Previous Questions & Answers of RRT Mark Mangus,  categorized and alphabetized by "topic"   -  2010   

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

If "you" have a question for Mark, click here





Aerobic Exercise

Exercise & Bloating Issues

Exercise & Lung Function

Multiple Issues & the Need & Type of Exercise

Pulmonary Rehab

Shortness of Breath (SOB) on Exertion

Shortness of Meds Still Occurs Even With Meds

SPO2 Increases with Exercise

The Need to Exercise Even with Severe COPD

Ventolin Before Exercise

Walking with Oxygen, Using a Face Mask & Straw


Finger Pulse Oximeters


ABG (Arterial Blood Gas) vs Finger Pulse Oximeters

Owning One

SPO2 Increases with Exercise


Medicines for COPD


Increasing Symbicort Doses - Smart Dosing for Asthma

Missed Doses

Pulmicort & Bricanyl

Sequence of Meds

Sequence of Meds 2

Sequence of Meds (timing)Symbicort & Spiriva

Sequence of Meds - Ventolin Before or After.....

Studies (?) On the Sequence of Meds

Symbicort Meds Not lasting 12 Hours

Symbicort & Thin Skin

Symbicort 200 vs 400

Taking Spiriva & Ventolin; Still Short of Breath

Uniphyl Question

Ventolin & Exercise


Misc COPD Questions


Allergies & COPD

Arterial Blood Gas vs Venous Blood Gas

Asthma - Could It Be?

Breathing is Worse & General COPD Q's

Chemicals & Lung Damage

Coughing & Nose Congestion

Coughing & CO2

Diaphragmatic Breathing/Stomach Breathing

Diaphragmatic Breathing/Stomach Muscles

Diffusion Rate & Shortness of Breath

Disease Progression

Disease Severity

Disease Stage

Dizziness & the Epley Maneuver

Cyst on Lungs

End Stage

Fumes from Cooking


Hand Sanitizer Vs Soap

Hyperinflated Lungs & SOB (Shortness of Breath)


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

Is the DamageReversible?

Lung Collapse

No Relief, Looking for Answers

Paint Fumes - Inhalataion

Pneumonia Vaccine - Frequency

Rib Cage Pain

Smells - Sensitivity

Transplant Q's






Lung Flute

Mucinex for Thiining Mucus

Mucous & Throat Clearing


Oxygen & Oxygen Saturation


Confusion, Memory Loss, Reduced O2 Saturation

Coughing & Oxygen Drop

Oxygen Saturation & Age

CO2 & Oxygen

Extra Oxygen Using a FaceMask & Straw

Headaches & Dizziness

Oxygen is Fine but Short of Breath

Overnight Oxygen Levels

Oxygen Conserver Devices

Oxygen User & Nosebleeds

Oxygen Saturation Question

Temporary Oxygen

Too Much Oxygen?

Oxygen Increase & CO2

Saturation Lower in the Evening

Supplemental Oxygen


Pulmonary Function Test (and Spirometry)


COPD Diagnosis w/o A Breathing Test

DLCO Question

Number of  Puffs of a Bronchodilator for a PFT

PFT Interpretation

Test Results Numbers & Question

PFT (Pulmonary Function Test) Results (Interpretation)



Scans & X-Rays


Spiral CT Scans

Chest XRays





Champix & Dizzy

Cravings - how long


Marijuana vs Cigarette Smoking



Q.  Disease Progression

Dear Mark,

Thank you so much for all you do for others, may it come back to you in all you do. smile. This is Sue, you answered my question on 12-5-10 regarding  my spirometry test results. I got really sick with "valley fever" I'm fine now,  however they did a cat scan on my lungs when I was sick and that's when they told me I have copd. I was very worried so that's why they did the spirometry test. I smoked cigarettes for 30 years. I quit when they told me I had copd. I will NEVER smoke again.!!!  I am still very worried even though my numbers are good. Even if I never smoke again do you think the copd will get worse? Thank you in advance for your time and shared wisdom.


A.  Hi Sue,

You took the most important step when you quit smoking.  That your numbers are good is a sign that you should expect very slow progression, if any.  What we see is that after a few years of not smoking, the rate of decline in lung function tracks a "normal" line, so that it shoud remain fairly stable for your age , as you continue to grow older.  Only events like lung infections/pneumonia will cause any more rapid or significant decline.  So, your quest will be to live as healthy a lifestyle and hope for the best with regard to avoiding those maladies.  Beyond that, no one can predict what "will" happen.  And, my cat knocked my crystal ball off it's pedestal the other day and broke it.  So, I'm not able to check the future for you (smile).  Whatever you do, DON'T live your life worrying about what "might" be, or tip-toing around trying to 'avoid' catastrophe.  Live each day for the gift that it is and make the most of it!

Best Wishes,


Q.  Oxygen User Experiences Nosebleeds

Hi Mark,
I have just recently discovered this website and am so grateful to have a qualified person to answer my  questions about COPD.  My mother is 88 years old with a number of health problems including COPD. She is using Advair 500 and Spiriva every day and Ventolin 200 Diskus when needed. She has been on oxygen for almost 2 years at a flow rate of 2 at rest. Recently her flow rate was reassessed by the oxygen provider and has been increased to 2.5 at rest (24 hours). We increase it to 3.5 or 4 when walking outside her room or showering, etc. 

The problem now is that she has started to get nosebleeds that are hard to stop. She gets very anxious and then she gets short of breath and her heart rate goes past 100. We took her to the hospital yesterday because a nosebleed wouldn't stop. The doctor cauterized a capillary in her nose and we are hoping that this solves the problem. It did bleed again when she coughed but we did get it stopped.  We have installed a room humidifier and have it on low all the time (even though the humidity is reading about 35). Also, she is using Secaris cream in her nose to help with the dryness. The doctor said to use a saline solution (Salinex or other) to wash the nostril when needed.

About a month ago, we  tried a humidifier bottle on her concentrator for a few hours but she didn't think she was getting enough oxygen this way - so we stopped this. Do you have any comments or suggestions for other things we can try to help my mom stop the nosebleeds?  Is this a common side effect of using oxygen or is it just her age, dry air due to heating, etc.

Thanks so much for your advice,  Ola

A.  Hi Ola,

Nose bleeds are sometimes a complication of oxygen use, though not often as such low flow rates.  I suspect your mother has other causes that make her especially susceptible.  I wonder if she is taking warfarin (coumadin, here in the USA).  It is a blood thinner that is frequently given to folks who have atrial fibrillation and some other heart rhythm disturbances.  It can make one especially susceptible to bleeding from various triggers and locations.  If she is on coumadin/warfarin, that could easily be the cause.  Yet, it is NOT something you would want to stop.  If she IS on coumadin/warfarin, AND is having the bleeding problem, then it is especially important to follow up at regular intervals with blood tests to assure that she is not taking too much or too little.  Levels of that blood thinner are significantly affected by foods high in vitamin K - - - or lack of them.  Her doctor can tell you more about those considerations, if she is indeed on that medication or other blood thinner(s).

I would recommend trying the humidifier on the oxygen again BUT, be VERY sure everything is screwed together tightly.  If the cap is even a little loose, oxygen leaks out before it gets to her.  Also, be sure the humidifier is well connected to the oxygen source.

Another couple of maneuvers you can do to assure you and her that the oxygen is coming through AND in the same amount with or without the humidifier is to dip her cannula in a cup of water and observe the bubbling of the oxygen AND the rate of bubbling. Check it again when the humidifier is attached to assure that it is visibly the same.

Lastly, there are devices available that deliver oxygen to the airway that do NOT involve tubes into the nares/nostrils.  Look online to see what you can find.  Here is a link to one such device, the "Oxyarm", manufactured by Southmedics, Inc.  Many folks have reported that it works well, though a few have found it necessary to increase the ooxygen flow by a half to on liter to get equivalency to a cannula.  It would certainly be worth a trial.

Best wishes,


Q.  SOB on Exertion

I have experienced shortness of breath since June !  My doctor has tried everything in his arsenal with no success . He is a GP.  It seems to happen when I exert myself ,not a lot but just a little exertion ! Any help would be appreciated !!

Thanks !!    Ken

A.  Hi Ken,

You did not specify what "everything in his arsenal" means.  So, I have no information upon which to base any kind of meaningful response.  The first suggestion I would make is for you to undergo Pulmonary Functions Testing (PFT's), to include 'spirometry, lung volume measurement and diffusing capacity.  Your doctor should know what these are and be able to order the testing for you to have done.  It would be done at a clinic or hospital that has a pulmonary functions department.  PFT's will determine if you have a lung disease that is causing your "exertional dyspnea" (shortness of breath with activity).  If you have been prescribed inhaled medications (from your doctor's "arsenal"), to know which ones you have used would be very helpful.  If you have NOT used any inhaled medications, then I would really wonder what it is that you HAVE used.

In any case, more information is a must if I, or anyone else is to offer any helpful information or guidance.

Best wishes,


Q.  Temporary Oxygen Therapy?

Hi Mark,

I have had 2 bouts of the flu so far these last few months, and I am noticing I am desaturating when doing exercise. I did not desaturate before I was sick.

I still have a bronchial cough, and I am not quite back to normal. My stats are as low as 86, but bounce back quickly. Many have said oxygen therapy is reserved for people whose sats are below 90 most times. Mine is very intermittent .

Do you think I could go on 02 just until I recover from this last flu bout. I am hoping my 02 stats will be back to normal when I fully recover.

As always Thanks Mark.


A. Hi Philip,

The evidence does not support treatment with supplemental oxygen for mild, transient hypoxia.  Though, it might last for a few weeks AND present discomfort for the duration, no discernable long term compromise of pulmonary or cardiac function has been shown under this scenario.  The cost of treating such hypoxia is prohibitive without discernable benefit produced.  If your hypoxia persists, THEN it should be evaluated for being 'chronic' and potentially long-term in nature, at which point treatment should be considered.  Oxygen therapy for chronic hypoxia has well-established benefit, as you might already know.  But, it should be fairly well established as being long-term AND not likely to resolve back to normal/acceptable levels without supplemental oxygen therapy.

Best Wishes, Mark

Q. On Spiral CT Scans

I am 49 years old and smoked for 27 years. I quit for good in July 2000. I was concerned about all of those years I smoked and went to see my doctor. She ordered a spiral CT scan of the chest with contrast. The nurse called me a week later and said the ct scan was normal. When I was talking to the doctor before the chest she said the new spiral CT scans show the lung anatomy in much greater detail and they can reflect emphysema and other chronic changes associated with smoking. I started reading some of the COPD boards out of curiosity and now I am not sure what to believe. Any insight you can provide about the spiral CT scan will be greatly appreciated. Thank you.


A.  Hi David,

The spiral CT is a very sensitive and accurate test for assessment of the physical features of the lung anatomy.  In my Chest update news letter from the American College of Chest Physicians, yesterday, an article described the results of a very large and long-term study using spiral CT to assess for evidence of lung cancers.  It was infinitely more accurate than was standard chest xray for that purpose.  It has long been used to ascertain if there are chronic changes of COPD.  A high-resolution CT is a more intense version and is even more sensitive to identify such changes, though does not provide much more information than does the spiral CT for the kind of changes your doctor was looking for.  I see no reason to doubt the results as reported to you.  Remember that while 95 % of those who have COPD developed it as a result of smoking, only abour 30 % of smokers actually develop COPD.  We reasonably suspect that this fact is owing to genetic influences, a point which is receiving intense scrutiny in research AND has produced some insights that are pushing us closer to potentially developing treatments and preventive interventions in the future.

You took the most beneficial and important step to preserve your lung function when you quit smoking.  Just be sure to have your lung function  monitored at least every five years as you age.  It could be that you will develop COPD at some point.  NOW, may simply be too early for it to manifest with any discernable evidence.  In the meantime, try not to dwell on or worry about what is NOT showing on your CT, at this time.

Best Wishes,


Q.  Spirometry  Test Measurements

My  doctor gave me results of spirometry test then rushed me out of his office without explaining anything. I have no insurance and no money to pay
for more visits. I did get a copy of results. can you tell me how bad my copd is? please?
 fvc   ref 3.35   pre meas 4.93
 fev1  ref 2.78  pre meas 3.18
fev1/fvc %  ref 84 pre meas 65
fef25-75%  ref 3.12 pre meas 1.55
fef 75-85% ref 0.98 pre meas 0.24
fev 3  ref 3.09  pre meas 4.00
pef  ref 6.20 pre meas 6.15

All I did was blow in a machine three times.  I'm scared


A.  Hi Sue,

While I suspect that something might have been out of calibration on the machine that measured your pulmonary functions (PFT), your FVC, FEV-1, FEV3 and PEF are ALL 'near' or significantly ABOVE predicted for your gender, height and age - unless those were entered with erroneous measurements.  Your mid- and small-airway flows (FEF 25 - 75 % and FEV 75 - 85 %) and FEV1/FVC ratio are significantly below normal, but not explained by the measurements I cited above.  As such, they literally do not match up to the measures, timed-volumes.  In any case, the timed- volumes are likely accurate.  So, I suspect it is the measurement of the flows that represents a poor calibration of the flow-measuring device IF it is separate from the timed-volume-measuring component.  In any case, your PFT's do NOT indicate clnically consequential COPD. 

Were you diagnosed as having COPD before the PFT was done?  If so, I would wonder by what means you would have been diagnosed, if not by the results of a PFT.  One other question nags me: Is this the first PFT you've ever had?  If not, how does it compare to those you've had done before you underwent this current testing event?

Best Wishes,


Q.  Champix, Inhalers,  Disease Severity

My boyfriend has just been diagnosed with COPD (not sure if its mild, medium or extreme) He'll most likely be getting an inhaler, don't know about any oxygen treatments yet.
He also has a prescription for Champix which he has not used yet - Can he take Champix as well as using an inhaler/oxygen treatments?
What possible side effects would  there be?


A.  Hi Barbara,

First, the question on my mind is: "How bad is he"?  You didn't say how old he is, what, his tobacco history might have been, what his symptoms are or anything else that gives me a clue.  Further, unless he was diagnosed using a PFT (Pulmonary Functions Test), any assignment of severity would be strictly opinion and not necessarily accurate, much less useful.  ONLY a PFT can assess severity with respect to stages.  If the likelihood of his getting an inhaler is on the "maybe" list, then oxygen treatment would likely be years away.  So, don't even entertain that idea until he is found to be severe - - - AND by that time you would likely know he is severe without needing to be told, as his breathing will have been a BIG problem - - - especially when he gets up and moves around - - - for quite some time at that point. 

I will assume you are speaking of Chantix, as we know it here in the states.  Using that drug and an inhaler is perfectly fine.  There are potential side effects with each, the inhaler(s) and the tobacco cessation aid medications. But, they are unique to each and different from each other.  BUT, the chances of any side effects that might be problematic from the inhalers is small.  Chantix on the other hand is impossible to predict AND can present problems for some folks.

If he has not had a PFT, he should insist on getting one done.  It may be that his COPD is not yet severe enough to need even inhalers, especially if he is successful in quitting smoking and gains some wind-power in doing so.  A PFT will certainly reveal what is the best course, at this point.  Also, exercise will be increasingly important, both to slow the progression AND to overcome or at least reduce the impact of any breathing difficulties he might now be experiencing. Exercising to a level that challenges his breathing is of utmost importance to both his future condition in general and in reducing symptoms and the impact of his disease in the future.

 Best Wishes,


Q.  Lung Cyst

I have a cyst (large empty balloon) in my left lung that cover 2/3 of my lungs.  Can you tell me how the thoracic surgeon would remove it?


A.  Hi Lucie,

Depending upon the cause of the cyst, the 'lung volume reduction' procedure (LVRS)  may likely be the approach of choice.  Either through an approach wherein the chest is opened up - - - through a median sternotomy, which is a cutting down through the breast bone and opening to expose the heart and lungs, as done for open heart surgery; a 'clam shell' incision which goes from one side to the other across the breast bone, under the breasts;  or through several small incisions and then using a scope and small cutting tools through which the procedure can be done videoscopically - - - the portion of affected lung is 'clamped' off and removed while at the same time a 'patch' using heart muscle from a cow is placed to 'seal' up the remaining lung section.  By removing the blown up and non-functioning section of lung, the remaining lung can expand and shift to occupy the space created by removing the cystic lung, allowing improved movement of air and significant reduction in work to breathe, while also allowing improvement in matching areas that get blood flow with the areas the get fresh air, improving gas exchange, in the process.

LVRS is a MAJOR surgery and not to be taken lightly. It produces wonderful results for many folks, but is not without it's risks and complications.  If that is what your surgeons are contemplating doing, my recommendation is to talk with them and ask every question that comes to your mind, including expressing any concerns and fears you may have about the process.  This is one of those instances when you cannot get 'too much' information.  You want to undergo this process as a 'fully informed' subject and NOT leave issues unaddressed.

Best Wishes,


Q.  Will Increasing Oxygen also increase CO2

Dear Mark

I can see by your reply that I did not give you much information. Fred my husband worked underground and above ground mining for 28 years, when underground he worked in gold mines, lead mines, copper and zinc. He had a LVRS in Feb of 2005. He has had in four years 4 lung infections. The Dr's tell me 2 were pneumonia they think?? When Fred's 02 went down to 71 he was having a bad reaction to a medication. This information is according to his Dr. that was on call in this particular hospital. When he was admitted he had 6 Dr and 5 different answers to what he had. Now I am confused on the amount of 02 he should have. Fred has end stage emphysema. He does not need 02 when he is resting. When up on his treadmill he puts it on 2L.When he is sleeping he puts it on 1/2 L and his sats are 95 with a heart rate of 65 Average. I am very concerned over he C02 I have no Idea what his baseline is anymore. We made an appointment to go to WestPark and get a sleep test done. He is in much better shape than I think I put across to you in my first email. Fred never goes above 3L of 02 in the 5 years he has been on Oxygen. What I was asking you was, does too much 02 make his C02 go up. Fred stats are usually around 92 to 94 the one thing that concerns me is his heart rate is about 90 to 98?? I am learning and appreciate your answers. I don't think I gave you enough info.

Thank you

A.  Hi Mitch,

Thanks for the additional information.  I am still not inclined to be concerned about his CO2 *when he is in his steady state*  When he is having increased difficulties, like exacerbations and/or pneumonia, THAT is when his CO2 needs to be monitored.  What it runs when he is feeling his 'usual' and 'decent', is irrelevant - - - both to how much oxygen he should use or to concerns over other problems.  His saturation is your best indicator and should be kept as you describe observing it.  He should (IMO) use as much oxygen as is necessary to "maintain" good saturations, especially when on the treadmill.

His heart rate of 98 is not a problem.  When ones "resting" heart rate exceeds 90 - 100, THAT is when their disease severity is increasingly an issue.  That his resting heart rate is 65 when sleeping, is GREAT!  Another misplaced concern folks tend to have is when exercise heart rate goes up to or over 100.  He can (likely) safely push his heart rate to at least 120 without danger! Indeed, if he doesn't shoot for a heart rate that high, he is not getting as much exercise benefit as he otherwise could.  NOW, keep in mind that a lot of folks will run out of breathing reserve during exercise before their heart rate reaches 120.  SO, if at 100 or 110, he has reached his tolerable level of breathlessness/windedness during exercise, he should let the breathing work be his 'limiter'.  As he gains conditioning, the breathing will improve and he will be able to push his heart rate ever higher. 

My hat is off to you and him, both for your quest for information AND the gumption to push on with trying to keep moving AND in the best state of health his lung disease will allow.  Carry on! ! !

Best Wishes,


Q.  Constant Throat Clearing (Mucous)

Hi Mark
I am a 44 yr. old woman. I smoked when I was younger for approx. 10 years. My dad was a smoker, he had emphysema, asthma. My mother died of lung cancer at 53.
My question is this...I am constantly clearing my throat. I have done this for years, however lately it is non-stop! From the time I wake up till I go to bed, I am clearing mucous from my throat. I have spoken to my dr. in the past and she said it is post nasal drip. I am having my doubts. People are starting to tease me about the throat clearing, and at times it is embarrassing. I have tried not doing it, but I get so clogged up with mucous I cannot talk.
What do you suggest? I have a dr. appt. on Nov. 22.

Thank you,

A.  Hi Susan,

Your smoking history does not give me great concern that you would be at significant risk to develop COPD.  BUT, you can set your mind at ease by asking your doctor to send you for a PFT (Pulmonary Functions Test).  That test will settle ANY question of if you have detectable or clinically significant lung disease.  That will also support or refute your doctor's suggestion that you have a problem with post nasal drip (a distinct possibility).  You could also have mild chronic bronchitis, which a PFT would reveal, which, while not significant enough to consider the various interventions of more serious disease, would be worth noting for future monitoring.

In the end, it doesn't sound to me like you have anything significant to be concerned about.  But, when all is said and done, you should NEVER stifle the mucus clearing, as that is your defense against infection and worse lung problems.  It might be worth asking about steroid nasal spray to control the post nasal drip, if it is significant enough that your doctor thinks it would be a good idea.

Best Wishes,


Q.  What's the difference between an Arterial Blood Gas (ABG) vs A Venous Blood Gas Test?

Can you tell me if there is much difference between an Arterial Blood Gas and a Venus Blood Gas?? My husband is a CO2 retainer. I have problems getting Dr to do a Arterial.


A.  Hi Mitch,

The arterial blood gas measures the same things as does the venous blood gas EXCEPT for the oxygen level and consequently, the saturation.  But, pH and paCO2 are very comparable between arterial and venous blood, though the difference may be exaggerated moreso in CO2-retaining folks.  You didn't say why your hubby's doctor is reluctant to do an ABG on your request.  The question has to be asked, is the information to satisfy your curiosity?  Or is it to determine if treatment needs to be adjusted.  If your hubby is doing fine and there is no reason to suspect that his CO2 is increasing from pathology, then the question has to be asked why the test needs to be done. Regardless of how much CO2 he is retaining, a pulse oximetry measurement will reveal is his blood gases are stable, whatever his CO2 might be.  That makes getting a  blood gas test of questionable value or necessity.  And you don't want to do tests that are invasive and CAN have undesirable outcomes or complications if you don't need to do them.   

Best Regards,


Q.  Uniphyl for COPD?

How do you feel about the drug Uniphyl for COPD patients?  I have only recently been diagnosed with emphysema, following pulmonary function tests.  I have been taking Symbicort and Spiriva, and Ventolin occasionally, since September, and while feeling better, I still have bouts of shortness of breath if I'm stressed or rushing around. I have just been prescribed the Uniphyl and having read the possible side effects, I am leery.......    How does the doctor know for sure that is what I have - I have no cough and no phlegm.  (I have not smoked since May 1st, when I fractured my femur, but I was a fairly heavy smoker for a long time.)  It was in hospital, following the surgery, when I was up and moving around with the walker that the shortness of breath became acute.  I know I'm still in a "rationalization" stage, but this new medication makes me nervous.


A.  Hi Jan,

While the published side effects of drugs like Uniphyl CAN be disconcerting, it is actually a very effective and useful medication for treatment of specific symptoms.  It is the brand name for the drug theophylline, a very old drug that has seen good days and bad days in its application to treatment of obstructive lung diseases.  It has long been used to treat asthma.  While it is not used nearly as much today as it was 30 years ago, that is because we now have better alternatives that allow only selective use of the drug for treatment of asthma.  Not too many years ago, some well-done studies demonstrated that low-dose theophylline was effective to relieve shortness of breath in those with COPD.  BUT, it is generally reserved for those with Stage III (GOLD) COPD, which you don't sound like you have, from what you relate is your activity level.  

The difference between using theophylline for treatment of asthma and for COPD arises when we look at doseage and blood levels of the drug.  In asthma, the general objective is to give enough to raise the blood level to between 8 and 20.  For COPD, the objective is to keep the level at 6 or less.  If a mistake is commonly observed in physicians using theophylline to treat COPD, it is that they over-dose the patient in an effort to try to get their blood level up to the 8 - 20 range. While that IS necessary for those with asthma, it is problematic for those with COPD who don't have a significant asthmatic component.  To get one to the 8 - 20 level, doses of 600 - 1200 mg twice a day are usually given.  To treat a non-asthmatic person with COPD, doses of 50 mg to 200 mg once or twice a day are used.  You can see the difference immediately between the proper prescribing according to diagnosis.  After that, dose is usually adjusted according to side effects.  The higher the dose, the more the side effects.  Common side effects include jitteriness, uneasy stomach, even to the point of mild nausea, disturbed sleep/insomnia and decreased appetite/indigestion.  Others that may be listed are rare and you should not be overly concerned

about them.

To determine 'why' you are on it and if it is really necessary and helpful, you should ask your doctor to tell you what his objective is in using it in your treatment plan.  It may be that your occasional shortness of breath may be cause by reactive airways (asthma).  In that case, it would be appropriate.  There may be COPD-related reasons why he is using it.  If he cannot give you a specific objective for its use, then question the need for it. You did not say if you have any side effects.  You only said you are concerned about those you read about.  But, if you are having any of those that I identified, then let your doctor know.  Perhaps your dose may be too high (though, again, you did not say how much you are prescribed to take).

So, the bottom line is you need to talk to your doctor and express your concerns.  Relate the effects as you are experiencing them, including any side effects if THEY are occurring.  Ask why you are having to use the drug and if there is an alternative that will cover the objective he has any better than can the Theophylline.  In the end, if you are not actually experiencing any side effects and you are not experiencing significant symptoms while using it, then it shouldn't present a problem or unnecessary concern for you to continue to use it.  It is likely helping you.

Best Regards and Wishes,


Q. How can I balance CO2 and Oxygen levels?

Getting too much O2 and CO2 ?? I started my question like this because I have trouble helping my husband thru this dilemma. When he has too much CO2 his brain is telling him to breath faster and get more O2, now his lungs really does not need O2 because he has too much CO2 right???

Now I got startled the other night when his breathing went way too fast like his O2 went down to 71 and his heart was 130. I called the Ambulance they came and they put his O2 unto 10Litres I told her my husband was a CO2 retainer and she proceeded to tell me I was not giving my husband his Ventalin right he needed a chamber, little did she know that the chamber was not something my husband wanted at that time. He does use the chamber when he needs ventolin. They never turned down the O2 until 45 minutes later.

Fred's C02 was 91 we proceeded to put on his BiPap for 15 hrs a day. The next day is was 71 and is still going down.

What can I do to get the two balanced out. Fred is on O2 most of the time at  1.5 liters  sometimes he turns it up to 2.0litres

I hope I explained this right??? Basically I worry about CO2 a lot. He went into a Coma after his LVRS and I will never forget that. Fred has end stage Emphysema he was a smoker and worked underground for 28 years. He quit smoking 4 years ago. I just want Fred with me for as long as I can hang on to him. He no longer works. He retired.

Thanks a million

Hi Mitch,

First, you did a pretty good job of providing enough information for me to figure out a few things to suggest to help (I hope) allay some of your concern.  BUT, in the process, I want to express some concerns that "I" have in view of the information you provided.

To be sure I have his scenario correct, please correct me if any of the following is not applicable or accurate.  He has (probably stage IV - GOLD) severe COPD such that he retainsCO2.  Without knowing what his corresponding pH is with the CO2 levels you report, I cannot ascertain how 'acutely' his respiratory failure (technical term) actually is.  He was a coal miner?  (You said he worked underground for 28 years, so I presume he was a miner and likely mining coal.  Correct?)  As with many miners, he also smoked, giving him a double-whammy of COPD.  That explains his severe gas exchange defect and the CO2 retention. Now, folks who retain CO2 BUT, balance it with retention of "bicarbonate" (a buffering substance in the blood) are said to exhibit "chronic respiratory failure", a necessary and desirable 'compensation action of the body.  We say that they have "compensated" for the retained CO2.  How much and how well they have compensated for the retained CO2 is indicated by the pH and the bicarbonate, both components of blood gas measurements.  When he is 'stable', or in his 'steady state', his pH will be in the normal range or slightly elevated AND his bicarbonate will be significantly above normal.  These two components match up to the elevated CO2 to determine if he is 'OK' at any given moment.  You also report that he has had LVRS.  But, you don't relate WHEN he had it done.  So it is difficult to ascertain where he is in his disease state and progression in view of having had the procedure.  BUT, that said, folks who have LVRS tend to decline back to their 'pre-LVRS' pulmonary function by four years, though MANY continue to do well for many more years beyond four.  With his history, I wouldn't be surprised if he has returned to his pre-LVRS state at this point, especially in view of the fact that he seems to be severely retaining CO2.

Now, one point I want to make is that there is not a "balance" relationship between O2 and CO2, per se, as you seem to put it. So, any notion you may have developed about too much oxygen being a problem is misplaced for several reasons.  But, the bottom line is he surely DOES need oxygen and probably more than you have thought in the past, or than some of his health care professionals may think, even now.  There IS a long-standing belief that giving too much oxygen to a CO2-retainer will cause them to retain even more CO2 which will then decrease their 'drive to breathe', causing them to quit breathing, even to the point of dying from it.  There is no empiric evidence that such thing happens.  And indeed, today, the growing sentiment is that the theory was misbegotten AND to practice the withholding of adequate oxygen from folks who retain CO2 in an effort to avoid decreasing their drive to breathe is bad medicine and leads to very predictable problems as time goes by, including premature death from more rapid disease progression.  In the meantime, the deprivation of adequate oxygen reduces their ability to function and move around so that they worsen more rapidly than they would if given adequate oxygen, despite CO2 retention.  And their ability to achieve any level of 'comfort' within their breathing difficulties is severely impaired, if not impossible.

In folks with normal lung function, as CO2 goes up, they are stimulated to breathe more to try to 'blow it off' to reduce it back towards normal.  This mechanism is thought to be defective and suppressed in folks who retain CO2.  But, in actuality, we do NOT observe that to be the case when we investigate the phenomenon in studies.  So, in one respect, you are correct that his rising CO2 DOES make him try to breathe more.  But, to think that he should receive less O2, or that his lungs don't need the additional O2 is where your notion goes awry.  He indeed DOES need the extra oxygen for reasons that are too intricate to try to explain here.  But, suffice it to say that he indeed SHOULD turn his O2 up, especially if you observe his pulse oximeter measurement of saturation to drop below 88 - 90 % for any significant amount of time.  71 % on the oximeter is critically low and very dangerous if left untreated.  Consider that the oxygen level in venous blood - - - after the body has extracted all the oxygen it needs and is sending the blood back to the lungs to pick up more oxygen again - - - is 75 %.  At 71 %, his lungs are sending out blood that is so poorly oxygenated that there is little to none to supply the body.  Remember that oxygen saturation measured by pulse oximetry is a measurement of the "arterial" content of oxygen.  As such it is what is going out into the body to feed it its necessary quantity of oxygen in order to continue functioning.  At 71 %, the body becomes starved for oxygen very quickly!

Now, he has some degree of "acute respiratory failure" which is 'superimposed' upon his "chronic respiratory failure".  How much he has is not ascertainable without knowing the pH of his blood that goes with those secerely elevated CO2's (the 91 that then dropped to a still, very elevated 71.  Normal is 35 - 45, 40 being absolute normal.) Only a blood gas ca measure pH, as oximetry, while being directly affected by pH does not give any indication of what it is.  You said that he uses BiPAP and increased to15 hours a day to get his CO2 to drop to the 71 it dropped to.  That tells me that he was in fairly profound "ACUTE" respiratory failure.  The BiPAP was a godsend and also effective as evidenced by his significant decrease in CO2. It would be invaluable to know what his "steady state" CO2 is.  But, that can ONLY be measured when he is feeling as good as he can, in view of his disease severity and requires doing a blood gas test. 

In any case, you have the tools to support him as best you can to help him breathe better and to "keep him around" as long as you can.  With his BiPAP and oxygen and proper and judicious use of each, he can better normalize his O2 and CO2 than he would be able to without them.  I hope you are 'bleeding-in' oxygen to his BiPAP when he is using it - - - and at a flow that is much higher than 2.  As well, I would bet that he needs much more than 1.5 to 2 liters ox oxygen even when at rest, though I can't be fully confident of that knowing only what I've learned from your post.  At the very least, when he gets up and moves around, his oxygen flow requirement is likely at least 5 or 6 or more in order just to keep his saturation while moving around in the mid-80 % range.  Only measurements while he is walking around and for at least 90 seconds or more of movement can verify or refute that speculation.

Another point that comes to mind is what inhaled medications he may be using.  I hope that Ventolin is not the ONLY medication he is inhaling.  While a spacer IS the best thing to help him get the most out of it, that drug alone is not near enough for the stage of disease he is in.  Ventolin should ONLY be a rescue medication for him and a "pick-me-up" as a preparation to walk or exert or exercise.  He should be on one of the long-acting forms (LABA) of the class from which Ventolin comes - - - like Formoterol or Salmeterol.  He should also be on a long-acting anticholinergic medication.  Spiriva is the only one at this time, though there may be other ones coming onto the market around the world.  He likely would benefit from an inhaled cortisteroid, like Fluticasone or Beclomethasone or one of a few others that are widely used.  Many folks take a combination inhaled drug mixture of these medications.  Advair and Symbicort are two that are widely used here in the USA.  Depending upon where one lives outside the states, they may have different brand names, though they are still combinations of the same generic LABA and cortisteroid.  One of those combined drug preparations plus Spiriva 'should' be his "maintenance" medication treatment regimen with the Ventolin used "when needed" beyond those medications.

If he is already using a combination drug plus Spiriva AND he is still severely retaining CO2and exhibiting hypoxia as you describe, then I'm afraid he is about as severe as he can get.  In that case, the BiPAP for as many hours of the day as he feels is helpful is likely his best treatment.  And, as I said before, he should be putting oxygen flow into the BiPAP system when he is using it, as well.

Lastly, while his situation seems so severe AND he undoubtedly abhors getting up and moving around and making his breathing much harder as a result, he nevertheless would benefit greatly from putting himself through that misery to try to move and even exercise (walk) as much as possible as doing so will improve his breathing ability, his muscle condition and tone and ultimately reduce his demand for oxygen and his over-production of CO2.  This is NOT an easy thing that I recommend.  And, if he is past a point where he is willing to try to improve, I would understand perfectly, as he seems about as severe as one can get.

I wish you both the best and success in improving his situation.


Q. Nothing is Working - Suggestions?

 I have had a serious shortness of breath since last Saturday (much worse than usual). I have had COPD for at least 20years.  I smoked Until 1987  I am now 81 years old. I live in small town called Maniwaki  which is located about 100 Miles North of Ottawa.

We have a small hospital and about  10 doctors to cover the area from Wakefield to Grand Remous .
The local doctors have tried me on most of the medications , nothing seems to work !! I have been told that the Emphysema  component has got worse.

Do you have any suggestions ? Any exercise at this point makes it very difficult to get my  breath !!
              Hope you can help!!

A.  Hi Ken,

Yours is a typical complaint of those with advanced  COPD.  AND, the solution seems counterintuitive, since to improve your breathing you must force yourself to move around/exerc ise to improve your oxygen demands and reduce your CO2 production, all of which reduces the load on your lungs.  While it may feel horrible when you move AND you may indeed think it will harm you, as bad as it feels, you MUST nevertheless move and exercise to get your breathing to improve.  And I can't stress enough that breathing hard like that WILL NOT HARM YOU!

A concern I have is if your are experiencing hypoxia during exertion.  If you are, you will only have limited success in improving your breathing unless you can get supplemental oxygen to use during exercise to help raise your oxygen levels towards normal.

You didn't say what medications you have tried.  But, I would strongly recommend a concerted trial of symbicort and Spiriva for at least a month or more before you dump them again.  They take time to work.  Even when they work well, they will NOT completely resolve your breathing problems.  BUT, they will go a long way to improve them.

Best Wishes,                        Mark


Q.  Shortness of Breath but Oxygen Levels are Fine

Doctor Mark,
                   I  have  just spent 10 days in hospital  with a lung infection & deep vein thrombosis & sob, the time spent in hospital made my sob worse due to the excessive heat in the ward. I am now home & trying to get back to normality, but I still have sob with my oxygen levels at 96=97  & I don't seem to be retaining any Co2, So what can the problem be.?   Thank you,  Ernie

A. Hi Ernie,

SOB with normal saturations as you report is an all too common problem.  Advanced COPD makes moving air more and more difficult because of the loss of "conducting airways" (bronchial tubes, especially the thousands of small ones out in the distal portions of your lungs) which causes one to trap air and further over-inflate the lungs.  This happens with exertion/exercise and is why pursed lips breathing (PLB) is SO important to learn and master.  It is during these times when you naturally trap more air that PLB does what it does to benefit you and reduce SOB.  Deconditioning is another cause of SOB when oxygen levels are normal.  One who sits in a hospital bed for any significant amount of time quickly becomes deconditioned which places additional demands on moving air and increases SOB. 

So, you have plenty of reason to be experiencing SOB as you are experiencing.  The solution is easy top say but much harder to do.  But, you've got to get up and get moving and find a way to persevere through the SOB to achieve better condition which will decrease demands on your breathing and result in improvement. 

Also, with your deep vein thrombosis, it is all the more important for you to continue to monitor your oxygen saturation as you are at greater risk for a blood clot to break off and lodge in your lungs - - - a potentially life-threatening event.

Best Wishes,                                        Mark

Q.  DLCO Question

I see references to DLCO as being part of the SOB problem.  However, I don't see any reference to it on reports of PFT's.  How do you find out what your DLCO is, and if it is the cause of your SOB?

Thank you for your help.


A.  Hi Toni,

DLCO is a separate test done during pulmonary functions testing and must be specifically requested by your doctor.  If you have not had one done, ask your doctor if you should get one done.  In any case, regardless of what the DLCO is, the result of a reduced DLCO is hypoxia.  That can be ascertained with measurement of your oxygen saturation using a pulse oximeter.  Ask your doctor about getting a pulse oximetry measurement.  Hypoxia is certainly a contributor to SOB.  But it is not the only or even always the prominent or primary reason for SOB.

Best Wishes,                                                                Mark


Q.  Shared Info (for Jorge) - Dizzy Spells, Loss of Balance  & Champix

Hi Mark:

Not to interfere or anything, but I couldn't help wondering, was Jorge (the person with the heavy dizzy spells) on the drug to quite smoking called Champix in Canada, but I think it is Chantix in the US?  I suddenly had severe dizzy spells (daily) after being on Champix for some time - very scary ones where I lost my balance and fell sideways and immediately stopped the Champix.  The spells stopped within a few days but I still went to my family doctor who immediately put me on the 48 hour heart holter test and followed up with ultra-sound and stress test to ensure it was not a heart problem.  I never had another one after stopping the smoking cessation drug so it might be worth mentioning to Jorge just in case.  Thank you.  I also want to sing the praises of the COPD Rehab Program that I have been attending since September.  These classes are so important and helpful to COPD'rs and really are worth attending.  Knowledge, exercise and help from the professionals have really helped to ease our expectations and enjoy our quality of life.  If anyone with COPD can enroll in one of these Rehab Programs, I highly recommend they do!!


A.    Hi Lynn, 

Good input and suggestions.  I hope Jorge will read your post and consider if it applies to him. 

I also second your enthusiasm about pulmonary rehab and its benefits!  Thanks for sharing your thoughts and suggestions with us.

Best Regards,                                                            Mark

Q.  Dr.  Diagnosed COPD But  Refuses  Function Testing

I recently went to my physician and he told me I have COPD but  when I asked for a lung function test or and x-ray he refused.  I am wondering where I should go from here, or should I just accept that I have this disease without knowing anything about it.  He also said that until I quit smoking that there is no point of finding out the damage because I'm just going to die from this or get lung cancer without any testing.  I'm scared but angry at the same time because I really have no idea what is going on with my body, what stage I'm at or anything because I'm not going to get the test for at least a year after I've quit smoking.  Is this correct??


A. Hi Joanne,

I must confess, I am disappointed to learn that proper and complete diagnosis of your potential COPD is being held hostage for the fact that you smoke.  While we can all appreciate how non-smokers can fail to see the grip that smoking has on its victims and that simply laying the cigs aside is gruelingly more difficult than waving a magic wand, to deny you proper testing to support the proclamation that you have COPD and will just have to go on to die from it without any care or support is very close to defying the oath of Hippocrates (do no harm) that physicians must swear to and fulfill.  Beyond that, it is difficult for anyone to support a proclaimed diagnosis without 'evidence' to back it up.  And that is what your doctor is presuming to do.  To hold you to an ultimatum to quit for a year 'before' you get tested is highly questionable, as well and is purely and simply prejudicial to your best interests.  Best recommendations for management of COPD are for testing, regardless of if someone is still smoking and ESPECIALLY if they are smoking in order to garner the information that may be the very point that convinces them to take action to quit.

I don't know if you have the option to seek another opinion from a doctor that you first screen for compassion and action to help you determine the extent of your affliction AND what course of action you 'must' take and 'when'.  But, if you can see another doctor AND your current doctor remains obstinate, I would urge you to do so.  You need to have a PFT, at the very least to (1) substantiate his diagnosis; (2) determine the extent of your illness and (3) allow you to gather information as to how important it is for you to quit smoking sooner than later to avoid affecting the rate of any unavoidable decline you may experience as the result of having COPD.  X-rays do not give a meaningful picture of COPD. CT'scans are only helpful when matched to PFT's to give clinically significant meaning.  So, I wouldn't push for them as much as I would strongly urge you to get a PFT.

Whatever you do, don't roll over and accept less than you are entitled to in terms of proper diagnosis.  Without such information, you have insufficient evidence and incentive to help you make the tough decision to go ahead and quit smoking before you push yourself beyond a point that you could more easily avoid by taking necessary action in a timely manner.

Best Wishes,


Q.  Follow Up re:  Neurological Problem - Epley Maneuver

Dear Dr. Mark

Several weeks ago you kindly answered me about a possible neurological problem citing me that I should try the Epley Maneuver, however the "spinning" continues  sort like I have a blood rush in my brain like with bubbles , intermittent. I ve checked several neurologists and find no answer. My COPD is moderate but this spinning is getting worse;  now my eyes close every time I feel it, what do you suggest.


A.  Hi Jorge,

I must answer your question with another one, before I can give you any further response.  Did you go to a physical therapist and undergo intervention with the Epley Maneuver?   If you did not, OR if it was done and was not successful or done properly, then I am sorry to say that the Epley Maneuver is the only suggestion I can offer, as your problem is beyond the scope of my training/education and also outside my comfort zone of advice.  I am not aware of or familiar with any other kinds of interventions or medications that might mitigate or resolve your problem.  I would also venture to guess, that any interventions for your COPD are not likely to impact your dizziness problem.

I am curious to know what your PCP has to say about possible causes?  Have you seen your doctor about the problem?  It could be something as simple as dehydration or over-medication with treatments for high-blood pressure or heart problems, like abnormal rhythms.  It could be more complex.  Heart rhythm abnormalities, like atrial fibrillation and significant heart block problems can cause severe dizziness/vertigo.  If all else fails, you should see a neurologist who is versed in your kind of symptoms and can diagnose and treat by your disorder, once delineated.

Best Wishes,


Q.  Possible GERD

I was diagnosed with COPD in Feb. I am on Spiriva and Ventolin. The last three months I have had heartburn about 6 times in the middle of the night. I have been watching what I eat. The burning in my throat lasts  30 t0 45 minutes. I have tried water tums milk ice cream and ice cubes. Do you know of anything that would relieve the pain faster

A.  Hi Elaine,

I think you need to see your doctor and have that problem evaluated, It sounds to me like you may have GERD (Gastro-esophageal reflux disease) a common problem with folks as they get older.  It likely has nothing to do with your COPD or the medications you take, though folks who have COPD often suffer from GERD.

In the meantime, you should try taking a proton-pump inhibitor.  Ranitadine is good and can be purchased over-the-counter.  Start with 75 mg and increase to 150mg if the 75 doesn't prevent or relieve it after using it for a couple of weeks.  You should understand that you need to take one every evening before bed - - - as a preventive.  It will do no good to wait until you are suffering the discomfort to THEN take something for it.  If the antacids haven't worked before now, they're not likely to work in the future.  Proton pump inhibitors need to be taken regularly to control the acid production.  That's what "prevents" future attacks (or at least reduces their frequency and severity).

Best Regards,                                   Mark

Q. Deciphering PFT Numbers

Hello Mark
          I have two doctors who are giving me two answers that are so far apart, that I am more confused. I am 49 smoked for many years both cigs and pot. I always got sick with bronchitis a few times a year and often coughed producing mucus. Got real sick in Aug 2009 and it lasted a while
 and then I quit smoking Oct 1 2009. I have felt bad ever since and now I have no cough and a hard time getting up mucus which is clear white
  Here are the numbers that the doctors are basing there dx's.

Thanks for any help you can give me,


             Predicted                                Reported                           % Predicted

FVC            3.83                                      3.94                                     103

FEV1           3.15                                      3.00                                     95
FEV1/FVC  1.65                                     76.24                                     93

FEF-MAX    7.97                                      7.76                                     98

FEF25-75     3.37                                      2.29                                     68
MVV            94.90                                  140.73                                   148

TLC              5.75                                       5.90                                    104

FRC              3.60                                       3.19                                    88

RV                1.86                                       2.18                                    117

RV/TLC      33.16                                      36.39                                   110

ERV               1.74                                       1.01                                    58

IC                  2.15                                       2.79                                    130

VC                3.83                                       3.80                                    99
DAB            27.81                                      27.81                                   100

DAB-HB     27.81                                      27.81                                   100

DV/ASB        4.83                                       4.65                                    96
DVASBHB    4.83                                       4.65                                    96

VASB            5.75                                       5.98                                    104


A.  Hello Robert,

Your PFT’s results are essentially within normal limits in all but a couple of specific aspects.  Thos may suggest a bit of airway reactivity (asthma).  You don’t provide “pre-“ and “post-“ bronchodilator measurements to allow determination of the presence of airway reactivity.

In any case, if you are having breathing difficulties and symptoms, then they are likely from causes OTHER THAN any kind of lung disease.  Your numbers are so high as to negate even early or the mildest lung disease as a contributing factor in your complaints.  What CAN be causing you breathing difficulties is simply a bad case of “OOS” (Out Of Shape)!  Folks all too often (and their health care providers, at times, too) mistake symptoms of poor physical conditioning and response to vigorous exercise/exertion for symptoms of underlying disease that simply doesn’t exist.  This is NOT to say that ten or 20 years from now you won’t have developed significant lung disease changes.  But, as this time, your pulmonary function is normal, according to your very good and very complete pulmonary functions test results.

Get moving, keep moving and continue to live the healthier lifestyle you have taken on with smoking cessation and get PFT’s every two to five years to monitor for any changes before they become clinically significant and problematic.

Best Wishes,   Mark

Q. Is 93 to 94% Oxygen Saturation a Concern?

Mark, I just sent you a question about oxygen saturations, and just realized how this format works. I sent the question then read your last response to me (Aug.29th) so this will seem backwards. Your response was most helpful and informative. Just for clarification, the pulmonary pressure of 49 was on an echo. The pressure on the right heart catheterization was 30/8. The last walking saturation I took showed 93 to 94%. I wondered if that was considered normal in a healthy person of my age. I know the previous readings in the 80's is not normal but I question its validity. I continue to be SOB with exertion and the more tired I get, the more SOB I am. By the end of a work week, I feel quite unwell and feel like I am coming down with a cold, my chest feels congested. With rest, its better by Monday, just to start the cycle again. If I try going out for walks, it gets worse and I get so irritable.
  As for my weight, I did lose 34 lbs but I am still about 20 lbs overweight. I can't imagine that is the cause of all of this. My family doc says I can't rule out COPD but my chest xray is normal. I have never smoked and the only exposure to chemicals would be that I gave chemotherapy for about 15 years. I continue to worry about pulmonary hypertension as from what I read, it can be very difficult to diagnose and there has been no other abnormality. So, getting back to my question,( I know I am rambling) is a saturation of 93 to 94% something to worry about or is it considered normal?


A. Hi Lori,

The short answer to your question is “No”.  A saturation of 93 to 94 %, while walking is not something to be concerned with.  Without a definitive reason for it, though, there is a need to know “why” it is reduced, even if by so little, since it is simply not normal for someone without lung disease to have a saturation of less than 96 %.   That said AND the fact that it seems to me you have not had a complete work-up to rule out any lung disease, let alone determine what lung disease you might have, l would urge you to continue asking questions until the information is sufficient to provide an answer.  If there is ANY chance you have COPD, a chest x-ray is the absolute worst tool to determine if that is so.  You should undergo complete pulmonary function testing (spirometry, lung volume measurement and oxygen diffusion capacity studies) .  A high resolution CT scan would show the presence of COPD, but would do NOTING to determine “clinical” significance.  So, the PFT’s are really key to learning what is going on. 

If you had a right heart catheterization and with normal oxygen saturation you had a RV pressure of 30/8, then there is SOME indication of at least very mild pulmonary hypertension, though to what degree of severity and significance it might be was not determined if your oxygen saturation was not challenged with a decrease to see if it pushed your pressures up even more.  30/8 is the upper end of normal, in and of itself.  An echo study is still the most inconsistent and unreliable study with regard to providing definitive measurements towards determining PA and RV pressures.   So the 49 from the echo is not helpful, much less reliable as being accurate. Yet, with significant PAH, I would expect that your saturation would dip a lot more than to only 93 or 94 %.  The only reservati0on I have is that unless you walked at least 3 minutes non-stop in obtaining that 93 -94%, then you did not see the ‘real’ low point in the process.  And, you saturation may indeed go lower than to 93 – 94 % with walking.

So, I don’t suspect PAH is a significant problem.  But, the bottom line is if any type of lung disease is suspected, then the least that should be done is a complete PFT.  So, push for that and see what it shows.   There are many reasons why you can have the exertional breathing difficulties you complain about having, not the least likely of which can simply be from being out of shape!  But, it seems you have some more testing that needs to be done to settle the issue and to ease your mind.

Best Wishes,


Q. Cigarette Cravings,  Exercise & Bloating Issues

Hello Mark:

While experiencing a short stay in the hospital for breathing problems, I was diagnosed with COPD at the end of April - I am 64 years old - have smoked a pack of smokes a day for more than half my life - at the time the doctor said that I was moderate - FV1 of 47%. 

I guess the most important thing is that, as of August 23, I have stopped smoking with the help of Chantix - I´m still using it and right now I´m taking it a day at a time.  My question is:  there is not a day that goes by when I don´t feel I want a cigarette - does this craving ever subside?  I´m worried that at some point I will give in to the temptation and I know that would be my downfall. 

Another question.  I know I need to get into some sort of exercise program because my weight is creeping up - actually way too much for my liking.  I always feel bloated and uncomfortable - is this all a part of the COPD or could the medications be making me feel bloated - I´m taking Symbicort, and Spiriva daily and ProAir for emergencies?  Other than the Chantix, I am on no other medications.  Is there something I can do to relieve the bloating?  Hopefully, I will be getting into a 12 week rehab program so maybe this will help somewhat?

Mark - I´m so glad I found this site.  I realize these are questions I should probably be discussing with my pulmonologist but I´m not sure that he really wants to hear any of it.  When I told him it was taking me somewhere near 2/3 hours to get to sleep he just made a passing comment, wrote it down and went on to the next subject so I´m not sure he wants to hear anything except how I´m breathing. 

Thank you for your time and sharing your knowledge.


A. Hi Lorraine,

You ask an age-old question for which there simply is no telling.  You’ll learn the answer to that as time goes by.  I realize that my response is not much consolation.  But, it is different for every individual.  I have met folks who put the cigs down and never gave them another thought.  Others still acknowledge cravings 20 years after stopping.  The bottom line is do the best you can AND realize that you are human.  If you falter, pick yourself up and get back on that wagon.  What ever you do, don’t beat yourself up about it and think that a single indiscretion and moment of weakness kills the whole effort.

You are correct in your idea about getting moving with an exercise program.  A Pulmonary Rehab program would be a great place to do that.  But, shy of that, you should be able to simply start a concerted effort to walk for at least 30 minutes at least three days a week.  While doing that, you would target doing it non-stop and building up speed until you can reach your maximum comfortable speed.  Do it on a treadmill, the mall, a big store that has isles and a suitable circumference/perimeter that can serve as a track. 

Your questions are perfectly appropriate for this forum.  AND, consider that with an adequate exercise program, your sleeping difficulties are likely to subside.  In the meantime, try taking melatonin (an herbal supplement) and see if it helps you to get to sleep any better.

Best Wishes,                                  Mark

Q.  Frequency of Pneumonia Vaccine

Hi Mark;

How often should a person have a pneumonia vaccine?  I've heard every 5 years, I've heard no; you just need it once. Which is it?
Thank You.  Ceilia

A.Hi Celia,

The common recommendation today is once every five years for the pneumococcal pneumonia vaccine.    No one has held to the life-time-effectiveness notion for many years now.  Ask you doctor.  Then be sure you get the vaccine!

Best Regards,                                  Mark

Q.  Breathing is Worse Since Quitting Smoking

In May or June of this year I went to the emerg with a bad chest cold..I was told I had Bronchial Pneumonia  I was given Prednisone and an inhaler..just as I was leaving the good Dr. turned to me as if it was an the way he said you have COPD  and walked away..I was still smoking at the time but not as much. I took the meds minus the inhalers for reasons I will explain....felt better but COPD bothered me...I knew I had to quit smoking and believe me I have tried a lot of tools to help with little or no effect..My daughter asked me to meet her and her girlfriend one day for coffee .  My daughter's girlfriend told me that she quit smoking and was doing well.. I asked her what she did ..She took Champix to help her quit..So I have tried it and it has been a month now without a cig..  I also realized it wasn't the nicotine but the habit I was having trouble with. I just turned 60 or 30x2  and want to turn over a new leaf in my life...but now I find that I have fatigue just walking the dogs need to rest, also tired. shortness of breath and a dull pain in the upper middle chest area..I think that if I have a good cough the pain will go away  but it does not.. My mother was ill for years with lung problems and was on all sorts of inhalers in and out of hospital and finally on )02  she became so ill that she was admitted and but on a ventilator and eventually the did a tracheostomy ..the med staff were administering a feeding tube  and it took a wrong turn and punctured her lung...anyway she eventually succumbed to the puncture..the doctors said that her lungs were sooo thin from the inhalers over the years...Hence I really do not want to start taking inhalers if I don't have to...why do I seem to be getting worse breathing wise since I stopped smoking...I exercise and eat well  and drink plenty of water..will these feelings subside over time...I currently have no family physician    gratefully    Kathleen

A. Hi Kathleen,

Inhaled Beta-agonist, anticholinergic and steroid medications are the backbone of treatment for COPD.   I’m thinking that “back” when your mother had COPD and her difficult journey with it, the inhalers were much different drugs than what we have today.  In any case, I also suggest that you misunderstood something along the way, as to suggest that the lungs “get thinner” - - - for ANY reason! - - - is just not something that happens or even “can” happen. And inhalers most certainly do NOT cause them to become thinner.   Your mother’s lungs did NOT get “thinner” and were NOTY affected by her inhalers in such a way as might be suggested. 

COPD is a ‘progressive’ disease process.  That means that it will advance, no matter what you do.  What folks CAN do is affect how ‘fast’ it progresses.  Inhaled medications, exercise - - - and I mean real and sufficient exercise - - - proper rest and nutrition and refraining from smoking are some of the most helpful things one can do to slow their rate of decline.  Along the way, you will have your ups and downs with symptoms and exacerbations.  They can knock you for a loop that takes a very long time to overcome.  They can cause permanent changes that make your symptoms worse more quickly.  But, you never know how much change will be permanent until you get up and try to do something to improve your condition.

Insofar as what you’re doing to improve your lot in life; if you mean by exercise that you’re doing at least 30 to 60 minutes of aerobic exercise (pedaling an exercise bike and walking, for instance) three to four days a week, then you are NOT getting enough exercise to make a difference.  If you cannot tolerate that much aerobic exercise at this time, then you need to start small and work up to it.  Exercise will improve both your fatigue and lack of energy.  Eating well is relative and in and of itself tells me nothing helpful.  What you eat and how much as well as knowing your height and weight would be meaningful information.  So I can’t tell anything by your eating well assessment.  Drinking plenty of water falls into the same category.  It means nothing with regard to your condition and what is wrong with you now.

In the end, you seem to have a lot of misconceptions about what you need to do to improve both your condition and your functional ability.  As well, you say nothing about having ever had pulmonary functions testing.  So to simply pass on that the doctor casually told you that you have COPD as he is talking over his shoulder on the way out tells me nothing helpful about if you indeed have it or how bad it is relative to your complaints.  If you haven’t had pulmonary functions testing, then you shouldn’t (IMO) have been given the inhalers in the first place.  So, PFT testing is a must.  Then to know how severe you are will dictate what inhalers you SHOULD be using, if any.  THEN you need to get up and get moving.  Exercise is the single most important intervention to improve COPD.  And you can’t call housework, shopping and similar tasks exercise.  Walking the dog is good, if the dog walks briskly and doesn’t stop at every fire hydrant along the way.

If you can gather more meaningful information and come back with it and your questions again, I can give you more helpful information.  But, for now, I can say no more.

Best Wishes,


Q.  Too Much Oxygen?

I just discovered this site, so you may have already addressed this.  When I told my general physician that I sometimes have to increase my oxygen intake from my usual 2L continuous flow to 3 and very rarely 4, he cautioned me not to increase my oxygen  if I can help it and to be careful when I do.  He said it could be very bad for me.  My question is, if I'm exerting myself to the point at which 2L seems inadequate, isn't it more beneficial to pump up the oxygen rather than deprive my organs of oxygen?  I always turn the oxygen back down to 2L when I recover my ability to be comfortable on that setting once again.  Why does my doctor seem so concerned that I don't increase the amount of oxygen I'm using, and exactly what happens when you do use "too much" oxygen?  How do you know when you're using "too much" oxygen short of actually checking oxygen sats, if your breathing is less of a struggle on a higher setting?


A. Hi Deborah,

Your doctor is concerned with what many of us consider to be a myth that holds that those with COPD who retain CO2 can compromise their ability to breathe effectively by using enough oxygen to normalize their breathing.  In more than 95 % of the instances where health care professionals of all types and credentials impose the rational associated with this notion, it is not only misapplied, but the person is NOT one of those considered to be at risk even by definition under the umbrella of the myth.  Consequently, a LOT of folks are needlessly admonished AND deprived of necessary oxygen in the name of saving them from something that not only simply will not happen, but it CANNOT happen!  As well, when one is using their oxygen as you describe - - - increasing it during activity and exertion - - - t\here is no way they risk inflicting harm upon themselves as those very activities force them to breathe at an increased rate and volume-per-minute.  So the suggestion that using more oxygen flow during those conditions besides being quite silly, also betrays their lack of both consideration of the conditions and understanding of the very theory they are basing their admonitions upon.

In any case, the bottom line is that turning up your oxygen WON’T hurt you!  Not turning it up CAN hurt you.  So, my recommendation would be to continue to do as you have been, though you must understand that I cannot “officially” advise you to defy your doctor’s instructions.  So, you must continue to try to work with him/her until a satisfactory solution is arrived at.  It may require that you spend the $50 - $100 to purchase an oximeter so that you can indeed measure your saturation and show your doctor that you are acting within the context of the measurements you obtain.

Best Regards,                                       Mark

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


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,


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?


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,


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.


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?



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


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

Q.  Oxygen, Ventolin Effects - 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.  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

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!!

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.  Steroids and Enlarged Stomach, (Weight), Oxygen Usage & Exercise

I am in the severe category, or so they say.  I smoked for 42 years and October 06 was told I would not live three more months if I did not quit.  Well it almost four years now.  In addition my expected percentage is/was 27percent (spirometry) five months ago. Dr.(s) smile and tell me I am in denial; up until three months ago, I was playing golf 3-5 times a week which was so psychologically good for me as well as physically.  I have backed down to once a week if I am lucky because of the heat.  However, and here it comes, for almost four years now I do not feel my  medications, activities and weight were monitored beneficially.  I had to ask for change consideration in meds and in doing a lot of internet reading on this found out that I was taking an inhaler that should NOT have been prescribed by my doctor.  It was like double dosing.  I am now taking three meds with oxygen therapy in the evening and occasionally during the day.  My co2 flow is 2.5 on the concentrator and cylinder.  Here is my dilemma:  no one will assist me with the weight issue.  I look like I am 7 months pregnant; it creates a problem with my diaphragm and stomach.  After reading so, so much with layman ability I am  totally frustrated; could you please direct me with an exercise program. As a second thought, I am wondering if the steroids from the drugs (and cortisteroids) are contributing to this.  Doctor says the amount of steroids is minimal, but it has been four years!  I just need a voice to communicate with; there are not a lot of "what ifs", but your bio has  been very encouraging to me.  Within these four years I had also qualified with two clinical labs for programs, however, the doctor was too discouraging and the last minute I cancelled out.

Thank you just for reading this.
My current drugs are Spiriva, Pro Air (albuterol) and Symbicort
Its been Spiriva for 4 years; with Advair during which time I had a "mild" heart attack
followed by Alvesco and Foradil with Spiriva

A.  Hi Andrea,

You gave me a lot of ambiguous information on which to base answers to yet even more difficult-to-figure-out questions.  But, let's try to sort it out if we can and see if I can give you some helpful answers. 

First, I will assume you mean that your FEV-1 is 27 % of predicted, which does indeed put you into the 'severe' category, but FAR from death!  So, like so many other doctor's predictions folks have shared with me over the years, I am happy yours turned out to be wrong, as well!  I can't comment on the inhaler you say should not have been prescribed by your doctor as you didn't tell me what the name of the medication was or the other inhaler you consider constitutes the "double-dosing" situation..  There are a lot of inhalers of which folks sometimes - - - appropriately - - - take more than one of similar versions.  Your Albuterol and Symbicort are examples.

With regard to using oxygen; using it in the evening and a little during the day doesn't sound like an effective pattern of use.  Most folks who need oxygen use it most during sleep and with exertion and exercise.  It does no good to use it casually during times when your levels are probably near or at normal.  Oxygen levels drop most often when one gets up and moves around and when they are asleep.  If your oxygen levels drop during activities like walking and you don't use oxygen to keep it at safe levels, over time, you stress your heart and cause predictable negative changes and allow your COPD to advance at a faster pace.  Using oxygen before or after these periods of "desaturation" does no good as oxygen is ONLY effective to benefit you when it is used 'during' times when your saturation drops.  I would also encourage you to use it when you sleep.

Having said all this about how best to use your oxygen, I am impressed that you have been able to play golf 3-5 times a week, especially if you have such a low FEV-1 (27%) and have enough energy/stamina and BREATH to do it with enjoyment.  Not only would that be "psychologically" good for you, but the 'physical' benefit, in terms of conditioning is ALSO a big plus.  BUT, if you are desaturating all the while you play golf, you are also inflicting harm upon yourself.  I would recommend you get a walking test wherein your oxygen saturation is measured while you walk, non-stop, for at least three minutes or more to see if it drops when you 'don't' use oxygen.  If your saturation is dropping into the 80's, then you need to use oxygen with exertion as much as is possible and practical.  This test can be done by your lung doctor, in his/her office.  If you find that it DOES drop, then you would do well to take your portable oxygen with you and use it while you play golf.  Even if you use it between swings, from shot to shot, you would be gaining tremendous benefit in keeping your oxygen level at a higher point than it might otherwise be, were you not using it.  And you'll be helping to extend the time that you are able to maintain good enough health and condition to continue to play golf for the foreseeable future.   Folks today purchase a personal pulse oximeter and monitor their own oxygen saturation during their activities, adjusting their oxygen (or simply using it as opposed to not using it) when they observe decreases in their saturation to below 88 - 90 %, as a minimum.  You might also consider getting one for yourself.  You can get a good one for about $100.

You spoke of your "co2 flow" from your concentrator and cylinder as being set at 2.5.  A small correction in terminology is in order here.  That is your "oxygen flow" from those devices, rather than "co2 flow" as you said.  CO2 is the gas that we want to expel from our lungs when we breathe.  O2 is what we breathe in and what comes from those oxygen devices.

Now, you relate that your "dilemma" is your "weight", but you describe what sounds more like a "shape and weight distribution" problem than one of being frankly overweight.  And you did not give me any information with regard to your height, weight and age to tell me if you truly are 'over weight' or simply have body shape changes that might be typical of having advanced COPD and being in your 'senior' years.  One thought I can offer is that for some folks, when their lungs become increasingly emphysematous, they become long and push down into the abdomen displacing the abdominal contents downward and outward, causing a 'paunch', which seems to be what you are describing.  As we age beyond middle age, we get a redistribution of fat and mass to our 'girth' as a natural shift.  Combine those two influences and you may have enough reason for the changes you note in yourself.  But, I agree with your doctor that four years of inhaled steroids will not likely play a part in that change.  If you've taken oral steroids with any frequency and duration during those years, then THAT could easily be a contributor.  But, not if you've only used inhaled steroids.  In any case, you would do well to shun vanity issues of shape and size and understand that while it may cause an increase in your work to breathe, you still need to concentrate you breathing efforts to employ the muscles of your lower abdomen, paunch and all.  That kind of breathing effort will help your diaphragm more than losing weight ever can.  (Do you use pursed-lips breathing, too?)  If you think you are truly overweight, give me some more information to show me that is true and maybe I can tell you more. 

I cannot give you a specific exercise program to change anything about your "shape" based upon the information you have given me and without having seen you and learned much more about you than I can gather from this means of communication.  BUT, I can tell you generally that if you are not walking for exercise AND you are playing so much less golf, then you are not burning the calories you would were you still playing as much golf.  You can do isometric exercises where you pull your tummy in as far as you can by tightening your abdominal muscles.  Folks who can do crunches or sit-ups can more directly influence the shape of their tummy.  But, you, personally, may not be able to OR to reap much benefit.  I can't tell you what to do in that regard.  This is only a suggestion to try.

You need to replace your golfing exercise with at least a walking program of perhaps three to four days a week and walking two miles each time at the most brisk pace you can tolerate.  Realize that when you play golf, you are walking at least a mile during the game, even if you ride in a golf cart.  You need to make up for that lost exercise when not playing so much and until you can return to playing more, as before the heat hit.  And, you may need to use oxygen when you walk.

I don't know what you mean by 'qualifying for programs at two clinical labs'.  But, if you refer to pulmonary rehabilitation programs, I would encourage you to go.  You can learn MUCH more about your disease and how to better take care of yourself while also learning more about exercise and what is specifically good for "you" and your particular concerns.  You shouldn't let the doctor's attitude discourage you from doing everything you can to live the most functional and healthy life you can within the confines of those limits of your COPD that you cannot change. 

In any case, if you're in good enough shape to be able to play golf as much as you have been AND you have an FEV-1 as low as you related, as an avid golfer myself, my hat's off to you for hanging in there and keeping up that level of activity, despite what must be a tough row to hoe!  I hope you are able to keep doing that for a long time to come!

Best Wishes,


(Webmistress Note:  For members of COPD Canada Patient Network, FaCT Canada offers a discount on Finger Pule Oximeters.  For additional info, click here. )

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?


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,


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

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


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,


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,


Q.  The Sequence of Meds - Advair & Spiriva


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,

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,


Q.  Extra Oxygen, Using a Straw With a Mask

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,


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,


More On the Sequence of Inhalers - 2 Entries

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.


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,


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" 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! :)  

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

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. 

n 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,


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?

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


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.

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.


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.


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.  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.  


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?


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

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.


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.  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  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.


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!


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.


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.


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 + ?


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  Does allergies affect my copd?


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. 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.

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?

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.


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,                                      


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,


Q.  Drop in Oxygen At Night

I realize that everyone's oxygen drops at night, but is there a certain % as an "average".
Thank You, Bea

 A.  Hi Bea,

It is NOT true that ‘everyone’s’ oxygen drops at night.  A person who does not have lung disease should NOT experience any change in oxygenation when sleeping.  So there is no “average” percentage to cite.  ANY decrease from the normal range would be considered abnormal and would vary according the ailment of the individual in whom it is observed.

Best Regards,


Q.  Aerobic Exercise; Increase in Pulmonary Capacity

Hi Mark,
          Can  sustained, dedicated aerobic exercise lead to an increase in pulmonary capillaries? I ask because I frequently see an increase in skeletal muscle and capillaries referred to , but not pulmonary. Either way I still intend to exercise daily as I hope to strengthen all muscles, including my diaphragm, but it would be most encouraging to know if improved gaseous exchange could occur by increasing the  pulmonary capillaries. I am FEV1 29% pre meds, and doing all I can to raise that baseline.
                                                                            Thanking you  in anticipation,   Vanessa

A  Hi Vanessa,

I’m afraid the changes you cite for skeletal muscles do NOT apply to pulmonary vascular or gas exchange.  What you suggest is essentially growth of normal lung tissue in the presence of lung disease changes.  What exercise as you describe DOES do is make more efficient the body’s use of oxygen and reduce carbon dioxide production accordingly.  It takes long term exercise to cause significant change.  That ‘can’ translate to less difficulty breathing for a given level of exertion than if one’s conditioning were worse.

Best Regards,


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,



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



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.... )

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


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.


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.



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.

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!


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.

Q.  Low Oxygen, Been On Meds... No Relief .....Allergies? 

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 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  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,


Marijuana Smoking vs Regular Cigarette Smoking

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.


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,


Q.  Hand Sanitizer vs Soap 

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,


Q. Mucinex for Thinning Mucus

Hi Mark
As usual the horse got out of the barn before I closed the door. LOL  It was suggested that I try Mucinex to help ease my getting rid of my phlegm. I did and now I'm not so sure I should have.  Am I leaving anything behind?

I did try the Mucinex. Actually I'm still taking it. (600mg twice a day)  My sputum is now not as "sticky"/thick as it was and I have an easier time coughing it up. However, now I'm wondering if I'm getting rid of it all. I suppose the question you would be able to answer is: Have you heard of Mucinex being prescribed to COPD patients before? If not, is there any reason I shouldn't take it?

Thx Bob

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

 Q.  Diaphragmatic Breathing Vs Stomach Breathing 

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,



Q.  Oxygen Drop and Breathing Muscles 

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, 


Q. Ventolin Before or After Spiriva or Symbicort?

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?

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


Q. Who Should Own A Finger Pulse Oximeter?

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.


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,


Q. Cooking Fumes  

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



Q. Dr. Dismisses Rehab     

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,



Q.  SOB (Shortness of Breath) "after" Exertion     

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!


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,


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

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

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


A.  Hi Lou,

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

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

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

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

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

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

Best Wishes,





 This page was last updated July, 2011