another few years until they had a viable test to identify carriers.  So, I’ve learned not to try to second-guess or prognosticate in this realm.  Like you and everyone else, I ‘hope’ it is “soon”.  What number to assign to “soon”, I cannot say.

Best Regards,                          Mark

Q.  Oxygen, Ventolin Affects - 6 Min. Walk Test

While sleeping and exertion my oxygen normally falls below 90.  This was decided in March after a 6 min. walk and a take home sleep & apnea test. Yes, I also have mild apnea. I saw a pulmonologist for the first time a few months ago.  I blew, had ventolin and blew again.  No change in those numbers.  They did not do a 6 min. walk test.

Yesterday I saw the visiting RT again. I blew, had ventolin and blew again.  No change in #'s.  Then he had me do a 6 min. walk test.  Halfway thru my chest started to hurt and I had to slow right down.  However, my oxygen only dropped to 90.

I quit using ventolin a few years ago when I thought it wasn't working anymore for SOB.  But was it working for oxygen and I just didn't know it?
Just a few hours before this I got SOB taking out the garbage and checked my oxygen.  It was 82.  So, it must have done something since I didn't take anything else before seeing the RT.  I didn't think it was working as an emergency inhaler but it must have been doing something for the oxygen.  Can you explain this?   

Thanks Mark. Sandy

A. Hi Sandy,

I can’t tell you definitively that the Ventolin had a direct effect to raise your oxygen level during the 6 minute walk done by the RT>  I would wonder if (1) you actually observed the number the RT recorded?  Was that day a “good day” compared to those when you are observing the low saturations.  When you see the low saturations on your own monitor, are they “stable readings?  In other words, have you given the monitor enough time to give you measurements that are consistent and not taken within say, 30 seconds of starting your measurement period?

Generally speaking we DO NOT expect for drugs such as Ventolin to have ANY effect on oxygenation except in some extreme instances like asthma where there is hypoxia due to very shut down airways that suddenly open up and after which the hypoxia is quickly corrected.  But, without any response to the bronchodilator evident on your PFT, there is no reason to believe that anything like I just described would be at play. 

Shortness of breath can result from BOTH or EITHER hypoxia or simply being in bad shape and having a very low FEV-1.  As you did not say WHAT your FEV-1 was on any of the tests you had done, I cannot comment further in your situation.  You cannot extrapolate so much from your observations, at least not to apply to your situation those few years ago.  And, I am doubtful that the Ventolin is responsible at this time.  There are too many other possibilities that are more likely.  But, I simply cannot put a definitive finger on anything with the information you have given me.  It is not enough information nor the pertinent information.  AND the necessary information may not be available or apparent to you.  

My bottom line to you would be to keep measuring your saturation under exertional conditions and if you continue to notice drops like that one to 82 %, badger your doctor until you get a proper walk test to verify or dispute your findings.  If you ARE dropping like that, you SHOULD be given supplemental oxygen for exertion.  Lastly, what did the sleep saturation study show?

Best Wishes,        Mark      

Q.  The Accuracy of Chest X Rays in Diagnosing Emphysema

My question involves a chest x-ray and the diagnosis of emphysema. It appears from the medical literature that a chest x-ray can be used to diagnose moderate to severe emphysema but is not very useful in cases involving early or mild emphysema. Can you share your thoughts on this ? Some of the radiology sites that I have visited conclude that lung changes are visible on standard x rays for certain stages of emphysema and even chronic bronchitis. It is difficult to find a consensus however. Thank you. John   

A.  Hi John,

Indeed, chest x-rays can show lung changes of chronic bronchitis and emphysema.  BUT, what they show cannot be used to “quantify” one’s disease, or assign severity.  CT scans, as radiological studies are VERY sensitive to identify changes associated with COPD and the specific ailments under that umbrella, among other types of lung conditions.   But, THEY cannot adequately correlate to “clinical condition and severity”.  PFT’s are the most sensitive to correlate with clinical severity and even they are not ‘sure-fire’.  BUT, combine PFT’s with clinical complaints and symptoms as well as a well-done walk test, and you have perhaps the best combination of information you need to effectively classify someone AND to treat them optimally.  CT’s and chest x-rays are helpful “after” those I just mentioned to round out the whole picture.   My 40 years dealing with all these modes and mediums has brought me to that position.

Best Wishes,                                                                   Mark

Q.  Vertigo Caused by COPD or a Neurological Disorder

I have been diagnosed with moderate COPD, I feel no shortness of breath however I have this sensation in my head only when I close my eyes of spinning, I have been tested for vertigo and it s not, I also have some problems relating neurological issues such as cortical irritation, whatever that means, but the sensation of spinning or like if I can feel the irrigation of blood (ie rushes) in my brain is overwhelming. I wander to which
ailment I should attribute this, to my COPD lack of oxygen to the brain ? or to a vestibular neurological disorder ? Thanks  Jorge

A.  Hi Jorge,

Your symptoms are not what we would expect or readily attribute to any aspect of having COPD.  They sound like a primarily neurological problem.  Only when COPD is severe enough that a person exhibits hypoxia would any suspicion of lack of oxygen to the brain be a difficulty attributable to neurological manifestations.  Even then, the symptoms you relate are not what we would expect from hypoxia of the brain.

On a side note, have you asked about the intervention called "spinning"?  It is nothing like the name implies.  But, it can correct vestibular abnormalities and the dizziness you describe.  It is a simple procedure involving repositioning of the head to 'realign' the 'crystals' in the inner ear which, in turn, corrects the vertigo symptoms.  A physical therapist trained in the technique can easily and quickly accomplish this intervention which may take more than one application to totally resolve the symptoms.  In any case, it certainly could not hurt to give it a try.  I have had the treatment my self for a remarkably positive result after I suffered a head injury that threw off my balance for some months afterward.  It has been effective to completely resolve my problem.  One of our physical therapists here at our clinic has applied it to many folks with nearly totally effective results.  Some patients had suffered vertigo symptoms from vestibular abnormalities for years.  So, I'm quite impressed that 'for the right problem' it can be effective.  

Best Wishes,                                                     Mark

Q.  Shortness of Breath (SOB) Regardless of Breathing Meds

 I wrote about taking Spiriva and Ventolin and being sob I guess I should elaborate. Will I still get sob no matter what kind of medication I'm on, when vacuuming or changing bedding, is this a common thing with Copd. If I do pursed lip breathing I regain my breath right away. thank you
Elaine

A. Hi Elaine,

While the medications you inhale for your COPD "optimize" airflow through your abnormal bronchial tubes, the basic disorder that causes your increased work to breathe is not altered in any way.  So, while the medications should have the effect to reduce difficulty breathing that would be there were you not taking them, they are not able to or intended to completely resolve or eliminate your added work to breathe.  Activities like you describe are classic for producing much increased work to breathe related to body mechanics and positions AND the fact that you are using your arms and chest muscles  Those activities take away assistance from the respiratory accessory muscles so that they can't help you breathe as well during the activities.  That's actually a 'good' thing as you don't want to rely on those muscles if/when you can recruit abdominal muscles to help do the work.  By doing pursed lips breathing your are doing exactly that, recruiting your abdominal muscles to help you breathe.  That it is as effective for you as you relate is a giant plus.  So, all I can say is keep up the good work.  And realize that while it is harder to breathe during those activities, the benefit to you to continue doing them is far outweighed by and negative considerations you might conjure up. 

Best Wishes,      Mark  

Q.  Missed Doses of Meds

So for the last month or so (since I  joined this site and chat room) I have been using my Advair first and then my spiriva. At night, I use my spiriva again and my GERD pill.....(what a wonder this is).

At first I was not sure, but more the weeks advanced less I needed my Ventolin....even though I had a terrible cold and was on prednisone. 

My first question is: does prednisone cause depression? I was very angry with my close family for the first few days and then it diminished, but I scared them heavily (I was prescribed a 10 day prednisone after 2 antibiotics "biacitin" did not work on my cold over a period of 3 months).....

My second question is: Today I had my morning puffers, however, we left for a day trip and I forgot my bag with my Advair dose. We came back home after 2am and I decided not to take my advair and resume my regular scheduling tomorrow am.  Right now it is almost 5am and I am not SOB, did not use Ventolin and will be going to bed soon * I hope* and intend to start fresh in the morning. Is this okay????

I know the med lasts 12 hours, but can I stretch it once in a while and see if it can last 24 hours???? just curious.

Thanks for all your great help, hope I gave you enough info if not let me know!!
Suzanne!!

A.  Hi Suzanne,

First, I hope you mis-spoke when you said you use Spiriva twice a day.  You should be taking a second dose of "Advair" in the evening, NOT Spiriva.  The rest of the information in your post indicates that you use Advair twice a day and NOT Spiriva.  BUt, I just want to be sure about that.

Prednisone is notorious for causing changes in mood, depression and other even worse psychological changes in some folks who take it.  If you experience these effects AND they seem as if they could be more of a problem than you can handle, let your doctor know as soon as you suspect a problem.  Dose may need to be adjusted.  Other medications may be necessary to combat the side effects.  But, at the very least, you shouldn't try to tough it out without the collaboration with your doctor which can help you through the difficulties. 

As to your second question, it seems that you did what was effective and OK.  Folks will miss doses of medications from time to time.  Depending upon the medication, it may or may not be important to take the missed dose and readjust scheduling to return to the exact prescribed interval and frequency.  In this case, time will tell if you have any difficulty as a result of your missed Advair.  At the worst, you might have to take an extra shot or two of Ventolin the day after the missed dose until your return to the regular schedule catches up. 

Best Regards,                                    Mark

Q.  SpO2 Increases with Exercise

Hello Mark,

I have severe to very severe COPD (I'm right on the borderline).  I'm not on oxygen.  But something really strange, at least to me.....  unless I "overexert" myself when I'm walking, my Spo2 goes up... not down.  Is there an explanation for this?  If I'm really pushing it, it drops,  if I'm not, like I said, it goes up.

Thanks, Jean

A.  Hi Jean, 

One of the tricky points of interpreting pulse oximetry is in knowing when the measurements you are viewing are stable and accurate.  If your oximeter has a signal strength indicator - - - bouncing bars or a flashing light that turns from red to green as the signal becomes strongest, for instance - - - then you should give it time to reach that point before believing what you see.  There is a lag time from placing the oximeter on your finger to when it telle you what your saturation actually is.  That lag time averages 10 to 15 seconds for most oximeters.

If you have reached a stable reading point and you are still seeing these changes, then what you see with the saturation going UP is the effect of "improved" ventilation".  But, for most everyone who has hypoxia, they will see their saturation drop starting usually at about 60 to 90 seconds and thereafter. 

In any case, you should use pursed lips breathing (PLB) if/when your saturation drops too low (usually below 90 %) to try to raise it and keep it at or above 90 %.  If PLB doesn't keep your saturation above 90 %, then you should ask your doctor about starting to use supplemental oxygen, at least for exertion and likely for sleep, too.  The chances of you "over-exerting" are very unlikely!  You should ALWAYS strive to push yourself, even with breathing becoming more difficult, as it will ALWAYS be beneficial in regards to keeping you in better shape and more functional, in the long term.  You can't change the breathing difficulties beyond a point.  BUT, you CAN condition yourself so that they don't limit you as much as they otherwise could. 

 Best Wishes,  Mark

Q.  Is the Damage Reversible?

I was diagnosed seven years ago with COPD.  I was wondering if there is a way to reverse the damage done to my lungs and broncilla tubes?

Carol

A. Hi Carol,

I wish I could say “Yes.” to your question.  But, the fact is that there is not only no way to reverse the damage, but the progression can be limited only so much to, even with the best lifestyle, medications and actions.  So, do the best you can with keeping infection free, active with exercise and take medications properly as prescribed.

Folks can live very long and functional, as well as enjoyable lives when they do everything right and take the best care of themselves once they know they have the disease.

Best Regards,

Mark

Q.  Still Short of Breath (SOB) After taking Spiriva & Ventolin

Why do I still get SOB after takin my spiriva and ventolin?

Elaine

A. Hi Elaine,

There are a myriad of possibilities why you continue to experience shortness of breath despite taking your inhaled medications.  The information you provide is not enough for me to even begin to guess.  But, I can suggest some things you might consider and see if they fit your situation.  But, understand, they are by no means suggestions of what is actually going on with you.

It is possible that Ventolin is not enough for you.  Perhaps you may do better with a long-acting version of the type of drug the Ventolin is.  That could be something like, Salmeterol or Formoterol.  It could be either of those two in combination with an inhaled steroid, like in Symbicort or Advair. 

You could be experiencing hypoxia.  Only measurements of your oxygen saturation - - - especially with sleep and moving around for a couple of minutes - - - could determine.  It could simply be that your FEV-1 is very low and shortness of breath is an unavoidable part of your existence.  Learning pursed lips breathing and engaging in a good and effective exercise program will go a long way to helping you deal with an breathlessness that you cannot get rid of.  Indeed, the worst part of breathlessness is the fear and anxiety it invokes in those who experience it.  What is also difficult to swallow is that no matter how much it feels like it might ‘do you in’, it WON’T hurt you!  AND, you CAN learn to function quite effectively, vigorously and with enjoyment despite working hard to breathe.

But, in your case, you need to first sort out the problem to be sure that you are not ill with something or that there is not a medical reason - - - other than the obvious - - - for you to be experiencing significant shortness of breath.  Have you talked about this problem with your doctor?

Best Regards,

Mark

Q.  Meds Like Symbicort Not Lasting 12 Hours

Hi Mark;

I've been reading previous posts  about the sequence of inhalers you're suggesting.  I also have a question. You say to take the long acting one (i.e. Advair or Symbicort) first thing in the morning.  However; I find that these meds only last about 10 hours.  So; let's say in fact you take it at 7 in the morning, by 5 pm it's wearing off but there's still another 2 hours. So; you take Ventolin to get you through till 7 pm, take your LABA again; you're apt to be short on breath again before morning.  Any suggestions?  Thank You, Rusty

A. Hi Rusty,

If it has been your practice to take the Ventolin and then to take the LABA, and you have not tried the order that I recommend, then the 10 hours you say yours has been lasting is not a true measure of the “potential” of the drug. Indeed, I would suggest that you could not know how long those LABA’s will last until and unless you try the sequence I recommend.  Only when you take the LABA first, then Spiriva can you determine just how long the LABA will actually work. 

But, let’s say that you DO take the LABA and Spiriva first thing in the morning (AM) and by 5 PM you need a boost.  Iv that pattern remains consistent, then I would recommend that at 4PM, you take a dose of Ventolin so that when 7PM rolls around, you’ll be 3 hours out from your last Ventolin.  I know I suggest two hours.  But, that is more an arbitrary amount as a minimum, rather than being based upon something like the dissociation half-life of the drug on the receptors within your lungs.  Any way, what “most” folks find is that after switching to my recommended sequence, their need for SABA decreases or ceases altogether.  So, if you can get to where your LABA and LAAC work sufficiently such that you don’t need the SABA in between doses, you’ll be that much better off AND save some money along the way.

As to the notion that just because you might not get to 7 PM without having to take a puff of Ventolin that the same thing would ‘necessarily’ follow for getting from 5 AM to 7 AM, that is not supported by observation.  Few folks wake up with breathing difficulties ‘before’ their 12-hour night time period is over.   Many folks wake up with difficulty breathing at their regular arising time.  But, they rarely report waking up early because of breathing problems.  So, I would opine that the question of 10 hours duration being fully and always applicable at night even if it is the pattern during the day is without substantiation.  The bottom line is, you don’t know how you will react without trying it.  And I would also caution that it doesn’t always maximize the effects of the LABA’s for EVERYBODY.  There are folks who will still fall outside the bell curve on that point.  BUT, they are few in numbers.  Most everyone reports improved effects of their long-acting medications and reduced use of their short-acting medications

Best Regards,

Mark

Q.  The Sequence of Meds - Advair & Spiriva

Mark,

I am 85 years old and have COPD and advanced emphysema. Also Asthma. I have been on oxygen since 1994. First only at night but now I am 24 hours at 4ltrs
I am not so sure about saba and laba but I am taking spiriva 18 ug and and advair 500 every morning.
What should I  be taking first, the spiriva or the advair?.
Thank you,
Pieta

A.  Hi Pieta,

First, congratulations for managing to fight your battle for these many years, especially the past 16 of them!

It doesn’t really matter which of those you take first.  The general recommendation is to take the Advair first and the Spiriva a few minutes later.  BOTH of those are LABA’s.  As such they are part of the questions of LABA’s versus SABA’s.  And order to take them is not the issue that it is when considering SABA’s versus LABA’s.  If you take Albuterol or Levalbuterol as a rescue or pick-me-up medication, THEN you DO cross the line of consideration of SABA versus LABA.

Keep up your good fight!  You have my best wishes!

Best Regards,

Mark

Q. Diaphragm Question

Hello Mark,

I have had more trouble breathing lately.  My Asthma is controlled with puffers.

Please tell me how my Diaphragm could get shifted.  That is what my chest x-rays showed.

Gail

A.  Hi Gail,

Your information is a bit vague, so I can’t give you an answer that is very definitive.  It would be infinitely helpful to know what “puffers” you are taking AND just what you define as “controlled asthma”.  If you are having more trouble breathing of late, then I would have to necessarily conclude that your asthma, assuming it is your major source of respiratory symptoms is far from being controlled.  I have more questions than answers, at this point. 

What do you mean by your diaphragm getting “shifted”?  How is it shifted?  Is it flattened?  Is it higher on one side than it is on the other?  Just what does “shifted” mean, in this context?  

Next, do you use a peak flow meter - - - at all, or on a regular basis - - - to measure your maximum airflow capabilities?  If so, what are your pre-inhaled-medication measurements and what are your post-inhaled-medication measurements?  This reveals how responsive your airways are to the medications in terms of how much it is able to dilate them - - - to ‘open them up’ so more air passes through them with less effort.  It is a direct assessment of how active your asthma is at any given moment in time.  It is a basic asthma management recommendation that folks with particularly active asthma should monitor it faithfully and regularly and frequently to keep track of symptoms, changes in airflow and airway reactivity and changes that bring about improvement in symptoms. 

One can have air-trapping which over-distends the lungs and pushes down on the diaphragm, making it appear ‘flattened’ and ‘shifting’ it downward toward the abdomen and compressing the abdominal contents.  This can also contribute significantly to increased breathing difficulties.

So, I’m sorry I can’t tell you more that specifically relates to you and your personal question and difficulties.  But, with more of the information I have inquired about, I might be able to tell you more.

Best Wishes,

Mark 

Q. Oxygen & CO2 Retention

Hi Mark,

Recently I purchased a 3 layer cotton, loose fitting mask to deflect the wind so I could go for walk on nice days that happen to be windy. I tested it out the other night and had some odd reactions and am concerned that, in fact, what I'm doing is safe. Winds were upwards of 45K and so I wore the mask over my oxygen as I would my cold weather mask. Admittedly, I did have to breathe a little harder as you do feel the presence of it and therefore a bit of back pressure but it deflected the wind beautifully. However, as I check my sats when we walk at night I noticed that at 5 LPM I was getting sats of 97-99%, which for me is incredible. Normally at 5 LPM, my sat level is around 91-93% at best when exercising. So, I am a little concerned about how high my sats got and I don't quite understand why this would happen. Also, I am concerned about retention although my normal co2 by ABG is only 37. Do you think these things are of concern?

It was fabulous to finally get out and walk and I have always loved to feel the wind so I'm hoping this is a safe way to go. This mask was recommended to me from members of another forum and it is meant for those with seasonal/environment sensitivities but does not have any other filter than the cotton. The only side effect I got from the walk was sore muscles around my ribs from breathing so hard. Just having something on my face seems to make me huff and puff a little harder. The other thing I should mention is that throughout the time that I wore my mask my heart rate stayed at about 105-112 which for me, when exercising is fairly low;  so I didn't see increased workload reflected there. Long and short of things Mark, do you think this is safe and why would my sats increase so much; of course always the concern about retention.

Apologies for being long winded,

Shelley

A. Hi Shelley,

What you have serendipitously discovered is the benefit of a technique of which I have advocated for several years that was originally recommended by my friend Ron Peterson.  We call it the Peterson Straw Mask, though with your version you did not use the straw component.  The mask acts like a reservoir, collecting the oxygen that would otherwise be blown away or at least would dissipate during the time you breathe out.  The mask collects it, the result of which is a bolus of that collected gas plus what’s coming in through your cannula.  It ends up being front-loaded, or the bulk placed at the beginning of your inspiration, which causes it to be carried the deepest into your lungs.  So, your 5 liters becomes more like 7 or 8 liters.   So, you are actually making MORE of the 5 liters than you would without use of the mask.  I recommend that as a strategy for folks whose oxygen systems cannot meet their demands with “standard use”. 

Insofar as the extra oxygen, it is my concerted opinion that it will NOT hurt you one bit!   Using lots of oxygen has NEVER been accused of “causing one to begin to retain CO2”.    A few folks have mistakenly interpreted it as such.  But, that has never been a component of the theory as professed by those who are proponents of it.  Now I DO have one small caution.  By not using the straw to “exhale” through - - - an action that would send CO2-rich exhaled gases directly out into the environment, instead, your mask is collecting SOME of that CO2-rich exhaled gas.  While the oxygen flow is flushing some of it out, you are necessarily “re-breathing” ‘some’ portion of your exhaled gases, and therefore CO2-rich gas.  At 37 on your blood gas, it likely doesn’t represent any problem or threat.  BUT, you could probable eliminate all chance of re-breathing of exhaled gas by incorporating the straw into your mask.  AND, you can use the system EVERY TIME you go walking for exercise, whether or not it is windy.  It can either give you higher oxygen saturations during those activities, as you observed with your current method, OR you could decrease your oxygen flow by maybe one liter and still maintain saturations in the 92 – 94 % range, while stretching your supply all the more through the conservation.  The only difference is a matter of “comfort”.  Many folks find they are significantly more comfortable with saturations of 96 % and up than they are at 90 or 90 %.  So it becomes strictly a comfort issue.

To add the straw, you simply get a large bore straw, cut it in half, snip a “t” in the mask and insert the straw through it.  When you breathe as you walk, you inhale from gas within the mask and you exhale through the straw.

In any case, I’m glad you use the device and that you get out and exercise.  There’s nothing bad about what you’re doing.  AND, you should have no reason for concern about either of the two points you raised.

Best Wishes,

Mark

More On the Sequence of Inhalers

Hi Mark:

With regards to the June 20th post to Sue regarding sequence of inhalers, did I understand correctly that you suggest beginning with your SABA first and then taking, in my case, the two LABAs immediately after.  Short acting is salbutamol and long-acting is speriva and advair (thru a chamber)?  Just curious if I am getting that right as it is usually advised against using together by my pharmacist?  Thanks and have a good week.

Lynn

A. Hi Lynn,

Either you misunderstood me or I wasn’t clear enough.  But, the order I recommend is the Advair, Followed by the Spiriva.  Then, if after 30 minutes OR MORE have passed an you think you STILL need a boost, go ahead and use the Salbutemol.  If the Advair and the Spiriva do the job well enough, you should NEVER have to take the Salbutemol.  It should be reserved as a “rescue” or “pick-me-up” medication that you use ONLY “ass needed”.  Salbutemol should NOT be taken on an arbitrary or regular schedule when you are taking Advair. 

As a point of clarification, the Salmeterol in the Advair is your LABA and the Salbutemol is your SABA.  Always remember that for those with COPD, SABA’s should be used only on an as needed basis IF they are on a maintenance regimen of LABA, LAAC (Long-acting anticholinergics) and ICS (Inhaled Corticosteroids).

Best Wishes,

Mark

Q   Hi, I am a 48 yr old female diagnosed with COPD 1.5 yr ago.  I believe my FEV1 is between 52 - 55% and I am going to see my pulmonary doc in August. I participated in the rehab program and learned many things one of them was taking my Ventolin before my meds.  I am reading your previous posts and notice you seem to say to use the ventolin after Symbacort only if needed. Makes sense to me. However, I do not use Symbacort but I used Advair 250, Spiriva, and Ventolin when needed.

For the last year or so I have used Ventolin 1st and 20min later, spiriva and then advair rinsing my mouth after each puffer.  Could you tell me if I am doing this right or not? My pulmonary doctor told me in January it was a useless thing to do, but I tried not doing it first and found I got a bad cold in January so I started doing it again back then.

I have received Antibiotics January (biacin) March (biacin) and now last week asked my doc to change the antibiotics as I don't think they work and he gave me (levofloxacin) 500mg 7 day dose.  3 days later I still have a terrible cold in my sinuses and chest area with heavy enough phlemm.

So to resume, could you direct me on how to take my meds for the best efficiency and 2: which antibiotic would be the best for me to get rid of this nasty cold. My family doctor says not to use a nasal decongestant (which I was using since my last cold off and on since March till 2 weeks ago).

By the way, I am so happy to have found this site and all this information - I am doing a so-so "happy dance"....lol and of course I am adding this to my favs so I can refer back to all this great info! Thanks for taking the time to reading my post and I hope to hear from you very soon! Have a great day! :)  

Suzanne

A.  Hi Suzanne,

 There is a widespread recommendation that got started back when long-acting beta-agonists (LABA) hit the market (more than 10 years ago) that is responsible for the confusion about which bronchodilators to take and when and in what order.  To explain what happened and how it came about, I offer the following.  Because doctors simply did not believe the information and conclusions of the manufacturers OR the clinical efficacy and dose-validation studies reported to our respective governmental approval agencies for drugs, they began an “off-label” recommendation for patients to use their ‘short-acting’ medications (Short-Acting Beta Agonist = SABA) FIRST and then follow some number of minutes later with their LABA. 

After several years of observing patients NOT benefiting for the 12 hours that they were supposed to with the LABA’s AND hearing complaints here in the USA from patients who were then spending DOUBLE the cost for TWO kinds of medications for NO better results than they had been getting with SABA’, alone, two things happened.  Many doctors discontinued the LABA’s and returned their patients to the SABA’s alone, opining that the LABA’s weren’t all they were cracked up to be.  The other thing that happened was that doctors simply told the patients they needed both and to continue as ordered, regardless of cost or question of efficacy and advantage. 

When this practice crept over into anticholinergic medications (Atrovent/Ipratropium Bromide and Tiotropium Bromide/Spiriva) Boehringer Ingelheim, who manufactures the anticholinergics, put out a directive to physicians telling them NOT to have patients take the SAAC (short-acting anticholinergic) before taking the LAAC (long-acting anticholinergics) because they occupied the same receptor sites and the SAAC would interfere with the uptake and action of the LAAC.  At the same time, I also had a LOT of patients who were transitioning to LABA/LAAC from SABA/SAAC who were following the SABA-first followed by the LABA and SAAC followed by LAAC with their anticholinergics AND they were complaining that they weren’t getting any benefit because they still had to take their short-acting versions just as much as before.  That was the constant discussion and results of hundreds of folks on the EFFORTS site (Emphysema Foundation For Our Right To Survive – www.emphysema.net – our version of your COPD Canada)

So, I called and spoke to several research and development pharmacists with the respective companies and learned that not only do they NOT endorse the recommendation to use SABA/SAAC before using - - - or as a “preparatory” - - - to using the LABA/LAAC, but they made the statement that they could NOT make such recommendations because they had no data to support any claim of benefit.  They simply had NOT studied it.  So, they could not recommend it.  They ALSO could not recommend AGAINST the practice since physicians, by license and law, are free to use ANY medication in an “off-label” manner with or without evidence of efficacy.  So, the practice got started.  Then it became the “mantra”.  “Use the SABA FIRST to open up the airways so the LABA can get deeper!”  Poppycock!  They both go to the SAME receptor sites in the lungs.  AND, those sites only go just so deep!  Getting the medication WAY deep into your lungs is NOT effective, as it would THEN bypass the receptors to which it is supposed to bind!  And what makes anyone think that if one form of the medication won’t get deep enough to open up the airways, that the OTHER one would have any better chance?

Any way, I advised my patients and those on EFFORTS to try cutting the short-acting medication use before taking their long-acting ones and see what would happen.  Almost unanimously, hundreds and hundreds of them found not only MUCH better effect from their LABA/LAAC’s, BUT, they also found out they could decrease and even discontinue use of their short-acting medications altogether!  I heard from several doctors and nurses in large pulmonary practices that they were observing the same effect after changing their patients’ pattern of usage.    So, with the help of Frank Barrett, VP of EFFORTS, I made a chart directing when to take what medications.  It is posted on the EFFORTS site.   In the interim, I field MANY queries, discuss and even argue with some about what should be taken when.

Still, I am convinced that the Long-acting versions SHOULD be the ONLY ones necessary for maintenance/control of one’s stable-state symptoms.  The short-acting versions SHOULD be reserved for rescue or difficult breathing times as a “booster”, only!   Thousands of folks NOW do very well with this pattern. 

I am asked to cite or provide research to support these recommendations.  But, JUST LIKE the pattern of use against which I argue, there is NOT literature or studies or evidence to support EITHER recommended usage pattern.  It’s all anecdotal.  The drug companies have no incentive to study the problem because they are selling more medicine when the doctors order SABA followed by LABA. 

In your particular instance, you should take your Advair and Spiriva in the morning, first thing.  12 hours later, you should take your Advair for a second dose. You should use the Ventolin ONLY if you need a boost during the day.  And, you should try NOT to use the Ventolin within two hours of your “next” dose of Advair.  I hope this is clear to you now.   I may have told you more than you wanted to learn.  But, I needed to provide the background information for your benefit and that of others who may question the recommendation to know and understand why I make the recommendation I do.  Also, as other health care professionals argue about doing it the other way, you have at least my nutshell explanation to give to them.  While your pharmacist is correct that you shouldn’t need to use your SABA and LABA together or in close proximity or on an arbitrarily scheduled basis, it won’t likely hurt you.  It’s just overkill and can invoke the side effects of too much of the medication (shakiness, insomnia, queasy stomach, reduced appetite, among others).

If the antibiotics you are taking now don’t do the trick, ask about “Omnicef” or it’s Canadian equivalent.  That is a good antibiotic for tough lower respiratory tract infections.

Finally, you are absolutely correct to rinse your mouth out after inhaling your Advair.  That is the recommendation printed in the literature that comes with EVERY inhaled corticosteroid!  NOT doing so can cause you to develop Thrush.  Even some folks who are diligent about rinsing their mouths go on to have trouble with thrush.  So, keep doing it.   And I HAVE to ask you if you were tested to be sure you don’t have Alpha-1 Antitrypsin Deficiency Emphysema, a hereditary kind that hits young women?

Best wishes,

Mark

Q   Thanks Mark :)

Thanks for sticking with me...I've given you quite alot
of trouble.

After Sue's good report and the fact so many other COPD'ers
also have good results from the LABA, I decided to try it
for myself. Yes indeed, it did importantly improve my
breathing.

I'm now of the opinion the LABA formoterol is stronger 
that the SABA's in 2 respects; it more relaxes and opens
the bronchia, and those effects last I quess about 8-10 hrs.

Your advice to wait at least 2 hrs after using a SABA before
taking the LABA is a big, important point. I'm gonna try
to wait 3-4 hrs to see if I can get even more from the LABA.

Thanks again...

Gregory J

A.  Hi Gregory,

You did present me with a challenge, to be sure.   I’ve found that given enough time and patience, most folks will come around.  I’m just glad you decided to give my recommendations a try.  Yet, I always encourage folks not to accept everything at face value.  Don’t be afraid to challenge and question.  If those whom you challenge cannot give you adequate explanation or evidence, then you are right to be skeptical.  At the same time, it is incumbent upon the challenger to possess sufficient and accurate understanding of what they challenge so as to be able to properly discern the valid response from the nonsense. My only objective is to help folks help themselves to feel and do better in the face of their COPD difficulties.

As you found - - - and as have so many others found - - - you DO get a better return from the LABA first and likely, exclusively.  AND, you have just started.  Wait until you’ve been doing it that way for a month or two!   I’ll take your word for the “stronger” characterization.  Post bronchodilator spirometry done under comparable conditions after inhalation of SABA and LABA reveal comparable improvement in airway tone and airflow which would tend to argue ‘against’ one being necessarily “stronger” than the other.  But, the intended and touted action IS the difference in ‘how long’ one lasts over the other.  In that the LABA has the expected edge.   Most folks find they last 8 – 10 hours, at first.  For some, that doesn’t stretch out to 12 hours.  For others it does.  But, if you have your SABA, you can last.  Yet, if you can wait until 10 hours, you can always do your 12-hour dose a bit early, too!  Let us know if you ARE able to get more out of the LABA.

Best Regards,

Mark

Q.  Why use your puffer BEFORE exercising?

Why would a person use their rescue puffer BEFORE exercising?  Wouldn't that negate one of the intents of exercising; to push our muscles a bit and our breathing?
Tim

A.  Hi Tim,

Working against constricted airways does NOTHING to help the muscles you want to help through conditioning with exercise.  Using an inhaled bronchodilator before exercise to improve ventilation and reduce work to ventilate is not only prudent and advisable, but, to purposely try to make your work to breathe harder as you suggest would make gas exchange worse AND reduce the cardiovascular conditioning possible as you wouldn’t be able to achieve the same work load intensity without bronchodilation as you could WITH it.  The work that is beneficial to conditioning is of the muscles OTHER THAN those that are involved in breathing.  Make it harder to breathe and you thwart the very primary objective you are targeting with exercise.

Best wishes,                                                     Mark

Q.  Increasing Symbicort Doses

Hi Mark;
I've read that Symbicort has what's known as Smart Dosing for asthmatics and the dosage and frequency can be increased during a flare up.  I've also heard that Symbicort can be increased with COPD; during increased inflammation and in the absence of asthma. Is this correct? Thanks


Sylvia

A.  Hi Sylvia,

The latest published information that I can find is from September 2009 and is a report of the results of the Eurosmart study.  It looked at two puffs versus one puff of 160/4 dosing of Symbicort PLUS as needed additional puffs between 12-hour maintenance doses.  The SMART study, looked at the same thing several years back and resulted in an application submitted to the European drug approval agency asking to expand dosing information of Symbicort ONLY to be included as BOTH “maintenance” and “reliever” medications.  BUT< the application was pulled.  The same was found NOT to be the case with Serevent (Seretide) and there was concern that confusion would ensue.   The Eurosmart study showed that Symbicort can be safely used as both maintenance and reliever medications.  But, it is not yet approved for such use.  In any case, the ONLY condition for which such use is recommended is asthma.  COPD is NOT included in there.   So, I would have to caution against using it as such in COPD.  AND, everyone should ALWAYS consult with their doctor before making off-label use of drugs.  This would constitute an off label use at this tie.

Best Regards,                                                               Mark

Q.  Rescue Med Dosing

Mark :

I read the Sunday June 20 comment by Sue concerning her good
result using the LABA first, and I have a specific question. 

This past Friday night I awoke from a nap at 12 midnight and
could not inhale !!! My bronchia had effectively entirely closed,
though I was able to get a very very shallow short small inhale,
enough to keep me from passing out (and passing away), and enough
to use my SABA (20 doses over 25 minutes). The SABA (salbutamol)
was not much effective, and I managed to get to my steroid med
pulmicort, pumping 4 puffs in about 5 minutes. In total in took
about an hour for my bronchia to finally open.

What if one dose of the LABA isn't enough to rescue a person
experiencing a likely fatal bronchia closure and needing
emergency dilation?

A.   LABA (Long-acting Beta-Agonist) bronchodilator medications are NOT recommended for rescue use.  There are very specific PRINTED warnings against using them for that purpose.  Also, every piece of conventional information regarding asthma attack or ‘sudden airway closure episodes’ such as you describe ALL recommend getting to a facility of emergent care since one can never tell if the attack they are having will be fatal.  Any reasonable health care professional would tell a person that if they experience an attack such as you describe - - - having to use 20 inhalations over 25 minutes to ‘break it’ - - - they should NEVER try to handle such episodes by themselves or at home or away from a properly staffed and equipped medical facility.  Doing so is without question asking for trouble, if not just plain foolish!  

It would seem to me that someone who doesn’t seem to know or understand that LABA’s are not only NEVER (officially) recommended as rescue inhalers under conditions as you describe, but are very clearly recommended AGAINST under such circumstances or conditions should not be trying to manage an attack that requires 20 inhalations of a SABA over 25 minutes time.  That kind of intervention we give ONLY in the emergency department AND with VERY close monitoring of vital signs and a cardiac arrest cart standing within arm’s reach! 

I would STRONGLY recommend you never try that again.  Surely, TAKE the quick and frequent puffs of the SABA - - - WHILE you are waiting for the ambulance to arrive and transport you.  But, next time, you might not be so lucky!  You may not succeed in reversing the attack and not wake up!  This is not so far-fetched a possibility, as a close friend of mine died a couple of years ago from a sudden asthma attack.  He was found in his bathroom clinging to his SABA and had his anticholinergics and other inhalers laying around him.  He was a drug sales representative for a company that produces BOTH SABA’s and LABA’s as well as other inhaled medications (Steroids and anticholinergics!).   He was about as educated and prepared as you can be.  STILL, he died when it got the best of him and he hadn’t called EMS when it first came on!

Lastly, my recommendation to Sue on June 20^th had nothing to do with rescue conditions or need.  It was strictly as a maintenance dose recommendation in her and others who are stable and nowhere near any condition remotely like you describe as being in.  So don’t try to even begin to compare them or suggest any similarity of either information or recommendations.  They are NOT comparable.

Best wishes,                                                     Mark

Q. The Sequence of Meds - Positive Results but Any Studies?

Mark, I have been following the sequence you suggested for taking Multiple Inhaled Medications, and the improvement is amazing.  I had a PFT following the first two weeks of the schedule and my FEV1 went up by 6%.  It was the first time I'd ever had an increase and I don't think it was just a fluke, I really do feel better.

The reason for my post is that I have tried to share this schedule with others and they want to have proof as to why we should use the meds in this order.  Can you site any studies or scientific information that I can provide for them?  For me, the proof was in the pudding.  For others, they want the facts, and if I'm passing this suggested schedule out I guess I should be able to back up my information, as well.

Sue

A.  Hi Sue,

Unfortunately, I have been asked that same question from MANY health care professionals, including physicians.  The quick and easy answer is “there is NO evidence” (no studies, no literature, no evaluation or no drug manufacturer recommendations) beyond the anecdotal experience like you have had to support my recommendation and the technique that you have found so helpful.  BUT, I can ALSO tell you that there is NO evidence - - - no studies, no research, no evaluation - - - of ANY kind to show that taking those medications the way most recommend them (short-acting FIRST and then the long-acting ones right away, after words) is the right thing to do!  Regardless of the cute reasons folks give - - - “to open up the airways to let the long-acting drug get deeper”. - - - there isn’t one shred of study data or evidence to show that that explanation is valid.  It sounds good!  But, it doesn’t make any sense.  They ALL go to the same receptor sites.  AND those receptor sites don’t go all that deep! 

Then I have to ask: If the long-acting medication can’t adequately and effectively get to the sites it needs to get to, then what makes them think that the short acting form can get to those sites any easier or better?  I have spoken with the pharmaceutical company researchers (pharmacokineticists, they are called) who assure me that NO bronchodilator manufacturer has EVER made the recommendation that short-acting bronchodilators should EVER be used *with* long-acting ones, let alone for the reasons that are touted OR in the order that is touted.  They simply say they cannot recommend use of the two drugs together as they are intended to stand alone.  Using short AND long-acting versions is “off label” use that has come from doctors and been perpetuated by doctors.  AND, they have not conducted any studies to determine if it is needed, or effective in the manner they practice it.   It is a usage pattern and rationale for which not one shred of research has been conducted to determine if (1) Is it needed? (2) Is it effective? 

I have asked about research support to study each method.  There is NOT a single incentive or desire on ANYONE’S part to do it, least of all the manufacturers.  Why spoil a profitable thing? ! ?  If they sell lots of BOTH short-acting AND long-acting medications they make all the more money.  The doctors have created the monster.  BUT, the manufacturers reap the benefits while patients struggle trying to pay for BOTH kinds of meds only to negate the effect of the most expensive one, the long-acting!  If the manufacturers try to question the doctors’ practice, they are then accused of trying to tell the MD’s how to practice medicine!  So, they shut up and count the profits!

Your results are typical and predictable.  BUT, the myth of the short-acting first then long-acting has been spread so far and wide that everyone thinks there’s evidence to back it us AND that it arose out of study-derived evidence, NONE of which is the case!  It will not likely go away anytime soon.  But, I’ll talk to anyone who wants to listen and discuss it.  In the meantime, I just recommend folks try the sequence I recommend and decide for themselves.  AND, in over 5 years of feedback from thousands of folks, I have not been disappointed.  EVERYONE has either done no worse or - - - as for the vast majority - - - done infinitely better!

Best Regards, Mark

Q. How Many Puffs of a Bronchodilator for a PFT (Pulmonary Function Test)?

When doing pulmonary function tests, how many puff do you give for the post. I have heard 4 puffs of the bronchodilator. We were doing 2.
Could you tell me what the standard is. We live in Ontario.

Cheryl

A.  Hi, Cheryl,

I don’t know that there is a “standard” policy on that.  It would seem to me that whatever you do, you note it on the report (ex: “4 inhalations of Abuterol administered and post-bronchodilator measurements obtained 20 minutes later.”) and be consistent within your lab.  I know that some labs use 2 inhalations and that require the MD to order how many he wants if he doesn’t want only two used.

Best Regards,   Mark

Q.  Follow Up on Previous Q & A from June 6rh Re:  Shortness of Breath & Diffusion Rate

From last weeks q & a, SOB, shortness of breath and diffusion rate....I apologize for forgetting to add my name at the end.  I wanted to thank you for your answer and let you know that I am going to take your advice and step it up on my TM.  I never considered turning my O2 up that high to gain some speed.  The one thing I'd like to comment on your answer was your referral to my practicing avoidance.  The time I have my most difficulty is coming from my car, up an incline, up stairs, and then into the house.    Kinda hard to avoid that, or even want to.  I do my pursed lipped breathing here but it's not working.  I do think that you are correct in saying I am probably out of shape, however, and I plan to rectify that immediately!  Thanks for your encouragement.  Sue


Sue

A.  Hi Sue,

I’m glad you found my response helpful.  But, there is one point I want to clarify.  When I speak about “avoidance” behavior, I am not speaking of it in a “critical” manner.  In other words, I was not criticizing you for avoidance behavior.  I use the term avoidance in this regard as a “descriptor” in that ALL folks exercise ‘avoidance behavior’ to try and steer clear of difficult breathing.  It is natural and understandable and NOT a “character flaw”.    So if you exercise avoidance behavior, you are doing no different than most anyone else would.  What I hope to get across in mentioning it is to help you and others understand it and consider it when you see the signs.  When you understand it better, it becomes easier to overcome AND more manageable until you can overcome it!

Best Wishes with your effort!   Mark

Q.  Pot Smoking &

Will exercise improve lung function 

Hello Mark
               My name is John   I am 37 years old, I have been smoking pot every day for 20 years with a break here and there., I never smoked cigarettes and I rarely drink. My lungs have been feeling pain that some times pulsates and it changes locations from the front to the back, An ekg was flawless and a chest x ray is negative. My pulse ox ranges from 98 to 96 once, usually in the 97 98 percentage. my internal med Dr. gave me ventolin , It didn't  do much, I feel like my lungs are getting filled and I find it hard to breathe sometimes and pain when taking deep breaths deep in my lungs where I have to stop the deep breathing immediately breathe out and shallow breathe for a few seconds then try the deep breathe again. I am starting to get worried. I saw a pulomonologist and he gave me symbicort, The moment I took it I felt a release on my lungs and my breathing improved, Am I going to have to take this inhaler for the rest of my life? I am serious and am willing to quit and start exercising, Can exercising improve my lung function being that I have copd through smoking pot only? I used to work out rigorously and can do about 30 dips non stop and I haven't worked out in a long time, But I do keep busy at work all day long moving around.  

John

A. Hi John,

I cannot tell you with confidence how long you will need to use the Symbicort.  With the response you relate to it, it sounds like you have some airway reactivity.  What you decide to do with regard to quitting smoking the pot is your decision and move to make.  If you look to make it hinged on the condition that you will or must get better, then you are doing it for the wrong motivation, IMO.  Returning to working out can potentially improve your breathing.  But, we are careful to tell folks that you CANNOT “restore” lost lung function through medications, oxygen or exercise. 

I would recommend you get a Pulmonary Functions Test (PFT) done.  A PFT will tell you and your doctor exactly ‘where’ in the lung disease process you may be.  It will certainly ‘quantify’ any ‘damage’ that may be there, as well.  But, the important thing it can do is to show you if you’ve done any significant damage to your lungs AND how much influence it can have.  You might be surprised to learn things are not as bad as you may think.  Of course, the opposite is possible, too.  But, at this point, you are worried about some real possibilities that simply cannot be defined without a PFT.  X-rays and scans cannot tell you as much as can a PFT.

Insofar as exercise is concerned, what you describe is a measure of strength.  What matters in lung disease and the conditioning that is meaningful to controlling respiratory symptoms is “endurance” conditioning.  Strength training results from short interval exertion against significant resistance.  It is “load dependent”.   Endurance conditioning results from repeated motion over significant duration.  It is time-dependant.  Folks often think that because they are busy doing things all day, even if it involves being on their feet and even doing some walking, that they are fit and in good physical condition.  Yet, when challenged with 30 minutes of brisk walking, they poop out very quickly OR really work harder than they expected to get through it.  They lack endurance conditioning because the activities they thought were exercise-equivalent simply are not.  There is no adequate substitute, unfortunately.

Best Wishes,  Mark

Q.  ABG (Arterial Blood Gas) vs Finger Pulse Ox - Accuracy

    Coughing & Getting Bad Air Out

Hi Mark; 

Thank you vm for taking the time from your busy schedule to answer our questions.  I visit this site often.  But I do have 2 questions I've not seen asked yet.....

1. with hyperinflated lungs you want to get the trapped air out. How come when a person coughs they can become short of breath?  it would seem to me that getting the bad air out should help?

2.  Is it possible to have had an abg showing you need oxygen but a finger pulse ox showing you don't?

Jenna

A.  Hi Jenna

If coughing did no more than to get the bad air out, it would indeed be a welcome improvement.  The fact is that because of the ‘dynamics’ and ‘physics’ of coughing, it does nothing to “get rid of bad air”.  For those who would need it the most, it does the least.  Because so much energy is expended in the act of coughing AND because of the changes in pressure within the chest and head, coughing is more traumatic and upsetting to the ‘balance’ of the body than useful to move any more than the air expelled during the effort.   Those factors and forces are more a part of the process than any expulsion of trapped or stale air.

ABG’s are the definitive and direct measurements of blood oxygenation and ventilation.  Pulse oximetry only indirectly measures saturation which is a combination of oxygenation AND ventilation, as both functions factor into saturation.  The ABG will always be more accurate.  The pulse oximetry measurements will ALWAYS be suspect and less accurate much of the time. It is guaranteed to within + or – 2 % of actual under ideal or best conditions.

That said, if you are sick when the ABG is done and you have recovered and made significant improvement by the time the pulse oximetry measurement is done, it is possible to have the difference you suggest.  But, it is not a function of the type of measurement or their accuracy.  It is s function of healing and improvement between one measurement and the next one done.

Best regards,Mark

Observation by Gregory J

Mark:

I realize you're a "pro-establishment" kind of fellow and you spin it up quite good, albeit you're talking over the heads of people here and their confusion makes spin work.

ALL science sites I read-over advised the dilator be taken before a steroid...all say the same...the dilator opens the bronchia so the steroid will penetrate further into the lungs. Common sense says the same would occur with the SABA 1st and LABA combination med 2nd.

All sites note copd'ers in an oxygen crisis apply as many 6-8 doses as per episode.

Your claim the LABA has a greater dilation effect is misleading. A longer lasting effect is NOT the same as a greater diameter of opening in the bronchia.

Though you say formoterol is as quick acting as SABA's, all sites advise its NOT to be used as a rescue medication. (Note fortmoterol fumarate is fast-acting and may be used as a rescue inhaler, but not if used less than 12 hours from any other dose of the same drug;
http://www.copdcanada.ca/index.html

The LABA Salmeterol is not fast acting. ALL sites read-ver advise copd'ers also use SABA's.  Oh yes, the SOB IS a lack of oxygen crisis.

Your claim dilators do not improve oxygen intake is bizarre!  In your own words...dilators "allow better ventilation"...
now...hypoventilation (also known as respiratory depression) occurs when ventilation is inadequate (hypo means "below") to perform needed gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapnia) and respiratory acidosis.
and..."The most serious consequence of hypoventilation, particularly during sleep, is hypoxemia...and...hypoxemia is simply defined as insufficient oxygenation or lack of total oxygen content of (arterial) blood. and...optimizing bronchodilator therapy has been shown to improve gas exchange.

I wasn't "Lumping" steroids...I specifically said combination drugs which contain a LABA and steroid...inhalers!!!

SABA's are safely applied in such extra amounts. HOWEVER, I did state LABA's are often in combination with a steroid,
which should not applied in such extra amounts.

ALL science sites read-over state steroids have no effect on lung function in copd patients...and have no effect on mortality
rates in copd patients.

In the March 5, 1997 issue of the Journal of the American Medical Association, Dr. Edeltraut Garbe and co-workers described the results
of their study to evaluate the risk of glaucoma in patients using inhaled steroid medications. In light of the widespread and long-term
usage of these medications, their results are nothing short of alarming. They found that ongoing usage of high doses of inhaled steroids for three months or more increased the risk of glaucoma by an astounding 44 %.

In addition to this increased risk for glaucoma, the likelihood of cataract formation is also profoundly enhanced in patients using inhaled steroid medications. In a large, well conducted study appearing in the July 3, 1997 issue of the New England Journal of
Medicine, Australian researchers reported a 300 % increase in incidence of cataracts in users of inhaled steroids.


Gregory J

 A: Hello once again, Gregory,

We have been down this road on these points in several previous posts in which I have as carefully as I can, explained the error of your thinking on the matter of short versus long-acting bronchodilators.  If you cannot accept the “evidence-based” explanation that I have given you, then that is your personal difficulty and does not in any way change the facts.  So, I can only refer you back to my previous explanations for the information I have conveyed.

The information that I offer is not some kind of “political stance” or “politically correct” ‘spin’, as you put it.  I offer what we can explain and prove according to the “evidence”.  You have offered explanations based upon your poor understanding of pulmonary anatomy and physiology which will not become any more correct no matter how loud you scream them or how many times you reiterate them in defiance.  Again, I have offered the best information I can according to the evidence that is available.  If you cannot accept it, I can do no more.  

Nowhere in the evidence-based literature or the manufacturers’ published drug information is there any suggestion that bronchodilators are administered to ‘raise oxygen levels in the blood’.  Nor will you find anywhere in the evidence-based literature that remotely suggests that their use is indicated by any such emergency as what you call an “oxygen crisis”. 

While I agree that decreased oxygen levels (“lack of oxygen”, as you stated it) can and will invoke shortness of breath, the degree of influence and intensity it produces varies among individuals.  Some folk’s oxygen levels can drop to dangerously low levels without causing them shortness of breath while for others only mild decreases in oxygen levels can invoke strong symptoms.  Shortness of breath, in and of itself, however, is NOT a necessary sign of low oxygen levels.  Further, low oxygen levels aren’t the ONLY cause of shortness of breath.  Indeed, the evidence in addition to common experience among those of us who deal with lung disease shows that as often, even more often than not, we encounter folks with severe lung disease who have severe SOB AND who have “normal” oxygen levels.  In those instances, it is their ‘ventilatory abnormalities’ (having to do with blood pH and carbon dioxide levels) that is the cause of their SOB.  Additionally, treatment with supplemental oxygen in those individuals does NOT curtail their SOB.  Often, it will simply have no effect at all.

While there is a significant amount of published literature that suggests that inhaled corticosteroids do not significantly benefit those with COPD or positively influence mortality, there is an equal amount of literature that finds to the contrary.  Those of us who prefer to let the evidence speak for the facts are content at this time to agree that the question is far from settled and that the best evidence has yet to be produced, as most studies on BOTH sides of the argument are rife with flaws and short-comings that render them far from definitive.  The current consensus for standard of care includes use of inhaled corticosteroids in a progressive stepwise fashion.  I refer you to the GOLD report (Global Initiative on Obstructive Lung Disease) for further information.

Insofar as your argument about the glaucoma and cataract incidence among users of inhaled corticosteroids, again the evidence continues even now, 13 years after your citation, to be mixed and inconclusive on systemic effects of “inhaled” steroid.  AND, when faced with a patient who can breathe reasonably well as a benefit of steroid use and one whose breathing goes south when their inhaled steroids are discontinued, we are faced with the choice to do what controls the symptoms and deal with the risk.  So, while we can argue the virtues and vices of inhaled corticosteroids, even the study you cite supports the contention that given the choice between systemic and inhaled corticosteroids, the inhaled steroids are far more preferable.

You are entitled to your opinion of how lung disease and airway reactive symptoms should be treated.  You can make choices for yourself.  But, you have questionable basis upon which to argue against the various treatments for others when the WHO and all of the individual international pulmonary medicine organizations recommend these very treatments as the current, evidence-based standard of care.  I am sure they would invite you to present your evidence and arguments to them.  Insofar as I am concerned with regard to your continued posts of the same arguments and same discredited explanation, I have no more to say.  And, future posts from you on this topic will not receive response from me.

Mark

Q.  Incontinence/ End Stage COPD

I have end stage COPD. I am wondering about a time line. When I have an attack it starts...then it exacerbates ..when it gets bad I peee myself and that's mi 911 trigger. is that too late or a good guide? after that point if I black out and loose bowel function how long do I have to get emergency breathing before I die.

Blair

A. Hi Blair,

Your problems are classic for someone who has resorted to sitting more than moving as moving provokes increasingly difficult breathing and so is to be avoided.  That, while being a very understandable response to increasing difficulties, is ALSO the recipe for disaster and early demise.   Your question cannot be answered as you ask it because you make certain assumptions that are in error which renders the rest of your conditional question inaccurate.   End stage COPD, while used a lot and rather cavalierly bandied about is a meaningless term, a primary reason why it has been abandoned and replaced with a well-defined “staging” system through the efforts of the WHO and the GOLD classification.

It has been my frequent observation that when folks lose urinary continence, it is because they have become hypoxic AND they have succumbed to a significant degree of anxiety and panic.  I would wonder is you are not becoming hypoxic and THAT is why you lose continency.   It does not ‘necessarily’ follow that after losing urinary continence you would go on to worsen to lose bowel continence and/or black out.  That is just not predictable.  As such, there is no way to say that you would then go on to die, OR that you would have any other predictable response of so serious a nature.  But, the likelihood of you dying from such a sequence as you present it is simply not there.  Death is NOT that predictable. 

I would urge you to have your oxygen measured WHILE YOU WALK for at least 2 minutes to see if your saturation is dropping a lot.  If it is and you are not currently using oxygen, you SHOULD be started on it.  If you ARE using oxygen, then you need to learn how much it needs to be increased in order to keep you from dropping so low as to lose continence.

Best Wishes,    Mark

Q. SOB (Shortness of Breath) & Diffusion Rate

It has been suggested to me that my unusually strong SOB is related to my diffusion rate.  I have a FEV1 of 37%, with a diffusion rate of 33%.  Is this true and can you explain why this is?  I can't do much around the house at all, nor work in my garden, bend over, walk up stairs or inclines, without extreme SOB.  My O2 level doesn't drop much, however, and I recover within a few minutes without O2  I am careful to watch my breathing, but still have a difficult time.  I have little trouble on the treadmill, doing 1.5 mph for 30 minutes on 2& O2. (no name given)

A.  Dear “Unknown” (You did not sign your name on your question)

With the numbers you offer from your PFT, I’m betting that your SOB is NOT from oxygen, especially when you tell me that when you measure it, you find that it ‘hasn’t dropped much’ (How much does it drop and WHAT does it measure?) and ‘quickly recovers’ (to what number?)  What you describe is classic for what we call “dynamic hyperinflation”.  That is a phenomenon where you breathe “in” more air from one breath to another in succession than you breathe “out” effectively “trapping” more and more air in your lungs until they are like an over-inflated balloon.  Your sensation at that point is that you can’t get enough air into your lungs - - - which is TRUE - - - but, the reason is because there’s no more room for any additional air!  Pursed Lips Breathing is of GREAT help in combating this phenomenon and to help prevent it or reduce its impact IF begun soon enough into an activity for it to work AND provided one has become skilled enough to use it effectively.

When you tell me that you are careful to “watch your breathing” that tells me more than you are looking for disaster as it tries to descend upon you so that you can put your “avoidance” behavior to work and “avoid the anxious and difficult breathing that inevitably comes on.

While 1.5 mph for 30 minutes on the treadmill is nothing to sneeze at (how many days a week?), if you think that it is enough to give your sufficient conditioning to climb stairs, walk up inclines or perform tasks that require upper body strength and action, then your expectations are misdirected.  If you don’t exercise to “challenge” your breathing, to get winded and “achieve” a state of ‘manageable’ discomfort, then you’ll continue to decline and ultimately become unable to do even simple tasks without getting severely SOB.  I know this sounds counterintuitive, but until and unless you challenge yourself to work hard enough to produce symptoms, you can NEVER overcome the limitations that now exist at the levels of activity they currently occur.

With an FEV1 of 37 %, you actually have a remarkable amount of “wind power”.  But, if you are ‘relatively’ out of shape, your breathlessness with exertion can be tremendous.  And I suspect that is more the case than any unalterable limitation of your disease severity that you might try to put your finger on.  And that’s GOOD news!  While your task is difficult, your reward can be GREAT!  If 3 or 4 L/min will allow you to increase your walking speed to 2 or more mph, then go for that goal!  Until and unless you can get up to a significant speed, you cannot expect the kind of conditioning that you lament not having at the moment.

If you have other questions or difficulties along the way, write us again and I will try to help as best I can.

Best Wishes,     Mark

Q Observation/Meds

After some 2 months of googeling to learn about the medications
and side effects, etc for the treatments of lung disease, it has
finally become obvious to me there is a critical absence of
concern, effort and resource spent on lung disease. Though
the WHO reports asthma and lung disease mortality rates are
steadily increasing and lung disease is the 3 to 4th leading
cause of death on the planet, when one delves into the sciences
of lung disease, they will soon discover 3 things; current
studies are incomplete, current research is contradictory,
or there is currently no research available on the subject.

In Canada, reports are the Gov't of Canada allocates only a
despising, scroogist 2% of all money allocated to cancer
research for lung cancer. Included in this issue are reports
of the consistent, widespread fact north American and European
Dr.'s do not involve their patients in the information,
discussion and decision-making of their own diseases and
treatments.

Furthermore, in Canada medical Dr.'s recently forced the federal
government to outlaw patients/victims rights to legal action against
Dr's. Now as it is, Canadian Dr's have an entire history of a
damning lack of humility, unwilling to accept criticism, unwilling
to admit mistakes, and unwilling to accept any losses for their
mistakes.

Undeniably, the west's medical Dr's have created a solidarity
labour union of absolute, monopolistic authority and control
over health services. 

Though the money racket of mass media is always running
TV series showing a medical establishment of richly compassionate
and determined healers, the real facts are most Dr's and such
are in the biz for their own personal gains, notwithstanding
a small portion are indeed compassionate personalities and
do make extra efforts to successfully treat their clients.

I suppose the 'Mr. Peabody' moral of this story is we cannot
simply trust the medical establishment to care about us, and
all people need to take a more assertive position in terms of
their visits and dealings with medical practioners. We need to
'google up' as much information about our illnesses as we can
and actively participate in our own treatments. Government
leaders are not concerned with our health, merely the
money-costs of the medical system, and it seems damn true,
tobacco users have been condemned and somewhat abandoned by
their societies.

Gregory J

A. Hi Gregory,

You do not ask a question here.  So I have no response for you except to say everyone is entitled to their own opinion, whether or not it is based in fact or fiction.  And you certainly are entitled to yours, much as I may disagree with you on so many of your points.

Regards,    Mark

Q. LABA's vs SABA's

Hi Mark :)

I need to clarity my view the SABA is the wisest and healthiest choice
for copd treatment.

1. LABA's do NOT dilate/open the bronchia any more than the SABA's.

2. LABA's typically have a much longer wait time before effecting
dilations. Commonly, 15-20 minutes, versus 4-5 minutes for the SABA's.

3. LABA's block the lungs receptors for a much longer time than
SABA's. Commonly, the shortage of oxygen crisis needs multiple doses
for recovery and the extra long wait time before those LABA's become
effective compounds the wait time for relief to occur. It makes no
rational sense to advise a copd patient to apply the LABA first and
extend their recovery period from what could be 10 minutes (SABA)
to what would then be up to over 1 hr (LABA) !

4. My price comparisons show LABA's are up to 3 times more expensive
than SABA's.

5. I suggest those American 'so-called' Dr's advising the LABA be
the first treatment so to reduce the costs of treatment are
themselves directly financially benefiting from advising the use
of LABA's. All those not born yesterday can see the great majority
of medical Dr.'s take-up the profession from their first concern
for personal gain and having, superior status and income being
the 2 greatest benefits.

Gregory J

A. Hi Gregory, 

Of your questions, three (3, 5 & 8) deal with the same issue, which is that which I also explained in answer to your questions last week.  I am glad you “clarified” your points and presumptions because it is now clear that you didn’t understand much of what I explained AND you still don’t understand the fundamental differences between SABA and LABA.  Were it true that you understood those differences, you’d also realize how horribly wrong your assertions and opinions are with regard to these points you continue to push.  It is also clear that you have poor knowledge and understanding of the anatomy and physiology of the airways, hence wherein lays much of the error in your assumptions and assertions.

First, the most important difference between SABA and LABA is in the very first letters and the letter to follow in each of them.  SA means “short-acting”.  LA means “long-acting”.  It is not simply a matter of holding onto the site longer than the other.  It is a matter of how long the bronchodilating action is exerted on those airways.   The action of SABA lasts an average of 4 hours.  The action of LABA lasts an average of 12 hours.   In order to get comparable bronchodilation with SABA’s as to that of LABA’s, you’d have to take three doses (at 4-hour intervals) of SABA to every one dose of LABA.  LABA’s when taken as intended not only negate the need for SABA’s, but, they have an overall better and more consistent action and effect than SABA’s can possibly have!   LABA’s by far, are the better choice for those who wish to have better and longer and more stable bronchodilation without having to take so many doses of medication.  AND when used as intended AND provided they work as intended, they will cost about the same, as SABA’s will be needed little or certainly much less than LABA’s. 

You argue for time to effectiveness with LABA’s and SABA’s.  Your declarations are again in error.  Formoterol has a rapid onset of activity that is every bit as fast as SABA’s at about 5 minutes.  Indeed, at one point, it was argued that Formoterol should be considered a “rescue medication”.  BUT, because people have a tendency to confuse medications and since Formoterol is an LABA, as is Salmeterol which DOESN’T have such a rapid onset of action, it was determined that Formoterol would NOT be promoted as a “fact-acting” or “rescue” medication.

You continue to state that these medications are used for ‘crises of oxygenation’.  That is simply nowhere near the truth, Sir.  Bronchodilators do NOTHING to affect oxygenation in any direct manner.  In severe bronchoconstriction, then relaxation of the bronchospastic airways allows better ventilation and indirect improvement in oxygenation as a result.   But, the problems you have with COPD for which the bronchodilators are most effective are NOT significant constriction.  They are NOT for improved oxygenation.  They ARE for reduction in dynamic hyperinflation and reduced work of breathing.

On another point, you are lumping ALL corticosteroids together in your condemnation of them.  Inhaled doses of steroids AND where they are deposited and exert their action along with the characteristics of their absorption and how much is absorbed, are so vastly different from systemic corticosteroids that to compare them is treacherous and fraught with pitfalls and error.  While ALL steroids “can” induce and exacerbate glaucoma, cataracts and diabetes, it is unarguably “dose-related”.  5 mg of prednisone taken orally will have a dose-effect on the body as a whole that is a hundred fold and more greater than several mcg’s of inhaled steroid medication.  While inhaled corticosteroids have been used for decades AND a veritable mountain of information gather to reveal the good the bad and the ugly about them, they are still infinitely safer and preferable to systemic steroid treatment.

To correct another error in your interpretation of what you say you’ve read in your searches, you declare that inhaled steroids do NOT decrease inflammation of the airway.  Not only is that diametrically opposite to the “fact” and “observations” and measured effects of inhaled steroids, but were it the case that you were correct in that statement, there would be no sense in inhaling steroids in the first place as they ARE anti-inflammatory and that is the intent of their use and action in lung disease treatment.  Inhaled steroids do NOT cause the serious side effects that you site.  What that information covers is “systemic” steroid treatment.  AND, while those are potentially devastating side-effects AND must be considered when weighing the advantages and disadvantages of using the treatment, remember one can recover from and/or deal with those complications IF they can breathe.  If they refuse to use the steroids and die, their problems are instantly solved, though maybe NOT as they had hoped.  

Also, you might want to go back and re-read what you found about inhaled anticholinergics.  While they “can” AGGRAVATE already existing “narrow-angle glaucoma” AND they “can” aggravate already existing prostatic hypertrophy and reduce response to signals to dilate for urination, they do NOT “cause” either one of those conditions if they do not exist in the first place.  It’s a far cry from “aggravating” a condition to “causing” it!  And, there are many other anticholinergic medications given for many other conditions in both systemic and topical applications that “can” cause the same side effects - - - - that is, to “aggravate existing conditions.  The bottom line is does the benefit outweigh the risk?

One more point, you surmise that if relaxation of the airways would allow deeper penetration of medication that more of the medicine would get deeper into the lungs and ultimately work better.  In terms of anatomy, the further out into the periphery of the airways that you travel, the less smooth muscle that is subject to or “able to” spasm decreases.  To get more medication out further into the lungs therefore does NOT do anything helpful and ‘could’ be argued to be a waste since it would go where there are no receptors much less any muscles upon which its actions could be exerted.

If you indeed DID read what you argue and profess in these regards on your Google trips, then perhaps you need to seek better sites with more accurate information.  You have pronounced and professed much erroneous thinking, reasoning and facts within these several posts you have sent to this forum.  In your error, you have made some unwarranted and undeserved condemnations of physicians and other health care professionals as well as the various health service powers that be and those who cover payment for those services, all this in addition to condemning several treatments for erroneous reasons.  If you seek factual and truthful information, you’ve come to the right place.  But, to present your arguments with the ONLY presumption being that you are inarguably correct from the start and all other information, explanation and argument must follow on those terms is not an effective approach. 

Regards,     Mark

Six  opinion/observation pieces were received this week; 4 have not  not been included or uploaded  above.  Although we welcome the ocassional argument for the sake of additional clarification  and in the best interest of our readers seeking information,  this web page is intended for specific questions.  Discussions should be reserved for forums or message boards.  Additionally we are unable to respond "directly" to any poster UNLESS they include their e mail address when submitting.

Q.  Inhalation of Paint Fumes

Mark replies to a question by Robert about paint fumes saying "Inhalation of paint fumes like that should NOT result in any pulmonary pathology"

I myself also did some indoor painting using both an oil based interior paint and an acrylic indoor paint.  When the weather then turned colder, I closed my windows and took a nap.  Upon waking after a few hrs my lungs had SEVERELY inflamed and closed, and that inflammation lasted for SEVERAL WEEKS. This incident was IN FACT a life-changing catastrophe from which my bronchia have never recovered !!!

Gregory J

A. Hello Gregory,

My response to Robert was for “him” question and conditions AND for paints labeled ‘non-allergenic’ and ‘non-toxic’ in general.  It was not intended to cover an “any or all” condition for paints.  You do not give a timeline on your event with which to judge that what you say is indeed “FACT”, nor do you provide any information to exclude agents other than the paints you used from being culpable.  I would suggest you double-check the label for those paints and see if there were any warnings about risks related to inhalation of the fumes.  If you find nothing, I would suggest contacting the manufacturer and ask for their “MSDS” (Material Safety Data Sheet) to review any potential toxicity for the ingredients or mixture.

If indeed, your paints were “the only” potential cause for your lung ailment event AND they are sufficiently guaranteed to be safe for inhalation under conditions comparable to those you encountered, then your answer lies in the fact that you are uniquely sensitive to THOSE paint products and should avoid using them OR make appropriate preparations for leaving your home during the time that their toxicity ‘to you’ is active.

It is well documented that fumes from formaldehyde and dyes in carpets, upholstery, paneling, furniture glues and many other substances that go into manufacturing of materials from which houses are built and remodeled can produce inhalation insults of quite a variety.  I would recommend you check out other possibilities to be sure other allergenic materials are not in your environment OR that might combine with each other’s toxic materials to produce a unique product that is the cause of your irritation.

Finally, I am sorry to learn of your respiratory difficulties, whatever the cause and hope that your ling function is continuing to improve.  And, I would ask  are you currently living in that space?  Do you continue to suffer recurrent symptoms when it is closed up such that all air you breathe is from within it?

 Best Wishes,Mark

Q. Coughing & Lung Damage

I've read a number of questions and answers here and have a few concerns. One person asks about the usefulness of Mucinex and the answerer recommends it's use. "keep coughing and  clearing what mucus accumulated within your airways as best as you can from moment to moment.  The Mucinex is good to help keep it looser and more mobile."

I am wondering if coughing isn't actually the original root cause for the scarring of the lining of the airways of the bronchi in the 1st  place, and it is the continued coughing which is the cause of the progressively worsening condition of the lungs. If so, coughing should be avoided. hard coughing should be avoided; repeat coughing should be avoided, etc. What are the facts regarding the root cause of the scarring the lining of the airways?

Gregory J

A  Hello again Gregory,

You ask an age-old question that would seem simple and logical, given the appearance of things on the surface.  However, your very question has been studied by many, many scientists over many years with the same conclusions.  Without going into a lengthy explanation of the “physics” of the cough sequence, I can assure you that there has never been any evidence produced that shows that the cough - - - a reflexive and “protective” mechanism for the lungs - - - has ever caused damage such as you suggest, whether a once in a while occurrence or a constant nemesis for one with mucus-producing lung disease.  Indeed, ALL injuries documented as the direct consequence of coughing are “non-pulmonary” or “extra-pulmonary” events, from pulled intercostal muscles to popping of hernias of several types and locations to dehiscence of wounds and even broken ribs, among a range of others.  The only pulmonary injury ever realistically suggested as being the result of coughing is rupture of lung surface blebs leading to pneumothorax.  Yet, the evidence is not there to give that concern traction.

While we can’t say beyond a point with “certainty”, the evidence for cause of “scaring” as you put it - - - we would more technically call it “airway remodeling” - - - is related to, among other possibilities, but commonly by damage to, killing of and replacement with abnormal cells those cells in the airway that “normally” comprise it’s layers and support structure.  In COPD, we have much evidence showing destruction and replacement of normal cells with abnormal cells as the result of the “inflammatory cascade” - - - the label given to the sequential release of substances in response to airway irritation - - - which cause the “metaplastic” changes we see.  If you want to learn more, Google: “Tumor Necrosing Factor”, “Cytokines”, “Phosphodiesterase”, Leukotrienes and Histamine, for starters.

Insofar as the “forces” at play in coughing, they, while being comparatively tremendous, are actually well balanced and opposed by air pressure, muscles and other bracing forces, while excess forces are dissipated through the soft tissues and the cardiovascular (and to a lesser degree) lymph systems. (This is the “physics” or forces and airflow associated with coughing, in a nut shell.)   Folks who cough hard enough or long enough have been observed to pass out or black out or suffer other events (hemorrhage in the eyes) secondary to sudden changes in blood flow that rob the brain of circulation and increase vascular pressure sufficiently, even if momentary.

When you get right down to it, the cough is a quite remarkable phenomenon, full of mystery and incongruity. It would seem that it should and could hurt you, as you suggest.  But, the “FACT” of the matter is that not only are we unable to find any evidence of truth in that possibility, we DO know that to “avoid coughing” or “avoid coughing hard” is a certain prescription for illness in the lungs related to failure to clear the airways of debris and bacteria containing mucus.  Spend a few years on a daily basis with anyone with Cystic Fibrosis and a severe lung disease phenotype and you’ll not only come to better understand the necessity and benefit of the cough, but you’d also develop an appreciation for the mystery and uniqueness you would observe in the phenomenon.

Best Regards,

Mark

Q  Supplemental Oxygen Info

Hi Mark:

Thanks for taking the time to help us understand some of the "weird" things we are now going through with COPD.  I have been diagnosed, one-and-a-half years ago with severe emphysema Gold Stage 3.  Last June my FEV1 was 38% and I will be going again for another PFT next month.  My question is -- sometimes shortly after I eat, I will have quite a coughing fit only to find it might be a tiny seed from the bread or a crumb from cereal or even a small peanut portion that is causing this rather intense coughing.  Is this o.k. ? My oxygen level is usually around 96% and I am on advair x 2 daily and spiriva x 1 daily with a fast acting salbutamol during the day.  I have recently stopped working and will be going into the Rehab Program at our hospital in September. Can you also tell me at what level your oxygen reading is that the doctor might recommend oxygen?  Thanks and I look forward to all the helpful info you give us each week.

Lynn

A.  Hi Lynn,

While from where I sit, I can’t diagnose why you cough as you do, there is the possibility that you may be “aspirating” food and liquids when you swallow or at other times without realizing that you are doing so.  I would urge you to relate this information to your doctor who might want to send you for some studies to be sure your swallowing mechanisms and mechanics are working properly and nothing is slipping onto your windpipe.  Your oxygen level of 96 % is fine.  BUT, folks can have a saturation of 96 % while at rest and dive-bomb to sub 90% levels with a minute or two or three of walking.  So you should have your saturation checked during exertion, as well. When one’s saturation drops below 88 % in most provinces in Canada, the recommendation is made for oxygen use to raise it back to above 90 %. 

Best Wishes to you.  And get your swallowing checked out, soon!

Mark

Q.  Sequence of Meds

I've read a number of question and answers here and have a few concerns. On one question as to taking the SABA ventolin and the combination LABA and corticosteriod drugs in Symbicort, the question raised was how to time each drugs application so each will not conflict with the other. The answerer, Mark, made a contradictory answer.

Mark first advises one should wait 30 minutes after taking the symbicort before then using the ventolin inhaler,  and later says one should wait at least 2 hrs after taking the ventolin before taking the symbicort.

Now, Mark says both the SABA and LABA use the exact same 'receptors' in the lungs and those receptors need some time to 'clear'  themselves before they are able to conduct/absorb a new application of drug. Common rational thought says it matters not which drug is taken first, each and both will need the same waiting
period before another drug can be effectively handled by those receptors.,So, what is the evidenced and known FACT.  30 minutes or 2 hrs, or neither.


Gregory J

A.  Hello, yet again, Gregory,

You certainly are a busy man this week with your questions. But, you are also sparking some learning ‘for the masses in your suspicions and challenges.  And I welcome the opportunity to explain!

In my response to the questions of sequencing and timing of dosing with SABA’s versus LABA’s, you are convinced I was contradictory in my answer.  I would submit that if you truly understood the questions and the facts surrounding the issue of what to take when or how, you’d not only have found no contradiction in my response, but you’d not have had to ask your questions, much less place the only responses you’ll accept in an ‘ultimatum-style choice for me.

The reason one would want to wait 30 minutes after taking Symbicort is to give it a change to saturate as many sites as it can for the longer action it provides before taking the Ventolin which would then compete for any remaining sites AND to let the Ventolin act as a “mop up” to the Symbicort’s LABA.  It’s the LABA that is the more important drug to have prevail and the 30 minutes gives it time to “have it’s way with as many receptors as it can.  ALSO, waiting 30 minutes before trying to take Ventolin will give the person an opportunity to determine IF they REALLY need it after all!  They may wait two hours, or four.  I’m just telling them NOT to take it any less than 30 minutes after taking the Symbicort so as to keep the Ventolin from interfering with the Symbicort.

If one takes Ventolin and then follows it with Symbicort in less than two hour (three, if you want to be a purist0 then too little of the Symbicort will be taken up because there won’t be enough receptor sites free of the Ventolin.  The rest of the Symbicort will then be cast off as waste because it doesn’t sit there for a few hours waiting for receptor sites to come free. It denatures after a period of time and becomes inert.  This being the case, one who uses Ventolin and follows too soon with Symbicort will NOT get 12 hours of benefit from the Symbicort since it couldn’t reach even 50 % of the receptors.  And they’ll consequently need to use more Ventolin sooner than the 12 hours until their next Symbicort.  The Ventolin negates the effects of the Symbicort.

So ultimately your misconception relates to thinking that SABA’s and LABA’s are alike which ignores that the “SA” stand for “short-acting” and “LA” stands for “long-acting”.  And the short and long feature of each is how long it holds onto the receptor sites.  So the fact then becomes that your statement that: “it matters not which drug is taken first, each and both will need the same waiting period before another drug can be effectively handled by those receptors” is wherein lies the error.  They both need DIFFERENT waiting periods because they hold onto the receptors for different lengths of time!  

I hope this is clear to you, now.    Best Regards,   Mark

Q.  Potential Transplant Questions

Hi Mark!

My mother is 61 years old and has Pulmonary Fibrosis and Scleroderma.  She has been in the hospital now for nearly 6 months.  She is on 24 hour oxygen (60%) and even just going to the washroom in her hospital room can create extreme shortness of breath at times, though she does admit some of it is anxiety.

She has been waiting for a conference call between the hospital in Toronto, herself, and her doctor's here (we are in Newfoundland) to discuss whether or not she will be a good candidate for a double-lung transplant.  The call is finally coming up at the end of this month.  Of course, I will also be there to help her to hear, to understand everything, to take notes, to advocate on her behalf, etc, etc.  My question to is.... What are the right questions?  Do you have any books or websites you suggest i read before going in to the call?  What are the MOST important things we need to know?  What would be some of the reasons they could say she WOULDN'T be a candidate for the surgery?  Please help us to prepare for this. 

Thanks in advance.

Tracy

A.  Hi Tracy,

I would imagine the conference call you await will have to do more with what her test results indicate than with “the process”, per se.  If she has had no tests, then there is even less you can ask about that will make any difference ‘at this point in time’. 

There are really no “standardized” questions that one should ask for what you and your mother will need to learn about transplant.  The transplant ‘team’ should be well versed in educating you about the process and all that it entails.  Within that effort, you will develop your own questions to ask.  Realize that NEVER will ANY transplant program allow one to undergo the procedure unless and until they are able to provide fully informed consent.  That cannot happen until and unless all questions possible to be thought of and asked are indeed addressed.  Even then, there are always little things that pop up that you can’t anticipate.  When/If they do, you’ll be long into the process and won’t be shy about asking.

My daughter has been through 2 double-lung transplants.  We were grateful for the thorough preparation though we still had little questions to ask during and after the surgery, even as much as we already knew about the whole process, too!

Second Wind is an on-line group of folks who have had, are waiting to have or are in the process of having lung transplants.  You can join them easily and or free.  Ask them what things you should be sure to consider when asking your questions.  They can probably give you a consensus of what to be most sure to ask.

As far as reasons she might not be acceptable as a candidate; other disease processes that might interfere with success of or life after transplant would fall in this category of consideration.   If she is not generally healthy such that new lungs would put her back on her feet with a vigorous life ahead of her, she might be declined.  She will need to be found free of cancer and Hepatitis of all kinds as well as other infectious diseases that could thwart her chances for success with transplant.

Lastly, with regard to her oxygen, I’m curious to know if her oxygen flow is being kept quite high to deliver that 60 %.  One of the most common errors we observe is folks who are being given a specific concentration of oxygen but not enough flow to delivery it ‘undiluted’ to the airway because too low a flow is being run through the system.  That is most apparent when one gets up and tries to move.  Insufficient flow lets the saturation fall rapidly AND can easily explain the extreme shortness of breath.  If desaturation is actually occurring, then the ‘anxiety’ she attributes a portion of her discomfort to is easily explained and NOT a ‘psychologically-generated response.  Indeed, it is instinctual in nature.

I wish her the best and a successful and happy outcome.

 Mark  

Q. Oxygen Saturation % at What Age Level?

What is the relationship between age and nocturnal oximetry - is one to assume that it decreases as age increases. What is an acceptable nocturnal SpO2% for someone 80 yrs + ?

Rob

A. Hi Rob,

While lung mechanics measurements/values are age and gender adjusted, oxygen values should never change significantly simply because of age.  While folks 80 years and older may have a somewhat lower resting blood oxygen value, it should still yield a saturation of 96 % or higher under ALL circumstances.   So, someone 80 years old should be able to maintain a saturation level of 96 % or better, as should someone who is 100 years old!

Best Regards, Mark

Q.  Portable Oxygen Concentrators - Best Brand

Dear Mark:

I am considering buying a portable oxygen concentrator.  Do you have a suggestion as to a good brand.

Thank you

Bill

A.  Hi Bill,

There are a myriad of concentrators, from continuous flow types to portable types, all with different capabilities.  It's not so much what 'brand' you would want as much as it is what capabilities you need in a concentrator.  That is dependent upon your usage and oxygen requirement. If you can tell me more about what flow capabilities you need and if it needs to be a portable concentrator, I can help you select a device much better.

Best Regards,  Mark

Q  Does allergies affect my copd?

Allura

A.  Hi Allura,

Allergies certainly “can” affect your COPD.  It is mostly on the order of heightened symptoms.  Unless you have uncontrollable allergies that give you constant and severe respiratory difficulties, no “permanent” damage should occur from you’re allergies.  However, because of the influence if inflammation and its attendant chemicals in your body, you CAN have some worsening of your COPD due to allergies if they cannot be well-controlled. 

Best Wishes,  Mark.

Q.  Lower Evening Oxygen Saturation Levels

Hi Mark;

You kindly answered a question for me a couple of weeks ago regarding a drop in oxygen at night.  Perhaps I should clarify a bit more.  During the day (normally;  but not when I'm exercising)  my Spo2 is generally about 97.  In the evening (before bed) it usually drops to about 94 or 95.  Is "that" normaI for someone who has  severe COPD (GOLD standards) I use Symbicort and Spiriva.  I mean; is it normal for someone like myself at this stage of things to experience a drop in the evenings?  Hopefully I've made my question clearer.  Thank You, Bea

A.  Hi Bea,

It is NEVER “normal” for one’s saturation to drop at night as if due, for instance, to a circadian influence.  Your “drop” is not significant if 94 – 95 % is all that it drops to.  Simple variations in accuracy of pulse oximeters could account for those fluctuations.  If you were dropping into a significantly lower range that represented potential danger, it would be something to be concerned about and perhaps explore further to find cause and determine corrective steps.  But, at 94% and above, you are still well within normal levels from a clinical standpoint and should not be concerning your self with such minimal changes, severe COPD (by GOLD standards) notwithstanding.

Next time you measure your evening saturation, WHILE you are in the midst of the measurement, take several deep breaths - - - not too fast, though, yet not too slow, either.  Watch the oximeter and note what happens to your saturation (and heart rate, for that matter).  Do this for at least one minute.  What I suspect you’ll see is your saturation rise to your daytime levels of 97 % and above.  That will illustrate the most common reason for fluctuations in resting saturations like you describe - - - subtle changes in ventilation.  They are normal and not of concern.  It will also eliminate any influence of breath-holding by you that might be influencing those evening measurements of 94 – 95 %. 

In any case, you should NOT worry over such minimal and insignificant changes.  They mean virtually nothing in the greater scheme of your lung disease picture and progression.  When changes become greater and saturation “stays” around 94 (does NOT reach 97 % except with extraordinary measures to breathe and push it up) THAT is when I’d be looking for other signs of trouble, like exertional desaturation.  You have said nothing about what your saturation pattern is when you are up and moving.  If you are dropping and dropping lower than that 94 %, say to 90 %or less, THEN you have reason to be concerned.

Best Regards,  Mark

Q.  Paint Fumes, Increased Shortness of Breath & Pressure

I am a COPD patient. Non-critical..no oxygen, Use puffers ADVAIR250 2/day and Spiriva18ug 1/day and use a C-Flex machine at night. Lately I did some extensive indoor painting with Benjamin Moore "Aura" 100% acrylic satin finish (526). I now have a shortage of breath condition and pressure in upper lung area. Could the paint be the culprit?  Please ASAP... Thanks.

Robert

A.  Hi Robert,

I would caution you and any others who have emergent issues NOT to seek advice or recommendations from this venue when timeliness of response is important.  We do NOT operate this resource in that manner.  I would hate to have someone become injured or further their injury for using this means for an answer and suffering because we simply cannot render “A.S.A.P.” responses.

That said, you did not provide me with any ‘clinically relevant’ or ‘significant’ information to be able to tell you anything.  Inhalation of paint fumes like that should NOT result in any pulmonary pathology.  I’d be looking for another cause long before I’d suspect the paint. 

Hopefully, by the time you receive this response, you will have gone for a chest x-ray and physician evaluation to investigate the cause of your symptoms.  I hope it turns out not to be anything serious.

Best wishes, Mark

Q. Confusion, Memory Loss - Oxygen Desaturation

Hi Mark,
My mother is 84 years old and was diagnosed with COPD at least 4 years ago. Although her Pulmonary Doctor has told her to use oxygen almost all of the time, she is reluctant to do so. At best, she uses it at night. She doesn't think she 'needs' it. A complicating factor is she is on a morphine patch for chronic back pain. She is experiencing confusion and memory loss. The GP says it's from the narcotic use. Could it be from oxygen desaturation? If I could tell her what oxygen desaturation symptoms were, she might use more oxygen.
Thanks,
Leslie

A.  Dear Leslie,

From what you’ve told me I can neither confirm nor dispute what your mother’s doctor says is causing her confusion and/or memory loss.  Both the medication and hypoxia as well as other factors potentially inherent with her age could contribute to, if not outright cause confusion and/or memory loss.  Pulse oximetry with exertion and during sleep are the only definitive means to determine if she does or doesn’t need the oxygen AND just how much she needs.  NOTHING short of measurements will tell you anything definitive. Unfortunately, for many folks, symptoms of desaturation don’t arise until they have long past the threshold of what’s considered safe. 

My best recommendation would be to check with her doctor to find out just how important HE/SHE thinks it is for her to be diligent about using her oxygen.  If they don’t think it’s a critical priority, then I’m not sure I’d be pushing the issue.  I am also assuming that she doesn’t live alone. 

Best Wishes,   Mark

Q.  Oxygen Usage - Headaches & Dizziness

My father has O2 available 24 hrs a day, but doesn't always use it.   He will use O2 at night when he feels he is having more breathing difficulty, but complains of a bad headache and sometimes dizziness the next morning when he arises.  Both (headache/dizziness) go away a short time after discontinuing the oxygen.  I think he would use the O2 more if he didn't have these reactions.  (O2 setting is 2).
He has decreased, but continues to smoke during the day. 
He usually gets up 1-2 x at night to use restroom, etc and does not have dizziness/headache at this time.
Can you give me insight into what is occurring or suggestions for decreasing side effects?
Diana

A. Hi Diana,

While folks on rare occasion complain of a headache when using supplemental oxygen, there is no good or convincing evidence that using supplemental oxygen “causes” headache.  AND, all that we know about the ‘physiological’ effect of oxygen suggests that it CANNOT ‘CAUSE’ headache.  That your father doesn’t acknowledge having a headache DURING the night when he gets up to use the bathroom while using the oxygen suggests that there might be more than ‘physical’ cause for his complaint.  That it goes away once the oxygen is removed is suspicious for somatic causes and possibly some potential aversion to the oxygen itself - - - not an uncommon OR unreasonable reaction to having to use it.  That he still smokes is also a telling sign. 

He should likely use the oxygen very night, all night without fail.  Using it only when he thinks he should is a treacherous path to follow.  He like others should be guided in when and how much to use according to pulse oximetry measurements done during those activities of each condition or circumstance.

Best Regards,  Mark

Q. Chemical Exposure & Lung Damage

Hello Mark.

In April of 2007 I was diagnosed with COPD after an accident on the Job. I was working with a chemical called powerchlor and a gust of wind blew a significant dose of the chemical in the air and into my lungs. I immediately fell to the ground and was feeling very sick. I was off work for two weeks and then went to the Doctor thus the diagnosis. I had been a smoker but am now 55 years old I was 52 at the time of the accident. I quit cigarette smoking over 30 years ago. I have been in the pool and spa industry for over 30 years and have been working with pool and hot tub chemicals for all those years. Is it possible that constant exposure and the single high dose exposure of chlorine powder was the root cause of my COPD. I thank you for your time. There is no medical record of a COPD condition prior to this exposure and I now have a 35 % impairment of my lungs. I struggle to walk to the mailbox 25 ft. away. Prior to the accident I was physically active biking skiing mountain climbing now I am basically confined to my home.

John

A.  Hi John,

I cannot tell you much beyond my suspicions based upon what you have told me ‘so far’.  But, to be able to more definitively tell you what’s going on, I’d need to see the results of your pulmonary functions tests AND hope that not only did they measure spirometry, but also lung volumes AND diffusing capacity.  I suspect that you may have more going on than simply COPD.  I also suspect that it is NOT likely caused by smoking, unless you had V-E-R-Y significant smoking history during the few years that you could possibly have smoked.  Just by the math alone, if you quit smoking 30 years ago and are now 52, you likely couldn’t have had more than 10 years smoking IF you started as young as 12 years old AND smoked at least a pack a day.  Folks with less than 20/day for 20 years ‘usually’ don’t have COPD caused by smoking.  Your statement of having 35 % impairment is pretty much meaningless since there is no standardized ‘scale’ or ‘assessment standard’ that assigns meaning to lung function in terms of impairment such as you have expressed it.  That doesn’t mean doctors and others won’t make up their own standards.  It simply means that I don’t know what they mean by such terminology without knowing what the ‘real’ or ‘hard’ numbers are that represent their labeling.  That’s why the PFT’s and x-ray tests are necessary.

As a man who has dealt with pools and attendant chemicals for 30 years, you have a lot more chance for development of restrictive lung disease than ‘obstructive’ lung disease, though it’s not unusual to see a combination of both in folks with your kind of industrial exposure.  I am curious to know what chest x-rays showed and if you had a CT scan, what it showed.  Exactly what is wrong with your lungs can ONLY be ‘definitively’ determined by doing PFT’s and a CT scan, though a chest x-ray would be a good start from the radiological standpoint.  At this point, it appears to me that you need further evaluation to more fully and accurately illuminate exactly what’s going on with you.  Only THEN, can any sensible/reasonable interventions be determined. 

Best Wishes,                                      

Mark

Q.  Shortness of Breath, Swollen Ankles, Incomplete Spirometry Test -  No Diagnosis

I'm worried my mother's doctor is dragging his feet, what do you think? 
My mother is 86 and has been a smoker for 70 years. She has been very healthy all her life except she has coughed for years and started wheezing about three years ago.  I suspect she has had COPD for years and not been diagnosed by her family doctor. One month ago she suddenly had a sharp pain in her back and chest, accompanied by shortness of breath and swollen ankles. She went to emergency where she received a chest xray, EKG and blood was taken. The tests showed nothing unusual and she was prescribed painkiller for sore back.
She went to her family doctor a few days later because she was feeling no better. He had read the emergency visit report. He gave her water pills for swollen ankles and told her to quit smoking because he thinks she has emphysema.  A week later I took her to see him again because she was so weak and still short of breath and had swollen ankles even after taking the water pills. Also I had been doing some reading on COPD and requested he book her for a Spirometry test. I also asked if there was something to help her shortness of breath. He gave her a prescription for Salbutamol. She has been taking it as prescribed it helps her a bit but she is getting worse because she can't sleep very well and wakes up feeling awful and is weak as a kitten. She did not have enough wind to complete the Spirometry test. I pressed the doctor if there was another test to check if she would benefit from oxygen therapy, he finally agreed to do a blood gas test next week.

Cathy

A. Hi Cathy,

I can’t say that your mom’s doctor is ‘dragging his feet’, per se.  There is indeed more to be discovered about your mother’s condition and the ‘speed’ with which it gets done can seem too slow, the more anxious you and her other loved ones are.  There are more questions to be answered, as well.  Does she consume too much salt? (. . . a common observation in folks her age.)  IS she also consuming too much water?  How much does her weight fluctuate from day to day?  (Is she even weighing herself from day to day?)

Without a good spirometry test, much about her lung condition is guesswork.  With her ankle swelling, the picture is even more confusing.  The blood gas will be a good thing to do.  BUT, if she has good blood gases while at rest, she could be experiencing desaturation (drops in her blood oxygen levels) when she gets up and moves around.  A resting blood gas will NOT detect those kinds of changes.  She would need a walking test where pulse oximetry is measured.  AND she would need to walk for at least 2 minutes without stopping in order to truly show the bulk of any change in her exertional oxygen level.

I would say keep hounding her doctor to continue testing her until he finds the cause of her ankle swelling AND resolves it.  That may take time - - - more than you think might be necessary.  But, sometimes the answers are elusive.  And you can’t test for everything at once or in rapid succession without injecting confounding factors into the picture.  That would not serve her needs, either!

Best Wishes, Mark

Q.  Disease Stage

Hi, Mark,

My chest x-ray showed some hyper extension. Im 59 years old and after 40 years of smoking quit almost 2 years ago. I experience the sensation of being short of breath after some sudden exertion but I have good exercise tolerance and can walk a mile in 18 minutes without struggling for air. My Doctor knows me well for years and feels Im in early stage of emphysema. I use an inhaler 1 puff to three puffs a day of albuterol. Would you tend to agree that Im in early stage based on what I have told you and can I slow it to a snails pace with continued exercise. Kind of a big question but why not!

Thanks, Bill

A. Hi Bill,

With the information you have given me, regretfully, I can tell you nothing meaningful. X-rays are the worst medium through which to ascertain the severity of one's COPD. You need to have a pulmonary functions test done that includes spirometry before and after inhaling Albuterol, lung volumes measurement and oxygen diffusing capacity (DLCO). ONLY those tests will definitively tell where you are in your ling disease and what you can expect to do to slow progression. In the long run, Albuterol is OK for short-term effectiveness. BUT, controller medications for COPD need to be used to gain long-term efficacy, in 'most' cases/scenarios. If you haven't had a PFT done, you should request that on be done as soon as possible. No one should be managed with respiratory medications like Albuterol AND treated for what is a life-long disease without first quantifying it and determining which medications are most appropriate at a given point in the process.

If you HAVE had a PFT, find out what your FEV-1 and FVC, along with your FEV-1/FVC ratio are and look up "GOLD COPD Staging" to assess where you are. That is the Global Initiative on Obstructive Lung Disease. If you still need more help figuring out where you stand in the process, Write back with those three measurements and I'll take another stab at an answer.

Best Wishes,

Mark

Posts as of April 3rd, 2010

Q.  Drop in Oxygen At Night

Q  Sensitivity to Chemicals, Smells  - Xopenex

3-4 years ago I had a spirometry test indicating moderate trapping of CO2.  I have never been given an official diagnosis.  I am very sensitive to some sprays, perfumes, formaldehyde in paneling products.  When we moved here we closed in a room with paneling.  After beginning to hang the paneling my husband had to take it down because of the odor from it.  We left it out & I painted the back with a white latex paint & within a couple weeks he re hung it.  It didn't seem to bother as much, but have wondered if there could be long term effects from that.  We live in Florida & there is much humidity in the summer, so no doubt there could be mold somewhere I may not be aware of it.  Smoke in the air,  humidity  & heat also hinder my breathing. I have been heat intolerant for some time, more so in the last 6 years.  Not long after we moved here I began experiencing nasal congestion, some difficulty breathing especially if I feel congested.  However my congestion is not what I call normal congestion.  Most of it seems to be in the throat & upper lung area.  I may keep this a few days & then be able to cough for about an hour in the morning relieving it.  What I found most interesting was the fact that when I had the spirometry test, the Xopenex inhalation & then retest did not reveal much difference, though I felt immediate relief from the congestion.  The past several months I seem more breathless & when I had my stress test, I walked slowly on the treadmill, had my heart rate up & completed the test without a problem.  The baseline EKG revealed a normal sinus rhythm at 82, Q waves noted in leads 3 and AVF.  During stress & recovery no significant ST segment shifts or Ventricular arrhythmias as compared to baseline.Normal study w/ calculated ejection fraction of 70%.  when I had the echocardiogram the day before, a standard 2D echo with Doppler.  Heart chambers within normal limits with mild concentric left ventricular hypertrophy with ejection fraction of 55-60%  Valve leaflets with some calcification.

A.  Hi Betty,

In all that you related in your symptoms complaints and test reports, I found only one question.  That was would I suspect there to be any long-term effects from your reaction to the odor from the paneling that was hung before being taken down and painting?  It is not uncommon for folks to “feel” better after something like inhaled Xopenex while not showing significant bronchodilator response to it on a PFT.

As there is no evidence that even significant exposure to those elements causes any pathology such as restrictive OR obstructive lung disease I would have to say that there is no reason to believe that your short term exposure to that inhalational irritant would be.  As far as the question of mold, only an inspection of your home only a qualified expert can answer that.  You tell me nothing in the tests and reports that give me reason to comment.  In any case, I don’t know why you told me all that information without asking an associated question.  Your tests say nothing about or to the matters of your information and questions earlier in your post.

Best Regards,

Mark

Posts as of  March 14, 2010

Q.  Lung Flute for Mucus Clearance

I have recently heard about a "lung flute" which helps clear mucous from the lungs.  Are they available in Canada and are they recommended for home
use?

Pat

A.  Hi Pat,

ANYTHING that will get you to ‘exercise’ your breathing control, muscles and abilities can be helpful.  The Lung Flute is one of several devices that can assist in mucus clearance.  They are indeed for personal (‘home’) use.  They are available in Canada without a prescription.  Your group has a connection through which you may obtain one, should you choose to give it a try.

Best Regards,       Mark

(Link  for info and discount  can be found.... http://www.copdcanada.ca/Lung%20Flute.htm )

Q. Lung % - What Does it Mean?

Hi Mark,

When a doctor tells you that your level of COPD is 60% what does that mean. I was at my local emergency again this morning because of SOB and this time pain in my chest (nothing wrong heart wise) I asked the doctor what level I was at and that is what he said to me, he also mentioned that a full examination of tests would be required to exactly state what level I'm at. Is there something that I should be asking my GP to do for me? I live in PEI and we don't have Respiratory facilities here. Any suggestions would be appreciated.

Thank you,

Penny

A.  Hi Penny,

I can’t speak for your doctor.  There is no standard terminology regarding “level”  of disease and relating it to a ‘percentage’.  Pulmonary Functions measurements are expressed as a percentage of normal.  But, there are many values. 

A pulmonary functions test would tell you what stage you’re in.  They can be done in the doctor’s office or in a respiratory/pulmonary department of a hospital.  Then the results can be fit into a “stage” of the disease according to GOLD standard. (Global Initiative on Chronic Lung Disease).  Ask your doctor for a referral to get that test done.  If those percentages of normal come out at 60 %, that will mean you have the mildest level of disease and shouldn’t be experiencing breathing difficulties or other significant symptoms that are attributable to the disease itself.   Rather, they may represent momentary complications.

Best Wishes,        Mark

Q. Chronic Rib Cage Pain

Is chronic pain (in the rib cage and around to the back) part of COPD? I am on 150mg every 12 hours of Lyrica for pain and although it reduces the pain it does not eradicate it.  Thank you for your time.  Brenda

Brenda

A .Hi Brenda,

Pain like you describe is not a ‘normal’ part of COPD.  It can be caused by a lot of things.  Your doctor should see you and evaluate you to discover the cause of that pain.  As it could be indicative of something more serious, I would recommend you not delay in seeing your doctor about it.

Best Wishes,      Mark

Q. Variance on Oxygen Conserving Devices

In the latest research and info list they talk about the variance in performance of oxygen conserving devices but do not mention which types DO NOT meet requirements. Is there anywhere where I can find the ratings of these devices as well as the battery powered oxygen generators. I presently use a Pulse Dose conserver and find it skips doses when I am breathing faster but  the manual does mention that it does limit the no of pulses per minute. I presently use an oxygen generator for at home exercise and at night.

Thanks for your tremendous and valuable input.

Roland 

A. Hi Roland,

That research report was done by a group of investigators who selected certain devices to test without regard to inherent features that 'produced' the results that they observed.  What they consider 'flaws' in the devices are well known 'limitations' of those devices.  After collecting their data and drawing their conclusions, they committed an all-too-often error in applying their conclusion to ALL conserving devices.  So, not only did they draw biased conclusions by expecting the devices to do something which they were not designed to do, but the ALSO applied those conclusions to all devices. 

The bottom line is the devices tested have well-publicized limitations that expectantly produced the results observed.  At the same time, the limitations of those and other conservation devices neither represent 'flaws' in the devices or their design, nor an inherent danger in their use - - - AS LONG AS the user understands those limitations and doesn't try to make the devices do something they're not designed to do.

As long as your device provides enough oxygen during your variable use conditions to keep you adequately saturated, then it is doing what it needs to do.  If you cannot maintain adequate saturation under all conditions of necessary use, then you should either trade your device for one that CAN meet those demands OR select another oxygen system from among the continuous flow options that can.

Incidentally, along with the popular media story covering the report of that research was an interview with Joe Lewarski, among others who explained where the efforts and expectations of that study went awry.  It would be worth your effort to review the story and consider Joe's remarks.  In any case, your conserving device is likely operating within the manufacturer's specifications and should not give you reason for concern unless you know that it is not meeting your needs to maintain an acceptable saturation level while using it.

Best Regards, Mark

Q.  Can I Mix  Pulmmicort & Bricanyl?

I am a 57 year old female with asthma and COPD. I will confess up front that I continue to smoke. My efforts to quit are freqent and short lived. Historically I have been on Pulmicort and Bricanyl 2puffs/4times/day. Last year doc added spiriva once per day. Seemed to control me well. After H1N1 snf Flu vaccine this fall (had a pretty bad asthma reaction) I have not been able to get my breathing under control. Recently doc added Symbicort (2puffs 4x/day) which seemed somewhat better at first, now not so much. I have a lot of bronchial congestion and generally am foggy and tired but sleeping is a challenge.
I have found that My question is can I mix the two groups. P & B seem to offer better relief at night and Symbicort seems to help during the day. Spiriva remains as 1/day.
Thanks

Paula
 

A:  Hi Paula,

The Symbicort contains a "long-acting, beta-agonist" bronchodilator medication plus an inhaled corticosteroid.  Your Bricanyl is a "short-acting, beta-agonist" which you take with a different inhaled corticosteroid, Pulmicort.  The Spiriva is a "long-acting anticholinergic" medication and in a different drug class from the others, so is a 'stand-alone' consideration in your query.

Our standard advice/instructions for your Symbicort is to use it every 12 hours, morning and night.  The Bricanyl should be used as a 'rescue' medication to tie you over between Symbicort doses.  You should always try to refrain from using the Bricanyl and closer than two hours before using your Symbicort as the two medications will 'compete' with each other for 'receptor sites' within your lungs, one reducing or canceling out the effect of the other.  Since you really want the 12-hour (long-acting) benefit of the Symbicort to prevail, you should make that your priority medication.  The Pulmicort shouldn't be needed, but "can" be taken in between Symbicort as long as you understand that you are increasing the total dose of your steroid AND you are taking two 'different' steroids.  Check with your doctor to be sure that is OK to do.

Needless to say, if you are smoking through this current difficulty, your problem may relate more profoundly to that than to any specific problem with your medications and what they should or should not be able to do for you.

Best Regards,  Mark

Q.  Timing Between Symbicort and Spiriva

Hi Mark.
So glad you are here to answer our many questions.

My question is, I take symbicort 200/6 and spiriva and singulair and a budesonide nasal spray.  Should I wait for any amount of time between taking the symicort and spiriva?  I hear about the different receptors and wonder if by taking these two one right after the other is the best way to do it.

Thank you.
Mary

A: Hi Mary,

You should take the Spiriva and Symbicort one after the other with only a few minutes space in between, if you wait any time at all.  They go to different receptor sites and so will not interfere with each other in any way.  Indeed, the evidence suggests that when used close together as opposed to hours apart, they may have an additive or activity-enhancing effect.  So they SHOULD be taken close together.  The Budesonide nasal spray and Singulair have no bearing upon taking the Symbicort and Spiriva. 
 

Best Regards,   Mark

Q.  Symbicort 200 vs Symbicort 400

My peak flow is within the normal range of 80% to 100%. But I feel a lot of phlegm and I have a severe dust allergy with the asthma. I still get shortness of breathe and my chest still feels heavy. I take symbicort 200 2x4 times a day which is the daily max. Would going to the 400 strength work better for me? As well, I was wondering how long can you drink water after taking Symbicort (not just rinsing of the mouth).  Thank you so much for your time on my question. Have a great day!

Beth

A:    Hi Beth,

Your complaint sounds as if you may need more or stronger medications.  Your solution seems a reasonable consideration.  So, I'd advise you to discuss it with your doctor.  You might also benefit from evaluation to be sure nothing else is going on to escalate your symptoms or make them more difficult to control.

As for the drinking water question, I'm not quite sure what you are asking.  Let me just say that rinsing your mouth is always advisable after inhaling your steroid medications,  What you drink, how much or when you drink fluids should have no bearing upon taking the inhaled steroid medication

Best Regards,  Mark.
 

I need to know what I should do next.

I had a bad bout of pneumonia beginning of December. Two doses of anti's by intravenous. Went for a follow-up xray in January and Dr. said something still there but didn't want to do anything just yet.   Oxygen level okay.

Beginning of February eyes and sinuses burning and nose plugged.  After a few days eyes and sinuses cleared up but nose was running a lot.

That's all gone now.  What I'm left with is SOB and low to mid 80's for oxygen. Went to doctor and took 5 days Prednisone & 7 days Avelox.  Just finished Avelox and no improvement for SOB or oxygen.

On the top of my list of allergies is mould...snow, leaf and household.  Lower down on my list is pets and tree pollen Take Singulair daily since last Spring. We had dogs ..then didn't for 3 yrs....now got a yorkshire terrier. Supposedly the most hypo-allergenic. I bath her frequently.  We also discovered a roof leak and suspect mould in the walls.

My question: Does it sound like allergies to the dog or mould could be causing the SOB and oxygen problem?  or : did this last exacerbation cause it?
Will nebbing something work better than the Symbicort and Spiriva I am on now.

If this is allergy related I can do something about it...hoping nebbing will help.  I would like the last resort to be oxygen.

What should I try ..or get the doctor to try..next?  Thank you.         Sandra

A.  Hi Sandra,

Allergies, in and of themselves should NOT cause hypoxia unless you have severe breathing difficulties with them, like asthma that won’t improve despite inhaled bronchodilator and treatment with oral corticosteroids.

You could ask about Albuterol and Ipratropium Bromide for nebbing in between Symbicort and Spiriva, or for Albuterol by itself, since some feel you shouldn’t take Ipratropium Bromide AND Spiriva at the same time (There’s no harm in it.  The question is potential effectiveness AND interference between one and the other.)

 If I were your doctor and you were noting consistent pulse oximetry measurements that were less than 88 %, I’d want to do a blood gas to verify the accuracy AND to do it under those conditions during which you have observed the decrease.   In other words, if you are desaturating (dropping your oxygen level) during walking, then you should walk for a few minutes and then IMMEDIATELY have the blood sample drawn for the blood gas before you have been stopped for more than 15 to 20 seconds.   A resting blood gas when your resting saturation is 96 % will tell you nothing about what it drops to when you’re active.   So, the conditions and timing of the blood test are CRITICAL!

Beyond that, you haven’t given any information to make it possible to tell you more.   The other information you included is not pertinent or helpful to the primary question and issue as those things shouldn’t cause hypoxia. 

So, my best recommendation at this point is to ask for a blood gas under the conditions you have observed desaturation IF the desaturation persists until you can get seen by your doctor.

If the blood gas confirms hypoxia, supplemental oxygen is the only intervention you can expect to correct the hypoxia.

Best Regards,

Mark
 

Dear Mr. Mangus:  My boyfriend is newly diagnosed and is having huge denial about the whole situation.  He has quit cigarette smoking but refuses to give up marijuana.  What are your thoughts on pot and lungs?  Thanks so much.

Deborah

A.  Dear Deborah,

The evidence suggest strongly that smoking marijuana - - - and any similar plant substance, for that matter - - - produces irritation that, if produced often enough can result in chronic inflammation and ‘metaplastic changes’ (fancy term for changes in cell type) in the airways and chronic disease similar to tobacco smoking.  Sometimes folks will think that they are not likely to get hurt because the additives and chemicals with which tobacco is treated are not there.  Yet, pot from various sources tests positive for herbicides and insecticides that can do a number on your lungs.  Since you don’t know from where the product comes, the kind and degree of danger is not ascertainable. Mexico, a place from which a significant amount of product is grown and supplied allows use of insecticides long-banned in the USA.  Folks sometimes reason that since they don’t smoke as much pot or smoke it as often as they would cigarettes that they don’t get as much exposure and therefore the risk is reduced.  We don’t know that to be the case.  Evidence is pretty good that that is not a good or valid rationale.

 The bottom line is to continue smoking marijuana is simply a role of the dice with respect to potential consequences.  When one has been diagnosed with COPD, their chances on that dice roll are increased toward the losing side.  You didn’t say how old your boyfriend is or how his COPD has been diagnosed or how bad it is, much less how much pot he is smoking.  And severity of disease, current age and how much smoking IS a relevant factor in estimating risk, at this point.  If he has had a PFT, and his FEV-1 is reduced to less than 90 %, he is on a slippery slope, though he could cruise a long time without facing consequences.  But, as COPD progresses slowly over many years before reaching clinical significance AND because the consequences onset years down the road, he simply can’t assume that he will be unscathed by continuing to smoke the pot. 

In the end, you can only stress ‘your’ feelings and concerns.  If he decides that your concerns are valid enough to change his behavior, he will make that choice.  If not, then you are faced with the choice to stick with him or . . . well, you know.  If he continues to smoke the pot, he would do well to monitor his pulmonary function so that he can see his rate of decline/progression of the obstruction and disease.

 Best Wishes,

 Mark
 

Hi Mark;

I know this isn't along the lines of a question for an RT BUT; I've gotta ask.

There's been a lot of stuff lately on hand sanitizers and it not being good  because of germs, just like antibiotic overuse, (the bugs) can get immune to it.  BUT; if soap kills germs,  though I don't really know how; and hand sanitizer does the same thing.... Does that mean we shouldn't be using it (hand sanitizer)?

Many Thanks, Joel

A. Hi Joel

 The active ingredient in had sanitizers today is mostly Isopropyl alcohol.  There are anti-bacterial substances put into some sanitizers, but their value, effectiveness and influence in promoting resistance in bacteria is not the issue that antibacterial substances in soaps is because of the alcohol content.  Alcohol inhibits life and growth of many microbes.  They cannot adjust to it because of the chemistry of it all.  So, hand sanitizers are a good thing when used appropriately. 

When all is said and done good hand washing with soap and water and especially the running water and friction of rubbing your hands is still the staple means to cleanse them.  Hand sanitizers are a good step-in when washing is impractical or not possible.  But, they are a ‘bridge’ to the hand-washing action.  AND< above all, hand washing is STILL established as the single most effective means to prevent spread of disease-causing germs and infection.

 Best Regards,

 Mark

Additional Information was supplied:

"the only numbers that are on this reported that was dictated  by the Pulmonary that Dr. that reads the tests from the function test  are it says "small airways flow is reduced to 54%  predicted consistent with a small amount of obstruction. There is no convincing change following bronchodilator. Maximum voluntary ventilation is mildly reduced at 76% predicted. consistent with a very mild loss of lung reserve, not explainable by the normal FEVI/
 After  my daughter read it, she thought I misinterpreted it, as on the one test I did have to cough - so that test had to be over and he said it was O.K. -- I think this is why  it said " some difficulty in patient cooperation with FRC was noted"-one reason I was  having all this checked  as in Nov. I had a light case of the HINI or whatever it is called and this cough  developed and has hung on.  That is O.K. My husband smoked ,  and I guess the second hand smoke is as bad as if I had smoked."

A. Hi Sandy,

Don’t take the comments as criticism.  When we do PFT’s we must characterize the patient’s effort and ”cooperation” with performing the tests.  PFT’s are extremely “effort-dependent”.  Poor effort - - - whether it be because of bad coaching from the tester, subject weakness or illness or simply a bad day for the test subject, or even something like willful interference in attempts to obtain a valid test MUST be noted on the test form so that interpretation can take those factors into account.  Otherwise you could be made to look sicker or healthier than you really are.

So, in looking at your notes, there was a problem in your being able to fully cooperate with the maneuver to measure your FRC.  That test requires a breath hold and stillness for several seconds AND the ability to take in a breathe that is at least a minimum amount.  You may not have been able to take in such a deep breath OR to hold it for the full duration needed.  If that was the case, then the measurement would be ‘off’ from expected or normal.  The physician would need to know that the deviation from normal was clouded by the effort/cooperation difficulty. The bottom line you need to understand is that the tester was NOT complaining about negative behavior or attitude on your part.  He/she was simply explaining that you were unable to cooperate fully to give the best measurement and result on that test, so it’s results may be suspect.

Your mid to small airways flows are reduced by a little under half.  That usually suggests some kind of obstructive defect, though it doesn’t characterize it.  If you are not at risk for the ‘usual’ COPD issues, then you ‘could’ have a bit of asthma.  You don’t report other aspects of your PFT, so I don’t know if you were tested pre- and post-bronchodilator nor what response you might have had.  In any case, you can have a bit of reactive airways problem or asthma for many reasons without having a smoking history or other known reasons or causes.  And unless other key elements of your PFT are out of normal range by a significant amount, then you don’t appear to have too much of a problem

 I’ll close with an encouragement for you to get with your doctor and put your questions and concerns to him/her.  With the complete test results in hand, he/she can answer ALL your questions. 

 Best Regards,

 Mark

A.  Hi Bob;

Let me answer once for both questions posted.  Mucinex (Guaifenesin) is potassium Iodide, a drug which favors pulling water into the mucus via/through the tissues that line the bronchial tubes.  It seems to be doing what you want, Bob, in that it has made the mucus easier to cough up.  One never knows if they are “getting all the mucus up” when they cough.  But, that is really a moot point, in many respects because mucus is produced and secreted in response to irritation and the airways’ need to ‘flush’ or ‘cleanse’ themselves of dirt and other debris that can be found within the airways.  So, the process is dynamic.  It is ongoing.  And it is necessary, too!  So, your quest is to keep coughing and clearing what mucus accumulated within your airways as best as you can from moment to moment.  The Mucinex is good to help keep it looser and more mobile.

Now, some would suggest that you need to drink lots of water to help thin that mucus.  Every bit of empiric evidence I’ve ever seen suggests that all drinking the extra water ever does is increase one’s urine output.  BUT, there seems to be something in the act of drinking - - - especially hot fluids and also with a sipping technique - - - that helps to raise the mucus at those times.  So, you certainly might try drinking ‘some’ fluids to see if it helps.  The reason I bring up fluid intake is because many folks have problems with fluid retention and salt management.  And if they are encouraged to drink excessive amounts of fluid to try to help thin and/or mobilize mucus, they can compromise their fluid management efforts and actually cause increased fluid retention.  That can all go towards increased breathing difficulties and worsened heart function, while also thwarting the action of diuretics, if those are being taken for fluid management, as well.

Lastly, Mucinex is a commonly prescribed medication to help with mucus clearance and management.  So, you are in the mainstream taking it for the purpose you are taking it.

 Best Regards,

Mark

Hello Mark and Thank you for accepting questions.

My question is.... What's the difference between diaphragmatic breathing and stomach or belly breathing? Or is there a difference? For me my chest is all the same and flat!

Thanks, Fran

A.  Hi Fran,

There is no difference between diaphragmatic breathing and “belly” breathing, also called abdominal breathing, per se, at least not in theory. But in actuality, between the three terms, it is the term “diaphragmatic breathing” that is the most incorrect simply because there is NOT ONE BREATH taken by ANYONE that is not generated by the ‘diaphragm’. AND, try as anyone might, we have no ability to specifically control movement of the diaphragm in any direct or deliberate way.  The diaphragm is a muscle that works on autonomic nerve signals.  And all the fancy breathing techniques that have been devised and written about for decades are just so much malarkey when it comes to ‘actually’ influencing the movement of the diaphragm during breathing.! 

We can enhance effectiveness of our breathing using abdominal muscle maneuvers that pull on the diaphragm and pull work away from the upper chest respiratory accessory muscles.  That is a GOOD thing to do since those respiratory accessory muscles require up to many times the energy to help enhance ventilation while only producing that help with about 40 % efficiency!  (Respiratory Accessory muscles of which I speak are those found in the neck, shoulders, upper chest and upper back, among which are included the scalenes, sternocleidomastoid, trapezius and pectorals.)  So, we work harder for less return when we shift breathing work AWAY from the abdominal muscles toward the chest/respiratory accessory muscles.

If you try to use the “diaphragmatic” breathing techniques most commonly found in publications, you will find that you have great difficulty in properly using your abdominal muscles to enhance your breathing.  That is because most techniques recommend placing a weight of some sort on your belly, below your ribs, but above your navel.  To properly utilize your abdominal muscles, you must pull them DOWN toward your knees.  That exerts a piston-like action on the diaphragm, pulling it down and filling the lungs through ‘displacement’.  Indeed, several studies found that traditional techniques of “diaphragmatic breathing” using weights placed midway on the abdomen while the subject lays recumbent or partially recumbent results in paradoxical movement of the diaphragm and exhalation when inhalation is desired and vice-versa.  It is not automatic.  BUT, it can happen without the subject being aware of the opposite movements occurring.  As such, some sources de-recommend the technique. 

I have always advocated practicing abdominal breathing while standing upright and leaning against something that will support your weight.  One foot is place forward and just rests upon the floor below a bended knee while the foot farthest behind you supports your weight below a straight and stiffened knee.  Next, you bring your arms up and cross them above your shoulders.  You then place your forehead into your crossed arms and squeeze your shoulders into your ears.  This action ‘locks out’ the major accessory muscles and frees the abdominal muscles (the belly, as a whole) to do the work to breathe.  As you inhale, your belly drops toward the floor.  As you exhale, you pull your belly up into your chest to help compress your lungs for the emptying.  Of course, you do pursed lips breathing when you exhale.  (The folks on the EFFORTS list call this the “tripod” position.)

Some helpful activities to promote belly/abdominal breathing are blowing bubbles, inflating balloons, playing the harmonica, singing.  You get the idea . . .   Anything that makes you work your belly - - - the lower abdominal muscles - - - will enhance movement of the diaphragm.  The single most common “complaint” I get from folks whom I teach abdominal breathing to is that they feel like they’re not working hard enough to breathe when they do it correctly.  I laugh, because if you DO do it correctly, then you SHOULDN’T do much work at all.   And it certainly should NOT be as much work as you do with the traditional techniques of “diaphragmatic breathing”  

Best Regards,

 Mark

Two questions for you Mark if you don't mind. 

Out of curiosity I've measured my oxygen (with a pulse ox) when I go into one of my coughing episodes and it drops by about 5 (at least) points.  It generally returns within a few minutes afterwards but is that normal for COPDer's?

And; I find my abdominal muscles get quite sore some days from breathing. Guess I tend to use my stomach more than my shoulders or upper chest. I know that breathing with the lower muscles is good but.....should i be trying to learn to use my chest more?  (I was a singer in my younger days; breathing from my abdomen comes naturally)

Thank You, Carla

A.  Hi Carla;

Measurement of oximetry DURING violent maximal exertion as occurs with coughing jags is fraught with inaccuracy.  You have movement to contend with.  You have circulation changes that occur rapidly in succession during the coughing.  AND, you have the ‘potential’ for desaturation.  Without having the opportunity to observe your measurements as they occur, I wouldn’t be able to tell you if they are even valid/accurate.  After that, a five “point” drop, (I assume you mean “percentage points”) tells me nothing helpful without knowing from what it starts and to where it drops.  A five point drop from 99 or 100 % to 94 or 95 % is not a problem, under any circumstances.  But, a drop from 90 % to 85 % is another story - - - AND is NOT a good thing.  If you are dropping from 82 % to 77 % that’s REALLY a problem and a danger!  So, you see, I can’t tell you what the significance of your observation is, though I’ve given you some idea with my examples to be able to ascertain for yourself if you have a problem or not.  If it takes as much as 5 minutes for your saturation to return to normal, then you have further problems that suggest you need oxygen therapy or a higher dose of oxygen, IF those drops are from a starting point of 93% or less.

 Sore or not, you are breathing correctly when you use your abdominal (lower abdominal) muscles to generate the greatest portion of effort to breathe.  Use of chest muscles (accessory breathing muscles) is a VERY bad idea!  We try to discourage folks from deliberately trying to use their chest muscles to support breathing.  Those muscles eat up a ton of energy without returning near as much as abdominal muscles in terms of ventilation per unit of work.  There are times when I’ve encountered folks (medical professionals) who counsel and coach use of upper chest and accessory muscles.  Besides jumping into action to help them realize the error of their thinking and understanding, I try to have them practice and gain a feeling for abdominal breathing - - - and NOT by using the commonly recommended “diaphragmatic breathing retraining methods”, which are very counter productive for a LOT of folks and can actually lead to worse use of the ‘wrong set of muscles’ to generate breathing effort.  We like to use harmonicas, singing and other similar activities that cause the person to have to use abdominal breathing as exercises to enhance mastery and control of exhalation.

 As a singer, you have likely learned the BEST way to breathe.  Stick with it.  And be SURE to use pursed Lips Breathing when you exhale.  That can go a long way to reduce your breathing work and ultimately your soreness.

Best Wishes, 

Mark

I was told by my doctor before taking my spiriva and symbicort, to take 2 puffs of ventolin 5 mins thus opening the airways so that the spiriva and symbicort will work better.  However, somewhere else, I read that by taking the ventolin before, if clears the airways so that  the spiriva and symbicort have nothing to adhere to.  Could you please tell me how you would recommend taking my ventolin?
Bonnie

A.  Hi Bonnie,

While controversy continues to some degree and I am at the forefront of pushing for sensible and evidence-based change, your doctor echoes instructions that are trumpeted by many health care professionals.  Regardless of how many promote doing as he has recommended, it is plainly contrary to every bit of evidence available AND is without one shred of evidence to support its practice.  

If you take Ventolin before taking your Symbicort, you will block the effect of the “long-acting, beta-agonist” (LABA) medication in the Symbicort, because they BOTH occupy the same receptor sites within your airways.  Ventolin is a “short-acting, beta-agonist” (SABA), lasting only up to 6 hours.   When the Ventolin gets there first, it ties up the sites so the Symbicort’s LABA has no sites to bind with.  By the time the sites are again freed up, the Symbicort’s LABA has long since been shed from the lungs.  So, the bottom line is by taking the Ventolin first, you negate the potential benefit and effect of the Symbicort LABA. 

You should take the Symbicort by itself FIRST.  If after 30 minutes, you feel you really need more, THEN take the Ventolin.  What I think you’ll find is that the Symbicort by itself, is plenty and all you need.  In that case, your Ventolin becomes strictly a back-up/supplemental medication if and when you ever need a ‘pick-me-up between Symbicort doses.  Also, Never take the Ventolin within TWO HOURS before you are due to take the Symbicort.

Best Regards

Mark

Should everyone purchase an oximeter after being diagnosed with moderate approaching severe copd.  There is no pulmonary rehab available in my area.  I am short of breath  when exercising very little and I currently take Spiriva, Advair twice a day and Albuterol when needed.

Jacquie

A. Hi Jacquie, 

A pulse oximeter is only of use to someone whose oxygen level in their blood fluctuates such that there’s a danger it will drop too low, putting them at risk for attendant complications.  If someone has mild COPD, they usually do not have a problem with oxygenation.  The best way to know when you should acquire a pulse oximeter is when it is first detected that your oxygen level drops to around 90 % or less.  You should have your doctor (Pulmonary doctor, most likely) measure your oxygen with a pulse oximeter in his/her office - - - especially while you’re walking around, NON-STOP, for AT LEAST two minutes.  A measurement done while you are sitting quietly and comfortably at rest is NOT suitable to detect “exertional hypoxia” (low oxygen level during exertion).  Before you exhibit signs of “desaturation” (drops in your oxygen level) there is no advantage to having and/or using an oximeter.

 Best Regards,

Mark

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Q. Cooking Fumes  Posted January 24th/10

I can't stand smell of food cooking;  cuts my air off so then I get a anxiety attack and it is no fun;

 Thank you, Jim

A.  Hi Jim,

I’m not sure what your ‘question’ is, as everything you said is in the form of a statement.  So let me make some general observations and statements along with imparting a few suggestions to hopefully help the situation.  Different foods and methods of cooking will have different effects on breathing for those who have advanced COPD.  First, to suffer as you describe, Jim, one usually has a very reduced FEV-1 (measurement from your pulmonary function test).  Frying foods can be especially difficult.  But, boiling pungent foods like broccoli or kidneys, for instance, can assault your nostrils and literally take your breath away.  So, using caution to begin with is of utmost importance.  Provide the best ventilation and source of fresh air possible within the limits of the design of your kitchen.  Use you stove fume vent to pull odors out of the air as they rise from your cookware.  Avoid breathing the air near pungent foods, especially if you know they have a negative affect upon you.

If you use oxygen, be sure you are using enough to keep your saturation as high as possible to minimize low oxygen symptoms.  95 % and more is not unreasonable.  Be careful to use the oxygen safely around the active stove/oven.  If you use a rescue or ‘short-acting inhaler, try taking a couple of puffs from that before you begin cooking.

Best Wishes

Mark

Hi Mark,

Thank you so much for being a part of  this board, your help is so very much appreciated.

Mark I have asked my  Pulmo about rehab, and he said it will not do any thing for me, what do you think?   He said I am severe, and i only have my left lung, and have  COPD/ASTHMA/ E  I should  also mention I am very active, do all my own housework and shopping and cleaning, I get very SOBA, but I try my best.

 Thank you in advance.

Sincerely Linndie

A.  Hi Linndie,

I would opine that it is presumptuous of anyone to summarily dismiss the notion that pulmonary rehab would or would not do any good for anyone based upon their having severe COPD.  While I argue at times about the uselessness of spending our Medicare Dollars on rehab for someone who has no rehab potential, much less desire to regain lost, but retrievable function AND I am leery of just how early we can justify intervening with pulmonary rehab on a person who has no symptoms or demonstrable need for significant disease management, I still have to remain reserved as there is much to be learned to avoid complications and to slow progression.  In folks who are extremely debilitated, BUT who are enthusiastic about regaining function AND are willing and able to tolerate the discomfort along the way, I say: “Go for it!”  I have witnessed some incredible results in folks on whom I’d have bet upon failure.  Those are times when I am MOST happy to have been wrong!  I have also learned over 20 years at this that it is a treacherous path to tread when trying to make predictions without having “the writing on the wall.”

You sound like you’re fairly robust despite your deficits.  So, on the one hand there might not be much in the way of conditioning that you could gain.  Yet, if you do not now have an aerobic fitness program, then you are missing a key component that could improve your breathing, muscle function and oxygen utilization as well as carbon dioxide production.  More efficiently functioning muscles produce less carbon dioxide.  That reduces demand on the lungs to ventilate in order to clear carbon dioxide.  And that translates to potential improvement in breathing work and anxiety.  So, Pulmonary Rehab could be the catalyst to get you started on a walking program.  Doing your household chores and similar daily work is good.  BUT, it’s NOT exercise.  You need “sustained, repetitive motion over a continuous period of time” to constitute the kind of aerobic exercise that will give you the conditioning to allow you to continue to do those daily activities without out avoidable difficulties.

You say you only have your left lung.  Am I to surmise that you had your right lung surgically removed?  If so, you need to be mindful of one thing that SOOOOooo many physicians fail to consider.  Your pulmonary functions measurements will ALWAYS be only half of what is predicted - - - even if they’re normal.   The best you can achieve would be around 50 % of everything except for airflow measurements.  If you have asthma, airflow measurements will be reduced.  But, FEV1 and lung volume measurements MUST be interpreted against the knowledge that only one lung is being measured.  Finally, if indeed you have only your left lung and no right lung, your COPD may not be the main cause of your difficulty breathing.  Simply having only one lung limits your maximum exercise and exertion intensity levels.  That is because you only have at best, ½ the reserve you would if you had two lungs.

Ultimately, your doctor should At least allow you the opportunity to go be evaluated and even give pulmonary rehabilitation a try.  If you find it is not helpful, then you can always say you gave it a shot.  But, to summarily shun it does NOT seem to me to be in YOUR best interest.  What’s your doctor got to lose by letting you stick your toe in and test the water?

Best Wishes,

Mark

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Q.  SOB (Shortness of Breath) "after" Exertion      (Posted January17th, 2010)

I have a short little upgrade from my driveway to my house, and then about 5 steps to climb.  I am breathing fine until I get in the house when I become extremely SOB to the point of gasping for air.  I plb the whole walk, and of course when I'm trying to get my breath back.  Why am I not SOB during the walk but am when I stop?  Thanks!

Sue

A.  Hi Sue,

You ask a good question that is often asked by folks.  The simple answer is “lag time”.  But, there’s more to it.  When you begin the trek, you are breathing slower and easier.  As you go on during the trek, even though you are doing pursed lips breathing (PLB), you are developing an unavoidable problem that is related to the anatomical changes within your lungs as the result of your COPD.  That problem is “dynamic hyperinflation”.  It is, in simple terms “breath stacking that occurs when you progressively breather more air INTO your lungs than you breathe OUT of them as you walk along and especially when you climb those stairs.  By the time you reach the end of the trek, you have pushed your lung volume to a level that is much higher than when you are comfortable and at rest.  In doing so, you also reduce your “inspiratory capacity”, making it such that you have less room to work with to pull in each succeeding breath.  That invokes continued efforts from you to increase ventilation which is increasingly less possible.  During this time as well, your CO2 is increasing in in the air within your lungs.  More importantly, your pH (the reflection of the acidity or alkalinity of your arterial blood) decreases commensurately with the increase in CO2.  This invokes even MORE stimulus for you to try to increase ventilation.  Since you have a reduced capacity to further increase ventilation because of the over-distended state of hyperinflation that results during “dynamic hyperinflation”, your only recourse is to increase your anxiety level.  So, when you finish the climb and get into your house, these factors are all affecting you at their peak of influence.  You stop the activity and continue to PLB.  And, because you are no longer making the greater demands for ventilation on your lungs as you were during the trek, you begin to “unload” those hyperinflated lungs, returning them to their “resting volume”.  At the lower state of hyperinflation, you are able to return to more effective and comfortable ventilation as you return to expelling more air during exhalation than when during the activity AND you return to a lower respiratory rate.

When I teach more effective ways to breathe to my folks in pulmonary rehab, I stress that just because their legs and body have physically ceased activities like you describe, doe NOT mean their work to control their breathing has stopped.  I tell them that they must continue to be deliberate and controlled and try to increase the effectiveness of their breathing for up to several minutes after they stop, as just as it takes a couple of minutes to develop, it also takes a couple of minutes to resolve.  Dynamic hyperinflation may sound like a difficult and abstract phenomenon to understand.  But, it really is fairly simple.  And it is essentially part and parcel what is responsible for the breathing difficulties folks experience as their COPD advances.  The lower your FEV-1 is, the more subject you are to Dynamic Hyperinflation, especially as the demand of the physical activity you engage in increase.

Best Wishes,

 Mark

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