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2005 - 2015

2012 Questions & Answers of RRT Mark Mangus,

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Unable To Complete Fvc Portion Of Spirometry After Exacerbation

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Tracheobronchomalacia – Status, Treatment And The Future?

Hi Mark,
I first posted here on February 26, 2012 (title “COPD or ASTHMA”).
(I tried stopping the Advair as you had suggested, and was OK for a day or so, but later my breathing got more difficult and chest very tight, so I resumed it)

Since that post, my situation has deteriorated even more. Almost constant,repeating bouts of exacerbated “Asthma”, “Bronchitis” or possibly “COPD”.

(I’ve had no more chemo. since the last round that I mentioned in December of 2010)

My Local pulmonologist kept giving me Prednisone tablets - I’ve been on a constant regimen of one Prednisone 5mg. tablet per day (more during exacerbations). “Exacerbation” = bad cough w. lots of mucus. He abandoned his diagnosis of “Asthma” saying he “didn’t know what was wrong with me” (but no further suggestions).

My NYC pulmonologist (who I only see when my oncologist sends me), all of a sudden concluded that the problem was the “Tracheomegaly” - which had shown up on the March 2011 & Jan. 2012 CT scans (in both reports and the “bullet list” summary part of both). He’d dismissed the finding initially as irrelevant to my situation. But now he was sure.

I did a lot of research, and found the “Complex Airways Group” at a famous cancer center in NYC. They examined me (and my scans etc.), and agreed that it was Tracheomegaly /Tracheobronchomegaly /Tracheobronchomalacia /aka “Mounier-Kuhn’s Syndrome” (the problem with it is that it impairs mucociliary clearance).

My team there consists of a thoracic surgeon and pulmonologist. The thoracic surgeon did a bronchoscopy with 3 lavages to remove thick mucus from lungs, and found that my trachea & main bronchi were grossly enlarged, and that my main bronchi collapsed on expiration. This confirmed the tracheobronchomegaly (w. bronchomalacia) diagnosis.

I felt better for weeks after the mucus removal via bronchoscopy, but have slowly deteriorated since then. More mucus and bad coughing.

My meds regimen is: nasal CPAP at night, Acapella PEP device on awakening and before bed, Advair500 am & pm, Xopenex 2 puffs around 4pm & 9pm, Atrovent via nebulizer (works better for me than Spiriva) around 5pm & 11pm, 1 Mucinex tab. 6pm. Antibiotics when necessary.

A heavy regimen, and would be OK, but I don’t feel well much of the time. Now that it’s winter and cold, my lungs are extra sensitive/twitchy.

My latest spirometry:
FVC (L) = 4.40 / 97% predicted
FEV1 (L) = 2.93 / 93% pred.
FEV1% = 67 / 96% pred.
FEV25-75 (L/S) = 2.07 / 53% pred.
PEF (L/S) = 8.97 / 105% pred.
FET (S) = 8.49
(these are “PREMED” values - the “POSTMED” ones are just slightly less, which I’ve come to see is typical for me)

I don’t doubt the diagnosis, but still don’t feel much better - my activities are more limited, and getting worse slowly. I wonder if there is anything more I can do to get better (or will I ever). Any comments or suggestions would be greatly appreciated.

Thank you,
Don
(sorry for the long post)

Hi Don,

I don't think I can tell you much you don't already know, from what you have shared in your post. According to GOLD guidelines, you do NOT have ANY "clinically significant" lung disease, since your FEV1, FVC and FEV1% are all well within normal limits. So, what you call - or want to call what you have is really a moot point. The only value reported that is decreased - and only modestly so - is your FE 25-75. And, if, as you suggest, your large airways are collapsing, it is NOT evident in your expiratory airflow - the period when any collapse of importance would be happening. So, I am at a loss to make anything of what you've related, especially with the clinical significance, if any, of those diagnoses you say you have now been given. I also can't comment on the need for, purpose or expected benefit of prednisone with the kind of PFT values/measurements you have. I have to defer to your physician and his/her ability to observe you with his/her own eyes and tools to determine that you are clinically ill, from what cause and how to treat you. Because all of your important measurements are normal - and despite the findings you report from your bronchoscopy, I can't reasonably advise you as to what to expect in the future. All I can say is that with regard to COPD, you have a V-E-R-Y long way to go before that diagnosis can be applied to your clinical picture with any relevant direction for treatment to be illuminated.

Best Wishes,

Mark

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Potassium Iodine

I doubt you have heard of SSKI or potassium iodine. I have used it for about 4 yrs after I got tired of having lung infections every couple months and then taking antibiotics and predizone for a few weeks to deal with the problem. I have told about 4 people with the same problems. They all have had good results. Most Md's have not heard of it. I have found a couple elderly doctors that were familiar with sski and its benefits. The only negative effect is on the thyroid if using too much or too long. Its interesting that the price varies from $3 to $40. I believe because of Japans problem with radiation. I have not had a lung infection for 3 or 4 yrs. By the way, I have emphysema and I am on 3 to 4 liters.

Roger

Hi Roger,

I think you over-estimate the eclectic nature of the knowledge you profess about SSKI. And, I would suggest that perhaps the numbers of doctors you have put your questions about SSKI to may be very limited with perspective of the greater physician ranks.

But, SSKI (potassium iodide) is no secret or mystery or obscure drug to those of us in pulmonary medicine. It has been around for YEARS and was the 'staple' "oral" mucolytic of the period of the 1980's and before. Guaifenesin came along and replaced it in popularity during the 1980's and thereafter to where, today, it is not the first-choice drug for loosening/mobilizing mucus.

I find it difficult to believe - and frankly, rather scary - that many physicians today, do not know what it is, what it's used for and other basic information about it. As a mountain of study data have failed to show predictable, consistent and even significant benefit from either SSKI or Guaifenesin, it's employment is done more for anecdotal reasons than scientifically verifiable action and benefit.

Personally, since thyroid conditions 'can' be influenced/aggravated by use of SSKI AND because there is so much thyroid dysfunction among the general population, it is not something I would be recommending to all my friends. And, I would not prescribe it as a first-line drug until and unless guaifenesin proved to hold no benefit for each patient needing pharmacological mucus mobilization intervention. I'm glad it works well for you.

Best Wishes,

Mark

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Evaluation of PFT numbers

I am a 54 year old white female 65inches and weight 165 lbs
FCV. 3.42. 2.21. 155
FEV1. 2.21. 1.88. 1.18
FEV1/FVC%. 65%. 85%. 76
FEF25-75%. 1.27. 2.19. 58
PEF. 3.05. 4.88. 62
Best FVC. 3.42. 2.21. 155
BestFEV1. 2.28. 1.88. 122

This was my test in May 2012

Then in Oct of 2012
FVC. 3.41. 3.22. 106
FEV1. 2.32. 2.63. 88
FEV/FVC%. 68%. 81%. 84
FEf25-75%. 1.30. 2.88. 45
PEF. 4.78. 6.00. 80
Best FVC. 3.41. 3.22. 106
Best.FEV1. 2.32 2.63. 88

Was wondering how bad these readings are ,I don't smoke I was a smoker but quit to get healthy and then someone was putting ammonia on there field and the next thing I know I am gasping for air and have been since I am on Advair twice a day and sprivia once a day and ventolin 2 puffs 4times a day. Have had two exacerbations since this started in may .JUST want another insight thanks Mark

Suzanne

Hi Suzanne,

Your numbers don't portray a picture of significant lung disease. while the FEV-1/FVC in May and FEF-25 - 75 % show some small airway obstruction, that your FVC and FEV-1 are within normal limits (even significantly exceeding the values predicted for your height, gender and age) any obstructive airways disease you may have is very minimal and early, in terms of progression. The October numbers, while lower than the May numbers, still exceed what is predicted for you as 'normal'.

I am puzzled as to why you had an "exacerbation", let alone two AND what exactly the symptoms were that generated that diagnosis. With the numbers you have, you shouldn't be having exacerbations. But, you 'could' have had upper or lower respiratory infections causing those two episodes. At the least, you are over-medicating yourself by using the Advair and Spiriva with the added Ventolin, fours times a day. You should be able to do just fine without the Ventolin.
I'd suggest you check with your doctor and ask if the Ventolin was not intended to be used "as needed" for rescur when breathlessness hits you or if you need a 'pick-me-up' between Advair doses. In any case, you should not need the Ventolin. It could also be possible that, at this point, you don't need the Advair and Spiriva, either. But, as you didn't include a PFT that shows what your numbers were before you started taking them, I can't say for sure. In any case, it appears that whatever lung disease you may have is very minimal and in it's early stages, as I mentioned earlier!

Best Wishes,

Mark

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PFT Test Question & Disease Stage

Hello,
I am female, age 76. and have recently been diagnosed with COPD/emphysema/asthma. I have been smoking for 53 years - for the past 22 years I reduced my smoking to 10-12 cigarettes a day. I have no negative symptoms, no coughing, wheezing, shortness of breath (as far as I know) but requested a PFT because for the past 35 years I exhale loudly when I am having deep thoughts about something which is worrying me. I believed this was a habit but at the suggestion of my daughter thought I would check it out. (Since the test, I seem to have quit this habit, or whatever it was).

When I did the PFT about a month ago at one point I had to exhale into the plastic pipe, which I did, but at some point I could not go any further, no matter how hard I tried to exhale. The technician was puzzled - told me that the readings on her computer had come to a halt, why was that? She asked me if my tongue had caused the problem. I told her that I didn't believe so, that the sensation I had was that a hand had been placed directly over my mouth. This happened twice, and the technician said something to the effect she would work around it. I later mentioned this to my doctor when he gave me the results of the test, and he said it was due to the bronchial tubes shutting down. If that is the case, how is it that the technician was so puzzled about the incidents. Surely she must have come across the situation before? Could it have been the fault of the equipment? The FEF25-75% Pre % Ref shows 35 and Post % Chg 57.

Hello, Mark,

I sent you a request yesterday (see the above question) and I must apologize for not adding my signature to the email. I wanted to ask you another question or two As mentioned, I am a woman of 76, 5' 1-1/2" weight 126 lbs. I was diagnosed about 3 weeks ago with COPD/emphysema/asthma. I don't have any symptoms that I know of and am in excellent health. I only requested the test because for the last 35 years I was in the habit of exhaling loudly when I was anxious and my thoughts were getting the better of me. I always assumed it was a habit. (Since the test and diagnosis, I no longer have this 'habit' - if that is what it was.) Until the diagnosis I was a smoker for 53 years, but reduced consumption to 10 or 12 cigarettes a day about 22 years ago. At my doctor's suggestion I am taking Atrovent, but I wonder if I really need it, as I feel fine without it. Should I use inhalers - I don't want to rock the boat when everything feels perfectly fine at present.

It would be appreciated if you would look over the PFT numbers below and let me know what you think. I hope they come through okay. Should I be worried unduly (at my age?). Should I request another test – I have an idea I was a bit distracted at the time of the initial test and didn’t blow as hard as I should have done.

Thank you,

Alex

Hi Alex,

Your PFT shows very early signs of COPD. Don't worry about the airflow stopping during the time you were blowing out. You likely just ran out of air. I can't answer why the tech didn't understand what she was seeing. But, it is not important.

I would also suggest that you not worry about any abnormal sighing or deep-breathing. There is nothing inherently pathological about doing so, habit or not.

What is important is that you have only the most mild disease, at this point. The Atrovent won't hurt you to continue taking UNLESS you have issues with glaucoma. If you do, or if glaucoma difficulties should materialize and your PFT's are still as good as the one you just had done, then you will want to stop the Atrovent and save taking it for a time when your PFT's have worsened much more than they are at present. In any case, you have plenty of wind power to keep you going for years to come - barring any infections and such along the way.

Best Wishes,

Mark

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Help For Chronic Bronchitis

I have chronic bronchitis all my life. I am 65 years old. I have had a bad chest with loads of Phlegm for this time. The Dr said he cannot give me more scripts. My x-ray was clear. You can hear me breathe. My spirometry at best was only 70%. I have been referred to a specialist he cannot see me till June. It is so hard to breath. I have never smoked but all Dr have asked me when did I quit. What is wrong with me? When I have taken puffers they do not work. When I had the spirometry she also said they do not work. They could tell. Please help. I have to work so I need my health.

Maxine

Hi Maxine,

I'm sorry to learn of your difficulties! it is interesting that you relate having Chronic Bronchitis "all you life", while not being a smoker. That is very unusual unless you have some genetic form of lung disease that has not been diagnosed.

when you say that inhalers do not work, are you basing that upon your experience with them or upon the results of your PFT as your doctor related to you? The reason I ask is that while inhalers rarely show significant improvement in airflow as measured by an increase in one's FEV-1 on their PFT, with those who have Chronic Bronchitis, improvement is usually more subtle than the frank increase we look for on PFT's as with those who have asthma. That doesn't mean that they "don't work". Often folks who use them will find they DO 'breathe' better. So, the improvement, while not significantly 'measurable' can be "real", nevertheless.

Now, if you use them and they DON'T seem to help you breathe better, then that is another matter. It could be that you have some kind of restriction or restrictive lung disease. That can only be discerned through tests like CT scans and complete PFT's that also include measurements of one's "lung volumes" and "diffusion capacity". The lung specialist should measure those when you see him/her. But, it is unfortunate that you must wait until June. June also seems unreasonably long to wait when you feel as bad as you do. Is there no other way you can be seen by a pulmonary specialist before then? Can you go to a university health facility?

In any case, IF the inhalers make you "feel better", however little, you should insist that the doctor maintain your prescriptions until you are seen by the pulmonary specialist, regardless of 'when' that turns out to be. They should NOT pull you off of medications before you have a chance to be better evaluated.

Finally, I would suggest that you should be taking the following inhaled medications: Symbicort and Spiriva. Anything other than those is not likely to have a chance to help your breathing. Albuterol is also OK to have for "back-up" rescue or pick-me-up between Symbicort inhalations which would be every 12 hours, or twice a day at as close to 12 hours apart as practical and possible.

You should also be sure to have your oxygen measured with a pulse oximeter WHILE YOU ARE WALKING for AT LEAST 3 minutes without stopping.

I hope this give you some helpful ideas and means to pursue to try to feel better until you can get in to see the pulmonary specialist.

Best wishes,

Mark

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Spiriva & Glaucoma

Hi Mark

This may be outside of your area of expertise so if you can’t help me I understand.

I went to see an ophthalmologist for my yearly checkup and was advised the pressure in my right eye was high and was informed it was a sign of glaucoma. I am currently taking Spiriva and Symbicort. I have been taking the Spiriva for a few years although only at times when I felt my breathing would benefit from it. I have moderate COPD but don’t really notice much of a benefit from inhalers so don’t take them on a regular basis. I was also given Symbicort in early October and took it until my PFT on Oct 19. The Ophthalmologist thought it was likely the Symbicort that has led to the Glaucoma. When I questioned him about whether quitting taking Symbicort would allow the pressure in my eye to return to normal he said it isn’t likely as the changes caused by the steroids are usually permanent. I wasn’t on the Symbicort very long and wondered if it is likely that the Symbicort would be responsible for the Glaucoma? I have also read that Spiriva can either lead to Glaucoma or exacerbate it so wondered which is the more likely cause of the Glaucoma and if I stopped taking the Spiriva would the Glaucoma reverse itself, or would the pressure in the eyes go back to normal thus eliminating the need for the eye drops (Travatan) that were prescribed for the Glaucoma?

It seems the Travatan I have for the Glaucoma can worsen COPD, and the medication for COPD can cause or worsen Glaucoma, so am not sure what to do or what to take. I certainly don’t want my eye sight to get worse nor do I want my COPD to get worse.

Thank you, Don

Hi Don,

Your suspicion about Spiriva is correct. Between the two medications, spiriva is specifically suggested as potentially worsening "narrow-angle" glaucoma. So, you need to find out if your glaucoma is of the "narrow-angle" type. If it is, then Spiriva will potentially make it worse. In that case, your best bet is to either try Ipratropium bromide which has a much shorter length of activity AND will not likely aggravate the glaucoma as would Spiriva. Yet, even Ipratropium Bromide CAN cause narrow angle glaucoma to worsen. That said, I would suggest that if you haven't been taking the Spiriva on a daily basis AND over a reasonable period of time, it may not be the problem as perceived, either.

Both Formoterol and Spiriva (Tiotropium boromide) should be taken on a daily basis as "maintenance" medications, whether or not you "feel" any significant improvement. Tiotropium's benefit is subtle and usually only measurable on a PFT after 6 months to a year of daily use. What folks DO notice is that daily activities - especially those which require a fair amount of wind power - get easier to do over time while taking Spiriva on a daily basis.

The Symbicort does not contain enough steroid to cause significant problems with your eyes - at least that is the case with most folks. Yet, your doctor can write you a prescription for Formoterol, by itself and eliminate the steroid.

In any case, neither medication is effective beyond a minimal amount if not taken on a daily basis. "Spot treatment" when you "think" you need them is not an effective or advisable method to use. So, I would encourage you to give a trial of taking those medications EVERY day for several months before judging whether or not they are helpful. At the same time, if your glaucoma is narrow angle, you should consider stopping the Spiriva and maybe also changing to Formoterol, alone.

Best Wishes,

Mark

 

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Newly Diagnosed With Mild COPD-

Do I need a respirologist and will disease progress

I am a 55 year old woman who has just been diagnosed with mild COPD. I quit smoking in January of 2012 after smoking for about 40 years. I am now taking Pulmicort, 2 doses twice daily (just gotten over a chest infection) and will reduce to 1 dose twice daily. I also take 2 puffs twice daily of Apo-Salvent before taking the Pulmicort but will return to as needed within a couple of weeks. After taking a Pulmonary test, the diagnosis is mild COPD with 20% loss of lung capacity with both the chronic bronchitis and emphysema.

As a newly diagnosed patient I was wondering if I need to see a Respirologist and will the disease progress as time goes on?

Brenda

Hi Brenda,

COPD 'IS' a progressive disease. But, at this point, no one can predict 'how' or 'how fast' "your" particular case will progress. From what you've told me, it seems that you have a long and productive life ahead of you as long as you take steps to maximize your best health potential. You've already taken the biggest step - to quit smoking. That alone can go far to make your future very bright and with the least worry about that "progression" potential.

Eat well, EXERCISE and simply take good care of yourself and you can look forward to many great years ahead. I would expect that you can get to a point where you need neither of those inhalers and will find they simply sit in a drawer gathering dust, all this the result of taking care of yourself. I would also expect that the day when you may need more regular treatment with ANY of the many medications used to treat those with far more advanced COPD than you have is too far off in the future to even try to speculate upon. So, get out and enjoy life. Don't be afraid to push yourself and to 'breathe hard' while being physically vigorous. The more you make yourself 'breathe hard' while engaging in intense exertion and enjoyable activities, the better you'll feel and do for a long time to come.

Best wishes!

Mark

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Question re: Hyperventilation Syndrome

Hi Mark:

My name is Ron, I'm a medical writer doing a piece on HVS (hyperventilation syndrome) and read with interest, your blog of 2009 on COPD and the 'myths' of diaphragmatic breathing. I had a few questions and was wondering if you could provide some insights? I'd appreciate it.

Specifically with regard to HVS, a popular commercial theory is that hyperventilators breathe only from the 'upper body' or 'intercostals' and 'not' as much from their diaphragm/abdominal muscles. But as I read your blog, you're basically saying this isn't possible, because people have to use their diaphragms. However, is it also possible that people hyperventilating are not using the correct abdominal muscles? Or perhaps that in HVS, people are simply OVERBREATHING, PERIOD---muscles notwithstanding---as opposed to using the 'wrong' muscles (abdomen), or NOT using the abdomen/diaphragm correctly?

PS- Incidentally, my take is that PLB without 'thinking' about the belly or diaphragm will fill the lungs and prove as effective as 'concentrating' on the belly, correct?

In any case, I'm trying to diffuse some of the myths out there and bring accuracy to my piece. Any help is, again, appreciated.

Sincerely,
Ron F

Hi Ron,

Congratulations on the article you seek to write regarding “Hyperventilation Syndrome” (HVS). The following are my thoughts on your questions, presumptions and issues with the portion of HVS considerations that you included.

First, HVS, is considered a syndrome that is psycho-emotionally driven. That it results in abnormal distortion of body physiology is what defines it and confounds attempts to characterize it, much less define its abnormalities. Let’s agree that the distortion of physiology to which I refer has to do with the resultant reduction in carbon dioxide (CO2) in the blood, the result of too much ventilation – more ventilation than normal body functions require with regard to shedding the waste product, CO2 AND the abnormal elevation of blood pH that accompanies the reduction in CO2. As such, it DOES fit your characterization of one who simply “over-breathes” – muscles notwithstanding – and is wholly a separate consideration from what muscles may have been used in its cause AND whether or not they are used wrongly or abnormally.

That said, you should understand that HVS, as an entity, is NOT in any way comparable to the alterations in breathing dynamics we see in those with advancing/advanced COPD. So, any description that I have provided along the way with regard to abdominal muscle breathing and/or shifting away from respiratory accessory muscle breathing (upper chest, intercostal muscles and those of the neck) cannot be applied to HVS.

During normal breathing conditions, muscles contributing to ventilation vary as demand changes. When one is breathing quietly, they use the abdominal muscles as primary drivers to inflate and deflate the lungs. The accessory muscles are ALWAYS ‘some’ component of the total effort of ventilation even under ‘normal’ “quiet” breathing conditions. When exertion enters the picture, while the abdominal muscles continue to be the primary muscle group driving ventilation, there is increasing recruitment of effort from the respiratory muscles. They assume an increasing portion of the ventilatory work load. This all occurs with little to no “intention” or deliberate thought-and –action, on the part of the person. At maximum, both autonomic AND deliberate driving of ventilatory muscles occurs – the best example being the person who is running. There is a ‘coordination’ of muscle and muscle group effort to bring about the effective result of total muscle participation in maximum ventilation. One does not “decide” to use one group of muscles over another. That is a function of physiology and normal ventilatory mechanics.

In COPD, as the lungs become more diseased and normal mechanics of ventilation become altered toward the abnormalities we observe, respiratory accessory muscles are increasingly recruited to assume a greater portion of the ventilatory effort/workload because the downward shift in “neutral diaphragmatic position” results in a decrease in the power generated by the diaphragm during ventilation. Still, body physiology requires a certain amount of ventilation to keep body functions ‘normal’. AND that ventilation is time dependent. The lungs have to ‘get the job done’ in the same amount of time it always has, despite the increasing “time constants” that are imposed by the abnormal shift in the composition and function of the lung tissues and their effect upon airflow into and out from the lungs AND ventilatory muscle position(s) and function.

Now, some folks are taught (WRONGFULLY) to become more deliberate about using more muscles of the upper chest to ‘help’ with breathing. Some folks come upon the notion, on their own and begin following it. For most, though, the shift occurs without will or knowledge as an unknown or not/poorly understood phenomenon. It just sort of ‘happens’. In abdominal breathing methods, we discourage the willful or unintended use of those accessory (upper chest and neck) muscles through training and paying attention to ventilation, making it more a willful and deliberate action rather than the autonomic action it was under previously ‘normal’ circumstances and conditions. We attempt to cause the individual to shift effort back downward to the abdominal muscles. We know that use of the accessory muscles comes at a cost of geometrically more calories burned, in terms of effort AND is also significantly less efficient at actually moving air than the abdominal muscles.

At this point, I would remind you and everyone that pursed lips breathing (PLB) while incorrectly characterized as both and inspiration and expiration inclusive technique is, in fact, SOLELY an expiratory-effect action. How one gets the air “in” has nothing to do with PLB. Yet, you will read that almost everyone who describes their understanding of or favorite method for PLB will include all manner of “fluff” with action and effort devoted to various controlling measures for the “inspiratory phase” of breathing. I must state emphatically, that ANY and ALL effort to exert ANY kind of ‘willful’ influence or effort over “inspiration” is misguided and simply superfluous. It adds NOTHING helpful positive or useful to the process, in and of itself. The lips are “pursed” during EXHALATION, for a reason. Doing so splints the airways and allows for more complete emptying of the lungs against the tendency (due to pathology) for the airways to collapse, ‘trapping” air in the distal portions of the lungs. The “incidental” result of PLB during the expiratory phase is to prolong the expiration, relative to the inspiration, which allows more complete emptying of the lungs and resultantly, less collection of CO2-rich air at the end of each respiratory cycle. It also ‘incidentally’ reduces total respiratory rate by ‘some’ amount, in the process.

The recommendations to breathe IN through the nose, RATHER than the mouth is the absolute WORST part of the popularly touted method that can be included. Breathing In through the nose is recommended for the following reasons: (1) It warms the air coming into the lungs. (2) It filters the air. (3) It humidifies the incoming air. (4) It necessarily slows down the total respiratory rate, argued to be a primary benefit of PLB.

Benefit # 4 is based in truth with regard to slowing the inspiratory phase and reducing total respiratory rate – but NOT for good or beneficial reasons. Consider that many folks have nasal congestion which narrows the “cross-sectional” diameter of the nose as a pathway for air flow. Additionally, it is anatomically factual that the “cross-sectional” diameter of the nose is almost one-half that of the cross-sectional diameter of the oropharynx (= open mouth). Poiseulle’s law states that as the diameter of a tube is decreased by ½, resistance to flow through that tube increases by 2-to-the-4th power – or 16 times! ! ! So, the imposition of nose-breathing INCREASES the work to breath by about 16 times! That’s a LOT of energy added to the already difficult work of breathing for those with COPD. It’s a bad idea AND singularly the reason why PLB under conditions of ‘significant’ or ‘intense’ exertion does NOT work for the very folks who need its benefit the most. My point is that breathing IN through the mouth when the nose becomes an inhibiting factor to get the air in during inspiration should be abandoned in favor of breathing in through the mouth! I suggest that one ‘get the air IN’ in the most comfortable and natural manner possible.

Insofar as the question of professed benefits of #’s 1 – 3, above, the answer is this: There is insignificant ‘consequential’ filtering that is accomplished by the nose. There is insignificant warming and humidifying that occurs, as well. We have, within our lungs a unique feature we call the “isothermal layer”. That is the point within the lungs at which the gas in the lungs reaches 100 % of body temperature and is 100 % saturated with humidity. It is found several branches into the bronchial ‘tree’ and is a “mobile” layer in that as the incoming air is cooler or warmer, it will move up or down within the airways to accommodate the objective to condition the air to 100 % of body conditions (temperature and humidity, that is). Consider when a person jogs or runs outdoors, in the elements of the weather on a winter day. The air coming into the mouth/nose may be 0- degrees Celsius (32 degrees Fahrenheit). Were it not for the dynamics that control the isothermal layer, that air would essentially freeze the body. But, through increased circulation, increased heat and moisture transfer through mucus dynamics, air reaches the depths of the lungs at 100 % of body temperature and 100 % of body humidity requirement by the time it gets there, regardless of the temperature at which it started out. When the person goes inside their home where the temperature instantly increases to, say, 24-degrees Celsius (75 degrees, Fahrenheit), the isothermal layer rapidly changes to a higher point in the lungs and the lungs reduce the rate of heat and humidity transfer as appropriate for the conditions of the air coming in.

Additionally, the air is as ‘clean’ as it will get, regardless of through which route of entry into the lungs it navigated – mouth OR nose – by the time it reaches the isothermal layer. When air comes into the lungs, it is nominally filtered of large particles by the hairs and mucus in the nose. The balance of filtration occurs as mucus within the bronchial tubes traps and holds particles and subsequently transports them out of the lugs through normal mucus movement. The amount of filtration that occurs with respect to the total action of cleansing incoming air is nominal with regard to the contribution of the nose, the bulk of cleansing occurring as a function of mucus activity.

So, as evidenced by the information of the previous paragraphs, the “need” for breathing in through the nose is not based in “evidence”. Indeed, it is strictly a “perceived” benefit and is without any merit when you consider the ‘evidence’. As such AND because it creates such ADDED difficulty for the already challenged person with COPD, it ends up being counter-productive and imposes an unnecessary and limiting burden upon the individual who tries to follow the recommended method.

In summary, PLB is a maneuver that prolongs exhalation, reduces total respiratory rate AND increases efficiency of ventilation SOLELY through its influence upon the “expiratory” phase of breathing. It has nothing directly to do with what muscles participate in the ventilatory process with regard to “INSPIRATION. As hyperventilation is related to the abnormal INPIRATION of more air than is needed to normalize blood gases and pH balance, it is a phenomenon separate with regard to consideration, cause and remedy from any notion of muscle or muscle group function. That considered, I would strongly disagree with ANY theory that suggests that HVS could in any way be caused by “wrong-muscle” use or “wrongful use” of respiratory muscles, no matter where they may be found. Such suggestions illustrate a lack of understanding of the physiology of breathing from a basic level.

As to your last speculation about what PLB would or would not do in terms of which muscles are used, deliberately or not, for those with COPD, it becomes an essential necessity that they at some point learn to exert deliberate control over ventilation such that they become able to shift effort downward to the abdominal muscle group as the primary drivers, in the process, avoiding increased use of the respiratory accessory muscles of the upper chest, intercostals and neck.

To reiterate, HVS represents, as you correctly speculated, a phenomenon of “OVER-BREATHING - PERIOD”! It is that and only that, independent of any consideration of correct or incorrect use of the muscles of ventilation. AND, its cause is one of psycho-emotional origin. It does not and cannot occur through any intrinsic physiological effect, in and of itself.

I hope this is helpful to you. And, perhaps, if you have further questions, they would best be handled through direct correspondence, rather than through a medium like this forum, since I suspect the interest and applicability to our COPD population is not inherent to this topic. This response HAS offered me the opportunity to better explain PLB, however, a point I would think is indeed of significant interest to readers of this forum.

Best regards and wishes to you,

Mark

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Comments re: your answer to recent 02 stats

Hi Mark.
I do respect your candor, and I know that your answers are 100% truthful, but please when you do answer also give the other side of the coin as well.

I know you keep mentioning that over time my symptoms will get worse as well as my 02 levels, and what you say is true. COPD is a progressive disease,
but I think you should have mentioned as well the other side.
It should read something like this.

”As you know Philip your disease is progressive, and the more exacerbations that you have the progression of the disease may accelerate , but by that time in your disease there may be many things on the market to assist you that were not available at the time you wrote to me.
Recently they have had some but limited success with " Lung coils ", as well as LVRS, and a new procedure where they spray a glue like substance into your lungs. New Medications are coming on the market as we speak, so by the time you reach the stage where you may see significant changes in the progression of your COPD, there will be many more options available to you to help you, that were not available at the time you are contacting me today.”

What I say mark is also very true.
As time goes on I sincerely hope that many will be helped, and that new treatments and medications will become available.
Stem cells look promising as well, but a bit more down the road.
And look Mark at the worse case scenario that if one need a transplant. Look at how much longer the recipients are living now as compared to years ago.
My point Mark is yes I am going to get worse, BUT!!! by that time I could also get much better.
From my mouth into gods ear.
Your great Mark. keep up the fine work you are doing .

Kindest regards Philip

Philip, Philip, Philip, my Friend,

As the recipient of the responses to your questions to me, I would urge you to be cautious about mixing ‘facts’ and predictions based upon ‘evidence’ with the propensity to try to mediate with what are no more than prognostications, especially when they are based upon no more than ‘wishful thinking’. While I will always support the notion of ‘hope’ – after all, without hope, we are doomed to cynicism – what you suggest is hopeful, but certainly not guaranteed more than through ’ maybe/if’ possibilities.

It is undeniable that COPD is a progressive disease that can be modified only in terms of the speed of progression for many and the hope that they will succumb to a demise sooner than and from different causes than their COPD. That is the fact based upon evidence. The conditions – both controllable and uncontrollable – of how that progression can be altered remain one’s best hope in living happily and productively throughout the course of their disease. That is also fact based upon evidence. But, also based upon evidence is the fact that one can suffer an exacerbation or bout of acute respiratory illness that drastically alters their rate of progression, changes their baseline disease at a ‘momentary’ point and results in a dramatic shift in what is predictably possible or likely for them from that point on. Your ‘revision’ of my comments to read as you suggest “I” ‘should have’ stated them is based upon the presumption that your, or even (maybe “especially”) most folks with COPD, will experience an unfettered disease course that entails no more than simple progression of ‘longevity’ with maybe the occasional uncomplicated exacerbation along the way. Such suggestion(s) is (are) based upon much presumption and NOT ‘necessarily’ upon evidence. So the question of whether or not what you say is “also very true” as you insist, remains open for debate. And that you can reasonably suggest to put words into my mouth is indeed arguable.

But, let’s take a look at some of the points you made that you feel I failed to include as “the other side of the coin” and try to put them into perspective and potential application. You speak of “lung coils, glue and LVRS and their “limited” successful application and positive outcomes – speaking as if they are options for the general COPD population. Unfortunately, as the NETT (National Emphysema Treatment Trial, in the USA) illuminated, those who are actually candidates for LVRS procedures – of ALL kinds – are limited to about 12 % of the emphysema population. Realize that among those with COPD, those with emphysema – as a primary disease – represent about 20 % of the total COPD population. THEN among those 20 %, only 12 % will lend to the procedure by having a “heterogeneous” disease pattern that can be treated with the “localized” effect and benefit of LVRS. It is true that perhaps as much as, even possibly more than 50 % of those with Chronic Bronchitis as a primary disease ALSO have significant emphysema. Yet, among them, there are very few who have that emphysema component that is truly heterogeneous. The fact is that for the overwhelming majority of folks with COPD, LVRS – in any form – is NOT a treatment option – at least not in its current form and practice. And, the future does not lend to optimism that ‘that’ fact will change any time in the foreseeable future.

While there is much research ongoing in the area of pharmacological treatment for COPD, still, the vast majority of it is concentrated upon singular effects or components of the “inflammatory cascade” that comprises the disease process of COPD – that cascade continuing to change as we – through research discoveries – learn ‘new’ facts about the disease process and how it works. Remember, that the more we study COPD, the more we are discovering that it is a systemic process that is also increasingly complex and that is influenced by many more contributors than simply lung deterioration and its resultant functional loss. Hoping for – no, as you suggest – “expecting” that there will be even a ‘few’, let alone “many” new drugs that will in some way not only alleviate, but also “mitigate” and/or “reverse” the disease process and its attendant damage is, IMHO, presumptuous and something that, were I in your shoes, would not ‘hang my hat’ on as “likely”. Sure, you MUST “hope” for such ‘breakthroughs’ – and lord knows, as I learned with Cystic Fibrosis, many years ago not to say “surely never” or, as I actually did: “It’ll be 30 years before the gene for CF will be discovered”, when it actually took only another 5 years from the point that ‘that’ fact was included in my CF Foundation-provided ‘speakers’ material’ – the fact remains that such hope must also be tempered with realism and what is reasonably ‘likely’.

In actuality, I think stem cell interventions may not be so far off as you might suggest. While it may not become a widespread or widely applied therapeutic in our life time, aspects of it may be brought to fruition and applicability in a surprisingly short time. You suggest that lung transplantation is the “worst case” scenario. While I would characterize it as the “last resort” possibility, I would also agree with you that it has come a remarkably long way in the last decade and as my daughter just passed 9 years in the post-transplanted life and is coming up on the 5th anniversary of her second transplant (and after yesterday’s PFT, has an FEV-1 of 82 % of predicted and an FVC of 96 % of predicted – both placing her within “normal” parameters for pulmonary function, though she is considered to be in ‘chronic rejection’ by her transplant team) – I know all too well, how positive the prospect of transplantation is in today’s treatment process. But, again, those who are eligible for transplant remain among an all too small pool of the total COPD population.

While I share your “hope” for breakthroughs and progress, you must appreciate my position with regard to giving people the advice and answers to their questions that they seek from me. I must deal with the evidence and facts as we know them to be today. If I take to the tack to temper my responses with unbridled hope in every instance, I cease to become the person who presents the ‘facts’ for what they are and stand to lose some amount of credibility and certainly helpfulness for those who hunger for ‘information’ that is both useful to them and based in the evidence as well as in realism. In that light, I lose my usefulness to them – NOT the result I intend or hope for.

So, while you have the luxury to speculate, as you are wont to do, I must continue, as I do, to give the best of what I ‘know’ and then ‘encourage hope’, thereafter.

My best regards to you, always.

Mark

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Safety of long acting beta-agonists

I sent you a question a week or so ago and I am not sure if I will hear back by email or on this site. I now have another question. I see the FDA has issued warnings about Advair, Serevent, Foradil and Symbicort. I have been taking Symbicort for quite a while and truly believe that it is not helping. I am now beginning to think, after seeing the article that it might be making me feel terrible and causing the uncomfortable feeling that I seem to get in my sternum area. I will be going to see my regular Dr tomorrow and will see if there is something else to replace this. I am also on Spiriva and use Ventolin very rarely. I am wondering if you think another puffer could replace Symbacort (other than the others mentioned). My Dr is not very open to new ideas so though it might be good to hear your opinion as well. Regards, Cynthia


Hi Cynthia,

Those warnings are for cautions of development of pneumonia in a "very" select population who have acute asthma. The concern applies to the steroid component in Symbicort. But, concerns over the long-acting, beta-agonist are also part of some warnings. They apply to those who do not need daily maintenance dosing with long-acting, beta-agonists, instead, needing only daily maintenance dosing with inhaled steroids PLUS specific dosing with short-acting, beta-agonists for those who experience more sudden-onset asthma. They do NOT apply to the majority of those who have COPD - even if they have an asthmatic component to their disease. So, I think your concern is unwarranted, in view of the information you have previously provided to me in answering your earlier questions.

Now, if you are concerned that the steroid component might not be needed, ask your doctor if you can/should try formoterol, by itself. If you notice a worsening in your breathing during such a trial, then you can return to the Symbicort and see if you improve. If that happens, then you know better that you indeed need the steroid component.

As for your chest tightness, I do not think that the Symbicort is responsible. BUT, again, if your doctor thinks it is safe to go without ANY inhaled medication for a stretch of days to see if (1) your breathing stays stable or gets worse, or (2) your chest tightness/discomfort subsides, then that may be a course of action you could pursue. In any case, you need to express your concerns and relate your symptoms to you doctor and work with him/her to find the right solution.

In any case, there is no "substitute" or "other inhaler" for Symbicort or Advair if you need the long-acting beta-agonist.

Best wishes,

Mark

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Change in O2 Stats

Hi Mark.
Many years ago ( 12 to be exact ) I got pneumonia and just getting out of bed to go to the bathroom my 02 levels went to 84. I had to call an ambulance and was sent to the nearest hospital. I was there for 13 days, and was on 02 24/7. My doctor at the time said he would not allow me to go home until my 02 levels were 95, without 02. It finally happened and I was home. I made a full recovery.

My question Mark is that I find that my 02 levels are much worse when ill. I am currently getting over a bad sinus infection, and it did make a difference in my stats. Upon feeling better I noticed my stats improving. They are not back 100% to what they were before the illness but we are slowly getting there.
As an example when walking up my stairs at home ( 13 to be exact ), my 02 levels would go to 87. Now they are 92-93. consistently.

Do exacerbation's mark sometimes leave permanent damage where your stats do not recover. ???
Perhaps I have been lucky. Mine always seem to bounce back.

Thanks mark, Philip

Hi Philip,

Exacerbations certainly "can" result in permanent changes for the worse in symptoms, work to breathe and oxygen saturation. It just depends upon the individual, the severity of their disease at the time of each exacerbation and the severity of the exacerbation.

You indeed have been fortunate to this point in your disease. But, as your pulmonary function worsens over time, you will likely start seeing changes that either take longer to bounce back, do not bounce you back to your previous steady state or result in a significant worsening of your symptoms and oxygenation. Hopefully, that is still some time in the future for you.

Best Regards,

Mark


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Hissing Noise In Ears (Tinnitus)

Just wondering; in all years have you heard of people who take meds for COPD including puffers had hissing noise in there ears mine is hissing and l had been on meds for 17 months. just wondering and if yes, what can be done if anything? TY for your time.

Doug

Hi Doug,

If you had tinnitus before starting the meds, then your answer lies in that fact and the meds have nothing to do with it. If your tinnitus started AFTER you started taking the meds, while I doubt that the medications have anything to do with the problem in a "causative" way, you could have developed a "co-incidental" inner/middle ear problem that may need treatment. In any case, if the tinniutus bothers you AND you have not been evaluated and/or treated for it by an Otolaryngologist, perhaps you should make an appointment and do so. In any case, as the meds are not likely culpable, DO NOT stop them without talking to your doctor(s).

Best Wishes,

Mark


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Is There A Remedy For Inflammation?

Hi I have COPD my question is I have infelemation lung and I don't want use it cortizon because I have one kidney. Can I use natural medication for infalametion lung? What kind of remedy is good for inflamation.... thanks lot.

Lida

Hi Lida,

I am left to presume that you have misspelled "inflammation" with your label of "infelemation lung", which is not an actual disease, diagnosis or problem. Now assuming I am correct in my presumption, I can tell you nothing about such a general diagnosis as (corrected) "inflammation lung" as that can apply to a whole lot of lung problems.

What I can offer is the following: If you have an inflammatory lung disease, then like it or not, corticosteroids are the ONLY "effective" anti-inflammatory treatment and are NOT substituted by any "natural remedies" that I am aware of that have been proven effective according to the existing evidence.

I can appreciate your concern about having only one kidney. BUT, I would suggest that if your doctors have determined that you would be best treated with steroids, then (1) they have considered the fact that you have only one kidney and conclude that the benefit of taking steroids outweighs any potential danger or adverse effect. (2) They feel that steroids are the best and most effective and NECESSARY treatment for your condition, what ever it might be in terms of 'cause'.

Now, that said, folks are finding "help" in regard to reducing inflammation by using NAC. And there is much evidence that NAC is effective in reducing inflammation. HOWEVER, NAC is not a treatment that can be used "alone" and is not a "complete" treatment in itself. It 'could possibly' reduce your need for "as much" steroid dose as you would need without using NAC. But, that is something you wouldn't know until you tried it.

Talk to you doctor and present your concerns and get the answers you need to feel better about the recommended treatment or to seek alternatives that have proven to be effective by results from proper scientific investigation. I would also URGE you to take pen and paper with you to your doctor appointment and write down the "specific" diagnosis you have been given. Simply saying you have lung inflammation is no diagnosis and cannot tell anyone what is actually wrong with your lungs.

Best Wishes,

Mark

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Further Questions About PFT Test.

Hi Mark
I just wanted to ask a couple of questions relating to your response last week about my PFT results which you were apprehensive to rely on. You made the following statement in response to my concern about my RV being 145% of predicted and my FRC at 136% of predicted.

Your statement
COPD results in increased air trapped in the lungs at the end of various breathing maneuvers. The values that will be increased are the lung volumes and in particular, the “resting lung volumes”. Those include FRC and RV. As well, TLC will be elevated. All of those are elevated in your case, so indicate mild to moderate COPD.

Does your statement mean those values are elevated as a result of the breathing maneuvers that were done as part of the PFT and that those values, while likely always elevated as a result of COPD, are not always elevated as much as is indicated in the report?
I noted in one of your responses to another individual, you recommended a quality rehab program, but have no idea what constitutes a quality program or what criteria I would use to judge it. We live in a small city and there is only one program here that I am aware of. I went for an assessment today which included what they called a six minute walk test. I walked 565 metres in the six minutes and my oxygen started at 96% and dropped to 95% for the majority of the test and 94 briefly at one point in the test, and my pulse was 137 at its highest/ I don’t know if you can tell from this what the rehab should consist of to qualify as a good program, I will find out what they have planned for me when I attend my first session next week but would appreciate your feedback as to what should be involved given your fairly limited knowledge of me through the previously posted spirometry and PFT as well as the six minute walk test. I am also waiting for the results of the sleep study I had done which will tell me about my oxygen levels when I sleep.

Thanks again for advice.

Don

Hi Don,

The increase in your resting volumes (RV, FRC) is NOT the result of the breathing maneuvers employed during testing. They are actually measured using 'quiet' breathing such that "dynamic hyperinflation" is avoided, a factor which 'could' increase them. While they may be decreased using inhaled long-acting, beta-agonsist (Symbicort/Formoterol, Advair for instance), anticholinergic (Spiriva) and steroids (in the Symbicort/Advair), they reflect the "mechanical changes" influenced by the 'physical' changes in your lung structure as the result of your obstructive disease. Again, as they are not elevated significantly and your disease appears to be mild to moderate in severity, that they 'require' inhaled medication treatment remains debatable and something only your doctor can answer.

When I speak of a "quality" pulmonary rehab program, I refer mainly to one that has good and comprehensive teaching materials, staff that are skilled at teaching that information, staff that are skilled and knowledgeable in appropriately exercising those with lung disease and also skilled and knowledgeable in optimizing treatment with regard to medications, oxygen and effective breathing techniques. The only way to determine the quality of a program is to participate in it and see what results you get from that participation. A few overall considerations would include if they encourage you to push as hard as you can and learn to contend with breathing difficulties attendant with the severity of your disease, rather than teach you "avoidance" behavior to keep from challenging your breathing or bringing on discomfort through harder work to breathe - a tactic that has proven to hasten worsening of lung diseases. They should appropriately measure your oxygen levels during activities to determine that you can maintain adequate oxygenation levels OR intervene with appropriate oxygen therapy to normalize your oxygen levels along with working with your doctor to initiate supplemental oxygen if/when found necessary. (I don't expect that the oxygenation component would apply to you, specifically. BUT, you will likely participate with others who are in a more advanced disease state than are you. If you observe them to be treated appropriately, then that should suggest to you the skills and knowledge of the staff to which I refer.)

I make these recommendations because there are too many programs in operation all over our countries wherein the staff are not well-educated in disease management of chronic lung diseases, not experienced and skilled enough to be able to "critically think" and evaluate and discern the magnitude and extent of problems AND where the program is conducted from a mainly "textbook" standpoint, without independent thinking on the part of the staff. As well, staff in some programs are not knowledgeable and skilled in principles and techniques of exercise for those with chronic lung diseases. Then there are the personal biases of those who staff programs with regard to what is good and bad and allowable or advantageous in terms of exercise, activities of daily living and function, in general. Those are just a few of the major concerns as I have observed over a few of decades of review of how many of my colleagues operate.

From what you report of your 6 minute walk test, you are indeed in good shape with your mild to moderate disease. You might be somewhat (out of shape) as suggested by the 137/min heart rate at peak intensity and interval of the test. But, that would expectedly come down over time as your condition improves with regular exercise three to four days a week for a couple of months. What I would expect you to receive is education on how to stay as good as you are for as long as you can, an exercise program that will help you maintain best fitness and health and retention of function for a long time to come.

Your sleep study should help to identify IF there are any pulmonary issues that cannot be detected with testing in other ways. I expect that you will likely be found to be just fine in terms of your oxygen levels when you sleep. That is also assuming that you don't have evidence of some previously not suggested obstructive apnea.

Best Wishes,

Mark

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Questions About Yawning, Sore Chest, Spiriva And Symbicort

Hi Mark

I read the questions last week posted by Cynthia, and they could have been written by me as they pretty much mimic my situation. I know she had asked about her lungs being sore and excessive yawning which you did not directly answer, and as I have the same two concerns/symptoms I would be pleased if you could offer your opinion on them.

I yawn a considerable amount, more so after supper and the rest of the evening until bed time, but also yawn more than I would consider normal throughout the day as well. I am also sore across the bottom of the rib cage, and it also feels like some pressure is there which really curbs my appetite as there is almost a feeling of fullness.

I am on Spiriva and Symbicort and have noticed from time to time you have recommended Formoterol which is apparently one of the ingredients in Symbicort but without the steroid and wondered exactly what the purpose of the steroid is, or why you would want the Symbicort without the steroid.

I recently saw an ophthalmologist and he told me the pressure in my right eye was higher than it should be and is going to do additional tests on the eye but feels it may be related to the medication I am taking but forgot to ask which medication, so just wondered if you could tell me if that would be caused by the Spiriva or the Symbicort, and if caused by the Symbicort, would it be the Formoterol that would causing it or the Steroid? If it is the steroid and I take Formoterol instead of Symbicort what benefit will I likely be missing?

I also seem to be urinating more frequently and wake up 3 or 4 time during the night. This is not a result of breathing difficulties, just wake up. Sometimes it is to urinate but often is not and wondered if this would also be a result of the medication and if so which one would likely be causing it?
Thank you

Wayne

Hello Wayne,

I did not comment on the lung soreness because it is a vague symptom that only one's doctor can - with eyeballs to put on the patient and knowledge of their specific condition - evaluate and found cause for. I would have to take the same tack with your question in that regard, as well.

Yawning is a phenomenon that is shrouded in mystery in many respects. While, with specific information, we can suggest - even correctly label - a cause for yawning, there are many aspects of why we yawn that simply are not known.

When you yawn a lot after a meal and at times throughout the day - specifically when being sedentary for a period of time when yawning onsets - we CAN suggest that the cause is to recruit more lung 'space' to maintain 'normal' ventilation. Your full stomach after a meal pushes up on your diaphragm and impedes 'best breathing' ability. So, you might yawn in order to increase ventilation as a result. We know boredom and other fatigue-related factors also stimulate yawning. Those have nothing to do with having lung disease or to severity of that lung disease.

Inhaled corticosteroids serve to reduce inflammation of the tissues lining the bronchial tubes. Any increase in the diameter of the airways that results from the effect of the steroids improves breathing mechanics and reduces work to breathe. Generally speaking, inhaled steroids combined with the long-acting, beta agonists invoke the greatest increase in bronchial tube diameter and resultantly improve airflow through the airways. As I have said to others with regard to inhaled steroids for them as individuals, only a tril with and without the steroid can determine if you benefit significantly enough from its use to continue using it. That is a question for you and your doctor to explore.

If your opthalmologist is noting an "increase" in your eye pressures that is approaching a point of concern, then the first drug that would likely need to be addressed would be the Spiriva. Anticholinergics have the potential side effect to aggravate glaucoma or cause it to manifest in those who are prone to developing glaucoma. Ask the opthalmologist about your Spiriva and its potential contribution to your increasing eye pressures.

Insofar as the night-time urination frequency, that is not normal (Once per night is not out of the ordinary. But more warrants consideration for cause.) You could have prostate problems. You could be diabetic. You could have blood pressure problems (hypertension). Or you could have some type of kidney dysfunction. Tell your doctor about your night time urinary pattern so that cause(s) may be discerned and intervention applied, if indicated. In any case, I doubt that your medications are causing the more frequent urination pattern you relate.

Best Wishes,

Mark

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Bronchial Provocation Test, FEV1 And COPD Stage

Hi Mark,

I was diagnosed yesterday with COPD and due to being very scared I didn't ask the right questions about my pulmonary function test. It was conducted at a hospital clinic and was completed first on a Tuesday evening and then a week later. The Bronchial Provocation Report is as follows. My height is 65 inches, weight is 125 lb, age 50 , a female, non smoker for 14 years, grew up in a home full of second hand smoke, prone to chest infections, work with young children prone to viruses, the codes on the form as follows: FVC ( L) REF Pre Meas Post Meas % Post Chg
3.60 4.00 4.47 16
FEV1 (l) 2.99 3.03 3.23 13
fev1/FVC(%) 81 76 72

Then the form continues charting different numbers as different I was asked to inhale different substances. I am not sure if you need everything to comment but it appears as follows.
REF PREBASELINE LEVEL 1 LEVEL2 LEVEL 3 LEVEL 4 LEVEL 5 LEVEL 6 LEVEL 7 LEVEL 8 LEVEL 9 LEVEL 10 POST
FEV1 2.99 3.03 2.85 2.98 2.88 2.72 2.73 2.48 2.49 2.60 3.23
%PRED 101 95 99 96 91 91 83 83 87 108

%cHANGE -6 4 1 -5 -4 -13 -13 -9 13

Then in bold print above a graph is: PC20 FEV1 My doctor has ordered a bronchoposy next week. I am not sure what stage of COPD I am at. Any advice would be most welcome.

Arlene

Hi Arlene,

You have not given me enough information to tell you what stage of COPD you are in, per se - and that is IF you even HAVE COPD, in the first place - a mater in doubt in my mind.. From the "numbers" you DO give, If I interpret them in correct order as you have stated them, I disagree that you have significant COPD, if any at all. All measurements seem to be above 100 % of predicted AND your FEV1/FVC ratio is above the 70 % threshold for a diagnosis of COPD. So, unless you did not copy some of the values correctly, I'd have to say that you do NOT have COPD.

Now the bronchial provocation testing may suggest that you have "reactive airways" difficulties (Asthma), but even then, I'm not impressed that your numbers suggest any abnormality. I don't know what sent you to the doctor for evaluation in the first place. And I don't know why your doctor is going to do the bronchoscopy, either. So there is MUCH information that I do not have at hand to tell you anything more than what I have.

At this point, this is all I can tell you. BUT I would say that it is GOOD news, at that!

Best Wishes,

Mark

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What Does ‘A Spot' On The Lung Mean?

Mark I have COPD my Doctor said I have a spot on my lung and I have to be checked every Six months with a cat scan. My Question is what exactly does it mean?

Betty

Hi Betty,

Usually, a spot on the lung that the doctor considers in need of observation with interval testing with x-rays, or CT scans or MRI is one that is suspicious for the potential of being cancerous. The interval testing will look for signs of growth and change in vascularity. Cancer tumors develop significant circulation that is abnormal compared to other tissues or nodules.

Often, many "spots" (nodules) in the lungs end up being no more than fatty deposits or calcifications, all normal changes associated with aging. Only time will tell what yours turns out to be. We'll all hope that it is nothing, when all is said and done.

Best Wishes,

Mark

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Questions About 'Sometimes Sob With Walking', Indigestion, Rehab, Salt Pipe And ?

I am a 62 year old woman that was diagnosed with COPD . I quit smoking 9 months ago but smoked for over 40 years. About 2 weeks after i quit the cough and phlegm stopped. I get a tiny bit of phlegm in the mornings only. I do not have my readings for you but will try to get them. I work out 3 times a week doing fairly hard cardio (is this ok) and I also do Yoga once a week. I have no problems doing these, but find I can walk a block sometimes and be short of breath. I am very tired in the evenings and yawn non-stop sometimes. I find I am also getting indigestion, something that I never had before. When they did my last breathing test, my oxygen was 95 and the Dr said my breathing had improved slightly. I find I get sore lungs and a tightness in them as well. I am on Spiriva and Symbicort and the Dr had suggested that I try stopping the Spiriva but felt I needed it after a day or two. I have the Ventolin also but find it does not help much at all when I feel this tightness. I also do the pursed lip breathing and that doesn't seem to help. I am going to try to go to rehab and learn more about it. I even tried a salt pipe but have heard different things about it. Any other suggestions would be very helpful.

Thanks, Cynthia

Hi Cynthia,

First, congratulations on quitting smoking! It is fine to exercise as vigorously as you can tolerate. So, the heavy cardio workout is good. The yoga is frosting on the cake. While you may experience increased work to breathe after starting your walk, that should progress to manageable work as you continue. You may be starting your walk at too fast a pace. But, again, that should ‘even out’ as you continue to walk. Continue to use the pursed lips breathing. If you are working hard to force yourself to breathe in through your nose, that will contribute to your increased breathing difficulties. Shifting to breathing in through your mouth should help. There is absolutely NO advantage to breathing in through your nose, especially if it perpetuates increased work to breathe. And all benefit to condition the air coming into your lungs is maintained when breathing in through your mouth, contrary to what many might say. You made a good choice to stay on the Spiriva. It is the single-most beneficial inhaled medication for those with smoking-related COPD and should NOT have been considered for discontinuance. The combination of Spiriva and Symbicort are good maintenance medications for COPD. Rehab would be a good idea if there is one that is of good quality nearby. You might also consider purchasing an oximeter to monitor your oxygen saturation and be sure it is not dropping during your intense workout(s).

Best Wishes,

Mark

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Wondering What The Future Will Bring

Hello Mark:

Thank you for the opportunity to ask a question and actually get an answer!

My husband (74) was diagnosed in 2006 with bronchiectasis and emphysema; in 2008 with aspergillomas. Was managing quite well until about a year ago, when he was advised to start using home oxygen. Used it only occasionally, and not at night. However got pneumonia and congested heart failure in March 2012. Was in hospital for 7 days and has not been without oxygen since that time. Got another infection in July, and things just did not get any better. He can keep his blood oxygen levels ok as long as he is resting. As soon as he does anything at all, it drops fast and hard. At home he uses continuous flow at about 4- 4 1/2, unless he really want to do something, we turn it up to five. Going out he uses a cylinder (which will give only 2 at continuous flow) he uses intermittent @ 5. We have started to use a wheelchair as he just does not have the energy (breath) to walk. By the way, he was a heavy smoker but quit in 1984.

He used to bring up blood quite regular, but not since he was in hospital in March. Now only occasional streaks in with the sputum.

Medications: spiriva, once daily. Azythromycin 3 times a week, ongoing. Blood pressure either normal or low. Has occasional heart arrhythmia (?)

Was on fungal medication for 3 months in 2009, results zero benefit with very bad side effects. Specialist decided longer period of this or other fungal medication would not serve any purpose.

I don't know whether you have sufficient info to give me some kind of an idea what we can expect in the near future. What will get worse, lung or heart function? How dependent will he get, how difficult will it be for me to take care of him? Aside from occasional chest pain, (preceding infection) he has not real pain. Will that change?

Thank you again for letting me share these concerns with you.

Annemarie

Hello, Annamarie,

I’m sorry to learn of your hubby’s difficulties. From what you report, he is severely advanced (as evidenced by the need for >4 L/min oxygen at rest and 5, pulsed, not being enough to maintain adequate saturation when he is moving. It is no surprise that he wants to sit as much as possible. Is there any way he can get a hoe oxygen system that will provide more oxygen? A high-flow oxygen concentrator would be appropriate (they go up to 10 L/min). A “Smart Dose” pulsed system can deliver up to equivalent of 10 L/min compared to continuous flow, which might give him the extra oxygen he needs to boost his saturation to a more reasonable and safe level during exertion. I hope he is well maintained no inhaled medications like Spiriva, once a day and formoterol or arformoterol twice a day with ventolin as a pick-me-up in between the formoterol/arformoterol. Symbicort combines formoterol and a steroid medication for a more complete coverage to keep the airways at their best tone possible.

I cannot tell you which – between his heart and lung functions – will worsen more quickly. If he is unable to better accommodate his oxygen needs. BOTH his lung function and heart function will predictably deteriorate and do so fairly rapidly. He could become a challenge to manage from a physical-need standpoint if he worsens much more. But, all is NOT bad news. If he can get into pulmonary rehab, they might be able to help him increase his strength, stamina and improve his breathing and oxygenation. Is pulmonary rehab available in your location?

Best Wishes,

Mark

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Further Questions About PFT Results

Hi Mark

I had the post last week that was titled Questions about PFT results.

I hope you can access my message and your response rather than reposting the entire thing. If you can access last week’s messages then I will address a couple of the questions and concerns you had.

The first set of numbers, the shorter of the two and the one that doesn’t include the DLCO was a basic spirometry done in the respirologist’s office in five minutes sitting on his examination table/couch, or whatever they are called. I don’t recall if he measured my height or relied on me telling him I was five foot eleven and a half inches tall which has always been my height.

The second test was done at an actual pulmonary lab, if that is the right term and included me being weighed and my height measured without shoes prior to the PFT. When I saw my height after returning home I measured myself with my shoes removed, which is what she had done before the PFT and I was indeed 70.5 inches tall rather than the 71.5 that I expected I was, and was likely done years ago with my shoes on, either that or I have shrunk with age. Anyway the test was close to an hour long and was done in a booth which at times had the door open and at other times had the door closed.

If I had to guess, I would say the second, full PFT would seem to be the one that would be the most accurate, at least based on the procedures involved, but as I know nothing about these tests and results I don’t know what to think. The lab is in the same office as the most respected cardiologist in the city so one would think it would be reliable. You seem skeptical of the results of the full PFT partially based on the results of the DLCO portion, and just wondered, are those results not possible, unlikely, or indicative of a worse condition than what is implied by the results of the first spirometry?

I think the difference in FVC may be explained by what seems to be a difference in the length of time used. The chart for the first spirometry showed an end at about six seconds where as the full PFT showed it going for twelve seconds, and it was still climbing.

If you ignored the shorter of the two results and only interpreted the full PFT could you give me your analysis and interpretation please? As I mentioned in my previous post was somewhat concerned by many of the numbers including the 145% of predicted for RV and the 136% of predicted for FRC. I would also like to know whether the results for all four of the DLCO readings, that were all above 100%, whether that is a good or bad thing. Also the FEF25-75% seems very very low or poor but I am not sure of the significance of it.

I don’t know if I mentioned in my original question but the first time I had a spirometry a few years ago I recall being out of breath before the test ended and kept being told to blow blow blow, so when I did the first spirometry in the respirologist’s office I blew forcefully but not an all out blast right from the start. At that time I was unaware of the importance of the first second of the blow which may also explain some of the differences as when I went for the full PFT I blew as hard as I could right from the start, as by then I became more aware of the importance of an all out effort.

It still leaves me somewhat confused as to why when I blow forcefully but not an all out blast right from the start, why I get a higher FEV1 both on my home hand held unit and also the one used for the second or full PFT. I did read something the other day which may have explained it and thought I kept the article so I could properly quote it but cannot find it now so will have to give you my recollection and condensed version. It said something to the affect that if you don’t give a maximum effort the technician should be able to tell by some chart they have which in fact is what the technician told me when she disallowed the FEV1 of 2.82 which was done without a real hard blast from the start but rather a forceful blow. It went on to say that an all out effort can cause some of the airways to close or restrict more or something to the affect but sadly can’t quote the article.

Anyway thank you for your time, and as I mentioned would appreciate if you could give me your opinion on the second full PFT as if it were the only one provided just for my own satisfaction. (Webmistress note: 2nd set supplied last week; see below)

Don

Hi Again, Don,

If you go back and read my response from last week, my comment that calibration and technique error make comparison between the two tests impossible. More importantly, I stated that the DLCO made that test questionable from the standpoint of machine error or calibration error. Just because the second test was done at a pulmonary function lab and on a monster machine costing 40 times that of the one in your doctor’s office – and considering the difference in your height, between the two, I still do not accept the accuracy and therefore, the validity of the measurements made at the lab. The technician took liberty to pick and choose measurements that serve only to emphasize the discrepancies within that test. By throwing out your best FEV-1 and other better values, the test became invalid according to international standards of acceptable testing technique and measurement. Having worked with plethysmographic systems many times, myself, I know the problems they can run into. And that systems may have some problems. The sometimes open and sometimes closed door is appropriate as only certain of the measurements require the box to be sealed as those measurements are made using pressure changes as the subject breathes in and out.

All the previous being said, some things can be pulled out of the results from a general sense as even accounting for error, the ‘trend’ of the measurements tells the story. COPD results in increased air trapped in the lungs at the end of various breathing maneuvers. The values that will be increased are the lung volumes and in particular, the “resting lung volumes”. Those include FRC and RV. As well, TLC will be elevated. All of those are elevated in your case, so indicate mild to moderate COPD. As well, your FEV-1 in the face of a much higher FVC, along with the FEV-1/FVC ratio being less than 70 put you in stage II (GOLD) level of severity. BUT, that said, a DLCO of greater than 100 % of predicted is just wrong. It should be decreased, even if only by a small margin over predicted – hence my distrust of the measurement and/or calibration.

FVC is measured by a couple of different approaches, depending upon the device. But, all are equalized for comparison through knowing what method the measurement is made. They can be counted for up to 6 seconds, with some devices, indeed, some calling it FEV-6, rather than FVC. Even if the measurement is done for 12 seconds, as you reported, only the first 6 seconds is counted. Again, it the technician adjusted the machine method to count all 12 seconds, then additional error was entered into the test results.

Once again, I repeat that PFT measurement is “effort dependent” for greatest accuracy. If you adjust or ’measure out’ and control your effort in a way that prevents a maximal effort, then your tests will not reflect your true lung mechanics, no matter who does them. So, any notion of blowing harder versus less hard or any other adjustments should be put aside in favor of the all-out effort.

Lastly, I cannot give you a meaningful interpretation or any further useful information based upon only the second test. It is the one which is most likely and predictably flawed and therefore should be trashed and repeated by someone who more thoroughly understand the standards of measurement AND on a system that has been properly calibrated and quality tested to assure proper function of its components. I cannot say that any of those conditions applied to your test from the pulmonary functions lab. And it appears more likely that your doctor’s office test was the more accurate of the two.

Best Regards,

Mark

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Normal Oxygen Saturation For COPDer’s

Hello Sir,
I would like to know normal oxygen saturation level of COPD patient. I am a nursing student.
Thank you.

Aparna

Hi Aparna,

There is no “normal” or ‘standard’ oxygen saturation level for those with COPD.  “Everyone”, to be considered within normal range for oxygen saturation should be at or above 95 %.  As one’s COPD worsens, and the FEV-1 falls below about 30 % of predicted normal, we increasingly observe oxygen ‘desaturation’.  There are some whose FEV-1 is greater than 30 % who exhibit desaturation.  Others may not exhibit desaturation until they fall below 20 % of predicted.  And the COPD population, as a whole falls within a wide range of variation in terms of when they begin to exhibit desaturation.  

Causes for desaturation include loss of circulation (perfusion miss-match) to the alveoli in the lungs, loss of numbers of alveoli (ventilation miss-match) and reduced ventilation due to air-trapping, increased volume in the lungs at end of exhalation and poor dilution of air in the lungs during breathing because fresh air coming into the lungs cannot sufficiently raise the oxygen level of the larger volume of air within the lungs that cannot be expelled. 

When saturation is seen to fall below 95 %, no matter the activity, lung disease has advanced such that the progression of worsening oxygenation is under way.  When we observe saturation to fall below 88 %, supplemental oxygen to raise oxygen levels to above 90 % is considered necessary.  So, while I can’t give you a direct answer to your specific question, suffice it to say that we want to see oxygen saturation above 90 % at ALL times, whether or not it takes boosting with supplemental oxygen use or the individual is able to raise and/or maintain it by other means.

Best Wishes,

Mark

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Lung Exercise Eqpt

Should I use any type of lung exercise equipment for instance: an acapella machine

Lisa

Hi Lisa, I cannot answer your question since I know absolutely nothing about you and you have not offered any diagnosis or medical history or information to allow me to ascertain what, if anything, you should use. 

Best Regards,

Mark

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Health Care Benefits & Pulmonary Rehab

Do you think that pulmonary rehab should be mandated for those individuals waiting on a lung transplant and/or lung reduction?  Why or why not?  Should all COPD patients that qualify for Pulmonary Rehab be forced to participate to receive health care benefits?  Why or why not?

Celia

Hi Celia,I do think that folks anticipating both LVRS and/or transplant should indeed participate in pulmonary rehabilitation.  The NETT (National Emphysema Treatment Trial overwhelmingly showed that significant benefit from pulmonary rehabilitation occurred in both the group that ultimately underwent LVRS as well as those who did not.  In many instances, pulmonary rehabilitation alone improved function in individuals such that they ended up not needing to undergo LVRS.  For those awaiting transplant, pulmonary rehab provides benefit in maintaining them at the highest level of function and condition to best tolerate the procedure.  As well, pulmonary rehab after both procedures improves post-surgical function and condition greater and sooner than for those who do not participate in pulmonary rehab.

Most transplant centers “require” patients to participate in pulmonary rehab as a preparatory measure to undergoing transplant.  The same is true for LVRS.  Most insurance programs also require participation as a cost-containment measure for both procedures.

Whether required or not, pulmonary rehabilitation has been shown to definitively improve disease state, function and symptoms related to one’s state of disease.

I know of no benefit plans that “force” beneficiaries to undergo pulmonary rehabilitation activities as a condition to receiving benefits.  Can you explain further why you ask your questions AND perhaps, why you put them in the context you do?

Best regards, Mark

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Fev1 – Will Improve After Quitting Smoking?

Will FEV1 improve after quitting smoking?

I am 60 years old and have smoked a pack a day for 42 years and have been diagnosed with COPD with a FEV1 of 67%. I know COPD does damage that cannot be reversed but reading the affects of quitting smoking, improved lung function of up to 30% within 9 months is supposed to be one of the benefits. While I would not expect to see improvements of 30% because of the existing damage one would think there should be some improvement and just wondered if that would be reflected in the FEV1, and what type of improvement is generally expected? What time period does one generally start to see benefits in breathing and what time period would one expect to see the largest benefit from having quit smoking? I quit 8 weeks ago but to date have not experienced any noticeable improvement to my breathing or any other aspect of my health.

Will a person see any improvement in FEV1 after exercising for a few months? Will there be an improvement in the FEV1 with taking Spiriva and Symbicort for a few months?

I had a spirometry done several years ago and was told I had mild COPD, but was not given any of the readings/numbers. I remembered being completely out of breath and being told to keep blowing blowing blowing. This past June when I went for the Spirometry where the FEV1 was 67% I did not blow as hard as I could right from the start and blew more at a constant rate so I would have more breath to make it to the end of the test. I wasn't aware of the importance of the first second of breath until after I got the results that I had moderate COPD and starting doing some research on the internet, so now am wondering if I had blown as hard as I could right from the start of the test is it likely my FEV1 would have been higher? Here are the results of the PFT. This PFT was taken a 6 weeks before I finally quit smoking.

I am a 60 year old Caucasian male 71.5 inches tall and weighing 166 pounds and smoked a pack a day for 42 years. At that time I was only taking Spiriva and the most recent dose was the previous day about 8 PM.

        PREDICTED - PRE DRUG REPORTED - % OF PREDICTED
FVC     4.71 - 4.03 - 86%
FEV1    3.77 - 2.52 - 67%
FEV1/FVC    80 - 63 - 78%
FEV3    4.30 - 3.52 - 82%
FEF 25-75%    3.78 - 1.37 - 36%
FEF 25%    8.21 - 3.56 - 43%
FEF 50%    4.64 - 1.70 - 37%
FEF 75%    1.75 - .5 - 29%
PEF   8.92 - 5.19 - 58%

Since quitting smoking I have purchased a hand held electronic meter that measures PEF and FEV1, and have to say that the readings vary dramatically. I appreciate that this meter is nowhere near as accurate as a spirometer but most of my FEV1 readings are in the 1.85-2.25 range and have only had a very few that were in the 2.40-2.50 range, which are all well below the FEV1 shown on the spirometry shown above. I had a friend that just had a spirometry and was told he was 106% of expected. I had him try my meter thinking that his reading would be well below what the spirometry showed for FEV1 however instead it was significantly higher. As he is the same age as I am as well as the same height and weight his FEV1 should have been 3.77 and if you increase it to 106% of expected it should be 3.96 but was 4.46 according to me meter, so if anything it would appear my meter is reading considerably higher than it should be even though my own personal readings seem to be considerably lower than the readings from the spirometry test. I should also mention that if I blow very hard from the start the PEF is quite high, usually in the 525-600 L/min range, but the FEV1 is in the 1.8 to 2.0 range, whereas if I blow more slowly and constantly right from the start like I did during the spirometry test, the PEF is often in the 300-400 L/min range but the FEV1 is in the 2.25 - 2.45 range, which seems completely backwards. One would think if you blew really hard at the start the FEV1 would be higher unless I am running out of breath before the full second is up, but the results do sort of mimic the spirometry tests done in that my PEF was quite low and FEV1 was reasonable.

I guess perhaps my FEV1 has dropped but that would seem to be a very significant drop in a relatively short period of time.

The last question I have is, is there any downside to not using my inhalers, aside from feeling sob, or do they slow the progression of the disease? If they don't actually slow the progression then I think I would prefer not to use them do to some of the potential side effects. If they do slow the progression then what would your recommendations for medication be based on my PFT?

Sorry I have rambled on for so long and realize I have asked a lot of questions, so will certainly be very appreciate if you can answer them all.

Thank you.

Don

Hi Don,

There is no guarantee that quitting smoking will result in an increase in FEV-1 or significant improvement in breathing symptoms.  Many folks notice that over time, mucus production reduces, morning cough goes away and they generally ‘feel’ better.  But, any increase in FEV-1 is usually the result of less airway reactivity from the irritation of smoking being gone.

Pulmonary function measurement and testing is a “maximum” effort test.  Accurate measurements “require” that the subject give an all-out effort – even if they feel they “run out of breath” halfway through a maneuver – especially the FEV-1 measurement.  By holding back and giving less than maximum effort, your FEV-1 is measured at somewhere below what it actually is.  In testing, we usually do three trials from which we choose the BEST effort as exhibited by the highest measurements among the trials.  If you did not give your maximum effort AND you still came in at 86 % and 67 % on your FVC and FEV-1, respectively, then your measurements reflect somewhere “below” where your actual function is. You should seek to have the test repeated and give a maximal effort to find out where you ‘really’ are in your disease process. 

And, to answer your question of whether or not you would benefit from taking medications at this point in your disease, your test should include “pre-“_ and “post-” bronchodilator measurements.  If there is a significant improvement in those measurements – especially in the FEF’s and PEF, then you should consider taking the medications. 

The side effects about which you worry do not out-weigh the potential benefit.  But, that said, if your PFT’s are found to be better than this test you included, you may not need medications for some time to come – say until your FEV-1 drops to below 70 % AND you notice more than expected breathlessness with significant exertion or exercise, especially if that breathlessness comes to limit the limit to which you can exert and function.

Best Wishes,

Mark

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Morning Shortness of Breath – The Worst

I have very severe COPD. I'm on spiriva, symbicort and ventolin. I'm not on oxygen. though I'm short on breath most of the day I do pretty good. But the mornings are terrible for breathing and moving around for a couple few hours when I wake up.  I check my oxygen level in the morning and it says 93 or 94 I only sleep about 6 hours a night and nap only sometimes.  Is there anything I can do to make my morning easier?
Thank you, Garth

 Hi Garth,

I am wondering if you are experiencing nocturnal oxygen desaturation – which will NOT be evident in your morning oxygen measurements.  I am also wondering if you are desaturating when you exert.  Since you have an oximeter, I suggest you put it on and walk around WITHOUT STOPPING for at least 3 minutes and see what your saturation does.  It is very common that we see folks with great oxygen saturation while they are sitting comfortably at rest only to see it drop like a lead balloon when they get up and move about.  IF you find that your saturation drops from that 93 or 94 to less than 89 with walking about, then talk to your doctor and see about getting a sleep test.  If you are significantly desaturating during sleep AND exertion, then it is time to start supplemental oxygen therapy.  Avoiding using oxygen will only make your condition worsen faster AND lead to your earlier demise.  Using oxygen when your measurements show that you need it not only improves your symptoms and prolongs your life, but it will make life and function much better and more enjoyable, despite what may seem a lot of inconveniences on the surface.

One last suggestion, if you are using your Ventolin too soon BEFORE taking your Symbicort, the you are reducing the effect and benefit from the Symbicort.  If you find it necessary to start the morning with the Ventolin, wait at least two hours before taking your Symbicort.  You can still take the Spiriva right after taking the Ventolin.  OR you can wait and take it right after the Symbicort.  When it comes time for your evening dose of Symbicort, be sure you have not taken the Ventolin for at least two hours before it is time to take the Symbicort.  Lastly, be sure you are taking the Symbicort at as close to 12-hour intervals as possible.

I hope these suggestions help you find some answers.  If not, write back again and we’ll see what we can come up with.

Best Wishes,

Mark

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What Does ‘A Spot' On The Lung Mean?

Mark I have COPD my Doctor said I have a spot on my lung and I have to be checked every Six months with a cat scan. My Question is what exactly does it mean?

Betty

Hi Betty,

Usually, a spot on the lung that the doctor considers in need of observation with interval testing with x-rays, or CT scans or MRI is one that is suspicious for the potential of being cancerous. The interval testing will look for signs of growth and change in vascularity. Cancer tumors develop significant circulation that is abnormal compared to other tissues or nodules.

Often, many "spots" (nodules) in the lungs end up being no more than fatty deposits or calcifications, all normal changes associated with aging. Only time will tell what yours turns out to be. We'll all hope that it is nothing, when all is said and done.

Best Wishes,

Mark

 

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PFT Interpretation/Changes

I am a 60 yr. old female, weight is 127, height 60". My last study was improved vs 4 prior studies.  Can you explain the following results to me and how serious(what stage)  is my COPD?
I take Spirvia 1 per day and Advair 1 per day.

06/29/12  FVC 2.71 liters  FEV1 .98 liters  FEP25-75%  .23L/sec  PEF  3.19 L/sec
11/03/10            1.82                      .80                                   .19                      2.70
03/18/09             1.69                     .76                                    .20                     2.54
02/25/08              1.93                    .88                                    .22                     1.97
11/08/04              1.97                     1.01                                 .30                     2.54

I do not understand all of this.
Thank you,
Patty

Hi Patty,

Your FVC is within normal range.  BUT, your FEV-1 is severely reduced at 44 % of predicted!  You didn’t say if those measurements were post medication, which would indicate reactive airways problems (asthma) , for instance.  But, another point of major puzzlement is that for years, your FEV-1 has been almost 35 % less than on your current test.  At the same time, while your FEV-1 is not much more than it was on the earlier tests, it is not increased by the same amount as is your FVC.  This suggests some sort of error in the measurement.  I would ask the doctor about the unexplained difference in this FVC, compared to years of others that were much less and more comparable.  You may simply need to repeat the test after the machine has been checked to be sure it is calculating/measuring the FVC accurately.  Other than measurement error, I cannot explain the significant discrepancy.

Best Wishes,

Mark

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Cornucopia of COPD Questions … Cont’d (Responses Are Shown in Red)

Hi Mark, and thank you for the excellent work you do here, it is greatly appreciated. I don´t think you realize how valuable your service is as many of us simply don´t have access to a specialist to get the answers we need in a timely manner, and most or at least many GPs are simply not well enough informed to provide the information and guidance we need. I wrote the rather lengthy message last week which you so graciously answered in great detail, so I have to thank you for that. I will apologize beforehand as I have another pretty lengthy message and series of questions. Your answers are a big help to me as the closest hospital with a specialist in pulmonology would be 180 miles from where I live and generally when you see a specialist your time is pretty limited so doubt I would get most of my questions answered, and there is generally a 2 or more month wait.

I believe I was originally diagnosed with COPD in 2005 or 2006 after some shortness of breath when walking any distance or going upstairs. Following a chest X-Ray and spirometry in the doctor´s office I was informed I had mild COPD but was not given any specifics. I was informed that if I quit smoking it would slowly reverse itself. Of course hearing that I took it as an all clear to keep smoking knowing that when I did decide to quit the COPD would reverse itself and I would be as good as new, although like all smokers I knew I should quit. I was prescribed antibiotics and Spiriva and in a short time I was back to normal, or at least my normal.   As each year passed I knew I was getting slowly worse as I was a little more out of breath mowing the lawn each summer then I had been the summer before, and from time to time my breathing would get worse at which point I would get another prescription for antibiotics and go on my way.
In late April of this year my breathing was not very good and I became short of breath more easily then what would be normal for me. At that time I saw my GP who prescribed Cipro for 10 days and my breathing improved to what I would consider is normal for me. He also scheduled an appointment with I believe a respirologist, sent me for a chest x-ray, and scheduled a stress test. Shortly after that we went to Las Vegas for a vacation and no matter what you do in Las Vegas if requires quite a bit of walking, which I handled pretty well, or at least what I would consider normal for me, so felt quite good that I was once again back to my normal.   I should mention that my GP had also prescribed Spiriva when I was first diagnosed however I only took it when I was having one of my shortness of breath periods and thus most of the time I was not taking it.

I had my appointment with the respirologist in June, and was informed that I had moderate COPD and I needed to quit smoking or I could end up on oxygen in as little as 5 years, and likely by 10 years. He also gave me a prescription for Advair to be taken twice a day in addition to the Spiriva I was already taking, or at least taking as I felt it necessary. His report to my GP said my FVC was normal, my FEV1 is mildly reduced, and the ratio is reduced, and that there was moderate obstruction consistent with COPD. His recommendation was smoking cessation, medical optimization (not sure what is meant by that), and repeat testing in one year. 
Medical “optimization” means that you should take the medications prescribed for you “as prescribed”, rather than only when you fell you need them.  They are “maintenance” medications and intended to bring you to a level of stability AND to hold/maintain you at that level. 

I used the Advair a couple of times but found my chest was very tight afterwards, and my breathing seemed heavy or labored. I am not sure if that was coincidental or not but stopped using it because of that, however my breathing has not improved to what it was before. Saying that I gasp for breath would be an overstatement, but that is what it seems like but not to the extent of actually gasping. It is like I can´t take a full breath and am always a little short of air, even when just sitting on the couch. If I walk on the treadmill for 15 minutes I do not feel anymore out of breath, but feel like I am not getting enough air, which is different from flare ups in the past where I would just get out of breath quicker when walking or going up stairs, which isn´t the case this time.  

A couple of possibilities can explain your difficulty with Advair.  Some folks are sensitive to the steroid component in the Advair.  You have a prescription for Symbicort.  I would recommend giving that a try to see if you have the same sort of difficulty.  If you do, then as your doctor for a prescription for formoterol, buy itself.  The formoterol is the specific component you need for maintenance of the best airway ‘tone’ possible.  You may not need the steroid component.

I used to cough up mucus daily, and after I did, my breathing was usually a little easier. Since the Advair my chest has remained very tight and I have not coughed up any mucus since that time, which is very unusual for me, and has now been about three months. My chest still feels quite tight even now and I seldom cough and if I do it is always a very tight non-productive cough, so feel no improvement after I cough.
I went to see my GP, who prescribed Cipro in early July which I took for 10 days with no change. He then sent me for a chest x-ray and prescribed Azithromycin for 5 days but again it has not made any difference. The chest x-ray showed hyperinflation consistent with COPD and noted no change from the previous x-ray. I went back to my GP the first part of August and he again prescribed Cipro for 14 days. He listened to my chest and said it sounded good.

Several years ago I quit smoking for several months and recall coughing up so much mucus I thought I would choke. I finally quit smoking on July 31 of this year and although it has only been eight weeks I still have not coughed up any mucus which seems odd, at least given my previous experience of quitting smoking.

I believe one aspect of COPD is the small airways get plugged with mucus and probably tar and other "muck" from smoking. It would seem when a person quits some of this "muck" would start to clear out which would improve one´s breathing, but so far I have not been coughing up anything, and just wondered if there is something I can do to aid my lungs in getting rid of some of the leftovers from smoking. I expected by now, based on my previous experience when I quitting smoking, I would be coughing up all kinds of nasty stuff left over from 40+ years of smoking but so far have not coughed up anything, and find this particularly unusual considering before I used the Advair I would generally cough up at least some mucus pretty much daily.

I have seen products like Smokers Cleanse and inquired with the company as to whether it would aid in clearing out my lungs and they said it would provide some benefit but really isn´t strong enough to clean out my lungs in a manner I was looking for, and which may not even be possible anymore given the COPD. 

It is not unusual NOT to have significant mucus production, even if you have had periods in the past when you seemed to produce even quite a lot of mucus.  With the irritation from smoking gone, your airways are not being stimulated to produce mucus – which, incidentally, is a defense mechanism to help protect the airways from the irritation of the smoke and to flush the airways of irritating components left behind by smoking.  Your understanding of the ‘physical’ changes in the airways in COPD is not quite accurate.  We don’t ‘collect’ muck in our airways, much less mucus plugging such as you characterize.  Irritants are constantly being raise and expelled, either as the globs of mucus you cough out, or as less mucus flow that you swallow without really perceiving the action.  You do NOT need any kind of “lung cleanser”, as you describe and suggest.  You lungs have a very efficient system to do that.  And what remnants of smoke remain in your lungs are part of the tissue.  For instance, if we were to look at your lungs and compare them to a non-smoker, we’d see that they appear grey, rather than pink.  The tar from smoking changes the color of the tissue (permanently) over time.

About mid August I thought perhaps if I started exercising it may loosen up my chest and aid it starting to cough up some of the mucus but again to date has not. In the past when I would exercise I would get to a point where I was starting to breath pretty rapidly and was getting out of breath, which seemed normal for me. Since I started exercising this time it is different in that I just have this tight feeling in my chest and feel like my breathing is labored. If I get up quickly from the couch and walk out to the kitchen it feels like my chest tightens up and my breathing is more labored, not like breathing through a straw but somewhat similar. The odd part is I can go for a two mile walk and it feels the same way as it does getting up and walking to the kitchen. I have worked up to walking about two miles a day in about 30-35 minutes, but so far feel no difference in my breathing nor am I coughing up anything.

I should mention that I had my stress test in the early part of July and only lasted 4 minutes on the treadmill. While I felt I could have done more, he thought I looked a little distressed so stopped the test. Again I was not breathing rapidly but breathing was definitely labored and it was like I could not get enough air into my lungs. He said my stress test was normal, my oxygen sat stayed in the 94-96 range, and my recovery time was normal.

Shortly after I bought an oximeter. Prior to quitting smoking my SpO2 was generally in the 94-96 range when resting. After quitting smoking it is now usually in the 96-98 range at rest. When I go out walking I will intermittently take a reading but often have to stop to get a reading so not sure if the reading changes because I am stopped. Generally it is in the 94-96 range after 15 minutes of walking but have had it start at 91 or 92 but goes up to 95 or 96 and sometimes 97 within just a few seconds.

I should also say I often find when I am standing in line somewhere, or just standing in general I often have my stomach really sucked in, and have to consciously relax it but a few minutes later find it the same way once again. Now that I have paid more attention also find my stomach sucked in even sitting at the table.

I am not sure if something new or different is going on but after three prescriptions for antibiotics, and quitting smoking my breathing has not returned to what it was like when I saw the respirologist in June and before taking the Advair, so again am not sure if this is an infection, worsening of the COPD which would seem to be a very rapid change or deterioration, or something else is going on, or what to do to find out.

I have not lost any weight based on the scale but my rings don´t fit properly nor do my pants or shoes, which are all a little loose.

Somewhere within the previous several paragraphs, there seem to be questions or at least points to be made about your observations and concerns.  The breathing worsening can be a combination of worsening of your disease – change in baseline, that is.  It can also be partly because of some process – whether or not it be infection – that is ma manifestation of the worsening, or of something going on at this time.  You have had chest x-rays, only (I assume).  I would suggest you ask for a high-resolution CT scan which will definitively characterize your lung tissues in a way that the simple chest x-ray cannot.  One concern I have is that you ‘might’ be developing some fibrotic tissue, which can contribute to the changes you ‘feel’.  The stomach sucked in is not an observation that I would consider consequential to any of the difficulties you relate.  It’s simply a unique and benign observation pertaining to ‘you’.  So, don’t worry about that.  Do watch to be sure you’re not losing weight that is unexplained.

At this point I don´t know if I should try the Advair again but am a little apprehensive given my past experience, but would appreciate your advice on this. I also have a prescription for Symbicort, so don´t know whether I should take nothing and keep exercising or what I should do. I am really apprehensive about talking Advair again as if my breathing changes as much as it did the first time I tried it I am going to see my breathing deteriorating a lot quicker than what I would want.

I would recommend getting the Symbicort and giving it a try.  If you have the tightness problem, see about getting the Formoterol by itself, as I suggested earlier.

Is taking anything beneficial (Spiriva, Symbicort etc) other then relieving symptoms? Does any of the medication actually slow the progression of COPD or are they just for symptomatic relief?

YES!  Folks who have reached a moderate level of disease should be taking maintenance medications to include the long-acting, beta agonist, like formoterol (Foradil) or salmeterol (Serevent) and a long-acting anticholinergic like tiotropium (Spiriva), EVERY day as prescribed, even if they “feel good’ and might think they don’t need it.  There is “some” evidence that tiptropium improves pulmonary function at baseline – the reason for we cannot say is definitively due to regaining lung tissue.  But, it HAS been shown to slow and even arrest progression, if only for periods of time.  The bottom line is to do what you can to slow the inevitable decline.  So, to answer the rest of your question: “:Yes, they ARE for ‘symptom control’”.

 
Ventolin makes me feel like I will pass out and my chest feels very tight afterwards. I know they say one´s heart will speed up, and mine does, but not excessively, I just feel sort of dizzy, and feel like I will pass out. Advair makes my chest feel very tight as well, and is a very uncomfortable feeling. Perhaps I just haven´t taken it for a long enough period of time to see if it will benefit, but as I said given how I have felt after only using it a couple of times I am pretty apprehensive about taking it.

Formoterol or salmeterol could also produce the same response in you.  If they do, stick with the Spiriva alone and you might be getting enough with just that.

My final question relates to one to one of the answers you gave in your response last week.

Your statement
While your 67 % and his 70 % FEV-1's represent only moderate obstruction, they are enough below the minimum range for "normal" values that the argument for obstructive disease IS valid. At the same time, at 67 % and 70 %, neither of you might 'necessarily' require medication interventions, OR cause you to experience significant functional and exercise impairment with regard to difficulty breathing. You both may 'breathe harder' with more intense exertion than you would with higher FEV-1. But, neither of you should experience enough airflow reduction and resultant breathing difficulties that it would keep you from being able to vigorously exert - to the point of jogging and running. Yet, those activities will cause greater breathing difficulties. But, they will not be prohibitively difficult. Your tolerance of discomfort, as individuals, will determine how hard and fast you can exert more than will the impairment that expectedly exists with your numbers.

Would it be appropriate to interpret the last sentence as saying that I can push myself well beyond where I start to feel uncomfortable in my breathing, and even though I may feel considerable breathing difficulties I should just keep going as long as I can?
Yes! Absolutely!  If that is what you are saying then will there be some benefit in doing that? Yes!   In other words will lung function improve, (no) or FEV1 improve, (no) or just my ability to run at 8 mph instead of 6 and to be able to walk for say 45 minutes instead of 30. (yes)
   Will it result in much less shortness of breath when mowing the lawn as an example, and perhaps less reliance on inhalers? 

It will possibly reduce windedness at a given level of exertion, over time.  It will NOT lessen your need for medications.  They are needed for symptoms control AND for maintaining airway tone and stability.

Thank you once again for your time and assistance, it has been invaluable to me, and I´ll do my best to shorten up any future messages.


Wayne

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Mucinex, NAC & Vitamin C

Mark,
Thanks for your wonderful help to all of us.  Now, I just read your reply to Doug about thick phlegm.  I have the same problem and my doctor says to drink a lot of fluid.  You say that is not necessary and I read your explanation, and that make me feel better because I try to drink more when the phlegm gets thick and it does just make me pee more.

Now my question.  Why take NAC and Mucinex together and how much of each?  I have read that if you take NAC you have to take a lot of Vitamin C.  Is this correct?  I have a real problem with phlegm and I will do anything to fix this problem.  Should NAC and Mucinex be part of my daily routine. 

I am trying extremely hard with my exercise, my diet and my use of Oxygen to live the best life that I can for as long as I can.  My FEV 1 Pred % is 34 so you know I have server COPD.  If I can control the amount and thickness of the stuff, I will feel better.

Thanks again for all you do; and I am waiting for your answer to help me tackle another one of the problems some of us have living with COPD.
Lillian

Hi Lillian,

Yes, it is advantageous for many folks to take BOTH Mucinex AND NAC.  Mucinex is usually dosed at 600 mg 2 to 4 times a day.  start with 600 twice a day.  Increase if you feel you need more help.  If you don't notice any improvement, you can decide if you want to stay with the higher dose or reduce to the lower dose of 1200 mg/day.

NAC should be taken in doses of 600 mg twice a day.  You can take up to 2400 mg, though I've rarely found anyone who requires more than 1800 mg/day.  It is generally recommended to supplement with 1000 mg vitamin C and up to 3000 mg for those especially prone to developing kidney stones.  This recommendation comes from the lay literature and anecdote, as it has not been empirically proven.  There is a study - a second trial similar to an earlier one done in Europe - being conducted through Duke U and also a group in Denver, looking at 600 mg of an 'effervescent' form of NAC.  They are NOT coupling its use with vitamin C.  Indeed, an inquiry to the Denver investigator has not yet returned a response regarding the necessity/advisability of taking supplemental vitamin C in conjunction with NAC.  When I get that response, I will share what I learn in a future post.

Best Wishes.

Mark

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Portable Oxygen Systems & Finger Pulse Oximeters

For the past 4 years, I have been on CPAP a night with 0.5 L/min.  Recent studies have shown that I now need 2L/min Oxygen for activities.  So, I am trying to figure out what system I should use for a portable Oxygen source.  I have always used an Visionaire Oxygen Concentrator for my night needs but I don't have much knowledge about the various options for portable Oxygen sources.

Could you direct me to any kind of website where I could find this type of information.  Also, I would like to get a Pulse Oximetry device so that I can monitor my O2 saturation with this transition.

Thanks so very much for your time and attention.

Lynn

Hi Lynn,

There are a number of portable oxygen delivery systems - liquid portable reservoirs of various sizes, shapes and delivery capabilities, compressed tanks of several sizes with more than 35 regulators to choose from and about a dozen portable oxygen concentrators.  What is best for your needs is impossible to say.  Telling you something about each device would take many hours and wear my fingers to nubs.

My best suggestion is to ask your oxygen provider what choices THEY have in their stock.  They likely have at least four or five, if not more.  As well, what ever they might consider suitable can be tested with an oximeter while you walk and do household chores/activities. 

There are a number of sources from which you can purchase an oximeter for the cost of anywhere from $50 up to a few hundred.  My preference is the Nonin GO2, which you can purchase directly from Nonin (in the US) , if you like, for about $100.

Best Wishes,

Mark

Webmistress Note:  You can also purchase a Finger Pulse Ox in Canada from FaCT Canada in BC  for  $60 http://COPDcanada.ca/Finger%20Pulse%20Oximeters%20from%20Fact%20Canada.htm

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PFT Interpretations & Recent Exacerbation Query

Hi Mark and thanks for all the helpful info you so kindly give us.  I have a question(s) I hope you can answer for me.  I am a 61 yr. old female diagnosed with severe COPD 3 yrs. ago.  I have a PFT done annually and will follow with some numbers.  Can you clarify why my Assessment in 2012 says, "severe partially reversible airflow obstruction.  Has been a reduction in forced vital capacity over a prev. study."  What is a reduction - is it good or bad?  My 2011 PFT Assessment says, "severe nonreversible airflow obstruction".  Not changed considerably since 2010."  How can it go from non-reversible to partially reversible?  Thanks for clarifying as I find it difficult to talk to my respirologist - very vague answers usually.
My numbers are:
FVC(L):  Pre:       Actual    Pred    %Pred     %Chng
                            1.53        2.95    52
               Post:      2.01                  68            31

FEV1(L)  Pre:        0.85       2.34    36
                Post:      1.05                  45            23

DLCO(2011)          12.18    22.90   53
DLCO(2012)            8.31    22.90   36

Am taking Advair, Spiriva and Ventolin as needed.  I seem to walk less than last year - very hot summer and dog can't make the mile anymore which is fine by me. I know I should try harder.  Thanks for your help Mark - I really look forward to your advice every week.  I also had a bad excacerbation last month.  My oximeter said my oxygen level was at 87 after a bad coughing fit.(happened a few times.) I was running at 90-91 for about a week.  I take my pred and antibiotics.  I am always hesitant to go to the ER during these spells.  I do not have oxygen at home.  Should I consider going when I get that sick?  Thanks again and sorry for so many questions

Lynn

Hi Lynn,

The difference in 'interpretations' is likely more to the 'moment' than to any significant difference or change from your previous study.  You likely had "some reversibility on your study, but it wasn't enough to entice the interpreter to call it "partial reversibility".  It is all a matter of personal interpretation and how the interpreter decides to sum it up at the time of interpretation.  If you gave your PFT results to 10 different pulmonologists, you might be surprised to find ten different interpretations all owing to points of focus that may differ in emphasis from one to another.  While there would be overall commonalities among interpretations, the subtle aspects would likely be different from one to another.

The reduction in vital capacity means you have more air-trapping on this study than you did on the previous one.  That is an expected change as one's COPD progresses.  It can also be owing to momentary influences that may get better, were the test repeated in a week or a month or more later.  It is difficult to hold your sights on the main numbers that tend to change at a slower rate - the vital capacity NOT being one of them.  so, don't spend too much concern on this latest change.

While it is difficult for me to tell you what to do, per se - you say you have antibiotics and prednisone to take when you have an exacerbation, so there's not much more to be done - with oxygen levels dropping to 87 % AND running at 90 - 91 % (do I assume correctly that the 90 - 91% is while at rest?), if you don't have oxygen to use during the exacerbation, it might be a prudent decision to go to the ER, or at least call your doctor to have the oxygen situation evaluated to see if you need temporary, if not more permanent oxygen supplementation.  At the least, you should be collaborating with your doctor when exacerbations strike, if for no more than to keep him/her apprised of your difficulties and progress during treatment.  That way, if you don't get better quickly enough, then your doctor can intervene further.  and, if the oxygenation problem is worse than it appears on face value, that, too, can be addressed.

Best Wishes,

Mark

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Blood Oxygen Levels – Shortness of Breath (SOB)

Dear Sir,
My mother suffers from severe cops.  Her blood oxygen levels are always fine, however she increasingly experiences shortness of breath and doesn't understand why this happens if blood oxygen levels are fine.  What could possibly be the cause?
Please help.
Thank you.

Audrey

Hi Audrey,

While any specific suggestions as to cause would be speculation from the little bit of information you've provided me, I can tell you some general things to consider and maybe have checked out.

First and foremost, I suspect that your mother's oxygen measurements have been obtained when she is sitting quietly at rest and has been at rest for several minutes.  While you said they have been found to be "fine", you did not say what "fine" means.  If she is at or above 95 % while at rest, then 'that" is within normal range - for rest, ONLY.  If she is lower than 95 % while at rest, while it may be adequate, chances are she is dropping her oxygen level to points below acceptable minimums of 88 - 90%. 

In any case, resting measurements DO NOT detect the most commonly observed oxygenation problems - exertional desaturation.  Your mother's oxygen levels should be thoroughly evaluated while she is walking and maybe also doing some common activities of daily living.  Many folks see their oxygen levels drop during exertion - those drops being quite significant.  As well, she may be dropping her oxygen levels while asleep.  That possibility can ONLY be detected with an overnight oximetry study.  That kind of study 'can' be conducted in the home. 

I would recommend starting with asking her doctor about those two tests to see if she is in need of supplemental oxygen use for sleep and exertion, during the day.

Best Wishes, Mark

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Full PFT & Interpretation

Hello, Mark.  It was suggested that I post my numbers from my first PFT and ask you some of the questions I have that I didn't have time to review (or think about) with the respirologist. I have been told I have Stage 1 COPD, based on this PFT, my medical history, and a CT scan.  I believe I understand the numbers from the first section, at least a little bit, but I would welcome any analysis or comments you may wish to offer.

What I really don't understand is what the numbers from the body plethysmography mean.  What do these refer to?  In most cases my numbers are above 100% but what does ERV mean, including a score of 32% for  that measurement? 

Finally, what is the difference between the DLCO SB and the DLCO/VA?  And what are VA and VIN measuring? 

I know you are away until later in September and I am in no rush for a response.  As I said, any observations you care to share would be good learning for me, and hopefully for others who may be faced with similar numbers or similar questions. 

                                                                                               

SORRY but I can't get the table to copy properly.  Let me know if I can just send the excel or PDF file.  Thanks again. 

Deborah

St. Paul's - Plethysmography

               
 

Predicted

Pre-Meas

%Pre

Post Meas

Post/pred

% change

95%

C.I.

   

Aug-12

           

Spirometry

               

FVC

3.27

3.6

110

3.69

113

3

2.6

3.95

FEV 1

2.63

2.5

95

2.58

98

3

2.07

3.19

Fev 1%/FVC

79.59

69.53

87

69.78

88

0

70.53

88.65

FEF 75-25

2.66

1.49

56

1.53

57

3

1.53

3.79

PEF

5.93

8.6

145

9.31

156

8

4.2

7.66

FVC in

3.27

3.49

107

3.28

100

-6

2.6

3.95

                 

Bodyplethysmography

               

VC

3.27

3.94

120

     

2.6

3.95

IC

2.16

3.65

169

     

2.16

2.16

ERV

0.89

0.29

32

     

0.13

1.65

RV

1.92

2.49

130

     

1.14

2.69

TGV (FRC)

2.89

2.78

96

     

1.83

3.96

TLC

5.14

6.43

125

     

4.06

6.22

RV% TLC

37.23

38.67

104

     

26.23

48.23

                 

Diffusion SB

               

DLCO SB

23.24

22.44

97

     

19.66

26.83

DLCO/VA

5.03

4.28

85

     

2.01

8.05

VA

4.88

5.25

107

     

4.88

4.88

VIN

3.27

3.85

118

     

2.6

3.95

Hi Deborah,

I would disagree that you have ANY COPD, at all, based upon these PFT results.  While you have some slight reduction in mid and small airways, it is not significant when compared to the results, overall.  Your ERV of 32 % is out of normal range but could easily be explained by simple measurement errors inherent in PFT testing and uniquely different among individuals.  That your RV is elevated relative to your TLC 'might' persuade some clinicians to suggest the presence of some - even though e-x-t-r-e-m-e-l-y mild - early COPD, I am not so persuaded, at this point.  Your DLCO-SB is the actual measurement made.  The DLCO-VA is a comparison of the size of the breath measured to the expected portion of ventilation it represents.  It is a measure of the reliability and believability of the DLCO SB to what would be expected to be seen.   That yours was 85 % of predicted shows that the DLCO-SB is very reliable.  That is good and speaks to a good quality exam, all the way around.

VA and VIN are simply other measures and calculations to reflect perspective to the more definitive and multiple measurements listed earliet in the PFT report for comparison and suggesting of reliability of the quality of the test.  That they are at or greater than 100 % of predicted is yet another indication of a good quality test suggesting normal pulmonary function.

Therefore, I would be inclined to declare your pulmonary function within normal limits and NOT suggestive of COPD in any form - at this point, any way. 

Best Wishes,

Mark

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Low Heart Rate (Pulse) At Rest

Hi Mark, Hope you, Kim and the family are fine.

Just a fast question for you.
If it possible mark to have too low a heart rate. I know many questions are related to one,s pulse being too high.

I was lying down the other night and decided to see what my 02 level was and what my pulse was.
My 02 level was 96 but my pulse was only 60, and I am a fairy large person.

Is that number considered normal for a resting heart rate for a 200 lb man or is it too low??

Thanks Mark,  Philip

Hi Philip,

We are all fine, indeed!  Thanks for your kind thoughts.   You ask a very good question and one that many folks wonder about fairly often!

While there is no "set" minimum heart6 rate to be called "normal" or acceptable, there are several relative considerations that make various lower-end heart rates a concern in various folks. 

60/minute is virtually always considered a normal and acceptable - even desirable resting heart rate - despite the influence and picture of many chronic illness.  So, in your case, you are quite good and have no concern about your 60/min resting heart rate.

Indeed, we generally don't consider a heart rate problematically low until or unless it drops below thresholds like 55/minute in someone who has reasons for 55/min not being 'enough' AND who displays symptoms that can be considered indicative of insufficient blood flow, etc that may be associated with that lower heart rate.  Yet, even 50/min in healthy subjects - and not uncommonly, 45/min in healthy and fit athletes - are not unusual or a point of concern AS LONG AS there are no concerns for abnormal conditions or causes.

I have had several patients in years past who presented with heart rates under 50/min - one even at 36/min - who were found to have some sort and severity of heart block.  Indeed, in a couple of case, the reason they were sent to me was because of shortness of breath and because a cardiologist insisted it was not due to cardiac influences.  In one case, the patient's EKG didn't manifest the block until she showed up at my clinic.  In the other case, the cardiologist insisted that the recent EKG showed no problems.  Yet the recent EKG ended up being about a year old, with the symptoms and change on-setting in the interim.  another had a pacemaker that turned out to be failing to function properly.

So, as you can see, the term "low" with regard to heart rate is relative to other considerations.  and in your case, I would say it's just fine that you have 60/min, under the conditions you describe.

Best wishes,

Mark

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ck Phlegm

Hello;  just wondering about phlegm l think l spelled it wrong but mucus mine used to be thin now thick and l have a hoarse voice.l  drink lots of water green tea with honey lemon and mouth wash cough syrup with loose mucus relief. I  take pred.-symbicort-spiriva-uniphyl-b.p meds; last breathing test l was at 27 percent lung function. Been on these for a year.Any help would be nice ty

Doug

Hi Doug,

Your thick phlegm could be from several things.  But, drinking lots of water, green tea and such will do NOTHING to help,  Indeed, all doing so will do is make you have to 'pee' more (pardon the expression/term).  The only study that I know of that was of good quality and well-controlled proved that dehydration and super-hydration did nothing to alter volume or viscosity (thickness/stickiness) of pulmonary secretions.

I would suggest you try taking oral NAC (N-Acetylcysteine) AND Mucinex and see if that helps.  Another trick is to sit in a steamy bathroom for 20 - 30 minutes and breathe in the steam.  OR point a cool mist room humidifier toward your face and breathe in the nebulized distilled water.  Either activity will add topical moisture to your secretions and loosen them for easier clearance.

Best Wishes,

Mark

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COPD Stage/Numbers  Query

After using my morning dose of symbicort and spriva my FEV1 was 89% or 13% better than the one last year when I was diagnosed and quit smoking..but my small airway was 48%..does this mean that I will leave the mild stage  soon..48%sounds scary.
thank you,
Mike

Hi Mike,

At an FEV-1 of 89 % of predicted, you are within the "normal" range, or Stage I.  You did not relay what your FEV-1/FVC ratio is, so I can't tell you more than that.

Peak expiratory and other expiratory flow rates and percentages of predicted do NOT determine what Stage (GOLD) you are in.  They simply point to where - within your airways - your airflow limitations are found.  That 48 % is not bad, actually.  (If it is the one I think it may be, though you didn't say which of the several flow measurements that came from).  You will NOT likely return to a "COPD-free" state.  But, with as much function as you have and the very good FEV-1, you are in great shape NOW and for the foreseeable future, if you keep up your good work and lifestyle/habits.  The reduction to 48 % may sound bad to you.  But, it is not all that bad in the big picture.  Don't worry about it.  Keep using your Symbicort.  It is working well!

Best Wishes.

Mark

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COPD And Lung Cancer

Hello.  We are researching for therapies for our mother.  We live near Toronto, Ontario.   I have to say upfront we do not have all of the medical facts or statistics as we are not the primary care givers.  However, we are looking to exhaust all alternatives and are wondering if our mother would be a candidate for some type of pulmonary rehabilitation program given her current state.

1)  she has had COPD for at least four years.  She is 67 years old.  Quit smoking 10 years ago
2)  Her COPD may very well have been lung cancer as in April 2012 she was diagnosed with non-small cell, adenocarcenoma, primary site. 7cm x 3cm mass across the top of her lungs and on her bronchial tubes
3)  Chemo was started May 2012 and stopped after three treatments. 
4)  She reacted very adversely to the chemo and has not been strong enough to restart
5)  Her oxygen levels never go beyond 80, and are as loss as 65 when moving around
6)  In March 2012, she was still going to the gym!  But now, things are progressing very rapidly.  Because she cannot breathe, she cannot eat/drink properly and now has a completely sedentary life.  She has lost 25 lbs and now is only 100lbs
7)  Because of this, the Oncologist has said the chemo is no longer an option, and her 1-5 year diagnosis has been shortened to an indeterminate amount of time not measured in years
8)  She has anxiety and claustrophobia issues and is on a variety of meds including 40mg of prednizone a day
9)  she has been hospitalized four times since May 2012, once for blood clots in her lungs, and three times for the fact that her oxygen levels were so low and would not rise

The current thinking is more of keeping her comfortable and palliative approach for the remaining time she has.  She has daily in home nursing, constant oxygen, and is working with a palliative care team. 

We have been reading about "pulmonary rehabilitation" on either an in or out patient basis, in the hopes that we could simply improve her breathing.  In your opinion, does this even sound possible?

Are there resources we can look to get alternative forms of therapies?  We want to make sure we have exhausted all avenues

Thank you in advance, Francis

 Hello, Francis,

First, let me say how sorry I am to learn of your mother’s predicament.  Her recent history illustrates the ravages of rapidly advancing cancers and especially that of non-small-cell adenocarcinoma.

Pulmonary rehabilitation can provide significant benefit for most anyone who has potential for improvement – in function, wellness and breathing symptoms.  Therein lies the crux of the dilemma with your mother.  Her cancer is very apparently advancing at such a rate that she has had the significant weight loss, clinical complications and increase in symptoms, especially that of hypoxia.

In her instance, I would not recommend pulmonary rehabilitation as an option as nothing offered within the interventions applied with pulmonary rehabilitation techniques holds potential to improve her breathing, much less most of the other factors contributing to her decline, at this point.  If she has had blood clotting in her lungs, the hypoxia is likely due to the shift in circulation.  Tumor could also be compressing blood vessels in her lungs and contributing to further clotting and circulation disturbance.  The hypoxia and the encroachment of the cancer on her ability to adequately ventilate are the main causes for her shortness of breath, anxiety and declining ability to move.  Therefore the sedentary existence she has adopted is one that simply cannot be improved upon. 

That said, it is possible that some of her shortness of breath may be better relieved with the use of liberal amounts of oxygen – enough to get her saturation to above 90 % - and better yet, to 95 % or higher, ‘if possible’.  That may require oxygen flows of as much as 10 L/min, even more.  You didn’t say how much oxygen flow she is using.  But, with saturations of 65 – 80 as her ‘usual’, I suspect that her flow is less than 6 L/min.

I would have to agree with her doctors that palliative care and everyone’s best efforts to make her as comfortable as possible are the most positive course of action you can take.   With no chance of improvement in the cancer AND her rapid and continuing decline, her time appears gravely limited. I would suggest you and your family work to make the most of the time she has left.   As her breathing difficulties and anxiety increase, you might ask the palliative care team about nebulized morphine which has been shown to relieve the severe breathing difficulties of folks in her state.

I am so sorry I can’t offer you any hopeful remedies.  As long as the cancer is ‘having its way with her’, we are all simply impotent to meaningfully alter her inevitable course.  My heart goes out to you and your family.

Best wishes,

Mark

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COPD Stage Query 

Breathing test show my lungs of 65yrs old.  I am only 54 what stage is that?

Suzie

 Hi Suzie,

The information you provided is woefully inadequate for me to tell you anything meaningful about your lung health, much less tell you anything about what stage of any lung disease you may be in.  Lung age is folly, in my experience.  While some in the world have developed scales that express lung function in terms of age, no one has standardized it to any meaningful application with regard to clinical or prognostic potential.  In regards to lung age, having lungs that trend to a mere 11 years your senior seems to put you in a mildly reduced state of lung function.  BUT, that said, how that worsened ‘basic’ lung function affects your health and function can be anywhere from very mildly limiting to producing significant, but not debilitating breathing symptoms with intense exertion.  In my experience, when folks get lung age that is 20, 30 and more years ahead of their chronological age is when I see folks who are significantly impaired and limited in what they can do and in their health in general.  Still, they can do a remarkable lot if they have the gumption to push through their difficulties.

If you want to relay some specific pulmonary function numbers (FEV-1, FVC, DLCO, lung volumes) AND some facts about your lung history (smoking, occupational, etc.) I can tell you much more specifically where you are in your state of lung health.

Best Wishes,

Mark

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Symbicort “May Cause Lung Infections” Question

Hi Mark;

I’ve seen the commercials on Symbicort for COPD.  They usually include the words; or something similar, “is for COPD which includes Chronic Bronchitis and Emphysema.”  However; they also include a disclaimer i.e. “may increase lung infections”   To me this is a good argument NOT to be taking Symbicort if a person has CB.  Could you please clarify this?  Or perhaps they’re just going with the stats “against” the chances of infections in which case…. how do they know what caused it (a lung infection)?  The med, or CB itself or maybe something else?

With thanks, Jackie

Hi Jackie,

In the interest of ‘full disclosure’ of findings from clinical trials, cautions like the one you cite are included with most all medications.  During trials a distinct subgroup of subjects exhibited side effects that could not be attributed to chance alone.  So, the side effect had to be listed with speculation of potential causative factors.  Suffice it to say that the greatest majority of folks who use drugs like Symbicort will NOT experience the side effect cited.  Never the less, in the interest of ‘fully informed consent’, you will see such warnings. 

What matters in the end is the potential for benefit versus risk, which, in the case of Symbicort, is far outweighed on the side of benefit.  Understand that the steroid component of Symbicort is an immunosuppressant.  And a few folks who are at risk for infection may experience that complication if all other conditions are present and at play.  Again, that number is very few.  If the side effect were truly a significant concern for enough folks, the drug would not be approved OR would carry much more specific warnings.  With literally millions of folks around the world using Symbicort for more than a decade, now, I am confident when I say that it has proven to be both safe and effective for all but a very small number of folks.  Concern over the potential for that side effect should NOT cause anyone to decide not to use Symbicort, IMO.

Best Regards

Mark

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Oxygen Saturation Levels & BICAP Q’S

Hello Mark,

I need some inputs from you regarding my dad who is a COPD patient. He has seized his smoking completely, however at times he smokes but very rarely.
He is on Oxygen therapy(since last ~3ys) in the night & his Oxygen levels typically are >90%. He doesn't need the O2 all during day time & his saturation levels in fact increase slightly when he is out in open. 
Also he is on Nebulizer therapy 3 times a day, sometime 2 depending on his health. (I don't know the name of the medication that is used in the Nebulizer)
Also the doctors have prescribed him steroids for his condition, which he has been taking for last ~2yrs. The dosage of steroids is varied by doctors depending upon his health. The max he takes is 16mg/day.
 Of-late at times he is having frequent COPD exacerbation and/or breathlessness. He is typically short of breath after lunch/dinner.
Previously when admitted to the hospitals his doctor were treating him with BICAP therapy. He responds to the therapy well & recovers from the infections & his CO2 levels drops back to <48- 50%.
Now due to his recent health doctors are recommending the usage of BICAP at home. 
Can you please advice on the usefulness of BICAP on regular basis to treat COPD & does BICAP therapy serve better for long term ?  I have read people being able to survive with BICAP for years & live relatively healthy life.
Should he take BICAP more often or limit the usage as much as possible ?
Doctors are saying to have start of BICAP usage 2 times/week & again depending upon his health increase or decrease it. Also I am worried that once he goes on BICAP therapy, his body would be habituated to it & he would not be able to live without it. Is that true ?
Any other tips would also be greatly appreciated.
Please advice.

Thanks,
Hardik

Hello Hardik,

I would be happy to tell you what I can about your father if you could first be so kind as to gather and relay some more specific information. 

If your father's lung disease is advanced enough for him to require oxygen and long-term prednisone therapy, then he should be taking much more medication that a couple or few nebulizer treatments, each day.  He 'should' be using a couple of long-acting inhalers that administer medication - similar to what he puts in the nebulizer - that opens up his airways to ease his work to move air in and out of his lungs.  Can you ask him to tell you ALL of the medications he takes and then come back and tell me what they are?

If he has been prescribed oxygen for 3 years, I would suggest that his need for it is a LOT more than what he uses.  To say that his saturations are > 90 % is helpful.  BUT, since saturation can change QUICKLY when one gets up and moves about, to know what his saturation pattern is "during" exertion - walking, climbing stairs, carrying out the trash, etc - would be much more telling of his true oxygen demands.   I suspect that if you measure his oxygen during a walking period of no less than one minute, you'll observe that he drops to below 90 %.  That, if true, has a significant impact upon his breathing that no medication can help.  The 'only' effective treatment is use of oxygen during exertion.

You say he is having more frequent exacerbations.  That suggests that his oxygen levels are more volatile than you seem to suspect and also another reason I would ask you to measure his oxygen saturation during walking.

See if you can measure his oxygen saturation after he eats to see if his oxygen level is dropping at that time.  If it is, then he needs to use oxygen for those periods after each meal.  If his oxygen is still above 94 % while at rest after eating, then the problem likely has a lot to do with his stomach taking up space his lungs want to occupy.  Smaller, more frequent meals often helps folks avoid the "too full" effect on their breathing.

The use of BICAP is not a bad idea, if it will help his energy level and breathing during the day.  I would suggest that he should use it EVERY night as there is absolutely NO evidence that using it only a day or two or a few days a week is of any benefit.  Yet, nightly use could indeed produce positive benefit for him.  In  any case, he will NOT become "habituated" to it - insofar as concern of it becoming a "crutch" of some sort.  If it helps, it helps!  Lots of folks use BICAP for many years - 30 and 40 and more! - without any problems.

In view of his difficulties, as you relate them, I fear that he is too sedentary.  If he is not staying as active as possible - IN SPITE of the difficult breathing - which WON'T hurt him to endure, bad as it may feel and look to those around him - he is heading down a slippery slope of decline simply due to deconditioning.  COPD is a "move-it-or-lose-it" disease.  Moving is also the hardest thing to do, especially the worse one's disease gets.  Nevertheless, unless one can learn to persevere through the difficult breathing and keep moving as much as possible and as vigorously as possible, they WILL decline rapidly and face a miserable existence for perhaps several years of not being able to do for themselves.  It's not a pretty picture.  So, anything you can tell me about his level of function and activity would clarify the picture for me.  

I hope to hear back from you soon!

Best Wishes,

Mark

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Will Exercise/Conditioning Reduce Oxygen Need?

Hi Mark
I have written before and you said I was in need of conditioning,no kidding as I have fev34. I also have had a heart rate of 120 plus.I have done more exercising, treadmill; not enough yet. I was doing 2 mins and now10.Within 4 mths it is an improvement. The question is do you think I can improve the numbers more as I am hoping,although I now it is progressive.I have been smoke free for a yr and half thank heavens for that. I do walk more 100 ft more than usual because I will wear 02 as I would not wear it in public before Do you think there is a chance for this 51 yr old to eventually not need the02 as much in time. as I feel much better due to exercise, B vitamins ,fish oils,  multivitamins .I am hoping for a miracle I guess but wanted to decrease the 02 use Thanks

Sue

Hi Sue,

As you improve in your condition and breathing - through exercise and the use of oxygen - your 'need' for oxygen will not decrease.  When one's disease advances enough to require oxygen, it is because enough tissue has been destroyed that what remains cannot get the oxygen into the blood at a rate sufficient to meet demand - while they breathe "ambient" concentrations of oxygen (that which is in the air, naturally).  So, the supplemental oxygen puts more molecules into the lungs to increase the rate and amount of oxygen transferred to the blood.  That rate is "fixed" and doesn't change, despite improved conditioning and better lifestyle.  It's one of those "what's done is done" kind of things, I'm afraid.  BUT, having to use oxygen is NOT a curse, much as it is unpleasant to contend with.  Think of it as a diabetic thinks of having to use insulin.  If you use it properly, it allows you to do more, do better and lead a healthier, more productive life. 

Now that you've come to grips with using oxygen in public, get out there as much as you can and increase your activity, along with it!  You may likely surprise yourself with how well you can  do as time goes by!  At the tender age of 51 years, you certainly have a LOT more life to tackle.  Get out there and enjoy it - yes - even with the oxygen as your companion! 

Keep in mind, it's one thing to hope for a miracle.  It's another to wish for the impossible.  Don't frustrate yourself with what is not realistic.  That just gets in the way of your being able to more fully enjoy life.  And there IS a lot to enjoy!

Best Wishes,

Mark

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Long term Pred Q – More Information Required

I have been having a very difficult time with SOB for the last 6 months or so . Usually prednisone has helped but this time it has not done as well as usual. I have been on pred. for two weeks now ?? It has been suggested to me that I should go on Low dose permanently. My question is : what is low dose prednisone and do you agree , I have not been able to eat as I had been because of my poor breathing and have lost quite a few pounds over the last 6 months . May I have your opinion ,please ??? I live in a small Quebec town with no specialists.
Thanks in advance !!!
Ken

Hi Ken,

You gave me only a little bit of meaningful information to help me consider your difficulties. So, I can't help you with much of an answer. Do you use oxygen? What is your FEV-1 on your pulmonary functions test? What medications do you use? Is it that your appetite is poor or that eating makes your breathing worse or what? Can you clarify/elaborate upon what about eating is currently so difficult that you are losing the weight you speak about losing?You shouldn't have to rely upon prednisone, alone for relief. You may need other ore specific and appropriate interventions, if they are currently not being used. Have you had your oxygen saturation measured? Do you own a pulse oximeter with which to measure your oxygen saturation yourself?

Please tell me more so I can give you some meaningful suggestions and information. I look forward to your response in a future post.

Best Wishes, Mark

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Prednisone And Skin Damage

Good afternoon Mark

Fred is having a heck of a time with bruising, he has been on prednisone for a year. He can only go as low as 10 mg can you suggest anything that could help with the bruising. He is very careful but a tap can bring on a bruise. Is the any way you can get rid of the bruising?? Seems like a silly question but I'm asking anyway??

Fred has been doing great he has had a lung volume reduction 5 years ago. He has had many hospital visits but keeps getting back on his feet. He is a very good patient as all Dr's say.

Thanks Mark
Mitch

Hi Mitch,

I'm glad Fred continues to do as well as he seems to be doing 5 years after his LVRS.  I hope he continues to hang in there for a long time to come!

Unfortunately, the bruising is something that for most folks, goes along with the long-term use of steroids.  Besides the 'aging' factors that change the composition of skin and its underlying tissues, steroids interfere to some degree with protein and phosphorous metabolism, causing thinning of the sub-cutaneous layers and loss of blood vessel wall strength/integrity.  The result is what I characterize as "cellophane skin", which is very fragile and translucent because it is so thin.  You describe the hazards spot on - the slightest bump causing a subcutaneous bleed.  At times, even brushing against something hard will literally tear the skin making a bloody mess.  I see MANY patients whose arms look like topographical representations of the earth with so many scars that look like rivers and roads, all 'war-wounds' from serving in the 'prednisone brigade'!

I can't say that anything I've ever read or heard about is predictably helpful to combat or reduce the bruising/skin-tearing problem.  Dietarily speaking, some folks have claimed some degree of help from increasing their protein intake in the form of protein and albumin (eggs and gelatin - NOT protein powders, though they may offer yet additional help).  Increasing phosphorous intake is tricky and I done have any specific recommendations for that.

Lotions can be helpful - as long as you don't rub them over/into skin tears or open wounds.  But, I can't say that they are effective as I have not seen any evidence or literature to support the notion.  It 'might' be worth a consult with a dermatologist who might be able to give you more specific recommendations. But, since the prednisone is a necessity and likely NOT to be done away with any time soon, it is something that Fred will have to learn to contend with as best he can, as the alternative isn't as good as the present issues.

Worse yet, when folks HAVE come off the prednisone, their skin has only in the very rarest few, returned back to normal composition and integrity.  So, considering stopping the medication OR expecting his skin to improve if and when he is able to come off the prednisone, is not a prospect you should count on.  I wish I had better news for you.

Best Wishes,

Mark

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Treadmill Exercise Questions – Heart Rate, Duration, Oxygen Staturation

Hi Mark.

I have really had my problems over this past summer. with planters in my feet and a wonky lower back. I just got back to my gym today after a 2 month layoff.
Because I have high blood pressure i called my doctor and he said it is ok to go back, just do not overdo it, and monitor your 02 stats and pulse.
I started doing 10 minutes.. 0 incline, speed 1.5. I monitored my stats a s the doctor asked.

I never went below 93 for 02 stats and hovered around 106 for for the 5 minutes.
Then things changed when I stopped. My pulse shot up to 112, and both my legs started to tingle. No chest pain, no shortness of breath.
I got the pulse back down to 106 and then left the treadmill to sit down. When I left ( about 6 minutes later ), my pulse was down to 87 and my 02 at 97.

The next part was very strange. Just for that short period of exercise it felt like I had a vitamin B 12 shot. I was suddenly breathing easier, quicker gait in my step
a feeling of well-been that was just marvelous.
I thought is this possible after such a short period of exercise or is this what happens moments before you die?? It must be the first one as I am still here.
I am at a loss as to what happened. Remember I have not been to the gym for 8 weeks.

What do you think??, and how should I now continue with my quest for more stamina.??

Thanks Mark. Philip

Hi Philip,

One's pulse rate going from 106/minute to 112 hardly represents "shooting up".  error and artifact from finger monitoring while walking on the treadmill alone can account for the observed "sudden" increase.  Still, 106 is far from impressive with regard to an exercise-induced increase.  And 112 represents no real difference.  BOTH pulse rates would be considered significantly sub-maximal in your case.  So the level of intensity represented by the 1.5 mph with no grade was not a significant challenge.  And, that your saturation remained 93 %, especially in view of the fact that it was monitored by finger oximetry, is not a significant change, either.  In other words, you can push yourself harder and still not be approaching maximum effort, let alone "over-doing" it.  I would suggest pushing for a heart rate of 120, which would still be sub-maximal for you. 

In any case, I would opine that a mere 5 minutes of that intensity had little if anything to do with your noted sense of well being after you stopped.  You could simply have been feeling good about yourself for having 'got back on the horse'.   But, that the intensity and duration were so little/short suggests that the exercise was not significant to cause any expectation of changes, let alone those that you describe.

Still, that you came away feeling better, is a good thing.  And you should appreciate that for what it is.  At the same time, 5 minutes at 1.5 mph on level grade is barely a drop in the bucket.  Let's see how you feel once you have gone 30 minutes at that load, at the least, or even at 2.0 mph.  You should be able to start out targeting 30 minutes if you desire to hold the speed at 1.5 mph.  And stay with the level grade until you can manage at least 2.5 - 3.0 mph for at least 30 minutes.

Best Wishes,

Mark

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Frequency Of Pulmonary Function Tests

I was diagnosed in November, 2010, following a PFT, with moderate to severe COPD. My FEV1 was Pre 2.31 and Post 2.35. I have been prescribed Spiriva, Advair and Salbutamol. Since diagnosis, I have only had two exacerbations - one resulted in a trip to Emerg, the other to my doctor's office. I am 62 years old, female, work full time and would say I am healthy overall. I have not smoked for over 25 years, try to maintain a healthy weight and try to keep to an exercise schedule. I do not see a respirologist as my family doctor has told me it isn't time yet. I want very much to be in control of my COPD, rather than the COPD controlling me. So, now for my question. How often should the pulmonary functioning test be administered? According to my doctor, it is only used as a diagnostic tool and I don't need to have it again. In my thinking, the first test should be considered my base, and then subsequent testing would tell if medications were working, if things needed to be tweaked, etc. I am not suggesting that the test be done every month, but annually seems to be reasonable. If I had high blood pressure, I am sure the doctor would prescribe medication and then continue to check my levels at each visit. Why wouldn't this apply to COPD as well? Thank you for your time.


Janette

Hi Janette,

Serial pulmonary functions should be done periodically according to a patient’s individual progression.  There is no universally accepted interval for checking PFT’s.  when one has stable disease – that is, no exacerbations, infections or hospitalizations for acute pulmonary problems, once every two to five years is not unreasonable.  Annual PFT’s in those with moderate disease does not tend to reveal information helpful to management in terms of alteration in treatments.  As symptoms escalate, interval testing should be more frequent with adjustments in medications being the goal of the outcome. 

My recommendations would be that at some point, you should consider at least a consult and evaluation of your disease and treatment regimen by a “Respirologist”, contrary to what your PCP may opine.  As well, I disagree (and so does the recommendations of all pulmonary medicine societies around the world) that PFT’s are simply a one-time test to establish the presence of lung disease. 

So, you are correct.  Folks with lung disease should get a baseline test – as you have suggested – and then periodic follow-up tests to ascertain the progression pattern and rate of their disease as well as to discern what and when treatments should be administered and changed.

Best Wishes,

Mark

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Unclear Diagnosis

hi. I have read with interest your COPD column. however I have severe lung damage caused by a doctor's opinion that he was godlike and his diagnosis  was correct. only when I felt he was wrong did I seek other information ( catscan, multiple bilateral pulmonary embolisms ). when I got to the hospital the doctors were amazed that I was still alive. to cut the story short, in the four years since, none of the accredited pulmonary specialists in phoenix Arizona are willing to accept what my condition is and they lump me in with the regular COPD crowd. I realize there is no cure as of yet for COPD but I am interested in finding someone who does not say "try this and see me in 6 months". do you have any suggestions?

Andy

Hi Andy,

Have you been evaluated at the Mayo facility, there in Phoenix?  When you ‘have’ been evaluated, has your diagnosis of multiple pulmonary emboli been the primary factor in your current pulmonary compromise?  Have you been tested for primary pulmonary hypertension – the most common cause of multiple pulmonary emboli?  You did not say what you were treated with once the emboli were discovered.  I would assume you underwent anticoagulation therapy for an extended period of time.  Were you treated with long term oxygen therapy?  What are the details relative to the diagnosis of pulmonary emboli?

Do you have COPD in addition to the history of pulmonary emboli?  What are your PFT measurements – especially, FEV-1, FVC, TLC, RV and DLCO?  (I would ask for the measured numbers along with your gender, age and height AND/OR the percentages those numbers represent of what would be expected as ‘normal’ for you – so called “percentage of predicted”.)  If you don’t know those values or what they are, you should ask your doctors about them, specifically AND get the corresponding numbers that go with them from your various pulmonary functions tests (PFT’s) over the years.  If you haven’t had PFT’s, or haven’t had them more than once or twice, you should seek to get a current test done.

If you are not satisfied with answers from the Mayo, then I would suggest you seek evaluation in Denver, at the National Jewish Health facility.

Best Wishes,

Mark

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CT Scans, Chemotherapy

Hi Mark...I have been reading your question and answer site and am very impressed at how you answer people's questions. You are extremely thorough and thoughtful as to how you answer. Thank you ahead of time. First of all...I would like to let you know about what my health conditions are and I hope I can relay them to you in an appropriate enough way. I have bronchiectasis, aspergillas, polyps and asthma in my lungs...excuse the spelling of these words if wrong please. For awhile there I was having cat scans on my lungs every three months to see how the polyps were doing I believe. Now, suddenly I am only having them done once a year. My question is why.I thought I read somewhere that too many cat scans aren't good for you...is this true...can they cause cancer? I have seen, in different articles recently, that chemo therapy can actually cause more cancer...a man of 47 just died here in my town It has been said he developed lung cancer (he was a fireman) and that it had reoccurred. He was given more chemo treatments and the treatments actually gave him cancer. I have not necessarily looked into the side effects of medicine until lately as I keep hearing more and more stories about the side effects of medicines. In that case I heard the cure killed this wonderful young man.Are there alternatives to chemo or radiation treatments? What could I do besides have cat scans to detect if cancer is present in my lungs? By the way...that is what this man died of...lung cancer. My father had that also was on chemo treatments and I was told he died of a heart problem..(he did smoke a lot). well...I hope my questions were defined well enough and not too scattered.thanks again for being there for people like us..God bless you! Joanne

Hi Joanne,

You asked a lot of questions.  I hope I have answered them all in the following:

Too many CT scans AREN’T good for you – IF they are done simply for the sake of doing them. When they are done for the purpose of monitoring changes in an active condition, then it is considered that the benefit outweighs the risk.  It is prudent practice to do fairly short-interval scans on someone who has polyps to detect changes that might indicate malignancy – especially when you have a family history of lung cancer.  If your doctors have reduced the interval to once a year, then I suspect that the polyps have not changed during the intervals between the earlier scans.  Therefore, the need for such frequent scans is considered unnecessary and not helpful to following your disease progression or to initiation of or alteration in your treatment plan.

The circumstances under which chemotherapy “causes” cancer are complex AND mostly related to the immunocompromised state that accompanies the chemo.  You cannot consider the chemo as culpable in the case of the young fireman you cite as lung cancers, especially CAN return, re-manifest or come out of remission AND can metastasize to other organs or areas of the body (a most common metastatic site is the brain) .  But, again, like the weighing of benefit versus risk, we roll the dice when we have to treat someone with an approach that can cause other difficulties.  And his lung cancer was no different.

But, I am confident in speculating that it was NOT the chemotherapy the young man received that ‘triggered’ yet more cancer.  Too often, what we see is that the subsequent rounds of chemotherapy simply aren’t effective AND that the cancers become stronger and more able to withstand efforts at eradication, while also differentiating into other cancer cell types along the way.  It is unfortunate that we lose folks like that young man.  But, sometimes we are simply powerless to produce a lasting and successful result.  As good as our medicines are today, we are far from having foolproof treatments, much less 100 % effective treatments.

In any case, years of treatment with chemotherapy agents show that the benefits without question, far exceed any risks associated with the medicines.  And, as long as studies continue to be done in the large numbers they are being done, we will continue to be able to evaluate if that remains the case or if things change and require re-evaluation of our approaches.

Best Wishes,

Mark

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Disease Stage Clarification & Possible (Down The Road) Interventions

I have just been diagnosed with emphysema and seeing the specialist for the follow-up July 10th. I have the "moderate" level and 50% gas/blood exchange with associated bronchial damage.  I am female, 59 who has smoked off and one since the age of 15 and as a child, lived in a home where smoking was constant..I also was born in Steel Town..Hamilton..ahhh the smell of sulfur, the blast furnace.. 

I am very pro-active in getting as much info as I can. I am going to ask the doc if I can get the bronchial coil ASAP or surgery to remove wedges of damaged lung tissue. 

Any info on this topic would be appreciated.

Teresa

Hi Teresa,

As one who asserts a proactive stance, you should be commended for taking the bull by the horns.  But, I would suggest the need to learn as much as you can not only about what treatments are available, but “when” they should be applied, as well.   As well, you should become as well-educated with accurate information about your disease and condition as possible so that you can ascertain which interventions might be appropriate for you and when you should seek them.  So, let me begin by helping you with some terminology and facts about lung testing and how you can better relate it to those whom you need to as you continue on your journey with lung disease.

In that interest, let’s start with what you report regarding your disease.  You wrote: “I have the "moderate" level and 50% gas/blood exchange with associated bronchial damage.”  That characterization is not helpful to tell me or any other health care professional relative to providing ‘real’ information in terms of tests and numbers we use.  We don’t refer to a term or measure such as “gas/blood exchange”, much less quantifying such a notion with a percentage (“50 %”).  To say you have a “moderate level” of disease also tells us nothing helpful unless you qualify it with something like “according to GOLD classification (More definition on this later.).  What we need to know is your actual measurements of FEV-1, FVC and DLCO to properly characterize your suggested factors of oxygenation/gas exchange and level/classification of severity of your disease.  And we need either the numbers PLUS your age, gender and height AND/OR the percentages of predicted they represent.  (This information is found in a print-out/report of your PFT results.)

So, I would ask you to go back to your tests – or your doctor – and seek to get the specific values for those measures I have listed and then return here with them in a subsequent post.  With that information I would be able to answer your questions more specifically as well as perhaps make some recommendations of what interventions you should consider in accordance with where you are “now” in your disease journey.

If it turns out that you indeed DO have only “moderate” disease (look up GOLD – Global Initiative on Chronic Lung Disease -  for information on ‘staging’ of COPD),(  http://COPDcanada.ca/pft_numbers.htm ) then neither the coils OR wedge resection ( LVRS = Lung Volume Reduction Surgery) are either necessary, appropriate or effective to improve your prognosis or length of survival, much less quality of life.  Indeed, you may not even have the proper ‘distribution’ of emphysema throughout your lungs to be a candidate for either of those interventions.  (Only about 12 % of those with emphysema are good candidate.)  So, they may not even be among your options.  In any case, those procedures are NOT done until one’s disease has become so severe that their quality of life and function have so deteriorated that the risks of harm involved with the procedures are no longer outweighed by the potential benefit.  So, this is not the point at which you should be seeking them.

Now, you may ask – as others reasonably do – “Why wait until I’m “that” bad to do LVRS or coils?  Why not nip it in the bud before I get that bad.”  The answer is because the risk of death and worsening of one’s condition are MUCH GREATER than the potential for benefit.  And, their effectiveness is still not seen to be more than 5 years or so, on average.  And, while working hard to breathe and putting up with the difficulties that go along with those breathing difficulties are far more tolerable than a procedure gone bad or one done that does not have the desired effect.  They can actually shorten your life.  So, you don’t want to do them until your life expectancy is rather dismal without doing them.  Additionally, these are major “invasive” interventions and not to be taken lightly.  They carry great risk for complications and worse.  Some folks think that LVRS is not as risky as lung transplant.  But, that is highly arguable, indeed! 

That brings me to my last point, have you considered lung transplant as an option – DOWN THE ROAD – that is!  If not, you might want to explore the ins and outs of that, as well.  Nothing beats being able to make fully informed choices and decisions.

Best Wishes,

Mark

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Relocation (Altitude And Climatic Changes)  & Impact On Medical Issues

I realize it is difficult to answer with any certainty with only a short amount of information and background, but any assistance would be appreciated. My concerns are returning home roughly 2500-3000 feet above sea level from sea level (will be explained below), and from relatively clean humid air (Lynden Washington state USA) to dryer somewhat more polluted area (Edmonton Alberta)

Currently I am a 56 year old male with Asthma, Anemia (multiple tests but no conclusions - scopes, blood, etc.) and Mild COPD

A little background, perfect health with no issues except a bad knee at age 20, athletic and basketball and volleyball, had taken ASA through out life to age of 20 for pain etc. Had knee surgery at 20  no previous allergies or problems. After surgery developed extreme allergies to everything organic, chemicals, and ASA (immediately closes bronchial tubes).

Managed to get allergies and ASA (avoidance) under control for a generally acceptable healthy life until 8 years ago I was exposed to isocynates from a paint supplier in a building behind where I worked,

ended up in emergency on oxygen overnight, developed multiple blood clots in lungs, and for over 6 months could not walk more then a few feet before resting, age 48. Was recommended to go on portable Oxygen but after discussing with lung specialist chances were I would have to be on Oxygen for rest of life, decided to see how much lung function
my body would recover by just trying a little farther and father walking each day. Since then I have recovered to the point where I can walk (not very fast) for 30 minutes, at which time I can rest and recover in 30-60 minutes to where I can function almost normally as long as I don't push it.

In November of 2011 my mother in law, Mom (Lynden WA), was diagnosed with ALS, which when my wife came to visit in early January to help organize support and assistance found that the disease was progressing so fast and health care was so expensive (no this is not a shot at anyone), that she could not leave her Mom and Dad. So she remained and we decided
that it was more then my wife and her Dad to handle, so I joined her in Lynden WA. Mom passed away June 12th and we are looking at returning to Edmonton Alberta, but I am concerned that my body has adapted to the sea level here, and the cleaner more humid environment. What cautions can you advise me of in this situation, pain, breathing problems etc?

I have always pushed myself not to lay down and give up, but I also want to be smart about my body and it's limits. Are there any tests that will determine what kind of damage has been done to my lungs such as condition of the aveoli or pulmonary high blood pressure that I need to be aware of to get done before returning. Sorry for the general direction of this commentary. Regards Bernie

Hi Bernie,

My best advice would be to see if you can arrange to go visit Edmonton for at least a week AND if you can time it for when the pollution and weather would be at their most severe point for the season that might have the greatest impact on your respiratory health.  If you develop difficulties, that would be a your cue. Otherwise, you might find out - too late - that you can't tolerate the location and have doubled your difficulties with some possibly avoidable financial cost.

One another note, folks who usually develop multiple pulmonary emboli (blood clots in your lungs) are almost always found to have primary pulmonary hypertension.  Were you treated (or still being treated) with anticoagulants (blood thinners/anti-clot medicines)?  Have you ever had an echocardiogram or right-sided heart catheterization to determine the presence of pulmonary hypertension?  What does your oxygen level do - especially when you walk for several minutes?

The fallacy in thee logic of seeing "if" and "how much" lung function you can regain in the face of hypoxia is that there is NO "toughening" or "conditioning" one's body to tolerate or compensate for hypoxia.  AND, if you have polycythemia (excessive numbers of red blood cells) - which one often develops with long-standing hypoxia that goes uncorrected - you greatly increase your risk for additional episodes of pulmonary emboli - any one of which could be fatal.

So, I would advise you to get checked for pulmonary hypertension, exertional hypoxia and possible polycythemia.  Understand that if you 'choose' to go on pushing to function in the face of hypoxia that you hasten the development of secondary pulmonary hypertension - a condition which is preventable through use of oxygen - REGARDLESS of age considerations or potential life-long need.  And after these many years, you possibly could have done quite a bit of cardio-vascular and pulmonary vascular damage.  Only testing would be able to tell "if" and "how much" damage may have been done.

Lastly, the exposure to the isocyanates from the paint factory would expectedly manifest in an interstitial lung disease component, if any damage was done.  I doubt that is the case.  It would NOT necessarily be responsible for the blood clotting and hypoxia, even though you had a serious respiratory emergent episode at the time of exposure.

Though you say you function well as long as you don't push yourself, my suspicion is that you are significantly below your potential functional level - especially if you were using oxygen.  But, that is only speculation from where I sit, since I can't lay eyes on you and test you 

I hope this is of 'some' help in determining what steps you need to consider in determining if your planned move is a potentially god one.  But, I'm sorry I can't be more definitive in my recommendations, at this point and from what you've told me.

Best Wishes,

Mark

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Treatment & Disease  Concerns & Still Smoking

Mark,
 
My Wife (age 53) has been diagnosed with COPD 2 years ago and is currently receiving BICAP therapy, supplemented with overnight oxygen only at 3 LPM...with Spiriva (18), Advair (500 mcg) and Ventolin as prescribed medication.

She also has a problem where without oxygen her saturation levels are below 90 sleeping without treatment and between 92-94 with oxygen...God knows what it is at work (Physical warehouse) during the day where there is no climate control and she gets light headed on some jobs???

My question is after all these years is that she apparently is maintaining, but no medical follow-up or therapy assessment has been competed!! She only sees a family GP and once a year a therapist from the oxygen provider (Gov't grant related I suppose)....Is this the acceptable or normal level of treatment to be expected?

She is a smoker (20-25/day) and I have not been able to get her to quit.

Thank-you, John

Hi John,

You have a tough situation on your hands AND about which I suspect, you can do little to improve upon.  That our wife has the symptoms she has and continues the behavior that is counterproductive to being able to improve her condition suggest that she is working hard to deny the inevitable and perhaps even the current problems and symptoms.  If she admits to the symptoms you relate, she likely is experiencing them to a MUCH GREATER degree than she'll own up to as a ruse to justify continuing smoking.

Until and unless she decides to ditch the cigs, she will likely continue to experience worsening symptoms.  And treatment can be only so effective as being taken in the face of improved lifestyle and treatment for the "whole" picture.  If she desaturates like you say at night, she likely desaturates comparably during exertion at the warehouse.  If she needs oxygen for exertion and isn't willing or able to use it and continue her work, that is a dilemma you - and especially "she" - need to resolve, at some point.

In any case, I also suspect that with her satisfaction in seeing only the GP and getting minimal follow-up testing, she exhibits even more 'avoidance' of coming to grips with and making the necessary changes she needs to in order to improve her situation and outlook for her future health.  The 'recommended' action would be to see a pulmonary specialist at least a couple of times a year and undergo serial testing of lung function and other health considerations with adjustment of treatment (and lifestyle/behavior) as indicated, along the way.

Unfortunately, all too often, folks will travel the path she is on until a health crisis hits them and jolts them to the reality of their vulnerability and frailty .  I hope you can find a way to prevail upon her to make changes sooner than later as if she waits until a crisis hits, her options - and the effectiveness of subsequent corrective measures she might be forced to take - can become greatly reduced.

Best Regards

Mark

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CPAP & Air Pressure

Mark,

I was wondering if a person with COPD (especially emphysema) should use a CPAP device if he or she has obstructive sleep apnea? I've read a study that reported that high levels (pressure) might predispose the lungs to progressive emphysema formation by causing mechanical stress on the alveolar walls of the adjacent normal lung tissue.
 
I have this so-called "overlap syndrome" (mild emphysema and severe OSA) and would be interested in your thoughts. Thank you.
 
Regards,
Jim

Hi Jim,

While you might have come across a study that suggests the "potential" for such complication from high pressure exerted on the airways, CPAP does not constitute "high pressure" that was likely referred to in the study.

Consider that the pressure generated - explosively - and percussively upon the airways, including both emphysematous and normal alveolar structures is MANY times greater than the highest airway pressure imposed by A-N-Y breathing technique applied to the lungs AND many studies and tissue examination of those with significant emphysema have not demonstrated damage and you have a perfect example of how 'strong' or 'accommodating' the airway structures and tissues actually are.

From a purely theoretical point of view and in understanding of the physics of positive pressure interacting with the airways AND in view of the physics of "distensibility and elasticity of airway tissues, especially the alveoli, I would argue that it is NOT the "normal tissue" or normal alveoli that we would need to worry about in terms of pressure risk as much as the over-distended emphysematous alveolar units.  Being more fragile and less distensible (already holding significant "trapped gas") they are likely to 'blow' first, before any likelihood of normal tissue being first to over-inflate and then blow.  We have mountains of data showing that pneumothorax from blown emphysematous units occurs with predictability of cause and timing.  Indeed, what we see "in action" is emphysematous airway units that compress and splint and PREVENT distension and ventilation of normal tissues.  So, what we actually see is the opposite of what your "study" suggested. 

IMO, I would question the understanding of those who conducted the study.  And since they suggest that "high airway pressures m-i-g-h-t predispose the normal alveoli to formation of emphysema tells me they found nothing concrete nor can they extrapolate to make any kind of prediction based upon their study.  I think they may simply be 'barking up the wrong tree'.

In any case, that you have mild emphysema and you have OSA, should not put you into any risk population they might be targeting with their concerns.  And, it is of far greater risk to not use your CPAP if it is effective to support your needs related to OSA than it would be to try to avoid such remote and questionable possibilities.   So, definitely, keep using the CPAP and disregard that study!

Best Wishes,

Mark

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Chronic bronchitis – A “Lull” in Symptoms

Hi Mark,

Something very unusual is happening, for the good.

I just returned from an appointment with my pulmo, and my lungs are clear for the second check up in a row. No Coughing, no sputum, No wheezing, no rattles, no colds, no flu, no flare ups, and this string of luck
has gone 13 months. ( 7 months ago was last check up ) with same result.

Believe me I am not complaining but I have NEVER gone this long without at least coughing.
It says that you have Chronic Bronchitis If you cough with phlegm at least 2 months out of 12.
I have had nothing wrong in 13 months now and counting. AS mentioned I have never had such a dry spell, and my doctor is ecstatic.

Is this really to good to be true ???

Thanks Mark and kind regards Philip

Hi Philip,

No it is NOT too good to be true.  And that definition isn't an "all or none", "absolutely must-be-exactly-like-it-says-or-it's-not-chronic bronchitis" definition.  It is a generalized definition that has MANY sub definitions that don't involve strictly cough and mucus production. 

Many folks experience quiescent periods with effective maintenance treatment that can go on for years.   In fact that is the treatment goal for everyone we see and treat for COPD and other diseases.  We WANT to get them to a point that their symptoms subside - for as long as is possible!

Enjoy the ride.  And remember, nothing lasts forever!

Best Wishes,

 

Mark

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Asthma & COPD. Is My Asthma Portion Controlled

Hello!
I have severe COPD and asthma.  My understanding is that asthma impacts breathing IN while COPD impacts breathing OUT.  I also have obstructive sleep apnea on a BICAP with 2 ltrs 02 at night only.  I sleep much better with the BICAP with no SOB at night.  When I wake up in the morning and take off the BICAP mask, I start having shortness of breath to the point where I need albuterol in the nebulizer and some oxygen until my symbicort and spiriva have had 1 hour to kick in.  Is this a sign of my asthma not being well controlled?

Thank you!

Suzanne

Hi Suzanne,

Your 'understanding' about Asthma is not correct, at all.  BOTH Asthma and COPD are "obstructive" lung disorders and therefore, affect the ability of the lungs to 'empty'.  As such 'getting the air OUT is the problem with BOTH disorders. 

While you may be diagnosed with asthma, I suspect, from your complaint and description, that you likely have chronic airway reactivity - or what we "used" to call "chronic asthma" before the GOLD conference convened and formulated common terminology and treatment recommendations for COPD. 

Today, we label the lung disorder as pertaining to "completely reversible airways reactivity".  As such, it is NOT something that is a constant, such as you describe suffering from.  It is intermittent, manifesting in discrete episodes that come on during/amid otherwise 'quiescent' (or "quiet") periods of no symptoms.

You describe your symptom as being a constant and daily problem.  So, as such, it is likely related to the COPD you have and is part of the 'whole picture', rather than being some sort of 'discrete' or separate problem or component.

I suspect that you are indeed poorly controlled, but not necessarily because your "airway reactivity" component is out of control.  Rather, you may not be taking your medications in the most effective way.  I'm curious to know if you use the nebulizer BEFORE you use the Symbicort and Spiriva.  If so, you are setting the stage for failure and delay of benefit from the Symbicort.  I recommend that the first thing you do upon arising and removing the mask from the BICAP is to use the Symbicort, followed a few minutes later by the Spiriva.  Then don't try to do much that is physical for about 30 minutes, if you can.  If you feel you need oxygen, go ahead and use it during that period.  If after 30 minutes you feel that your breathing is still not where it needs to be, THEN use the Albuterol nebulizer.

You didn't say anything about the rest of your typical day.  How many times do you use thee Albuterol nebulizer during the day? Do you find you need it more than twice between Symbicort doses?  Are you using the Symbicort at as close to 12-hour intervals as possible?

How active are you?  What is your FEV-1?  How old are you?  Height?  Weight?  With more information, I can get a better picture of you and your situation rather than shooting in the dark with sketchy and incomplete/insufficient information as I am now.

Best Wishes,

Mark

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Genes

Mark.

This is just a general question.

My Mother g-d rest her smoked 2 packs of cigarettes a day until she was 84. She quit at 85 due to being diagnosed with high blood pressure.
She ate anything and everything including finishing a whole box of chocolates at one sitting. Her parents lived to 88 ( mother ) and 97 for her father.
she died at age 93 from lung cancer.

Why is it mark that some who go way beyond the scale of what medical science tells us, and regardless of how they abuse their bodies they are just fine.
My mother never had COPD, got around well into her late 80,s and lived a life that went against everything medical science has told us to do.

This Mark has to be more then luck. I am wondering if your genes have something to do with it.With her lifestyle, My mother should have possibly lasted until 50 let alone 93.
Perhaps some studies should be done to find out why some are effected and not others. Perhaps the answer to COPD would be found in those findings.

Best to you Kim and your family. Philip 

Hi Philip,

You are honing a great penchant and technique of answering your own questions as you lay them out!  It IS hereditary and has been stated as such for decades.  When looking at the statistics of the number of those who smoke against the number of smokers who develop COPD, Heart disease and cancer, it is clear that some possess protective elements that keep them from experiencing the hazards and changes well-known to be associated with smoking.

Studies have been done and continue to be conducted looking for genetic differences between those who develp COPD nand those who do not, despite similar lifestyles and behavior throughout their lives. 

While environmental factors are also being shown to have an impact, it is genes that continue to be shown to be most influential.  Certain substances produced by genes are being studies as possible interventions to prevent, slow or reverse lung damage and dysfunction from COPD.  Perhaps in our life time, we may see some of them cone to the point of clinical trials, even approval for use in the general population.

Keep an eye open for developments in this realm.

Best regards,

Mark

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Unable To Complete FVC Portion Of Spirometry After Exacerbation

Dear Mr. Mangus;

Thank you for all that you do to help educate.  I have a question if you don’t mind.

Recently I had a spirometry test.  I’m not a newbie to the tests.  I have severe COPD.  My FEV 1 was 34% of projected.  But I  had problems with my FVC portion.  Seems I couldn’t blow out fully. It’s showing 67% Ref but also with a note from the tech stating….  “FVC does not meet ATS standards for expired time due to shortness of breath”  I thought I was blowing pretty hard!  Anyway; I had a flare up 3 weeks before my test and had been on antibiotics and Pred for a week.  Would my having been ill affected my FVC number?

Thank you for all you do for us.  Beryl

Hi Beryl,

It is possible that you had not reached your steady state yet after your exacerbation.  But of greater suspicion to me is that you might indeed be at your baseline AND that you do not have "just" COPD.  Have you had lung volume measurement and diffusion studies lately/ever?  if not, it would be worth pushing for some.  It might b that you have combined "obstructive" and "restrictive" lung disease, which would account for the dual reduction in FEV-1 and FVC, especially if your expiratory flows are relatively high for the degree of obstruction suggested.

In any case, you need further evaluation - either to see that your first suspicion was indeed the case - or to determine if you have other difficulties developing.  Let us know what you do and what the results are, please.

Best Wishes, Mark

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BICAP Usage & CO2 Retention

Hello Mark,

I've been on a BICAP machine at night only for 6 years now.  I was prescribe it by a pneumologist when I left hospital after having acidosis respiratory.    The parameters are the same as they were  then   4  12.  I have always managed to keep CO2 at around 47, except for the last 2 revisions which I had 54 CO2.  The PH was within normal.  Can you tell me when a doctor should change the parameters of a BICAP?  Does my higher CO2 indicate that the parameters of the BICAP should be changed now after 6 years the same?   Should the effectiveness of the use of these machines be controlled as in 6 years the doctor up to now has not made any test with the BICAP while in use.  I use 1 and a half litres of oxygen with the BICAP, and in the day I use 3Lpm pulse.  Hope you can throw some light on this for me  and thank you so much.   Regards Valerie 

My BICAP is not assisted breath.

Valerie

Hi Valerie,

Your condition indicates that you have "chronic CO2-retention" that has been normalized as exemplified by your pH which remains in the normal range.  That is a condition about which you can nor need do nothing, as it is a natural progression for many with COPD that is a permanent adjustment.  In your case, BICAP serves a different purpose than it would for those who have obstructive sleep apnea which would reasonably require periodic testing and adjustment of the settings.  If your long-time settings allow you a comfortable and uninterrupted night's sleep, then there is no reason to make changes, even now, six years into using the intervention.  Its purpose is NOT to normalize your CO2, per se, though it likely does reduce it somewhat while you sleep.  BUT, that reduction pushes your pH higher without causing it to change. 

Your use of BICAP is more specifically to help improve the quality of your sleep while also helping to increase your energy during waking hours.  The only benefit observed with long term use of BICAP or CPAP for folks with your condition is simply to help keep the effects of CO2-retention at bay while having no necessarily significant effect on CO2 levels. 

When CPAP/BuPAP was studied for use in CO2-retainers, it was the hope of clinicians that its use would thwart the progressive increase in CO2 levels and keep the pH from normalizing.  In some folks, it was hoped that pushing the pH up and CO2 down would cause the kidneys to release and expel bicarbonate, thereby normalizing pH and CO2 and 'reversing' the natural process.  But, as exemplified by your continued and progressive CO2-retention, it does not do what it was hoped to do.  That is not necessarily a bad thing though.

The important point is that in your situation, it does provide what is now observed to be the benefit that can be expected - to make daytime breathing better, more effective and easier than it would otherwise be were you not using BICAP.  Indeed, you are fortunate to be one of those who tolerates the intervention so well, as MANY - more than 50 % - who try to use it under the same premise and conditions find that they cannot tolerate or 'get used ' to it.

There should be no need to make adjustments or do more than periodic measurement of blood gases.  But, if you are concerned, don't hesitate to discuss your concerns with your doctor who, I suspect will encourage you that things are as they should be with what you are doing.

Best Regards, Mark

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Ease Stents & Nebulizer Meds Q

Hi Mark two questions. have you heard of EASE exhale airway stints for emphysema.  Is it in use for patients. Will it help breathing problems?

Next I am On Foradil 12 hours and spiriva 24 hours Now I use a nebulizer with 2.5mg of albuterol solution I take the other meds at 9;am For. and 9:15 Spr. when would it be best to nebulize  I can use it every 4 to 6 hours
Thanks

Elaine

Hi Elaine, 

EASE exhalation stents are being studied for efficacy and safety in clinical trials at 37 locations in the US.  For information on the study and how to enroll, if you are interested in being considered for participation, check out this link.

http://clinicaltrials.gov/ct2/show/NCT00391612

Whether or not they will prove helpful is not known, as yet.  Their applicability is likely to be dependent upon - as with other lung volume reduction approaches - the candidate having fairly localized emphysema as opposed to having it disbursed generally throughout the lungs.

Insofar as the nebulized albuterol is concerned, I would suggest that it should be used on an "as needed" basis, only, as opposed to arbitrarily on a fixed schedule.  With the Foradil and Spiriva you "should" be getting all the bronchodilation you need for maximum improvement in your breathing.  HOWEVER, if you find that several hours after taking the Foradil, your breathing consistently goes south, then perhaps adding a nebulizer treatment or two into your daily regimen might be of help.  In that case, I would recommend that you use the Foradil 6 hours AFTER dosing with Foradil.  In any case, be sure NOT to use the nebulized within TWO HOURS "B-E-F-O-R-E" your next dose of Foradil is due.  In the case of the night time, I would say take the albuterol about four hours after your PM dose of Foradil to perhaps enhance your breathing during sleep.  If, for some reason you find it necessary to take more than those two treatments, time your first of three or four for the day to be taking NO LESS than 30 minutes AFTER taking the Foradil and likely at about two hours AFTER the Foradil so as to allow another nebulizer treatment four hours later AND also two hours BEFORE your next Foradil dose is scheduled.  This pattern will help keep the two drugs (Foradil and albuterol) from competing against each other for space on the receptor sites within your airways.

I would NOT recommend using it up to the 6 times daily that your prescription allows!  AND, if you find that even four extra albuterol treatments a day are not keeping your breathing difficulties minimized, you need to call your doctor quickly, as you could be heading into an exacerbation.

In any case, if you DO use the nebulizer AND "do not" notice a significant and positive difference in your breathing, then understand that the extra medication/nebulizer treatment is NOT doing anything for you and might be better left not done.

Best Wishes, Mark

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Onbrez

Have not heard anything recently re: " onbreeze*breezhaler* which seemed to be a medication that might help us ???

Ken

Hi Ken,

Onbrez - Indacaterol - is available in the UK and, Canada as well and hit the market last year.  Indacaterol is sold as "Arcapta", in the USA - both being marketed by Novartis.  It is a long-acting beta-agonist (LABA) that is touted as a "once-daily-dosing" as compared to formoterol and salmeterol which are dosed twice a day. 

It proved to be efficacious in once daily dosing sufficient to cause the FDA in the US and comparable authorities abroad to approve it's marketing as advertised.  If you are interested in giving it trial, talk to your doctor.  (S)He may have samples which you can try to see if it works better for you than the LABA you may be using now.  It's main benefit over Formoterol and Salmeterol is it's once daily dosing as opposed to the twice a day dosing necessary with the other two medications.

Best regards, Mark

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Antibiotics & Cardio Issues

Recently there was a study linking an increase in cardiovascular problems and death with antibiotics such as Levifloxacin and Azithromycin. (NEJM http://www.nejm.org/doi/full/10.1056/NEJMoa1003833  )  and is now under review by the FDA.   For those of us who taking these meds to some degree of regularity, particularly the Zithro for daily maintenance, how concerned should we be by these findings?  Thanks, J

Hi J;

The issue with the class of  'macrolide' antibiotics - of which azithromycin, levofloxacin and ciprofloxacin are included - is that it is known that they increae the propensity of those who take them to experience cardiac arrhythmia.  While that phenomenon. in and of itself,  is of one degree of concern, the greater concern is: Do those arrhythmias result in more severe events/consequences.  So the study undertook to look at a VERY LARGE cohort who used the three macrolkide antibiotics AND amoxicillin (penicillin) to see if there was a comparison AND if there was a difference in cardiac difficulties and death between the groups.

They found that with use of amoxicillin and ciprofloxacin, there was no increased risk of death associated with their use.  BUT, with azithromycin and levofloxacin, there was a significant increase in risk of death from cardiac events that directly correlated with the dosing period (5 days - z-pak, etc) as compared to amoxicillin and ciprofloxacin.  The point that needs to be focused upon is that the increased risk for death was seen almost exclusively in those patients who had underlying cardiac disease that involved arrhythmia.  The study, itself, may have further separated the types of cardiac arrhythmias (ex: atrial fibrillation vs hear- block caused vs ventricular) and specific cardiac conditions to further zero in on which group(s) might represent what portion of those at increased risk.

The bottom line is this:  If you have significant cardiac disease and/or arrythmia, you are among those who were found to be at increased risk for death associated with taking those antibiotics.  Your doctor should take your cardiac status into consideration when prescribing them.  You - now that you are aware - should ask your doctor if (s)he feels you are at specific increased risk, if you are concerned AND have a cardiac condition that may put you into that risk pool.  There is no substitution for peace of mind which you can receive through information from your own doctor.

I suspect that the FDA review will NOT result in any revocation of those antibiotics.  Rather, it may result in a  mandatory warning to be placed in the drug/prescribing literature for them as well as a caution to doctors to consider their patient's cardiac conditions and risk when deciding if they should prescribe those antibiotics.

Overall, the risk is very small, but definitely present.  I suspect that the vast majority of you who take daily azithromycin will be safe and just fine.  But, don't be afraid to bring up any concerns you have with your doctors.

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Self Managing COPD Study Stopped Due to Increase of Deaths (U.S.)

In a clinical trial  for self managing COPD, the study was stopped early because of excessive deaths.  Here’s a link so that you can see what I’m referring to 

Self-Management Program Flops for COPD  - http://www.medpagetoday.com/Pulmonology/SmokingCOPD/32715

I am curious to know what your thoughts are or if you have an opinion on why this might be.

Thank You,

Jackie

Hi Jackie;

I am intrigued that the study resulted in a WORSE outcome, but can see specific considerations that could explain the findings.

First, there is considerable evidence that well-educated patients who have prescriptions for antibiotics and corticosteroids with instructions to initiate therapy with them when signs of infection/exacerbation arise do better than those who are managed solely with office visits and no front-line means for early intervention. 

The patients in the VA study were NOT well-educated, provided a booklet of information about COPD and 90-minute educational sessions for four weeks (presumably once a week for 90 minutes each session).  They were provided no specific instructions or standing prescriptions for timely intervention when needed.  They were managed using office visits and emergency back-up for sudden escalation of symptoms (so called 'standard care') the primary difference between groups being the study group received follow-up management by phone monitoring by case managers (likely RN's). 

The finding that those with no additional education in self-monitoring and self-management did worse could have resulted from any number of causes.  The education may not have been effective or pertinent to aiding in self-monitoring or management.  There could have been difficulty in subjects understanding of the material presented to them.  The subjects may not have taken the instruction seriously enough.  The follow-up by the case managers could have been ineffective/inappropriate to obtain or impart pertinent information from or to the subjects.

There is widely held suspicion that home-case-management and health-coach intervention for needs specific to COPD leaves much to be desired, let alone may not be effective.  Many of those who have received follow-up at home with case management or whose insurance companies have provided health coaching as an intervention and management tool have noted the inadequacy of knowledge specific to COPD and other chronic lung diseases among those providing those services.  Too many health care professionals and adjuncts simply have limited, poor and ineffective knowledge of COPD and IMO, should NOT be providing services like these, as they can do more harm than good.

Ultimately, the study suggests - indirectly, if nothing else - that the best management is and continues to be visits to the physician office where highly knowledgeable health care personnel are present to better manage problems experienced by the patients.  AND, it would further suggest that perhaps the better model is the self-monitored and self-managed patient who has an ability to communicate directly with those office personnel who better know the patient and their disease processes, as well as individual capabilities and difficulties.

The study model was cited as being quite different from other management models, though a reviewer; Stuart J. Pocock, PhD, of the London School of Hygiene & Tropical Medicine, opined that he could find no glaring difficulty with the approach.  But, I would not be so quick to agree with him, knowing what I do from many years of experience with  COPD disease management and working with those who have it and DO learn to effectively self-monitor and mange their disease. 

So, I suspect the study needs to be chalked up to being a poor design, for what ever specific reasons can be identified.  Perhaps another, better-designed study might provide different results that are more positive and helpful.

Lastly, it would be easy to dismiss the study as destined to its ultimate findings since it used a population of VA patients who tend to be the poorer group to study for many reasons.  I can't say that was necessarily the case, though I suspect that factor did indeed play a part.

Best Regards, Mark

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Stem Cell /Regenerative Treatments Question

Dear Mr. Mangus,

Pardon my contacting you directly by e-mail - I’ve read so many of your responses on this site, that I have to say you are really one of the best sources/persons I have come across in my searches, thank you!

My request is simply a personal one.

My older brother is 65years old and has severe COPD (stage 4), and does seem to not have much time
or common treatment options - so he is insisting on having stem cell treatment in Mexico soon.
he lives near Victoria, b.c., Canada - he is on all the regular medications & full-time home oxygen since 3 years.

I do not even know, if my brother would be able to travel by air to Los Angeles - maybe with 1-2 POC's (sequal or devilbiss),
but I am still researching this.

As I share his hopes, but not his desperation to want to pursue a "cure" at over-promising "clinics" in Mexico  - I am now diligently searching to find alternative treatment solutions or clinics in Canada specializing in regenerative stem cell treatment; particularly, with treatments that may have promise for COPD patients.

If you could either share with me some of your medical knowledge, suggestions, or simply direct me towards colleague's  or potential resources in British Columbia - that I could follow to find hopeful treatment for him.

If not, I will understand it if my e-mail request goes unanswered, but I hope you find the minutes to respond.

Thank you & kind regards,

Rupen

Hi Rupen,

First, all messages come to me indirectly.  So, you didn't "directly" contact me, per se, but did so in the manner in which all messages from COPD Canada come to me.  In any event, I am happy to try to respond helpfully to your questions and concerns.  Please read on . . .

I cannot in good conscience recommend or support your brother's notion to travel to Mexico for stem cell therapy.  While some folks claim to have benefited from Mexican stem cell treatments, they are few and far between.  Far more folks have not only NOT found benefit, but have also experienced severe effects from the intervention.  Understand that there is NO scientific or government control or safety measures in place for assuring quality of materials used, safety of the interventions or effectiveness in any empiric way. 

Many resources are being put into stem cell research in Canada, the US and Europe, among other locations.  BUT, no specific applications to lung disease have been approved or even reached a clinical trial level, though there are a couple of promising approaches in advancing development.  I have included some links to information to give you direction to inquire about 'any' potential - even through 'compassionate interventions', if possible - in Canada through your country's resources.  I cannot tell you if they will produce fruitful results.  But, they are a beginning which might start you down the trail towards finding at least a potential study for your brother to inquire about becoming a subject for.  I received these links from a friend who found them in a search for resources/information for stem cell therapy and research in Canada.

http://www.stemcellnetwork.ca/index.php?page=faqs

http://www.terryfoxlab.ca/people/khumphries/keith.aspx

http://www.ic.gc.ca/eic/site/lsg-pdsv.nsf/eng/h_hn01705.html

http://www.uhn.ca/applications/iNews/ViewStory.aspx?s_id=366

Has your brother sought help through pulmonary rehabilitation (PR)?  While it may seem hopeless and that he simply has no chance to improve his symptoms and function, I can tell you from more than 22 years experience working with folks with well-advanced COPD, that there is potential for surprising improvement and regaining of health and function, even in those with the most severe disease - and yes, even  with using significant amounts of oxygen.  COPD is NOT a disease one can fight with inactivity.  Breathing difficulties, while difficult to overcome and seemingly of potential harm CAN be managed and counteracted.  But, it takes perseverance and hard work to achieve meaningful gain.  That is best accomplished with the help and guidance of skilled staff of PR programs.  And BC should have a number to choose from. 

I will close with wishes for improvement and success in finding effective help for your brother.  And, I want to reiterate my concern for his thoughts about going to Mexico for such a risky and potentially life-threatening treatment.  Please try to convince him that it is a BAD idea!

Best Wishes,  Mark

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Blowing Bubbles & Balloons

I was told that blowing balloons will help strengthen lungs, do you agree?

Jeanne

Hi Jeanne,

Blowing up balloons is a good exercise for a couple of benefits.  But, the notion of "strengthening ones lungs - as in similar to how you can strengthen your biceps with lifting weights - is NOT possible, as the lungs are NOT muscle tissue. 

Two things that represent the primary problem in COPD is air movement and the obstruction to 'emptying' the lungs that tissue damage and lung physical change cause.  Pursed Lips Breathing (PLB) is a wonderful counter-measure to combat he effects of those changes.  So learning and mastering proper PLB technique is essential to being able to get a handle on one aspect of the cause of shortness of breath (SOB) and it's attendant difficulties. 

The other point is that the lungs trap a lot of air - increasingly as time goes by - air that cannot be expelled no matter how hard you try.  PLB and prolonged exhalations counter that problem to a great degree thwarting SOB to enough of a degree that you can see great improvement in function and reduction in and better tolerance of SOB.

Here's where balloon inflations an exercise comes in.  I recommend using a 9-inch (25 cm) "party balloon".  You take in the deepest breath you can and blow into the balloon.  You work to blow as much air out of your lungs as you can with the goal to inflate the balloon to its 25 cm diameter in as few breaths as possible.  Doing this s-l-o-w-l-y over several minutes time - to avoid dizziness caused by too much ventilation, too fast, in too short a time span - for about 15 repetitions each episode will, over time result in decreasing the total number of breaths required to fill the balloon.  BUT, the benefit is in more efficiently emptying your lungs against the obstruction imposed by COPD while also learning better control of your ventilation pattern AND learning/developing a degree of PLB control and technique in the process.  Balloon inflation is only one of several potential techniques you can use to improve your ability to move air more effectively.  Do it with grand kids in the mix and you have a fun activity that may also interject laughter and possibly some coughing which can be both beneficial and problematic, unless you are careful and prepared to work with it.

In that spirit, blowing bubbles can also enhance the learning and mastering of better breathing while also providing a fun activity with children, if you like.  My recommended techniques for blowing bubbles involves two exercises.  First, try blowing a steady stream of bubbles about 3 - 6 cm in diameter with the biggest breath you can muster.  Blow 'til all the air is out.  A second exercise - more difficult, but more productive in terms of mastering very controlled exhalation and PLB is to blow a single bubble to about 8 - 10 cm in diameter - keeping it open while blowing - not allowing the bubble to separate and float away - AND, not allowing the bubble to collapse back into the ring - for as long as you can during a single exhalation. It requires that you take in the deepest breath you can and blow it out as long as you can using PLB.  Over time, you will see your inflation time increase.  As well, because you are inflating the balloon enough to give it size and HOLD that size throughout the exhalation AND you are controlling the rate of your exhalation so as to keep the bubble from collapsing back into the ring OR so much as to cause it to release and float away - you will find that it is an excellent exercise to accomplish the goals of longer exhalation time, more complete emptying of your lungs and mastering effective PLB.

Have fun with balloons and bubbles!  Best Wishes,  Mark

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Antidpressants /Anti-Anxiety Meds

I have COPD and I take Valium for anxiety,however I am very depressed and was wondering if I should also take an anti-depressant. Its so hard to do things when you feel this way and I was hoping that may help me want to do more.Sure hope you can help. Thanks

Jeanne

Hi Jeanne,

There are a couple of choices that may be better than Valium AND will have less effect on your ability to breathe as Valium does.  Xanax is what we call an anxiolytic (AN-zio -li-tick).  It serves as an anti-anxiety and anti-depressant medication, so packs a double punch as compared to Valium's single punch as simply an anti-depressant.  Valium does more to dull your senses than to relieve anxiety or depression.  Xanax more directly affect your mood and your anxiety response mechanisms.  It might be worth inquiring about with your doctor. 

Another drug that is under-rated and under-used (IMO) is BusPar.  It is a non-narcotic anxiolytic.  It can help tremendously with anxiety control without the 'dopey' feeling that other class C narcotic-type anti-depressants/anti-anxiety medications can induce.  The caveat to reaching effectiveness with BusPar is that it requires establishing a blood "titer" - a minimum dose level in the blood.  It must be taken diligently every day and maintained on the 'discovered' effective dose to be effective AND it takes several days to a week or two to reach that 'titer'.  Often it is 'phased in' over time while other anxiolytics/anti-depressants are weaned away.  Again, it might be worth discussion with your doctor to see if it is a reasonable option for you.

Additionally, it would be well worth a discussion with your doctor to relate your difficulties and see if (s)he thinks there might be other medications that might be better suited to your difficulties.  You may need to go into a collaborative 'trial and error' phase with other medications to search for one that does better for you than Valium.  At the same time, you may find that Valium ends up being the best and most effective drug for you after all, though I am doubtful that that would be the result.  Talk to your doctor and see what you can come up with.

Best Wishes,  Mark

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Chronic Bronchitis But Lungs Sound Clear

Hi Mark. I have a question.

It may be in my head but when I turned 65, I think I have slowed up just a bit. I still work but now I look forward to going home. On weekends Sat and Sun I usually have an afternoon nap for an hour or 2. If good enough for Winston Churchill  Cant hurt me right???. I am active, go to the gym regularly, eat well,
and my breathing is day to day. ( Some good some bad )
I am the one who has the big asthma component. and I seem to be effected by what is in the atmosphere. The other day I was stuck in traffic  and I had the outside vent open in the car. I noticed I smelled exhaust and in a matter of moments I felt my chest constrict and my breathing becoming difficult. I had to pull over and take 2-3 inhalations of Ventolin. It took about 15 minutes for me to continue .
The last checkup I had the doctor said that my lungs were clear. No rattles, wheezing crackling, etc. Can you explain Mark how you can have COPD, with chronic bronchitis and have clear lungs
I have not coughed in months. Also unusual.

Thanks for your help mark, and as always the best to you and family Philip


Philip

Hi Philip,

 I'm pretty sure you have seen my answer to your question more than once before. But, here goes, again. There's nothing obligatory about having mucus with the diagnosis of Chronic Bronchitis. So you have a 'dry spell'. I wouldn't complain, my friend! Your episode in traffic, besides being likely from the exhaust fume odors, could easily have been from ozone and carbon monoxide, as well. Be careful about that, in the future.

Best, Mark

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Daxas

What is new  on Daxas?

Ken

 

Hi Ken,

 I'm not aware that there IS anything new with Daxas, beyond what the insert and efficacy/safety studies showed. Do you have a specific point of concern that prompts your question?

Best, Mark

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COPD -General Inquiry

Hello and thank you for this opportunity.
My mother has COPD...she has absolutely no energy and cannot breathe well during sleep. 
What dietary recommendations would be given to help ease this disease.
What else can be done...her current doctor tells her nothing can be done for COPD.
This website gives us hope there are small steps we can take.  Please help us.

Twil

Hi Twil,

There is indeed much folks can do to improve their lot in life with COPD. But, without knowing much more about your mother, I can't begin to tell you anything specific that might help. Nutrition is only one part of the equation. But, it may or may not be significant in her particular situation. Can you tell me more about her condition? Do you know what her FEV-1 is? Does she use oxygen? Has her oxygen saturation been measured while she is walking?

Best wishes, Mark

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E Cigarettes

Is it safe to smoke the electronic cigarette if you have chronic bronchitis. I also take symbicort for my chronic bronchitis.

Ed

Hi Ed,

 Smoking 'anything' is not good for you with COPD. Electronic cigarettes don't produce smoke. But, they can still irritate your lungs. And there is a danger with them potentially exploding. I would recommend the patch or other quitting aid, rather than a 'substitution' involving the same behavior.

Best wishes, Mark

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Unknown Reason For Breathing Problems (Possible Allergens) Also  Cholesterol Discussion

Hi Mark,  NO COPD, hopefully. Smoked in my youth, quit at age 24.  now 59. haven't been seriously sick in years 20 or so, except occasional lethargic sensations. approx three years ago. started taking cholesterol meds. pravistation, cholesterol in the 350's in spite of many years of exercise and good diet.
starting suddenly in august of last year 2011, I awoke to what I thought was pneumonia. I had just started a new job one week , data entry info from old files.  There were no other symptoms. no nasal congestion, I did seem to have a flavor of medal in my throat for weeks. Once seeing a doctor. The did chest x-rays. that came up with some bronchitis. He gave me antibiotics. it slowly cleared. Now I have no decent medical to be sure. That doctor is no longer there and I see a nurse practioner.  I had taken antibiotics off and on for about three months.
They insist it is allergies, but I get a bad episode almost every three months. Terrible hacking and coughing. Lungs sound scary. congested.  I will have quiet spells, and then all of a sudden coughing.
I've been taking the equivalent of Claritin for three months, that seems to help, but I got hit will a spell again, and when it happens, it also drains me, It really feels like a serious cold.  but there is no nasal congestion. since the claritin no  post nasal drip and itcy eyes.

any suggestions. 

ps the metallic taste cleared after the second round of antibiotics. 


Laura

Hi Laura,

It's tough to guess what may be going on, though, if they think it's allergies, I wonder if you have had a work-up for that - skin tests, etc?  How about a PFT (pulmonary functions test)?  Spirometry, pre- and post-bronchodilator might show airway reactivity - the symptom most commonly manifested with allergies.  Chronic bronchitis could be another possibility.

I'm intrigued that you began having symptoms after starting your new job.  You spoke of "old files" and data transfer as your function.  Are the records 'musty' or been in storage for long?  Could you be reacting to something in the paper they're composed of?

How's your cholesterol 'now' with the prevastatin?  Is it normalized?  How about your triglycerides?  I ask because I had a severe problem with elevated cholesterol and triglycerides that I was able to normalize without using statins.  For more than three years, now, I have taken high-dose Niacin (3000mg/day) - (had to work my way up to my current maintenance dose from very low dose over a period of months) plus higher-dose flax seed oil (3000mg/day).  But, I dropped my cholesterol from almost 300 to about 110 and my triglycerides from almost 500 to the 90's on both AND my high-density lipoproteins (HDL) are almost double what they were when I started my regimen (in the 50's). 

Many statin preparations contain low-dose niacin.  But, it is not always enough.  AND, because of the discomfort of flushing, many folks abandon it quickly, rather than tough it out 'til it no longer occurs.  (Flush-free Niacin is not nearly as effective as regular, sustained/prolonged release is).  I didn't want to take statins because of the side effects that are so common with them - if I could avoid having to take them.  And I'm so pleased with what my regimen has done for me and continues to do.

If you can give me more to go on, I might have some suggestions for directions to point you in for further investigation and possibly even a possible reason for your troubles.

Best Wishes,

Mark

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Pulmonary Fibrosis

I have Lung Fibrosis I was diagnosed aboutt 10 yrs ago. now getting worse, I am on oxygen 24 - 7. The doctors I see do not seem to help me at all, just waiting for the day I stop breathing.
I would like a second opinion on this condition. And even trying for a lung transplant if possible.
OR they are interested in other findings like Pulmonary Blood Pressure.

Marjorie

Hi Marjorie,

I'm sorry to learn of your troubles.  Pulmonary Fibrosis is a nasty problem for which we still have a paucity of tools to combat/treat.  Pulmonary Hypertension is a condition that develops as pulm. fibrosis develops and advances.  It is due to the accompanying hypoxia as it affects the heart, over time.

Unfortunately, today, the most effective treatment to resolve pulm fibrosis is lung transplant.  So, I think you're thinking correctly in your surmising that it may be worth pursuing.  The sooner you find out if you're a candidate, the better, even if it will end up being some time before you actually need to undergo the procedure.

Best Wishes,

Mark

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Meds Sequence And Wheezing

Hi;  just returning my question.l take symbicort twice a day 2puffs each time plus half tab. unihyl,spirva once. Wheezing still there. What l was asking they should put something in the meds that we could taste and then we would know we are getting the dose. Do you agree?l was shown how to take them but l still have breathing problems and wheezing. Ventolin helps for a bit. My test showed l have 38 percent lung function. Oxygen on finger test is at 92-94.ventolin l take 2 puffs 4 times a day.  TY for your time.

Doug

Hi Doug,

If your saturation "at rest" is running only 92 - 94 %, it is reasonably easy to predict that when you get up and move, it is dropping below 88 % and doing so fairly quickly.  If you haven't had a 6 minute walk test, you should seek to have one done.  You likely need oxygen for mobility and potentially, also for sleep. 

If you are taking Ventolin that many times a day, you could be taking your meds in a order that thwarts the effects of the bronchodilator medicine in the Symbicort.  Be sure you are taking the Symbicort BEFORE you take an Ventolin, in the morning.  Then wait at least 30 minutes before taking any Ventolin - IF you still need help.  When the evening dose of Symbicort is due, be sure that you have NOT taken any Ventolin within the previous two hours.  Ventolin binds to the same receptor sites within the lungs as does the Ventolin.  If the Ventolin is taken too soon before Symbicort, the receptors cannot bind to it and it is shed from your body before having exerted any beneficial action.

The spiriva should be taken within a few minutes after taking your morning Symbicort.  I'm left wondering what your "post-bronchodilator" FEV-1 changes to on your PFT's.  If a pre and post FEV-1 measurement hasn't been done, then, again, you should ask for at least one to be done - especially in view of the fact that you have wheezing. 

There could be other things going on with your lungs.  But, these are some obvious starting points for you to consider acting on.

Best Wishes,

Mark

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COPD Or A Bad Cold

I think I have a bad cold. I was sent for a chest x ray my doc thinks I have mild COPD oxygen output was 94% on azythromycin. What do you think?  Nose is stuffy phlegm is clear

John

Hi John,

You could be right.  Be sure to have your saturation checked after you recover from your bug to be sure that it returns to normal.  Ask for a 6 minute walk test to be sure you are not dropping your oxygen during exertion.

Best Wishes,

Mark

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Nebulizing Meds

Can I use Glutathione with a nebulizer and also use Symbicort?  The Glutathione is from a pharmacy in southern California. Each is to be taken twice a day.

Maureen

Hi Maureen,

First let me be sure I understand what you're asking.  You are asking about taking the two medications at the same time and concerned about any interaction between them, correct?  You are NOT asking if it's OK to "nebulize" BOTH drugs, either separately or mixed together, correct?  Symbicort is not suitable for nebulization, if that's what you were asking about.  It must always be taken from its designated inhaler.

Those points settled, you CAN take both medications without concern.  They are completely different and do different things.  One will not interfere with the other.  And taking both is not going to put you at any risk of harm. 

Best Wishes,

Mark

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Oxygen Desaturation..... Dangerous When?

Hi Mark
Just a fast question for you.

My question is. At what 02 saturation level does the number registered become dangerous to one,s health??

I have looked up many articles on this very subject, and no one has the same consensus.
One article said. Any number below 92. Others said 90 is the cut off , and then others swear by 88 or below.
Why Mark is there not a more world wide definitive number, and why does nobody agree .
The answers in regards to the number seem to be all over the map.

Just to give you mark an idea.
In my province of Ontario, the government will NOT pay for supplemental 02 unless your numbers are consistently below 88. 
Other countries have another number that they use.
Why Mark can they not agree on a Universal number??

Thanks mark and the best to you and your family. Philip

 

Hi Philip,

Needless to say, this is a carry-over question from the same issue discussed extensively over the last week on the EFFORTS list.  So, I feel a bit "baited", here.

The reason you will find no agreement or a definitive number as you lament not being able to find is because there simply IS NO SUCH NUMBER . . . at least not with the conditions you and others are bent on applying.  It is simply NOT black and white!  It is different for everyone and dependent upon many subtle factors of their own condition. 

As I explained the other day in a post on EFFORTS, the 88 % comes from the NOTT and BMS studies where it was selected as an arbitrary low point for purposes of delineating populations in the study groups and ascertaining survival with and without using supplemental oxygen and for how much of the time they used it. 

Again, I explained that even the 88 % or 85 % opined by many in yet other countries - or the 80 % set in one province of Canada as the lowest acceptable saturation without trying to correct it with supplemental oxygen is relative. 

Consider the inhabitants of the Andes or the Himalayas.  They live NORMAL lives with saturations in the low 80's and aren't considered "hypoxic" until their saturation drops into the 70's.  When we fly, our saturation drops to 87 % (I just measured mine during several flights to Las Vegas and San Francisco two weeks ago) and , while we may feel a bit tired and have less than stellar energy, we are fine for those short periods of time.  I'm certainly not going to suffer and organ damage because of those several flights.  And flight attendants and pilots and their crews withstand drops into the mid 80's daily as they fly for their livelihood. 

The fact is that what is "damaging" to a person is the long-term, repetitive drops in saturation in the face of having clinically significant lung disease and a vulnerable cardiac condition as a combination of influences.  And it is not that their saturation drops to or below some magic number, because it drops to different lows at different times under different circumstances and influences of the moment. 

The answer to your "damage" question lies in the example that may be likened to a boxer who takes many punches to many places of different kinds and strengths and who after enduring so many over the course of several boxing rounds finally takes a final fall and passes out because he can't take any more punches.  Now, you ask me: "Which punch was it that did him in?"  I don't know.  The last one is the one after which he fell.  But, it took the cumulative effect of all the previous punches to lead to the culmination in that last punch.

And so it is with desaturation.  While you and so many others are trying to put conditions and numbers into a tidy and neat box, the contents of the box are like a glob of Jell-O that doesn't want to fit into the box and is too difficult to handle to tame and control it. 

So, the best I can do is to reiterate what you will repeatedly find when you do find the information in the literature, 85 to 88 % seems to be the most evidence-based range of lows below which long-term, repeated drops to and below will eventually result in permanent changes for the worse in cardiac function and pulmonary blood pressure increases.  That's the best we can say and do.  If it's not enough, I have to say: "I'm sorry!" 

Still, the 'general' recommendations we have to go by is to do your best to keep your saturation above 88 % as much of the time as is possible.  90 % or greater is the recommended 'minimum' target for 'sure' safety with higher saturations targeted for increased comfort.

Best Regards,

Mark

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Frequency Of Ventolin Use

l use ventolin like lm told and more when l walk is this ok? Should they put something in symbicort and spiriva so we are getting the dose?  TY

Doug

Hi Doug,

I'm afraid I don't quit understand what it is that you're asking.  If you are taking Symbicort and Spiriva, then you should need ventolin ONLY in-between the Symbicrot doses and ONLY on an as needed basis.

You say you use your ventolin as you're told".  But, you don't say how often you've been told to take it OR under what conditions you're supposed to take it.  And, you say you take more when you walk.  So, it sounds to me like you're not taking your Symbicort (and possibly also your Ventolin) properly, since it seems to require more than is usually needed for normal doses under usual conditions.  Can you write back and tell me by what pattern you take your inhaled medications - times and which ones when?

Best Regards,

Mark

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Treadmill Walking Vs Outdoor Walking

Mark,

Your explanation to Norma recently re difference between walking outdoors and treadmill is a good review.  But I have a slightly different question.  What value is it to only use a treadmill in PR when life requires many different grades?  Decisions for supplemental O2 based on a treadmill seems inadequate - I understand about adding grades, but wouldn't that take many weeks to equal walking outside?   I too experience the difference.  With warmer Spring weather I have been walking outdoors rather than use my treadmill (45in at 2.5., lowest sat 92)  While I don't find any significant change in my breathing outdoors and it does have several long and short increases in grade. I have been tracking my starting HR, O2 sat, periodically during my walk, and when I finish.  I've slowly increased my time and distance (now 38-40 min, 1.5-1.8 miles.)  My heart rate has decreased from106 to now 92-96.  Good, right?  Originally my lowest SaO2 was 91, but now it is 85-86 and lasting much longer during my walk.  It comes up to 90 when I finish and then back up to 96 over 3-4 minutes.  I would much rather walk outdoors as that is real life  So I guess my question is just how realistic is treadmill work in PH compare with real life activities?  How would criteria for O2 in RH match outdoor work?  Or am I splitting hairs?

Doris

Hi Doris,

You're not splitting hairs. But, some of what you tell me causes me concern.

First, when one works out in the gym, they chose things like the treadmill, cycles and eliptical/step gliders, etc AND they generally work out quite differently from how folks tend to work out in PR.  While I've said that walking on the level treadmill doesn't exactly match the work of moving your body from point "a" to point "b" when walking outside, that doesn't mean that you can't achieve comparability. 

You note that your hear rate has dropped from 106 to 92 - 93.  But, you don't say if that is resting heart rate or during walking.  But, to be clear, the objective of exercise is to raise your heart rate - 120 - even higher, if your symptoms will permit AND if you can maintain an adequate oxygen saturation while exercising at that higher heart rate.  So, whatever mode and method of exercise you choose should have those objectives.  So, the real question is not the value of treadmill versus walking outdoors on natural terrain.  But, it is the 'manner' in which you walk, which ever means you choose.

Now with regard to saturation, it is NOT desirable to sustain your saturation at the 85 - 86 % you observe yours to be when walking outside.  If you have supplemental oxygen available to use and are prescribed to use it, then you should use it.  You should target keeping your saturation at or above 90 % during walking - whether it be indoors on a treadmill or outdoors on the natural terrain.  That it comes up to 96 % when you stop (after 3 - 4 minutes) does not make sustaining 85 - 86 % during walking any healthier for you.  Recovery time, contrary to what some will say, has NO bearing upon the adverse effect of sustaining saturations that are below an acceptable level of 88 % during exercise.

So, my recommendation for you would be to exercise as vigorously as you can to raise your heart rate AND sustain an adequate saturation so as not to put yourself at risk for organ function compromise (mainly, your heart) in the long run.

Best Wishes,

Mark

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COPD & HOCM

I have recently been diagnosed with COPD.  I also have HOCM and I'm wondering how they will affect each other.

Diane

Hi Diane

That is something I can't begin to speculate on.  Your cardiologist and pulmonologist have infinitely better means to answer that question for you than I or anyone else could.  I suspect that they will likely tell you that only time will tell.  But, certainly, put your questions and concerns to them both!

Best Wishes,

Mark

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Oxygen Level Query

Hi Mark, my daughter suffers with FA ,she was taken to hospital a few days ago where they found her blood pressure was low and her oxygen was at 8% ,and said she could have slipped into a coma, I am so worried that this may happen again now and we won’t b able to tell ,please help me understand this ,thanks Julie

Julie

Hi Julie,

I'm afraid you haven't provided enough information for me to help you at this time.  As well, your relating of your daughter's oxygen level is not correct.  No one can have an oxygen level of "8 %" and be alive, in any of the possible ways "8 %" could represent.  I am not familiar with an abbreviation for a diagnosis of "FA".  please spell out her diagnosis completely so that I will not misunderstand what it is she suffers from.  If you can write back with the correct and more complete information I will be happy to try to provide some answers for you. 

Best Wishes,

Mark

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Prednisone

How bad is prednisone for flare ups of COPD....my doc tries to keep me away from them but yet that’s what opens me up to breath better....I’m already on all the inhalers and a nebulizer


Allan

Hi Allan,

Prednisone is the drug we "love to hate".  It DOES work very well to subdue symptoms and make the user feel better.  But, it is a mixed blessing, as it suppresses your immunity, making you more susceptible to infection AND playing havoc with calcium distribution and use in the body, leading to susceptibility to loss of bone density and osteoporosis, if used too much for too long.  And, how much is too much or too long is different for every individual, making determination of what is safe for a given individual very difficult to ascertain.  That is why your doctor is hesitant to prescribe it very often.

The trick is in being able to tolerate the symptoms that cannot be changed and to counter them with activity and exercise as well as good diet and life style/habits (like refraining from smoking, etc.)  Pulmonary rehabilitation is of great help in learning to overcome and tolerate difficult breathing.  Taking medications in the proper amount and sequence is another key to living well. If you are using your nebulizer with short-acting medications and then following it with long-acting versions, you are working against yourself to achieve effectiveness of the long-acting medications.  AND you could be taking much more medication than you really need to because of the ineffective sequencing of your medications.  So, simply being on all possible medications alone PLUS a nebulizer may not be as effective in reducing your symptoms/breathing difficulties as you might think.  If you can tell me more, especially what medications you are taking and in what order/sequence/timing/interval you are taking them, I might be able to glean more of from what your difficulties may arise

Best Wishes,

Mark

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Good Pft  Numbers, But Having Problems With Breathlessness

Dear Mark,

We exchanged emails back in 2004 when I started out on this road. Regrettably I'm still on the same page but living with this the best I can, myself and my wife have had a number of children since we last spoke.

To recap I had asthma as a child and smoked for 17 years foolishly taking steroid inhalers to counter act the effects of the cigarettes. I gave up in 2004 at 34  after a bad chest infection and a constant sensation of not being able to get a deep breath. After 8 years I still cannot get those elusive deep breaths and this has a constant effect on my life. I also have some phlegm most days and a cough. My breathing bothers me.

I had more PFT's in 2009 (values unchanged) and I also own a handheld spirometer and I have some insight. My pulmos verdict is that I have twitchy airways and he puts the uncomfortable breathing down to anxiety. His Verdict; I may have some small airway re modeling which should not cause the symptoms I experience.

I have an FEV1 at 4.25 and an FVC of 5.82 (I'm M, 42yo and 181 cm) so my numbers are good. Diffusion is normal and I have no reversibility.

I have started biking to lose weight (14st) and can do 50mls in 2 hrs. After I bike my breathing is not right for two days at least, I cannot get a deep breath which drives me nuts, although I can exercise well.

I have three questions for you..

1. Where to now with this, is this as good as it gets?
2. Should I use a short or long acting bronchodilator for what seems to be Exercise Induced Asthma.
3. What do you think of my FE1 / FVC ratio in light of my symptoms. I see Crapo and others say this value should be over 80%.

Lastly have you ever seen anyone with normal FEV1 & FVC and a history of Asthma / Smoking complain such as this.

Thanks for your time,

Con.

Hi Con,

With your pulmonary functions as good as they are and your FEV-1/FVC ratio still within normal limits (at > 70 %), you have extremely minimal obstruction and none that could possibly be considered clinically significant.

The complain of not being able to take in a deep breath is relative and very subjective.  You obviously can indeed take in plenty of deep breath with your FVC at 5.82 L!  So your 'sensation' is a mis-fire in your brain.  What causes folks who have clinically significant COPD to develop the sensation that they cannot get enough air in - a.k.a. a deep enough breath - is the fact that they are trapping so much air that they have no room for 'additional' air to be taken in.  Their quest is to use pursed-lips breathing to help "EXHALE" more effectively so that on subsequent breaths, there will be enough room for MORE fresh air to come in.  They need to 'make space' to accommodate a bigger breath. 

That is not your problem at all.  In fact, there simply is no good reason for your sensation and therefore, no reasonable way to explain it aside from the possibility of some amount of airway remodeling resulting from the combined smoking and steroid inhaler use.  Still, your changes are simply not enough to explain your breathlessness/complaint of not being able to take in a bigger breath.

Inhalers will NOT do anything for you and should not even be a consideration.  Try exhaling more deliberately and using pursed lips breathing to see if you notice any difference or improvement.

Best wishes,

Mark

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Smoking, Industrial Exposures & COPD

Mark;  I am questioning the band wagon approach to the medical and worker comp boards insistence that COPD is only caused from cigarette smoking.
I was exposed to Asbestos and Silica dust in my 20's with the added fun of being involved in a natural gas fire/explosion at the same establishment.
All of this was not enough.  The fire sealed up my nose,damaged my sinus and left lung.  Further after trying to keep working I was involved in a business that used Industrial Chemicals to strip furniture which lead ( no pun intended) to Peripheral Neuropathy (toxic). Our neuropathy group has noted over 100 neuropathic health problems.
My  question is with all of this happening what are the chances that my COPD is more related to Industrial exposures than having been (20 yrs without)
a Cigarette Buffer not a heavy smoker.
I thank you for your time and will be interested in hearing your reply.
Best Regards, R

Hi "R",

COPD can indeed be caused by inhalation of asbestos and silica.  Thermal injury to one's airways can result in a combined defect of restrictive AND obstructive lung disease. smoking history up to about 20 years for many is not enough history to presume as a primary cause of COPD when one is younger.  You did not indicate how long you smoked, only that you've been quit for 20 years.  Lastly, inhalation of the kinds of agents used in furniture restoration can cause either or both restrictive and/or obstructive lung diseases

Unfortunately, with your history of several incidents that can cause COPD and a smoking history, it is virtually impossible to separate each factor to ascertain if and how much each might contribute to your COPD.  Asbestos inhalation is dose-dependent, so requires significant and dense exposure for a short duration effect and moderate long-term exposure for a sustained effect.  Silica is the same.   Your inhalation injury from the fire should have been well-documented in order to determine what permanent damage was caused by it.  Regular follow-up with x-rays/CT scans and especially, PFT;s would be necessary to gather that kind of evidence. 

So, if, on the surface your smoking history seems to be significant (> 20 pack-years - 1 pack/day X 20 years) then it is impossible to tease out the other influences.

In any case, with your multiple exposure history and smoking on top of it, no one can reasonably or reasonably accurately estimate how much of your lung disease, if any was cause by what.  Insofar as any neuropathy, only well-performed and sensitive tests of muscles and nerves could possibly detect any such affect on your condition and symptoms.

I'm sorry to be unable to give you more specific information or answers.  But, it's just not possible, based upon your history and from where I sit.

Best Wishes,

Mark

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Pulmonary Rehab Needed?

Mark,
I appreciate your answers.
I am 51 and was diagnosed a few years back with severe emphysema/COPD. My pulmonary dr. told me I'm at 37 or 38%. I work full-time as a probation officer. I quit smoking 3 years ago and in the last year have become more active. I've been walking, doing recumbent bike and since Aug. 2011 have done 2-3  1 hr. sessions of yoga per week with a personal trainer. This has helped me tremendously gain strength, confidence, energy and my breathing.

My yoga teacher is aware of my COPD and  has read up on poses good for the lungs. She now wants me to do planks to strength my core and abs. I can get in the position and hold it fine. However, because of the straight position (similar to a pushup) I can't get in a full-inhale because of the position of my diaphragm.
Is this okay to do with my lung disease? I am a little anxious doing it because it restricts my breathing, but if it will get better with practice I'm willing to do it. What do you think?

Also, my pulmonary dr. doesn't have the best bedside manner. I asked him about doing pulmonary rehab (at least the exercise part with the respiratory and physical therapists.) He told me pulmonary rehab was for those who couldn't exercise on their own and I was capable of doing this on my own. I'm thinking the extra support and expertise would be helpful!

Thanks for your input.

Moe

Hi Moe,

First you are to be commended for exercising on your own.  In my opinion, one can do most anything they wish - including the strenuous yoga positions - as you describe.  Yes, breathing is restricted by the position.  BUT, it presents an ideal opportunity to learn to control your breathing more with your 'abdomen' while in that position, despite the restriction.  So, I would encourage you to continue.

Since you are indeed exercising well on your own, it is hard to justify the expense of pulmonary rehabilitation, especially since you are able to be so vigorous as your condition currently allows.   So, save the pulmonary rehabilitation for a future time when you may find you can no longer effectively control your symptoms and are less able to exercise so vigorously.

The Internet and forums like COPD-Canada provide ample opportunity to continue to learn more about your disease and how to live well with it.  So, there is plenty of "expertise" to be gleaned through your own efforts and searches.

Keep up the good work!

Best Wishes,

Mark

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Treadmill Walking Vs Land Walking

Why is it that I can walk on a treadmill with no problems, but when I walk off the treadmill, e.g. outside or even in a mall, we become short of breath..nobody seems able to answer this question. It's not just me...I have spoken to others in my BreathWorks program and they have the same problem.

thanks

Norma

Hi Norma,

Yours is a common complaint that seems to be related to the fact that on a treadmill, with the belt coming to meet your feet, you don't do as much work at a given speed as you do when you move the mass of your body from 'point A' to 'point B' as when walking on land.  Add to that terrain variations and the fact that you're also not able to "hang on" to rails, as on a treadmill and you have significantly more work when free-walking than when walking on a treadmill.  If you were to add grade to the treadmill, you would see an increase in your work to breathe that compares to free-walking on land.  I'm not recommending adding grade.  Indeed, if you add anything. add speed until you reach your maximum comfortable walking speed (somewhere over 3 mph)  Then add grade or interval increases and decreases in speed with an 'easy trot' when moving faster - all this ONLY if possible and tolerable.

Just remember to make yourself breathe HARD when you walk on the treadmill so that it will better translate to  similar work when free-walking on land.

Best regards, Mark

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PFT Info Review

Hi, I have been recently diagnosed with COPD as a "former cigarette smoker with wheeze" and am trying to better understand my PFT numbers, specifically
       
                           Pre Bronch                                                                   Post Bronch   
                           Pred   LLN       Actual   %Pred                                Actual     %Pred   %Chng

FVC (L)               3.32   2.64       1.86       56                                      2.04         61        +9
FEV1 (L)             2.60   2.04       0.98        37                                     1.22         46        +24
fev1/fvc(%)           79      69          53          66                                      60           75        +13

Lung Vol.
TLC (pleth) (L)    4.90  3.82        5.06     103
RV  (pleth) (L)     1.83  1.07        3.13     171
RV/TLC (Pleth) (%) 37  26           62       167

I am a 54 yr old caucasian female, 84kgs, 160 cm.,  with a history of smoking about 15 cigs/day for approx 32 years. I quit 5 years ago. I had bronchitis at Christmas that just wouldn't go away and was given antibiotics, but my breathing difficulties continued. I am currently using Advair 250 and Spiriva which seems to help.(I don't know what would happen if I stopped using them)
I have been told the deficit is severe, but I feel fine and have never had any problems until I had bronchitis. Could the test be incorrect and the results be skewed because of the bronchitis? When I calculate the numbers as a percentage of LLN rather than pred I get a slightly different story. Do you need more info?
Thank you for your help.

Laura

Hi Laura,

Your PFT shows significant airflow limitation AND evidence of increased "resting lung volumes" indicating fairly significant COPD.   As well, you also have a clinically significant response to bronchodilators (an 'asthma' component.  So, I would say that you indeed NEED to continue the Advair and Spiriva, as they are exerting a significantly beneficial effect. 

I doubt that the results are erroneous, as such limitations as demonstrated on your PFT, while certainly subject to the potential to reflect acute illness, when present, are not going to change all that significantly from your baseline.

That said, that you don't 'feel' all that limited is a GOOD thing!  Being able to function - especially from a physical point of view - without significantly limiting breathing difficulties is your best news AND a factor with which you should be able to improve your breathing and function by adopting a regimen of exercise that will serve to keep you enjoying minimal functional limitations for some time to come. 

So, get out and exercise like mad and make yourself breathe HARD while doing it.  Remember, working hard to breathe, though uncomfortable, will NOT harm you!  It will serve you well to desensitize yourself to what lies ahead in the coming years.

Your FEV-1 of 46 % while significantly reduced, is not low enough to produce significant symptoms during mild exertion.  If you try to run a marathon, you will certainly feel the effects, though.  Still, as others with similar airflow limitation have found, even running a marathon is not a possibility that is out of the question.  I always remind folks that one with "normal" lung function who undergoes removal of one of their lungs is physically reduced to 50 % of their capacities as measured on a PFT.  Yet, folks with one lung DO run marathons - though with having to do much more work to breathe while doing so.  So, again, the bottom line is, you have plenty of lung capacity with which to work.  Don't be afraid to use it!

Best Wishes,

Mark

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COPD & Hope

Hi Mark,

One of the things that I hold on to is some of the good news that comes by us regarding all the strides they are making to cure or stop the progression of this disease. You can exercise all you want, you can run in a marathon, you can go beyond the call of duty with your exercising and doing absolutely everything
right to fight this disease, but without this element to keep us motivated all will be for not.
The element is " HOPE ". WE are all done without it.

I think there should be more discussion and information about what they are working on around the world to help this disease.
As an example.
University of Pittsburgh Announces that COPD is an auto-immune disease.
Stem cells show great promise in rejuvenating lungs with COPD
60 Minutes shows lungs, heart, ears nose being grown in a lab.
People now living far longer than before when receiving a double lung transplant.
Now available non invasive lung reduction surgery.
This Mark is just the tip of the iceberg.
Without HOPE we really have nothing. Hope is what sustains us even through our exercise, because we know if we can last a bit longer, there will be something to come on the scene to help us.
So when you answer Mark someone who is scared that COPD is a death sentence, you have always answered correctly by saying it is a progressive disease
with no known cure at this time. Just do not leave out the " HOPE "

Hope ( no pun intended ) all finds you and your family well

Regards Philip

Hi Philip,

I couldn't have said it all any better than you did.  Hope MUST be an ingredient and an inspiring force in the life and mind of anyone with COPD - - - and many other chronic diseases, as wel, for that matter - - - if they are to survive and thrive in the face of the difficulties attendant with having those diseases.

As well, we can't forget "purpose", which goes hand in hand with hope.  If you haven't got a purpose for getting out of bed each morning and living life toward a positive end, then you are doomed, as well.

While having worked with 'older folks' so much of my career, I can tell you of the warning signs I have come to recognize that bode poorly for folks' survival and thriving.  When one loses their reason for living, hope goes with it.    And even a chronologically young person can meet an earlier demise than would ever be likely.

So, the message for all is to stay engaged/involved with life and living and realize that despite the troubles you may face in living life to the fullest, you have something to contribute to the world and a good reason to trudge on - even in the face of adversity when things get rough

Thanks for reminding us of these important points!

Best Regards,

Mark

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Tech Smart Dose Regulator & The Importance Of Exercise

Mark,

I cannot thank you enough for your answers.  Yes you are right Houston is a great town for people in my condition, I did not do enough investigation on my own and was not put on oxygen early enough and did not know about physical rehab until I ask for it four years ago.  Like everything in life you need to be your own best advocate.

The regulator that looks the best to me is Tech Smart Dose because I am a very active person who forgets to turn back my regulator.  I love the idea that it regulates itself and frees you up.  Does it really do what it says it will?  I have become afraid of not getting enough oxygen and this would help eliminate a lot of my apprehension.

On the subject of me being too thin; I have loss most of my weight the last few years since I started working out so much.  I think I really eat a lot.  My body mass index is 19.1 and the good range for my age, height and weight is 18.5 to 24.9.  It does not say anything about % but if I read you right I need to get to the 24.9?  If this is true I guess I need to eat more.

Also the rehab here in Houston, did not push you that much.  They were good but they never ever gave you goals to obtain.  Is there a good exercise program for someone in my condition or a site I can go to that will help me stay as strong as possible.  Is there a book on exercise that would be good for COPD patients?

I am so glad I have found your website.  It has really inspired me to keep on keeping on.  You have so much knowledge and you are wonderful for sharing.

Lillian

Hi Lillian,

The smart Dose 'should' indeed be able to deliver the oxygen you need.  BUT, you can't rest on my guarantee, alone.  Get one and check your oxygen saturation during all manner of activities so that you can learn what it does for you. 

Remember, no matter what device or system you use - if you find that your saturation drops significantly AND there is no better system out there for you, realize that your next option is to slow down or stop and rest as needed to recoup and keep your saturation within therapeutic (and comfortable) levels. 

Remember, also, that exercise and the improved conditioning that comes through doing it will also help you breathe better AND improve your body's efficiency at using the oxygen that you CAN get into your system with your 'frumpy' lungs!

Best Wishes,

Mark

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PFT Review  - COPD?

Hello Mark, Once again I seek your advice this is for my husband.  He was a very heavy smoker but gave up when he was 50, now he's 65.  He got worried as when he was doing some very hard work awhile back he felt he wasn't performing well and  got tired quicker than usual, so he saw my lung doctor who gave him a spirometry test.  The results were very good,  I write them here:  FVC 104.4 %, FEV1  102.3 %, FEV1 VC/MAX  106% PEF 129.5 %,  FEF25  97.5 %.   Now  FEF50 57.6%,  FEF75  42.7 %,  MMEF/7.5/25  69.9%.        I have written % as it's much easier.  However  the FEV1,FVC PEF are excellent for someone who smoked for 35 years, and the doctor hasn't given any treatment .  However, he doesn’t' understand why the other readings are so low, and indeed what these initials mean.  He feels these low % factors could be why he felt tiered when doing some very hard digging (with pickaxe)   Could you possibly explain to us the significance of low reading of FEF50 FEF75 and MMEF, when everything else is so good.   Thank you very much.  all the best,  Valerie

 

Hi Valerie,

Your hubby's airflow is GREAT!  And, accordingly, he has no evidence of 'clinically important' COPD.  That said, when you get to looking at FEF at 50 and 75 %, you are looking at airflow in the small airways - where evidence of COPD first shows.  AGAIN, that said, your hubby doesn't have changes significant enough to make the reductions in his small airway flow culpable in his complaints.  The MMEF is simply a reflection (relationship) of the expiratory flows reflecting the individual measurements as a comparison.

Much as I hate to suggest - your hubby is 65 years old.  And slinging a pick axe and doing the hard work you describe SHOULD make a man tired - even a younger man.  I would suggest that perhaps his expectations for himself and what he thinks he should 'easily' be able to do may be a bit inflated, when one considers age.   That he can manage to do that kind of heavy labor AND 'only' get 'very tired' is GREAT and would likely make many younger men feel a bit wimpy.

In any case, my bet is he'll be around for a long time and the likelihood of COPD becoming a significant difficulty in his life is quite doubtful.  Indeed, I suspect, he is one of those lucky ones who has the 'good jeans' that allow him to be in that percentage of the population that can smoke heavily and yet NOT develop COPD.

He needs to worry more about crossing the street in heavy traffic, playing golf in a thunder storm or getting shot by a jealous husband (or his lovely wife)  (thoroughly kidding on that last one, of course!) before he needs to fear COPD as any likely part of his foreseeable future.

So, tell him to keep slinging that pick axe AND exercise more for endurance-building, which will increase his tolerance of such strenuous activities!

Best Wishes, Mark

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Can You Recover From COPD?

Can my mom ever recover from COPD?

Heather

Hi Heather,

Would that I could wave the magic wand to make your mom better, that is simply NOT in the cards.  COPD is a permanently damaging disease, irreversible at this time and progressive in nature.

The best we can hope for once one is diagnosed, is changes in lifestyle, effective treatment for symptoms and complications to slow the rate of progression.  It is very much a "move-it-or-lose-it" disease.  That one regain as much health and function and become every diligent in exercising to gain and maintain strength and improve symptoms is absolutely imperative.  It is also MUCH easier 'said' than 'done'! 

Because shortness and difficulty of breath and breathing are hallmark to the disease AND because challenging breathing with exercise and movement feel simply horrible as the disease progresses - and because such difficulties seem like they will harm one who continues to move while experiencing them - AND because those who care about the sufferer have difficulty watching the struggle, desiring to ease difficulties by doing more and more for them - there results a major hurdle to being able to effectively manage rate of progression with the singlemost effective means to doing so.

So, your quest is to help your mother get moving and keep moving.  She must learn that she CAN challenge her breathing, feel very bad doing so and still come out down the road in better shape than she was before AND in better shape than she would be if she didn't endure the difficulties of moving. 

Nutrition is of great importance to avoid dropping weight as time goe by, such that ideal body mass falls below 100 % of predicted for age, gender and height.  Using medications and - when the time comes that it is evident that oxygen becomes a necessary intervention - using oxygen properly are the other major components for keeping the rate of progression in check.

Keep asking questions and learning all you can.  Your role in helping your mother do well in spite of her disease is a very important one, indeed!

Best Wishes,

Mark

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Mucus Problems

Hello Mark -
I have COPD and bronchiectasis diagnosed 9 years ago
I have been on oxygen for over 2 years, right now 2.5 LPM walking. 1.25 LPM sleeping
I cough between 200 and 300 times a day to remove mucus from my lungs
I am on 8 medications and use several machines to help me breathe
I use a VPap machine all night to help keep CO2 down
I am having more and more difficulty getting the mucus out as it's so thick and sticky.   
     I do use the little white pipe vibrating ball thing  which helps a bit
     My wife pounds my back 20 minutes a day
     I have been to the West Park Rehab. Centre for their full program

Any ideas for what else I can do to get this mucus out?  Thanks

John

Hi John,

You didn't say if you are using Mucinex or other preparation of guaifenesin.  If not, that might be worth trying.  Many folks find NAC (N-Acetyl Cysteine) a nutritional supplement (over the counter) of benefit in helping to thin mucus for easier expectoration.

Breathing steamy air (for those who can tolerate it) - as in a steamy bathroom - helps many folks to loosen and bring up mucus.

There are other more 'robust' positive pressure - with and without vibration - devices like Acapella, Resistex and others.  They exert a positive pressure - and in the case of Acapella, add vibration to your airways - during exhalation which helps to mechanically move mucus.  What you describe using is the "flutter" valve.  It is convenient, but doesn't exert a very forceful vibration.

There are several devices that are of a higher level of effectiveness - and cost - that do a much better job of moving mucus.  My first recommendation is one of two positive pressure devices.  MetaNeb is a device that delivers an aerosol and two levels of pressurized vibration. It is convenient and easy to use and less expensive than the next device I recommend. 

IPV (Intrapulmonary Percussive Ventilator) is a more robust version of MetaNeb.  It has a higher pressure and vibration capability and also delivers an aerosol with the vibration through positive pressure breathing.  It is very effective, though expensive.  And, while I think it is available in Canada, I don't know what the ability to get it covered by your health care benefits is.

Many recommend high frequency chest wall oscillatory vibration using one of the three versions of 'vests' that are on the market.  Personally, I don't like vest therapy (as much ballyhooed as it is most everywhere) as much as I like positive and negative ventilatory maneuvers provided by IPV, MetaNeb and the Hayek device (described in the next paragraph).  But, if the vest were to be all you could get, it would suffice. 

A new device finally on the market in the USA, but long available in Europe is the Hayek chest curiass high-frequency ventilation device.  It does pretty much the same thing as the IPV and MetaNeb, but does it with "negative" pressure on the outside of the chest wall, rather than exerting positive pressure against the airways internally, as with IPV.  I don't know the availability of that device in Canada, either.  It is VERY effective at moving mucus.

One other intervention worth discussing with your doctor would be the use of 'nebulized hypertonic saline'.  You breathe in saline that is about 7% concentration which pulls water into the mucus in your airways and thins it out.  This is used in the bronchiectasis we see in Cystic Fibrosis, but has similar application in non-CF bronchiectasis. 

At the very least, if your wife is pounding your chest (percussion) then you should ALSO be using postural drainage - positioning your lungs so as to recruit gravity to help 'drain' your airways.  There are lots of descriptions on-line for positions that would be effective for your needs.  If you are not using postural drainage with the percussion she gives you, then you are missing a big - FREE - piece of the puzzle that can help improve your mucus movement, immediately.  Be sure to do Postural Drainage and Percussion within 30 minutes after using your aerosol (nebulizer) medications for best mucus movement.

I hope somewhere in these thoughts you find something to add to your regimen.  If not, let me know and we'll see if we can think of yet others.

Best Wishes,

Mark

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When Will Oxygen Be Required & What Does Moderate To Severe Mean?

Hello,

My husband has just been diagnosed with COPD Moderate to Severe.....what does that mean?....Can we expect to lead a normal life with this diagnosis ?...At what stage does a person with Mod-severe need oxygen.

Thank you for your help
Terri

Hi Terri,

I'm afraid I can't very well answer your questions beyond a general response because the term "moderately severe" or its variation "moderate to severe" as used in your hubby's case, tells me nothing specific.  Indeed, the days when "moderately severe" as a characterization or label for COPD was acceptable are LONG gone, having been replaced by a world-wide standardized severity grading system under GOLD (Global Initiative on Obstructive Lung Disease).  GOLD classifies severity of COPD in "stages" - stages I, II, III, IV according to FEV-1 and FEV-1/FVC ratios derived from pulmonary functions tests.

What will help is knowing what your husband's "FEV-1" measured on the pulmonary functions test (PFT) - a test he should have had done - that revealed his COPD diagnosis.  If he has NOT had a PFT, then a return to the doctor who made the diagnosis would be in order to demand that the test be done.  It is unconscionable to diagnose and treat someone who is said to have "moderately-severe COPD" without having first established the diagnosis with a properly performed PFT.  If indeed he DID have a PFT, then you should call and ask what his FEV-1 and FVC measured on that test. There should be absolutely NO reason why they would hesitate to give those numbers to you.  AND ALL COPD patients (IMO) should "know their numbers" (FEV-1 and FVC)!

Some times a physician will run a CT scan and make the diagnosis from that.  While a CT certainly "shows" the tissue changes of COPD, it in no way characterizes the "clinical" severity of the disease - a much more important and meaningful measure that tells us how well a person "functions" and is able to live life with their level of disease.

COPD is a progressive disease.   It will gradually worsen over the years.  The key to keeping the rate of progression as slow as possible is "movement"! COPD is a "move it or lose it" disease.  While moving can bring on significant breathing difficulties and symptoms, the trick is to learn that breathing hard and being VERY uncomfortable (1) will NOT hurt a person - even though it may FEEL like it will kill them (smile) and (2) will actually allow them to keep moving and functioning very well while improving the severity of breathing difficulties as they get in better shape and stay in that improved condition.

Oxygen is most often not part of the picture until one's COPD has reached an extreme level of severity.  An FEV-1 of less than 30 % is almost ALWAYS a necessity to see hypoxia (low oxygen levels in the blood) that requires oxygen therapy to correct.  Often the FEV-1 is found to be much lower for oxygen to be necessary, though necessity for use of oxygen is NOT specifically or obligatorily tied to FEV-1, per se.

So, if indeed your hubby falls into the category of "moderate to severe" as it 'used to be referred, he is still some years away from needing oxygen.  You didn't say how old he is or anything about his history (especially that of smoking).  So I am at a loss insofar as being able to ascertain anything that might be an influence of age.

So, the bottom line is you have a lot of good questions that cannot be answered until and unless you gather and provide much more information.  Feel free to come back and post your questions again once you have obtained the information I've suggested.

Best Wishes,

Mark

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COPD & Sinus Infections

Is there any connection between COPD/Asthma and sinus infections. I was diagnosed with COPD last year and was prescribed DAXAS in August. Since then, I have had ongoing sinus infections that cause runny nose, congestion and cough. I use a saline solution daily but
there is little improvement. Is the sinus problem a symptom of COPD or could it be the DAXAS. Appreciate your input....Ron

Hi Ron,

While folks who have COPD often have problems with sinus infections, that they are necessarily caused by or a necessary part of having COPD is not established.  Daxas does have some side effects of which rhinitis and sinusitis are included.  Your doctor should be able to tell you if Daxas is suspect in your difficulties.  As well  a consult to an ENT specialist should be of help in discovering the cause of your difficulties and perhaps a good course of treatment.  Don't simply stop the Daxas without first collaborating with your doctor(s) and looking for alternative solutions.

Best Wishes,

Mark

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Daxas

I have had asthma for a number of years and was taking symbicort, singular and spiriva and they allowed me to carry on with my life in a normal fashion. Things changed last year, when I had pneumonia in January, later a viral infection that lasted two months and in  the spring I was experiencing difficulty breathing with many panic attacks. In August I was put on Daxas and despite some bad effects, my breathing improved. I have experienced  insomnia and I am presently taking trazodone with good sleep results. Since being on Daxas my sinus's are mildly infected most of the time with a runny nose and nasal congestion. Is this a common occurrence with Daxa`s.
I am using a saline solution 2-3 times a day and while this clears the nasal passages, this infection does not go away.
My latest breathing test in February indicated I was at 51% capacity. I still have breathing difficulty when exerting myself so I have been hesitant in doing any exercises although today I will give it a try on my treadmill.
Is Daxas the answer for long term management of COPD.

Ron

Hi Ron,

Since this post seems to be an elaboration on a previous post describing the same problem(s) and somewhat the same questions, I'm going to assume that you are the same Ron who posted the previous question.  If you are not one and the same person, I apologize for the erroneous assumption.  But, my response to that query holds true here, as well.

To answer your additional questions: Daxas is only one piece of the COPD management pie.  As such, it does not hold any broad benefit or singular basis for COPD management, but rather works with the other pieces to produce an overall improvement in symptoms.

With an FEV-1 of 51 % of predicted, you have PLENTY of lung capacity.  Even though you may experience some hard breathing with exertion, you should strive to exercise despite the hard breathing.  Indeed, you should target "achieving" significant windedness and work to breathe in order to improve your long term breathing and reduce the degree and impact of breathing difficulties and symptoms.  To decide not to exercise because of some mild breathing difficulty can be the kiss of death over the long run.  The more one avoids breathing hard with COPD, the faster it progresses and the sooner they die.  That may sound harsh.  But it's simple and it's true.  Don't get caught in that trap!

Best Wishes,

Mark

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NAC

I see  people referring to NAC...what is it and what are its effects on COPD?

Heather

Hi Heather,

NAC is "N-Acetyl Cysteine".  In the body, NAC acts as an antioxidant.  In the lungs, it does two things that are of major benefit.  It helps mobilize mucus for better clearance from the lungs.  It also stimulates production of glutathione in the longs - an anti-inflammatory substance that decreases airway inflammation.  It is sold as a nutritional supplement and is recommended in doses of 1200 - 1800 mg/day along with 1000 - 2000 mg vitamin C which helps prevent the metabolites (in this case 'salts') of NAC from forming kidney stones.  It is generally a good thing for folks with COPD to consider using. 

Best Wishes,

Mark

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Oxygen Eqpt & Usage

Mark,

I have COPD, I am 73 woman.  I am on Oxygen 24/7 for the last 2 years.  I am fine at home because I am on a concentrator to get my oxygen and on one at the gym where I do my exercises.  I actually turn it up to 5 liters to excercise to keep my blood oxygen in the 90s.  I am very thin, work out as much as I can when I am not sick.  Another words I am really trying to be as active as possible. 

Here is my problem.  To go out shopping etc. I carry a bottle of pressured oxygen with a regulator with a demand setting.  When the oxygen in the bottle drops down I can no longer pull the oxygen out.  I have tried two different types but I am not having any luck keeping my oxygen levels up when I start moving around.  Is there someone who can test me and find the right system for me so get out of the house and stay active for as long as I can.

I live in Houston, Texas.  I wish I lived in Colorada because things are more advanced there because of Dr. Petty.  I know there has got to be an answer for me.

Thanks for your help in advance.

Lillian

Hi Lillian,

First, you say you live in Houston, TX, but suggest that medicine and medical practice are somehow not up to date or up to par, let alone comparable to Denver, CO.  While Denver arguably has some world class lung facilities - and as Tom Petty played a large part in bring notoriety to Denver, his influence reaches far beyond Denver as a significant part of what we call the standard of care, today throughout the practice of pulmonary medicine.  Another point to consider is that Denver is at a mile high altitude which makes having lung disease AND hypoxia especially difficult, since that altitude carries it's own inherent set of negative influences on one's breathing and oxygenation!  Those who use oxygen require much more than those living closer to sea level like you in Houston and me in San Antonio!  

I would also remind you that Houston has some world class medical facilities and is no slouch in the medical field, by any means!  That doesn't mean that those who serve you aren't up to par with the general level of practice in Houston.  But, that is neither here nor there.  You have available all the services and quality of service you need right there in Houston!  So, let's see if we can help you with what information you need to obtain those quality services.

If you are very thin, I am concerned that you are maintaining sufficient body mass to keep your disease progression and symptoms to the minimum possible.  Check to see if your body mass meets predictions for "ideal body mass" for a person of your age, gender and weight.  If you are not greater than 95 % (and it would be better to be at or over 100 %) of your ideal body mass, then you need to put on some weight.  It is a common finding that folks who have advanced COPD (as indicated, especially in your case, by the need for oxygen 24/7) die sooner than they would if they had greater body mass AND they suffer worse symptoms during survival.  So, consider what influence your "thinness" may be exerting on your symptoms and even your need for how much oxygen you use.

If you need 5 liters of oxygen from your concentrator to maintain saturations in the 90's during exercise, then you surely need that equivalence when out and about using your portable oxygen system.  It is obvious that the conserver you are using is NOT putting out nearly the equivalent of 5 L/min compared to continuous.  In fact, there are only a few compressed gas conservers that can achieve that kind of output.  You need to ask for them specifically by name/model and accept NOTHING different, as other simply will not compare or measure up.  Puritan Bennett CR-50, Salter Labs O2Xpress and Inspired Technologies Smart Dose are really the only ones that can deliver the amount that you need.  Ask for them and have your saturation measured during several minutes of walking and activities similar to shopping, etc.

As well, understand that the size of the tank you use determines how long it will last.  If you are using M-250 also called B-cylinders, you must understand that using as much oxygen as you do when walking, they will not last but a couple of hours.  If you are walking then sitting for spells, be sure to turn DOWN the flow so as to stretch the supply for a longer duration. Try using C-cylinders and D-cylinders whenever possible.  Even putting an E-cylinder on a cart and schlepping it along behind you will increase your supply duration.

But, the natural and expected phenomenon of using the gas in the cylinder will result in the pressure drop you see to a point where you will not be able to get any more oxygen out of the tank simply because the pressure has dropped too low to power the delivery device.  This is usually somewhere at or below 150 pounds pressure in the tank.  So, the problem is NOT with the system or any malfunction.  You are simply observing the results of having used up all the usable oxygen in the tank and need to be prepared to change it out for a full one so you can continue your away-from-home activities.

You sound like you're working hard to keep yourself in the best shape you can.  Keep up the good work.  I hope this information will help you get a better portable oxygen system.

Best Wishes, 

Mark

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Portable Oxygen Systems

Hi Mark...What do you know about the Helios Oxygen systems?  I want something very portable and very light while getting more time out of the unit before refill is needed.....I sure would also like continuous flow.....Let me know your thoughts.....hope you are having a good holiday....Thanks....Heather

Heather

Hi Heather,

Everyone wants the lightest oxygen system possible that delivers the most oxygen and lasts for a long time and can -provide continuous flow.  The fact is that unfortunately, this is truly one of those situations when you simply can't have your cake and eat it too!

Helios 300 is under 5 pounds - very light weight, indeed.  But is delivers ONLY pulsed oxygen - and not close to continuous flow equivalent, at that.  It lasts forever (10 hours at setting 2), but does so by delivering a stingy amount of oxygen along the way.  So, you get a long time of use, but are deprived of adequate oxygen while stretching the supply duration.

Helios Marathon is a bit larger and heavier, but delivers up to 6 liters of continuous.  The caveat is that at 6 liters continuous flow, you will use the supply in two hours.  so you sacrifice duration for the continuous flow feature.

With ANY liquid system (LOX), you will have to either return home for refills at intervals or carry a reservoir in your vehicle to refill from while out and about. 

Compressed gas cylinders offer some advantages in the categories you cite AND allow you to carry several cylinders for replenishment of supply without having to return to home base for refill, as with LOX.

Now a good conserving device will help you stretch ANY compressed gas system to as long or longer than LOX systems while still providing plenty of oxygen to keep you well-saturated.  Devices as I named for Lillian are those which I recommend for those who have significant oxygen demands during ambulation.  Take a look at my response to her for those device names and models. 

Best Wishes,

Mark

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Heredity

My sister and I have both been diagnosed with Emphysema. She continued smoking and still has not quit. I quit smoking 3 years before I was diagnosed with COPD. My sister has recently been diagnosed with lung cancer and will off course be getting treatment. Does this mean that I am likely to have lung cancer eventually also? I am a 59 year old female and my sister is 61!

Linda

Hi Linda,

While heredity DOES play a significant role in who gets COPD and who doesn't and as you and your sister both have it suggests that heredity is at play in your family, that you will necessarily get cancer too, is not possible to predict or foresee.  You quit smoking sooner, so "may" have less proclivity to develop it.  At the same time, heredity could indeed play out such that you end up developing cancer somewhere down the line, too.

No one can say one way or the other.  All you can do is to continue to live as health and best as you can and stay as active as you can.  Don't live your life fearing and behaving to avoid getting cancer.  Live your life for the best each day can bring.  That way, if you DO someday develop cancer, you won't have regrets for wasting your time in the meantime.

Best Wishes,

Mark

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Frequency Of RT Visits

Hi Mark
My name is Marie and I was diagnosed with COPD June 2006. I am 64yrs old.
I took the Pulmonary Rehab course with Surrey Memorial Hosp and continue on a maintenance program with the YMCA in Surrey BC

The last time I saw my RT, she told me I did not have to comeback as my lungs had not changed in 2 years. She said to keep doing what I am doing.

My GP has some knowledge of my condition.
I used to use oxygen on exertion and overnight, I am finding that I no longer need if for exertion and am looking to be tested for that again soon.

My question is do you think it is ok that I am no longer seeing my RT and I should I continue to listen to my body and carry on.

Thank you
Marie

Hi Marie,

It sounds like you are doing fine.  I would suggest seeing who you think you need to see at intervals that "you" are most comfortable with.  Keep up your exercise at the YMCA. 

Why not purchase an oximeter to measure your saturation under multiple conditions to be sure you do or do not need oxygen any longer.  Oximeters are cheaper now than they've ever been, running as low as about $40!   To simply stop using oxygen because you "feel" you don't need it is not a good idea as you could be desaturating to levels of concern during exertion and not feel it.  Going by feeling is NOT a good method for determining when to use oxygen.

Best Wishes,

Mark

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I Have Emphysema

I have been told that I have emphysema and that there is nothing to do about the disease except the usual  puffers  ? May I have your comments ,please ??

Ken

Hi Ken,

To say that there is "nothing to do about the disease is a complete mischaracterization of the facts!  While the "puffers" you speak about are  mainstay of the inhaled medication management of symptoms of the disease, they are not the only medications that may be of  value.  At the same time, there is no 'magic bullet' that can stop the progression or reverse the tissue damage or the like.  COPD (which includes chronic bronchitis and emphysema as predominant diagnoses under the umbrella term)is a progressively deteriorating disease, the rate of which can be slowed by proper nutrition, exercise and smoking cessation, among other things.  Folks can easily live 20 and 30 or more years with COPD before it becomes bad enough to cause their demise.

So, to say that there's nothing more than the puffers to do about COPD is simply wrong and short-sighted.  Folks who sit around, do nothing and feel sorry for themselves will deteriorate rapidly and be miserable in their remaining time alive.  That doesn't have to be.  Indeed, next week, I am cruising the Caribbean for 10 days with the SeaPuffers - a group of folks who have advanced COPD who ALSO use oxygen therapy.  They are FAR from giving up or even slowing down because of their now-advanced disease!  So, it will be what you make of it - no more and no less!

Best Wishes for a bright future DESPITE having COPD, Ken!

 Mark

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Oxyview Glasses

If you are using pulse dose can you still get oxyview glasses or does it need to be continuous?
Tom

Hi Tom,

The answer is: It all depends . . . "  It depends upon which pulsed dose device you are using and how sensitive it is to being triggered by your inspiratory effort.  If you contact the folks who make OxyView spectacles, they should be able to tell you, if you tell them what machine you use.  If not, ask if you can demo a pair or get a guarantee for your money back if they don't work for you.  I have known the makers of OxyView to be very accommodating and reasonable with their customers.

Best Wishes,

Mark

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Undetermined Diagnosis

Hi
First of all I would like to describe my health issue's. I have been coughing for a very very long time and I have had the pulmonary test done by Dr Rahimi and she ruled out asthma. I have had my sinuses surgery last year Mar 24,2011 by Dr Turner.  I also had the tube put down my throat to check for things and he did not see anything wrong with my throat area.  Dr Telang did a esophagus test and seems to think that my esophagus is not working the way it should. 
So my family Dr Pratt has put me on inhalers to help me breath and it does not always do the job.  I have been on the inhalers for a long time now and I want to know how safe it is to be on the inhalers like that.  My cough is a wet and very rattling cough; especially on my left side it really rattles and I can feel it rattle and my husband hears me at nite when we are asleep. I have had this for so long and not sure what to do any more.  I cough all the time and I am tired of it. My inhalers are APO-salvent(blue inhaler) I take this one every 5 hours or so 2-3 puffs and my other one I take at nite to help me is Alvesco -2 puffs at nite before bed. I get SOB lots and it is scary when you can't get your breath. I think that I may have  bronchitis because my Dad used to cough a bit if I remember. I just don't want to cough any more.
My question is I don't know what to do anymore I am at the end of my rope and so tired of it all and I want to know where do I go to really check into this and if it is safe to be on inhalers every day?   I have ask Dr Pratt to help me but I am not so sure she can. I wish I could just get one Dr to help me out and believe me.

Jean

Hi Jean,

I'm sorry to hear of your difficulties.  Are you telling me that while your doctors have ruled out asthma as a problem, they have not given you ANY diagnosis?  Have they mentioned bronchitis, or chronic bronchitis, since you speak of having lots of mucus production?

Have they opined that perhaps your sinuses are culpable in your cough and mucus production - a fairly common occurrence  in folks who have significant sinus illness?

If your cough were dry and hacky, I'd suspect the potential for an interstitial diseased process, like pneumonitis of some kind or a collagen tissue disease or fibrosis process, or something.  Those types of ailments are detectable using high-resolution CT scan.  So, if you haven't had one of those, then that might be worth asking about.  You say you've had the breathing tests.   But, you didn't say what ANY of your numbers were.  Do you know what your FEV-1, FVC  and TLC and/or DLCO were found to be on that pulmonary functions test (PFT)?

In the end, I can't tell you much of anything because you only vaguely described the testing you had done and didn't provide any "numbers" to tell me specifically, or in lingo "I" can understand what might be going on.

In any case, it is safe to use inhalers for many, many years.  Many folks have safely used inhalers - in some cases, the same ones - for well over 15 and 20 years.

Best Wishes, Mark

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Working In A Manufacturing Plant

I have just been diagnosed with COPD, and I work in a furniture manufacturing plant with saws sanders and other industrial size machines is it still possible to keep working at that job, I haven't smoked cigarettes for about 7 years, thank you. I'm 53 years old

Chris

Hi Chris,

There is no reason why you should give up your work, especially if you love doing it.  You SHOULD and MUST take precautions to interrupt the exposure to the harmful inhalants you undoubtedly have taken into your lungs so as to minimize and further exposure or danger of reaction to inhaling those substances.

Stay away from glues and varnishes in poorly ventilated areas.  Wear a mask to filter out sawdust and small particles. so you don't continue to inhale them.  They are your worst enemy, by far.  Use your inhalers.  Get plenty of exercise.  Stay balanced in body mass and nutrition,  Exercise to optimize your physical condition and stamina.

Best Wishes,

Mark

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Alpha 1 Test

Can you explain the benefits of getting the  Alpha 1 Anti-Trypsin-Deficiency blood test? I have also heard that a person should look into having tests to check the functioning of the thyroid, especially, if, as I do, have hypothyroidism and have had for years.  Thank you, Dianne

Dianne

Hi Dianne,

Not too long ago, Aplpha-1-Antitryosin Deficiency Emphysema (the genetic form of Emphysema/COPD) was considered to be a fairly rare disease and one that not only did we not know much about, but had little ability to treat, short of drastic measures like lung transplant and enzyme replacement therapy.  As our understanding grew AND we saw new, more effective treatments coming to market, we increasingly realized that the disease is far more prevalent than we had earlier thought, indeed, a LOT more prevalent.  When the blood test to identify those with the defect became available, it was found to be easy to do, very accurate and not expensive (for most, it is free).   It has become increasingly clear that the only responsible thing to do today when someone presents with COPD, especially which is primarily emphysema and also especially if (1) they have insufficient history to suggest predisposition to developing COPD (smoking history, certain occupational or environmental influences, etc) AND if they are under the age of 60 at diagnosis or advanced stage, then they should be tested for the disease.

We know today that the sooner one is diagnosed, the better chance to treat and control it we have.

As far as the thyroid test you ask about, it may be true that if you or someone in your family has thyroid disease, you have a history of thyroid dysfunction or you have symptoms suggestive of a thyroid disorder, you should get checked and perhaps with regularity to detect problems and monitor interventions.  As far as one needing to check their thyroid function because of any connection to having COPD, I am not aware of any such correlation.

Best Wishes,  Mark

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Lung Condition Summary

I have severe COPD condition, my lung capacity is less than 50%.
Since last Sunday I have been on prednisone 50 mg and co azithromycin 250 mg
for exacerbation.
My shortness of breath and coughing has been increasing daily for a few weeks.
I have other problems with my lungs, such as unknown nods .Have had a broncoscopy a needle biopsy
and they are considering an open lung biopsy, I have had kidney and prostate cancer, worried about metasis .
I also have sleep apnea.
With my condition the open lung biopsy is probably questionable.
I have seen pulmonologist and urologist on a regular basis. Awaiting  to hear from them,
saw both last week.
I am an almost 77 year old grandfather.  Larry

Hi Larry,

You told me lots of good information about you and your condition.  But, after reading it over a few times, I don't see a question in there.  Do you have a question for me regarding your condition or anything within the information you provided?

If so, please try again next week and be sure to ask your question!  I'll do my best to give you an answer.

Best Regards, Mark

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COPD or Asthma?

My respiratory problems have GREATLY increased since I underwent 2 yrs. of chemotherapy (Rituxan, Cytoxan, Fludara) for Non-Hodgkin's Lymphoma (which is now in remission).
 
I've been told for about 12 yrs., that I had asthma, and it was pretty well controlled with Advair250.  In the fall though, I would usually get a bad case of bronchitis.

Then came the chemo.  In the middle of the 1st round of it, bad bronchitis emerged.  They gave me drugs to help, and we finished that round.  Four rounds and 2 yrs. later, the same thing always happens:  bad bronchitis emerges during the round, and lingers longer and longer with each round.  Since this last round (Dec. of 2010), I have been sick (bad cough, mucus, a bit of SOB) more often than not.  My oncologist minimized it.  He sent me to his favorite pulmonologist, who said "mild obstructive lung disease:  COPD/Asthma" but stressed COPD in our discussion.  The onc. & pulmo. are in NYC and I'm an hour away in New Jersey, so I also have a local pulmonologist whom I can get to when sick - his diagnosis, "asthma".

I have had spirometry, gases etc. by both pulmo's, and 2 chest CT's ("mild emphysema" shows on both, "ground glass" and "pneumonitis" only on 1st).  I smoked 1 pk.of cigarettes per day for 20 yrs., but quit smoking totally 21 yrs. ago.

I don't understand the "asthma" diagnosis, as my spirometry shows little change before and after bronchodilator.  I also don't understand the "COPD" diagnosis, as my spirometry is essentially normal (by my understanding of GOLD standards).  On Jan. 20th, 2011, just as I was getting another bit of bronchitis, this was my "after" spirometry:

FVC (L)             = 4.60 / 101% predicted    %Chg -1
FEV1 (L)           = 3.25 / 102% pred.           %Chg -1
FEV1%              = 71 / 101% pred.              %Chg 0
FEV25-75 (L/S) = 2.07 / 69% pred.             %Chg -6
PEF (L/S)          = 9.30 / 108% pred.           %Chg 4
FET (S)             = 8.71                                %Chg 11

So, from my understanding, the spirometry is good (except for low FEV25-75).

Does this look like asthma or COPD, or both (or neither)???

The worst part is I keep getting the bronchitis, over and over, and am on Advair, Spiriva, Albuterol as needed, Prednisone tablets as needed when sick.  Sometimes the only thing that makes it better is the Prednisone.

I am confused about the diagnosis, and my life is much more limited from the now frequent bouts of bronchitis.

Sorry for the long question, but it's my 1st one (and I've also become a bit afraid as to my future - things seem out of control).

Thank you,
Don

Hi Don,

According to your numbers, I don't see any evidence of Asthma OR COPD.  at greater than 100 % of the two most important values measured (FEV1 & FVC) and inview of the other measures you reported (including the 69 % FEF 25-75) nothing even suggests reactive airways disease (asthma) OR COPD.  So, I disagree with both diagnoses - especially in view of the CT scans and your history of exacerbation of your symptoms.

First, with the numbers you have, you shouldn't be having any breathing difficulties that are generated by any influence of lung function.  It is also possible that (1) you indeed have VERY MILD reactive airways disease that is absolutely 'normalized' by your medications or (2) your symptoms of difficulty breathing are a paradoxical response to the Advair which may be 'early-kill' or 'over-kill' for such mild disease, if it even exists.

Now the CT findings and the fact that ALL of your bronchitis episodes have onset during the middle of immunosupression therapy for your cancer are highly suspicious for a combination of infectious response to 'opportunistic pathogens' ("bugs") AND the finding of interstitial pneumonitis and ground glass appearance screams of just that diagnosis.  It also stands to reason why you feel better when you take prednisone.  You have had enough episodes that your pneumonitis has likely become a permanent feature of your lung tissue profile.  That being the case, you are subject to repeat bouts of bronchitis without need for immunosupression like that imposed during chemotherapy.  It is not surprising that the oncologist shrugs it off.  Those chemo agents (cytoxin, especially) are known to have an effect (interstitial pneumonitis and fibrosing changes) on the lungs.  Unfortunately, this is one of those times where the benefit outweighs the risk as in your case, it has out your N-HL in remission - a very good thing. 

Ask your doctors about trying the following: stop the Advair for a few weeks.  See what happens to your breathing.  Use the prednisone for perhaps a bit longer and at low dose and then repeat your PRE and POST spirometry in a month and see how it looks.  If your values drop be 20 % and you get a response of greater than 10 %, you will be able to say there is significant airway reactivity.  BUT, if in the interim, you get to feeling and breathing better without the Advair, then the question becomes which is worse, a bit of airway reactivity that doesn't produce significant symptoms or enduring chronic amplified symptoms secondary to a medication that you arguably may not need to be taking.

Best Wishes, Mark

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Very Severe COPD & Exercise

Hi Mark,I have severe COPD.on 02 3yrs.I am 5 1yrs old and have had COPD for 5 yrs or longer quit smoking  yr go .have trouble walking, but you explained that to me last week. I go only 50 ft.Saw my pulmonary Dr. last week.My fev1 has dropped to 11%i feel sick about that.I thought I would of got better as last yr it was 17.Ithe Dr. said don't worry about the numbers,worry about exercising .I do not go far. She said try to go 3 times per day. I know I need to move it. I bought oximeter through membership and keep an eye when on treadmill but my heart goes too high.145.the Dr's never said anything about it high. It is between 115-120 when sitting. I am waiting ekg.Eating healty,fruits veggies fish etcMy family Dr. put me on a lot of b vitamins   and iron were low.Please help Sue in Ontario I am scared if m fev goes lower, my Dr said we cant do any thing about the numbers?

Susan

Hi Susan

It is clear that you have very severe COPD, with such a low FEV-1.  Your numbers speak volumes to your symptoms and having great difficulty breathing, especially with movement.  Nevertheless, it is imperative that you find a way to get moving more and keep moving DESPITE the breathing difficulties that moving elicit.  That your resting heart rate is 110 and more says that your basic physical condition if very poor.  That ADDS to your breathing difficulties and CASN be improved with better conditioning.  But, as you well know, it is easier said than done.  At the same time, NOTHING else will potentially improve your condition, symptoms and function.  So, you must find a way to put your nose to the grindstone and learn to overcome the temptation to stop and or do nothing for fear of the breathing difficulties.  It WON'T hurt you to breathe hard.  And until and unless you can bring yourself to put up with the breathing difficulties AND keep moving, you cannot expect to have a chance to improve.  It's a tall order, I realize.  But, it is the ONLY way to a better life.  Don't worry about the 145 heart rate unless if causes symptoms in and of itself that become dangerous.  Talk to your doctor about that and what you should look for and avoid.  Be sure to use PLENTY of oxygen when exercising.  ANY drop in your oxygen level (say, below 93 %), will greatly amplify your breathing symptoms.  So, as much as is possible, you should try to use enough to keep your saturation as high as possible so as to move as much and as long as possible at a spell.

Best Wishes, Mark

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Pleural Pain

I have COPD.  I was admitted to hospital with pneumonia.  I was released Feb. 7.  I have completed the antibiotic and  prednisone regime I was prescribed.  I take spiriva, advair and singulair for my condition.  In addition, I take zoloft, xalatan, and zopoclone.  I am working to get well.  On or about Feb 12, I developed to a pain.  It is a nagging pain that is located in the location of my right breast and goes through to my back.  The pain at times is a catching pain that will cause me to utter out involuntarily.  I attended to my family physician Feb 16.  he examined my chest and said that it was clear, not rattling or wheezing .   He believed that the pain was cause by the pleura that was being disturbed and causing the pain.  When in hospital, I was visited by  a  respirologist  in hospital and he said I had a lot of damage to my right lung.  I have a lot of tests scheduled in May.  Meanwhile, I am wondering if the pain I have now will gradually subside or could it be something else.

Elaine

Hi Elaine,

Your pain sounds pleruitic to me, too.  All I can say is that we need to wait for you to complete those tests, as anything at this point would be wild speculation and not helpful with regard to anything you could or should be doing to help or avoid it.  Let's see what the tests show.

Best Wishes, Mark

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Spirometry Numbers Definitions

What do FEV1 and FEV5 mean?   I notice you people using these abbreviations and am stumped...is there somewhere I can go to get all this translated?   Someone has most likely already asked this but I am rather new to the site.....

Heather

Hi Heather,

What you mean rather than FEV"5" is FEV"6".  FEV6 is the same value by definition as FVC that you'll find in any set of references using FEV.  FEV1 is a forced expiratory maneuver that measures how much air you can blow out with your most maximal effort in the first second of your exhalation, when the measurement maneuver is performed. 

For a good explanation of all the types of tests done to obtain an assessment of one's pulmonary function, go to the following link and peruse the site.  For specific definitions and values of these two and other "spirometry" measurements, click on the link in the "spiromnetry" section that says "main article: Spirometry".  This is actually one of those times when of all the references I perused looking for one that is easily understood by a novice and lay person, Wikipedia actually turns out to be better, IMHO.

http://en.wikipedia.org/wiki/Pulmonary_function_test

Best Wishes, Mark

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You might also want to try http://COPDcanada.ca/pft_numbers.htm

The Use Of Fans

Does a fan help? 

(Q extracted from the Message Board)

And, can a COPD’er in fact breathe in their own CO2 enough when they’re laying/ sleeping (assuming their face isn’t covered with blankets) that it would have a negative effect?

It has long been observed that a significant portion of the COPD population shows preference for air blowing at their face or simply circulating the air in the room.  Indeed, the worse the person's FEV-1, the more they gravitate to fans as an adjunct (common observation among my professional colleagues and a good observation by the nurse mentioned by a respondent when she was in the hospital).  What ever the reason for benefit - reduction of claustrophobic sensations, facial cooling, trigeminal nerve stimulation, etc., the fact remains that despite definitive evidence of source of benefit, the response from those who rely on the method is consistent: "reduction of dyspnea."   

The notion that CO2 plays a part may have some validity to it but most certainly NOT from  any consideration of "stale air", lack of available oxygen or "re-breathing" exhaled air, as suggested by so many of the respondents.  One needs to understand the physics and chemistry of air to realize the impossibility of re-breathing under all but some very specific conditions (like breathing into a bag, as has been used over the decades to help thwart panic attacks in those who suffer them from a cause of hyperventilation).

The content of CO2 in the air is less than 1 % - virtually negligible, as a CO2 as high as 7.6 mmHg partial pressure would stimulate increased breathing in those with normal lung function (the 1 % threshold at sea level).  CO2 levels coming out of the lungs are a little under 6 % with dissipation and, consequently, dissolution occurring in a matter of milliseconds.  An example of the rapidity of dissolution is the respondent who was dysgenic in the "aisles of the grocery store, where air volume is monstrous compared to that in a closed car.  Yet, when she got closer to the door, her anxiety and dyspnea became noticeably decreased.  Yet no difference in available air volume occurred.  Then, when she went and sat in the car, her dyspnea went away completely.  That had everything to do with a psychological response to claustrophobia and nothing to do with air volume or availability of "fresh air" which necessarily was "LESS" in the car than ANYWHERE in the grocery store.  The warm feelings, etc, she experienced when her anxiety level rose in the tall-shelved aisles was a sympathetic nervous response, NOT the result of lack of fresh air to breathe.  That scenario exemplifies the strong effect that folks experience that can lead them to the erroneous conclusion that the force was 'real' and 'environmentally mediated', rather than what in fact occurs and is owing to psychological forces and influences.

But, unless one had the covers in bed over their head, the chance for re-breathing significant amounts of exhaled air is simply impossible.  The high collar sweaters and all, simply do not produce the effect cited by respondants.

So, the question becomes: "How can CO2 potentially play a part in the equation?"  As one with increasingly lower FEV-1 experiences dyspnea  and breathes faster in their effort to overcome it (tachypnea), they tend to move to the phenomenon of "dynamic hyperinflation" which by its mechanical effect causes an increase in CO2 in the blood because of less efficient clearance of CO2 resulting from the dynamic hyperinflation.  Saturation can be observed to decrease - not because oxygen levels drop, but because CO2 rises.  When CO2 rises, its influence on the acidity of the blood cause saturation to drop from ventilation-related causes, NOT from oxygenation related causes (another example of how saturation measurements do not reflect ONLY the influences of the amount of oxygen in the blood).  

The abstract is good information and has the best presentation of valid evidence, though difficult to confirm.  The contention with regard to the clinical practice guideline cited, that evidence is lacking to make the recommendation for using fans as a therapeutic intervention is just that:  There isn't enough evidence to support a scientific basis to make the recommendation.  That some like it and some can't stand it makes a case for a hard and fast recommendation unsupportable.

So, in the end, the choice needs to be left to the user and justification or explanation left to remain a mystery.  It is truly a situation where the adage applies: "If it feels good, DO IT!" 

Best Wishes,

Mark  

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Unusual Oxygen Saturation Readings

Mark,
  Firstly, you offer an amazing service! I have asked you questions before. Briefly, I am a 48 year old female with a 4 year history of shortness of breath on exertion. I have had elevated pulmonary pressures of 48 to 50 but a right heart cath showed a mean of 18 which is normal. My PFT's have been borderline normal. Last October, I had a TIA and the MRI showed 3 previous strokes. They do not know what caused them. I recently started cardiac rehab and the physiotherapist got me on the treadmill with a sat monitor. My sats are normal at rest but within minutes of walking, they dropped to 83%. My heart rate gradually increased accordingly and seemed accurate. They physio tried it on every finger but it stayed the same. As soon as I stopped walking, my sats went up to 100. The monitor was sitting in a holder so it wasn't moving and I was holding on to the treadmill so my finger wouldn't move. The scale on the left on the monitor would turn red when the numbers started to drop and then would fluctuate from red to green. The physio didn't know what to think. I was short of breath but I always am when exercising. This happened a couple of years ago and when the doctor repeated it with a different monitor, it did not happen. I hate to ignore it in case it might have something to do with these strokes. What do you think? Could it just not be picking it up? And if not, why?

Lori

Hi Lori,

I am concerned about your reported symptoms and what measurements you also have been found to have.  While a mean of 18 mmHg PA pressure may be normal, the fact that measures of systolic PA pressure are 48 - 50 is nevertheless abnormal and disturbing in themselves - also, especially in view of your elevated heart rate, shortness of breath and possible desaturation on exertion.

First, there may be a problem with the quality of measurement when your physiotherapist uses the finger oximetry.  You say that your fingers are not moving during the measurements that drop to 83 % and that motion is not a factor.  BUT, you are not considering "circulation artifact" which results from the variation in blood flow to (all) your fingers during "gripping" of the treadmill handrail.  The pressure exerted during gripping the rail impedes circulation to your fingers by compression of the 'palmer arch' AND digital arteries that branch off that arch.  The observation of the alternating signal quality strength light between red and green suggests that circulation artifact may indeed be at play.  As well, if your doctor did his/her measurements when you weren't gripping a hand rail, it would be no surprise that the same phenomenon didn't occur, back then.  But, since that was a "few years ago", it likely has little, if any, bearing on what's going on today as a lot can change in your condition over a couple of years time.

Next time your physiotherapist measures your saturation while you walk on the treadmill, release your grip and let your arm hang at your side.  No movement, no gripping, as still as possible.  See what happens then.  If the signal strength light stays green AND your heart rate goes up AND your saturation goes down, then you need to report that to your doctor, again.  With the fluctuations in PA pressures and their being elevated to 50 AND desaturation, tachycardia and tachypnea during exertion that are more than expected, you need to be evaluated further for pulmonary hypertension.  AND, if that doesn't appear to be significant, then a diffusion study to see if you have a restrictive lung disorder should be considered and likely done.  Another thing that might be worth considering doing during the right heart cath or at least during an echocardiogram would be to inject an IV dose of adenosine to simulate exercise and see it your PA pressures increase to more than 50 and/or your saturation drops with the increased cardiovascular stimulation.

Ultimately, I don't think your pulmonary hypertension and lung difficulties have a direct bearing or effect upon the TIA/stroke situation.  But, if you are over weight or have diabetes or systemic hypertension, those kinds of things will usually play a part in one's propensity towards cerebral-vascular problems.  Consider those points in deciding if you have risk that can be reduced with regard to avoiding future cerebro-vascular incidents.

Best Wishes,

Mark

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How Does Prednisone Work?

Without being too technical….

 

Let’s say you’re on 50 mg of Pred per day for a week to help reduce inflammation and SOB.

 

I’m trying to grasp “how/why”  Prednisone can increase a person’s FEV1.   Is the increase “above” what their “normal” FEV1 is

  and does that always happen?

 

I realize it’s a “temporary” increase but how long does the increase usually last once you stop taking it?

 

Many thanks,

J

Prerdnisone is an anti-inflammatory medication.  As such it reduces swelling in the airways.  Less swelling means greater airway lumen.  Greater airway lumen means easier air movement with less work.  With COPD, the greater airway lumen also means less air-trapping.  So, the net effect is an increase in FVC and FEV-1.  The effect lasts as long as you are on the prednisone and while it may not hold after ceasing prednisone, some measure of the gain realized during the prednisone regimen "can" be retained.

Best . . . Mark 

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Stage IV COPD & Ativan For Anxiety

Good Morning Mark

I have not asked you any questions for awhile. I read you questions and answers with great interest. My husband Fred has End Stage COPD things most of the time are the same. This past weekend we did something stupid, we never checked his puffer closely and he was not feeling good for about two days. One night he started to get very anxious and it got worse I called the ambulance and the ambulance attendees said Fred blood pressure was 180 over 110, I got scared. They took him to the hospital and did the Ventolin and Atrovent puffers after a short time he was fine. His Saturation was 85 when they took him to the hospital and after a bit his saturation was back  to 95 which is very good for Fred. Now the stupid mistake we did was one of his puffer the Symbicort was on empty. We figure it was empty for about 2 days,  anyway it took him a day but he is fine again.
Now after this story the Dr gave Fred some Ativan to take he does get anxious easily. After a short time Fred  seems to be dependent on Ativan whenever things go wrong. Now do you know if many ppl with end stage COPD take Ativan, I am a little leery of the drug but also is it addictive.
Please understand I do not question my Dr's diagnosis the only thing is when we spent 3 months at rehab and I stayed with Fred every day for 3 months to learn about this disease I don't remember anyone talking about Ativan.

Hope I explained myself correctly.

Thanks Mitch

Hi Mitch,

 

You did just fine explaining your difficulties.  While Ativan would not be 'my' favorite choice for anxiety control, it IS effective.  It is also habit-forming.  So, you suspicions are well-founded as are your concerns.  At the same time, many of the anti-depressants/anxiolytics are habit-forming.  So, it ends up being kind of a "pick your poison" dilemma.  If Fred seems to be using what you fear is becoming an excessive amount of Ativan (look at the prescription to see what he "can take" as a regular amount and maximum), talk with him and especially with the prescribing doctor.  If it becomes a significant concern insofar as how much he's requiring, then his doctor can consider other medications with less consequences.  Buspirone is a non-addictive anxiolytic.  But, it doesn't always work too great for some folks.  And in ALL folks, it must be taken for several days to build up a blood level that is effective for the individual.  It "can" be taken along with drugs like Ativan which can then be weaned down or phased out once the Buspirone has reached stable effectiveness.

 

In the meantime, try to work with him to exert conscious effort to control daily anxiety so that his need for medication is minimized.  And, be sure he doesn't run out on his inhalers again!

 

Best Wishes,

 

Mark

 

 

The Best Place To Live With COPD

I know each person with COPD/emphysema has a different set of symptoms, so a lot depends on that. However, I'm looking at different areas to possibly relocate to and there is a lot of conflicting information on the internet.

I live in the midwest. Cold dry winter bothers me--surprisingly hot humid summer does not (I don't hang-out outside though in the hot, humid weather). Humidity does bother me from the shower, though.

Can you state which climates/states might have clean air and ideal weather for COPD/emphysema? I'm in my 50's have severe emphysema but still work full-time and function pretty well.

Thanks.
Moe

Hi Moe,

The question you ask comes up quite often.  I'm afraid that I simply don't have an answer for you.  That is also why you are finding so much confusing and contradictory information when you search the internet.  The fact is, there is no "ideal" location for those with chronic lung disease because their sensitivities vary so much.

My usual advice to folks is, it you don't like where you live, pick a few locations where you think you might like to live.  Visit those locations for at least a week - preferably during those segments of the year when you might be most sensitive to climatic and seasonal influences that affect folks' breathing and symptoms.  If you find a place that seems to strike your fancy, go there a couple of times at different times of year and make sure they are better suited to your needs, as best you can.

In any case, I recommend AGAINST jumping and moving without careful investigation an taking what may seem a lot of time (a year or so) to make a better educated decision.

Best Wishes,

Mark

Spirometry Results Reviewed

Spirometry test: I had this test today at work. I took the test twice. First set of results were FVC 5.90 FEV1 1.97 FEV1% .33 . 2nd set of results were FVC 6.08 FEV1 2.13 FEV1% .35.

I am a 44yr old male who does not smoke. I weigh 233lbs and do snore at night. I was told I should see my internist regarding these results as they were not good. Just wondering what these results could mean.

Thanks for any input you can offer

Rick

 

Hi Rick,

 

First, it sounds like you had a ‘screening test’ to identify those who should be evaluated further for “potential” problems with lung disease.  The veracity of that test you underwent is dependent upon the skill of the person who conducted it, the integrity of the spirometer they used and its calibration and the quality of your effort.  Missing in your information that is key for my ability to interpret your numbers is your height.  If you are 6’4” (193 cm) tall, then 223 lbs (101.3Kg) is not bad.  But, if you are 5’6” (167.6 cm), then your weight could play a significant role in reducing your FEV-1.  It is your FEV-1 that appears, on first glance, to be significantly reduced and presenting suggestion that you may have airways disease of some kind.  But, not knowing how tall you are makes such assessment impossible, from where I sit.  As well, that you say you snore is in itself a worrisome problem and can lead to reactive airways disease among other problems if indeed a clinically significant problem – like having the presence of obstructive sleep apnea.

From the results you report, you seem to have performed the test adequately.  One factor that was NOT evaluated was if you have any airway reactivity (a.k.a. Asthma).  When we see someone like you in the clinical laboratory who produces numbers like you did AND who has no obvious contributory history for lung disease, we ALWAYS do a “post-bronchodilator” repeat spirometry study to assess for “reversibility of obstruction.  

 

In any case, you SHOULD follow up with your doctor.  Have a more controlled and better quality PFT (pulmonary functions test) done that repeats those measurements (3 times, each) after inhaling some bronchodilator medicine.  If you produce the same results AND have reversibility, then you have some degree of ‘asthma’ which can likely be treated and controlled.  You should also request a sleep study to determine if you have sleep apnea.  If you do, then getting that treated and controlled is imperative as it can cause high blood pressure, heart disease, diabetes and obesity, in and of itself!

 

Best Wishes,

 

Mark

 

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Condensation When Nebulizing

 

Dear Mark,

When I take ventolin nebules with a mask, I get white droplets from my nose dripping back into the little cap. The solution becomes cloudy white.
What would be the cause of this?    Thank you, Madeline
 

Hi Madeline,

 

Most often, those drops are condensation of the nebulized fluid.  Because they are mixed with a lot of air bubbles (too small to see with the naked eye), they make the fluid appear to be white in color.  The solution turns white for the same reason.  As solution is taken up into the nebulizing mechanisms and “smashed” against the ‘baffle’ to break drops up into minute droplets which can then travel to the depths of your lungs, they fall back into the solution and make it appear to be a white color.

 

Now, if the solution were to change consistency (become thicker or ‘slimy’) that could be due to mucus flowing back into the nebulizer.  While I would say it is unlikely, it’s not impossible. 

 

In any case, the effectiveness of the solution shouldn’t be changed by what you observe.  Be sure to clean your nebulizer (rinse with water and air dry) after each treatment and thoroughly wash it at least once a week with soap and water and a disinfecting agent (dilute vinegar or very dilute bleach or commercial disinfecting product made specifically for inhaled medication devices [quaternary ammonia, for instance]).

 

Best Wishes,

 

Mark

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Desaturation & Oxygen Needs

 

Hi Mark,

Sorry to beat this desaturation thing to death, but I just realized something. When doing extreme exercising by doing plb helps to keep the numbers up.

I am going to presume that when you plb and can NOT increase the numbers then you are in a bit of trouble.

I ran into a gentleman at one of the long term care homes that i visit, and he is 84, and has been on 02 for 20 years. He is in a wheelchair but not in bad shape.

As mentioned Mark one can not get a script for 02 until the 02 levels are consistently below 88, and that has to be most of the time either when exercising
or just sitting or both.

Yesterday while at the computer my 02 was 97. I think I have a way to go yet without needing 02 on a daily basis.

Thanks Mark for all your help.  Philip

Hi Philip,

No apology needed!  I think you’ll likely beat that horse for some time to come as you think of yet new and different – or just different angles of consideration to approach it with questions.  And, who knows, there are likely other folks who might be wondering the same things that you wonder about.  So, let’s go for it!

What you have discovered about PLB is precisely what we say is one of the potential benefits of using the technique.  And, you are absolutely correct, when it doesn’t work to improve your oxygen, you are indeed in “a bit of trouble”!  At that point, you need to use oxygen to raise your saturation – IF it has dropped to or below qualifying levels.

I suspect you are correct in your assessment that you probably don’t need to worry about needing oxygen on a daily or continuous basis for a long time to come.  With the desaturation you have reported under ONLY extreme exertional conditions, it may be sooner than you might think.  But, I would be surprised if it is any sooner than two years.  And even then, it would likely be only for sleep and exercise/exertion where you must get pretty vigorous/intense.

Best Regards,

Mark

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COPD - General Information & Understanding

 

Hi Mark,

 

I have written to you a couple of times now about my mild COPD.  I am on Seretide 500 powder inhaler.  What type inhaler is this?  I was on a purple spray one last year.  Does it take a few weeks to get in your system?  I am breathing a lot better, now.  Was the shock of being told I have mild COPD (that) sent me a bit over the edge as I have never smoked.  Am blowing regular 450 on peak flow.  Am 56.  But, now I have started a treadmill, running about a mile and a half with ease.  Can this COPD ever get better, or am I doomed to go downhill?   Also, I have Herpes.  Been told this gives you flu-like symptoms. Can my spirometry test be wrong?  I hear someone got told they had COPD then went for a second opinion which said they never had asthma.  I also have been doing breathing exercises, breathing in ‘til I can’t breathe in no more, hold for a second, then breathe out with pursed lips and get every drop of air out my lungs.  I feel a bit light-headed at the very end of breathing out.  Is this normal?  Also, sometimes I sneeze when I do exercises, getting a bit of sputum up.  Is this sputum badness out of my lungs getting’ spat out good for your lungs?   Do you think there will ever be a cure for COPD or anything to stop it getting worse?   With better medication?  Also, I was getting over a chest infection when I had spirometry test.  I was diagnosed with asthma when I was 21.  I had a lot of chest infections.  Then I worked out all my life, Karate, weights.  I never have too much fatty stuff.  I eat fruit.  My doctor said don’t worry, we got it in time.  Is he just trying to make me feel better.  When you tell people they have emphysema, they say, oh that’s bad.  My nan died of that.  So, you can see my concern.  Thanks for your answers.  Paul

 

Hi Paul,

 

You continue to be very concerned about your possible lung disease, though you don’t seem to appreciate that if you can “run” on the treadmill, especially for a mile and a half, that you are in pretty darned good shape DESPITE your COPD.  Now you didn’t say if you ‘actually’ RUN.  So, if you are walking very slowly for that mile and a half, that is a different story.   If you are doing that mile and a half in less than 30 minutes, then you are walking briskly.  If you actually run, then you should be covering that mile and a half in about 10 minutes or less. 

 

Once one had COPD, the NEVER get rid of it.  If they take good care of themselves – and it sounds like you are doing just that AND doing it well – then they usually see very little progression of their disease even over many years in the future.  So, you should expect to stay in good shape and be able to do most anything you want to do for many years to come.  Just because a loved one died from COPD doesn’t mean that you will automatically do the same thing!  Many people have mild COPD for the last half of their life and die of OTHER causes, not from the COPD.  It seems like you should be able to expect to do the same!  So, I don’t think your doctor is just trying to make you feel better and is not telling you the truth.  He is right – you SHOULD b e fine for many years to come if you keep doing all the right things.

 

A cure for COPD is something we all dream about.   But, I suspect it is a long way in the future.  In the mean time, we need to work hard to prevent it and to treat it with the best tools we have until a cure is found.  In ANY case, I would urge you to stop worrying!  You should be in good shape for a long time to come!

 

Best Wishes,

 

Mark

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 Exercise Concerns, Longevity And Hope

Hi Mark,
   I am fairly new to site, I was using COPD international. I should of been here sooner. I am a 51 yr old female with severe COPD.I have been on 02 3 yrs.I despise the 02.It took a long time to accept it. I got off it once but back on. I purchased an oximeter from this site and love it. My 02 respiratory guy came over and when I walk without it it drops to 88.He also said my heart is 120 and above which scared me.I am going for another ekg.I quit smoking 1 yr ago and since have not been in hospital as I have been close to death 2 yrs ago when my 02 was low and carbon was high I eat healthy,veggies,fruit,grains,etc weigh 130 and bought treadmill but when exercising my pulse went to 146 and I go only 2 mins.I can not seem to walk far. I was hoping to increase my walking by spring and wondered if my chances of living till 60 or longer are slim. My life feels dreadful with this disease. I am going to pulmonary Feb.16 and I can not blow out good I think my fev1 was 17 I yr ago.  is there hope for me?
                               Regards, Sue

Hi Sue,

There's ALWAYS hope!  That is the one thing you should NOT give up on!  Have you been tested for Alpha-1-Antitrypsin-Deficiency Emphysema?  You are too young, comparatively speaking to have developed COPD so severe - even with a significant smoking history.  So you should ask your doctor to help you get tested.  I don't know about Canada, but, here in the USA, it is a "free" test!  And it is easy to do, in terms of collecting the necessary specimen.

When one has COPD severe enough to cause hypoxia AND they become significantly limited in their level of activity, they get "out of shape", though it might come on slowly and insidiously.  When they DO get up and move, beyond their oxygen dropping if not adequately supplemented, their heart rate will expectedly increase in the manner which you describe.  That, in itself, is not a problem  If you continue to exercise, despite the high heart rate, keeping your exercise "intensity" appropriately low enough not to invoke problematic consequences, yet high enough to allow for conditioning to occur, then you will see that over time, it will come down to much lower levels AND will not jump as high with increasingly more intense exercise.

If you are walking too fast on the treadmill or if you have it on ANY incline, it is not surprising that you play out so soon.  You should be sticking to a low speed that allows you to go up to 30 minutes, NON-STOP, before increasing the speed.  Then you should NOT add any grade until you can walk for at least 30 minutes at a speed of about 3 mph. That may take you months to achieve.

It is good that you are getting started in Pulmonary Rehab.  Hopefully that will set you on a better path of regaining conditioning and health.

I doubt the EKG will show anything that isn't already known.  But, you should be getting one annually, if not more often, anyway, as part of your routine health screening.  You didn't mention any inhaled medications you use.  Hopefully, you are on a combination of inhalers that fits your very low FEV1 (17 %).  At that low a level, you are in serious shape, but, again, NOT without hope to improve a LOT.  Is lung transplant something you would consider - or available as an option for you?

In the end, no one can say that you will or will not see 60.  There is much you can do that you are on track to get under way.  That and time will tell.  Work on living  - NOT on avoiding dying!

Best wishes,

 

Quitting Smoking & Will The Numbers Improve

Hello,

My FEV1/FEV (%) was 78 the last time I had a Spirometry Test --- I am on Champix and have quit smoking - my quit day was a few days ago - I am scheduled for another Spirometry Test in a couple of days .  Will my % improve from the 78? Am I in the "mild" range of COPD?

Thank you for your time in answering my questions.

Sandra

Hi Sandra,

Yes, you ARE in the "mild" range of COPD.  Congrats on quitting smoking!  Don't expect much change in your FEV1 - at least not this soon - if any change will be forthcoming.  At 78 % you are still very high in pulmonary mechanics and shouldn't have any significant symptoms from your COPD.  Over time, you should notice even better breathing.  Keep active!  Eat healthy! Get plenty of rest for your needs.  And you should be in great shape for a long time to come! 

Best Wishes,

Mark  

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What Is Atrovent?

What is Atrovent  hfa Spray q i d  Wht is it for ?

Tom

Atrovent is one of the two primarily administered "bronchodilator" medications.  They relax your bronchial tubes and improve your ability to move air into and out from your lungs with less work.    It is from the class of medications called "anticholinergics". 

Atrovent is usually paired with another complimentary - but different-acting - bronchodilator from the "beta-agonist" class.  Each does what it does through a different mechanism or "pathway".  So, one is not necessarily a 'replacement' or 'substitute' for the other.  But, together they work better than each one can alone to produce an overall improvement in your breathing.  The most common beta agonist used/prescribed is 'albuterol'.  You may likely be prescribed BOTH medications to be taken close together for best effect.

Best Regards,

Mark

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Low Iron, Tight Chest

Hi Mark;

 I wrote to you a  week ago about my mild COPD.   This week my chest was a bit tight and I have been having panic attacks thinking about it. I  don't want to be on oxygen in a wheelchair;  cant stop thinking about it.  I  went to the hospital on Saturday  because my chest was tight,  had x-ray,  came up clear.   Had blood tests said my iron count was 9 and a bit should be 13 in a man.  I was diagnosed as a anemic last year my count was a 7;  felt terrible couldn't really work or do much with out getting tired.  I went on iron tablets in August and they worked;  felt good,  doc said come of them and I did but when I had a blood test in the hospital it was a 9 so I am losing iron.  Also I was  told I had a hiatus hernia. I  use to get heart burn;  don't get it much now but hospital said its probably my worrying about COPD that's making my chest tight.  It's not too bad this week;  after x-ray was clear.  I got COPD mild;  never smoked.  Can my working as a tree surgeon caused it with the pollen as I did have asthma when I started job.  Was in job for 20 year; s just want to breath easy.   Also I blow 450 to 500 on meter blower may b 400 when I get up when my chest is easy and clear I blow a 500 am 56 years old, always watched what I eat, and work out with weights. Could it b because my iron is low that I am chesty?

Paul

Hi Paul,

No one can tell you "why" you develop COPD when you are not a smoker.  Most likely, 'we believe' it is related to heredity and triggered by histories like you seem to have - your asthma and working with the trees, though they likely are not the source of a significant factor or problem anymore than having had asthma for some years.  BUT, with the peak flows you report, you don't seem to have any 'clinically significant' affect from it - 500 ml being an excellent peak flow.    Even 400 is very good!  Asthmatics who have problems are down around 250 and less!

I'm thinking - as you seem to be - and as others seem to be telling you - that you have very mild disease.  It would be helpful to know what your FEV-1 is.  But, going out on a limb, I'd bet it is greater than 70 % of what would be predicted for you and your age. Folks can easily 'worry' themselves into symptoms like you report having.  I feel confident in telling you that your worst fears - being on oxygen and in a wheelchair-  are so far off into any possible future that you'd not be able to see them, even with a strong pair of binoculars! 

You should actually be most concerned about your iron deficiency and get that corrected.  It is of much more immediate concern than ANY concern you have about lung disease.    And it can do more to make you feel bad - AND contribute to any difficulty breathing and/or chest tightness you are feeling!  Realize that iron carries oxygen in our body.  If your body senses that it is not getting enough oxygen, it will signal to you to do more work to bring in more oxygen.  THAT more than any COPD you might have can be the cause of any breathing symptoms you now have, including the tight chest, though worry and panic can easily play a big part, too. 

Above all, keep foremost in your mind the fact that folks with half the lung function you have - who have MUCH MORE advanced lung disease/COPD than you now have or are likely to progress to in the next MANY years - are able to be VERY active, don't yet require oxygen and are far from needing a wheelchair.  You need to read more about the disease to learn where your fears can be misplaced.  Until folks' FV-1 drops to less than 30 % of what it should normally be - a LONG time off in your future - they don't have limitations that present significant difficulties in their lives.

If you live each day worrying about what is predictably many years - even decades - off in the future, you will miss so much of living and everything that is good in life.  Don't WASTE your life living like that!  You likely don't have enough lung disease to worry about what you are spending lots of time and emotion worrying about NOW.  You may likely NEVER reach a point where COPD becomes a primary ailment and limitation in your life.

As I said in an earlier response, STAY ACTIVE!  Eat well and get the rest you need - and QUIT WORRYING - and you'll live a long and happy life without problems with lung disease!  If you have a little bit of asthma along the way, keep it controlled and at bay and you shouldn't have any significant difficulties.

Best Wishes,

Mark

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Can A Person Tell If They’re Retaining CO2

Assuming a person isn’t a usual retainer, Is there any way for a patient to know, or tell that they’re starting to retain CO2. (Not as an on-going issue but something that can crop up)   If there is a way to tell, is there anything a person can do to minimize or avert it?  Thanks

Scott 

Hi Scott,

The only way to know if you retain CO2 is to directly measure it.  That can be done with a device that measure the air you exhale.  It measures how much CO2 is in your exhaled gas at the END of your exhalation.  A blood gas is an "invasive" but the most accurate means to measure your CO2.  Not unless other clinical information suggests that you 'might' be at risk for CO2-retention, would we/I recommend getting one done. 

Folks rarely begin retaining CO2 before their FEV1 drops below 30 % of predicted.  Even then, many don't begin retaining until it drops progressively below 20 % of predicted.  If one develops pulmonary hypertension, their tendency to retain CO2 will be enhanced at the high FEV-1's, but, still most often below the 30 % line.

CO2-retention doesn't "crop up" as a usual and/or 'short-lived' problem.  In advanced COPD it is a response/result of the physical damage to the lungs that results in chronic hyperinflation, as we see it in advanced emphysema.  So, you are thinking off the mark if you think that you can develop it as a short-lived or passing ailment.  Once there, it is there for the duration.  There is NOTHING you can do to "avert it" or "prevent it" or "minimize it" or "make it go away", once it's there.

CO2 can "acutely" increase because of sudden respiratory compromise.  That is an emergency and it is obvious that those who experiences it are very ill and in trouble.  We call that occurrence "Acute Respiratory Failure" and jump on with rapid intervention to resolve it.  That is not something you should spend time worrying about as it is rare. 

Again, the only way to "know" that you retain CO2 is to measure it.  You should NOT worry if you might be entering the realm of chronic CO2-retention until and unless your lung disease is WELL-advanced and you are struggling to do simple daily activities.

Even when CO2-retention DOES occur, it is not a problem that needs resolution!  It is actually a 'positive' adjustment that the body makes to contend with the poor ventilation that goes with well-advanced COPD.  Once there, to try to make it go away or be less would actually mess up bodily functions rather than provide any positive effect or improvement.

Best Wishes,

 

Mark

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COPD or A Fungal Infection

My father came in contact with some serious fungus two years ago while helping a friend clean out the basement of a flooded cottage.  Doctors won't acknowledge or entertain the fact that it's a fungus in the lungs and sinuses they keep saying and treating him like he has asthma or COPD.  I have read many things and he has become his own doctor for approx.2 years now.  He has been in and out of hospitals half a dozen times due to not being able to breathe.  Doctors fill him up with Prednisone, Antibiotics and symbicort or Advair.  He had severe allergic reactions to symbicort and advair while in hospital so Doctors finally realized these two medications could not be used to assist him in his breathing.  The breathing difficulty subsides after approx.two weeks stay in the hospital because the prednisone and antibiotics are only suppressing the symptoms (which are asthma like) of the fungus.  I have read many forums and all the people discussing their symptoms are exactly like my Father...sinuses fill up with mucous, nose drips clear liquid, lungs fill up with mucous, when he is able to clear his lungs, it's clear, frothy mucous that's being expelled occasionally with little "fungus plug like substances".  He even went as far as purchasing his own monitor to track his oxygen level and heart rate.  This week, he is fighting for breath, oxygen level staying mid to low 80's up to 90 or 91.  He is petrified to go back to the hospital because they just want to fill him up with drugs to cover up the symptoms and get him home.  He has limited his diet extremely, no sugars, anti fungal products galore, he is doing everything possible as I said he has researched a lot and has become his own "doctor".  I am at a loss!  We don't know what to do...my Father has asked me to type up his Will and Power of Attorney to prepare for the worst.  My Father feels that if he had oxygen at home, he might be able to fight this fungus naturally, (oxygen gives him the strength to expel the mucous) but no Doctor will agree to prescribe oxygen

Cindy

Hi Cindy,

I'm sorry to read of your father's difficulties and frustrations.  But, my first impression is that he is on the wrong track with his insistence that he is suffering from a fungus.  While I can't say one way or another, from where I sit, that he "doesn't" suffer from a long-term fungal infection, I 'can' say that from a clinical standpoint that the likelihood is remote, at best.  Had it been a fungal infection, evidence more than what you have related - and much more meaningful - would long ago have become apparent.  Much of his problems can be argued to result from a combination of his rejection of appropriate treatment for his breathing difficulties and - perhaps even more so - from self-treatment with substances that can easily be worsening, if not outright causing his symptoms.

I am very curious to know what his "severer allergic reactions" were to Advair and Symbicort.  Can you describe them more specifically for me?

I am further suspicious of the potential for a fungus to be at fault since prednisone suppresses immunity such that fungi and other opportunistic pathogens have an "easier" time causing symptoms.  Were the prednisone simply temporarily suppressing any fungal influences, they should come back with a vengeance within 72 hours after his last dose at the hospital.  Then again, if he takes long-term/maintenance prednisone, his symptoms could (and should) be continually suppressed, so the notion of a fungal infection - especially lasting this long without being more readily detectable by now - is highly unlikely. 

The worst part of his situation is that by rejecting the assessment and interventions of the medical team he is entrusted to AND by self-medicating with all manner of anti-fungal supplements, he is fostering the more rapid worsening of his COPD.

If he is truly observing desaturation with his pulse oximeter, he should take it with him to the doctor and demonstrate his observations.  You don't say if he has had pulmonary functions tests or what any of his measurements might be.  So I have no 'objective' information upon which to determine where he is in his lung disease process.

Oxygen, or use of oxygen will lend "NO" 'specific' assistance to fighting a fungal infection - naturally or otherwise.  His thoughts on that are misplaced.  BUT, with the desaturation you describe, it suggests he is in an advanced state of his COPD and would definitely benefit both from a health and a functional standpoint, from the use of oxygen.  In most locations in Canada, the requirements for needing supplemental oxygen are the same as here in the US.  By those means, he seems to qualify without question.  So, push for it - and push HARD!

That is about all I can tell you at this point.  There is one other test that 'might' settle the question of the presence of fungus.  If he has not had his sputum 'cultured' for the presence of fungal organisms, that is a simple enough test to do and won't break the health care system bank.  If he has suspicious or inconclusive results, a bronchoscopy to obtain deeper-residing specimens can often provide the definitive answer.  You might ask his doctor about those two possibilities.  In any case, you simply CANNOT say that you are seeing "fungus plug-like substances" in expelled secretions.  Mucus plugs are mucus plugs, regardless of contents or origin.   There is nothing beyond specific colours or odors that can indicate the presence of one kind of bacteria or another.  And those colours and odors are VERY specific to each pathogen that produces or emits them.

I fear that his rejection of qualified medical assessment and opinions and insistence upon his problem being a fungal infection AND the rejection of interventions that can certainly provide significant benefit in favor of those his is concocting from his lay resources are both responsible for his rocky course (several exacerbations and admissions) over these past two years AND his inability to get satisfactory collaboration from his medical professionals.   At some point, they too become frustrated and take on an attitude of "What's the use? He won't listen to what we have to say or suggest."

Perhaps you all need to sit down together and sort out all the questions, suspicions and frustrations that are interfering with your ability to find effective relief and improvement in his condition.  Otherwise, I fear that sadly, you may be giving attention to his will sooner than is necessary.  Please step back and give thought to the possibility that he is wrong and that his medical team have a better idea of what is going on and what should be done.  But, also push for oxygen in the meantime, as I described.

Best Wishes,

Mark

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How Bad is My COPD?

Hi  Mark;   I live in the UK am a very young 56 kept in shape all my life when I left school at 15 worked at a car components grinding the left over asbestos of the car brake shoe to glue a new one on no mask on was only in the job 1 week was not doing the grinding of shoes all day just now and again then in 1977 started work as a tree surgeon and developed a cold that lasted 4 a year had breathing problems was told I had asthma I have never smoked done this job 4   20 years then after that got finished up done a bit of car spraying on off as hobby was on ventolin inhalers then in sep this year had breathing teats done in my local hospital test said I have mild COPD am very worried thinking am going to die soon I have been around smokers 4 years passive do u think the asbestos has caused this or passive  smoking I am on a powdered inhaler now they r very good keep my lungs easy to breath I can walk up 10 floors my legs do get bit tired round the 6 floor when I get to the tenth floor my lungs sort of burn will I get all the stages of COPD then die at the last stage I feel ok on the inhalers my doc says I don't have asthma now but mild COPD and not to worry


Paul

Hi Paul, 

I suspect that you are worrying way too much about the disease and your future, as well as a lot of things in your past that have little if anything to do with any COPD you might now have or the course you can expect it to take in many years of your future.  The simple fact that you can climb those many flights of stairs tells me that ANY lung disease you may 'now' have is not "clinically significant">  Your asbestos exposure was not enough to present concern for that type of lung disease.  Your other activities - including exposure to second hand smoke - are not significant enough to play a meaningful role in development of "problematic COPD" or other lung disease.

My bet is that you have a better chance of meeting your demise in any number of other accidental ways LONG before you'll succumb to lung disease.  Just keep active and as vigorous as you are now and I'll look forward to reading your posts to COPD-Canada 20, 30 and more years down the road - that is IF "I" can still read and pay attention! 

Best Wishes,

Mark

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Follow Up From Last Week (January 8th Q’s & A’s)

First of all thank you so much for answering my previous questions.

I have since returned to the doctor for my 3rd visit. I have  quit smoking. I requested this visit (1 week earlier than planned) because I have been having headaches every morning, dizziness, continued chest pressure and all I want to do is sleep all the time.At this visit I was only seen by the P.A. not the doctor. She said my lungs sounded better. She stated she could not repeat the ABG's because insurance would not pay for it. I asked if my HbCO levels could cause any of my symptoms and she said usual not. She stated that I could see my PCP or a cardiologist for the chest pressure they didn't do EKG's. She wanted me to have a Sinus CT which I refused at this time. She continued all meds but added a Nocturnal Oximetry. I always wait over an hour to see the physician, he has never given me any education on pulmonary rehab and frankly seems annoyed when I ask him questions. I firmly believe in research and patient educating themselves on their disease. I have been in the medical field for over 25 years (until my illness) and I recognize when a physician is not "listening" to the patient. When I ask about other medical problems I am having to see if it relates to my lung disease he states I need to see a specialist (ex: gasto problems/gastoenterologist, heart/chest pressure problems/cardiologist, headaches, dizziness/neurologist) without explaining if any of these problems are/can be related to my COPD. Frankly, he looks at the numbers, tells me briefly what some of them mean, listens to my lungs & "see you in 4 weeks".
Is this typical COPD treatment? What about education, rehab? I feel like this is as good as it gets and they simply check the values, change/increase medications and make another appointment. On my 2nd visit with him he stated "you are being anxious". I was so calm and at peace with the diagnosis realizing I need to help myself and go on with life. I always leave his office feeling bad and as if he shows no concern for helping me as though my problems have little validity and he's too busy to give me proper care. I am a compliant patient. I try not to question his decisions.
I guess what I'm asking is what should on expect from their physician in the way of treatment for this disease? Or are my expectations too high?
I just feel so lost at this point.  Thank you for listening.

Susan

Hi Mark,
 Thanks for the good information. I have since returned to my doctor on 1.5.2012. He didn't see me the P.A. seen me. She said my lungs sounded better but couldn't repeat the ABG's due ti insurance wouldn't pay for it! She stated she didn't know why I was so sleepy all of the time, having morning headaches that maybe I needed to see a neurologist?? When I asked about the 8.2% side effects I had researched  that coincided with my problems, she stated it was not likely to cause any of them. No repeat CXY,ABG's just listened to my lungs and ordered a Sinus CT and Nocturnal Pulse Oximetry. I refused the CT for now but agreed to the pulse ox. They have never offered any rehab to me. When I asked about checking my heart they said IF they seen any problems they would refer me to a cardiologist ( I have MVP). When I ask about staging they tell me they don't stage Emphysema/COPD. When I question results they simply tell me it takes a long time for the meds to work and they will see me in 4 more weeks. I really feel like they don't listen to the patient. I always feel bad when I leave the office visit. I believe they are telling me this is
as good as it gets.


Susan

Hi Susan,

I'm going to respond to this question and the one that follows since they were apparently duplicate posts from you, sent at different times, this one with more detailed information.

Your PA is correct that the HbgCO you reported should not be responsible for your complaints.  It's GREAT that you have quit smoking.  THAT should go far towards allowing your CO levels to return to normal for a non-smoker.  Have you considered that it is a frequent response for someone to experience symptoms of depression when quitting smoking?  One of the advantages of Welbutrin and Chantix are their anti-depressive action which helps combat the problem when quitting tobacco consumption.  Your complaints are suspicious for mild depression, though I can only offer that as a possibility and speculation from where I sit.

While it seems that your doctor wants only to address your pulmonary problems - and seems to be addressing them in a reasonable manner as best I can ascertain, perhaps you should see a cardiologist for an EKG, if you are concerned there might be a cardiac problem - and in view of your MVP problem.  It is possible you have reached a point in your life when you need a medication to assist in correction of difficulties that might be developing in relation to that problem.  It wouldn't hurt to rule it out, anyway, even if all it does is set your mind better at ease.

It is possible you are overly concerned about your condition at this point.  Yet, if there is something going on that needs attention, you would do well to learn that sooner than later, too.  Think about seeking further opinion from others.

Best Wishes, 

Mark

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As COPD Progress, Is Oxygen Inevitable?

Hi Mark.

COPD is a very interesting disease as no two cases are exactly a like.

I was diagnosed in 2002, and I can honestly say that I am better now then in 2002. The proper exercise and meds have done it for me BUT the greatest factor has been my component of asthma. When Diagnosed I had an FEV1 of 25% of predicted. After a few puffs of Ventolin, My FEV 1 shot up to 46% of predicted which is a huge difference.
My Pulmo said that adult induced asthma in patients with COPD is usually attributed to having allergies as a child. He was right. I had severe Hay fever as a child.

My question Mark is this.

Currently I only need 02 when flying. On the ground I am fine almost all of the time. I sometimes desaturate with extreme physical activity, yet when on the treadmill
for 30 minutes I seem to be fine. I have taken my 02 levels on the treadmill and the numbers seem to bounce around from a low of 91-95. It is NEVER below 91.

Will all or most COPD patients Mark require 02 at some point in their disease, or have you seen some people go without requiring 02 for the life of their disease?

Here in Canada Mark in order just to get a prescription for 02 requires that your 02 levels must be consistently below 88. I was able to get a script for 02 for flying because I took a H.A.S.T.  Test.

As always, thanks for all your help, and my personal best to you and your family

Philip

Hi Philip,

While we have had the "no two cases are alike" discussion before - in which I have contended that while there may be individual quirks much of the time, the pattern and progression, as well as the symptoms and defects have MUCH in common among individuals, the notion of the condition "exactly alike" does not speak much to the issue as a whole.

The answer to your question about the inevitability of need for supplemental oxygen therapy is essentially: "Yes."  Most all folks whose COPD continues to advance to the more severe side of the disease end up requiring supplemental oxygen therapy.   You, yourself, might be in need of it down the line as evidenced by your mild, but nevertheless persistent decreases in oxygen.

All you can do is do your best to stay in the best shape and pay close attention to optimizing your lifestyle to keep progression on a slow pace.  Who knows, you might even succumb to something else - many years down the road - and long before you reach a point of needing LTOT.  That would be my hope for you, any way! 

Best wishes,

Mark

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Lung Scarring

Hi , my husband was told my the specialist that he has some old scars in his lungs and if she were to write a diagnosis it would be pulmonary fibrosis. My husband is 33 years old... He was never exposed to anything and was never a smoker. He doesn't have any symptoms and has normal pulmonary function test. I am wondering if you can help.
He was told to be reviewed again in 6 months - which is in March. I am concerned and sometimes worried. Can the hospital admit him and do all necessary tests to diagnose efficiently and look at previous test results and give an opinion?

Dahlia

Hi Dahlia,

I would go out on a limb, based upon what you have told me, and say that your young hubby has nothing to worry about with regard to lung disease.  Folks are often found to have scarring in their lungs that plays no part in their health picture.  If he feels fine and has normal pulmonary function, then that should be all you need to know to feel confident that he is OK and has a bright future in terms of lung function.  You didn't say why or how the finding of the scarring came about.  So, I don't know if he was having problems that resulted in the test being done that found the scarring.  But, if it was an incidental finding, then he should chalk it up to just that - an incidental finding.  If his follow-up in 6 months finds nothing new or of concern, and he continues to be without symptoms of concern, then I would think that further interval follow-up should not require more than a look at him and maybe an x-ray every several years.

Best wishes,

 

Mark

 

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Exercise (Treadmill) Goal and Oxygen Question

 

Hi Mark.....This is my first time to ask a question so I should give some background.....I was diagnosed with COPD in 2000 and was able to do most hings in my life for quite a few years....in the past couple of years though my life has become more restricted.....I use Spiriva and Advair and also take  recently turned it up to 3l.....I now live in an area where there is no respiratory therapist  so have a question...  I walk on the treadmill at a pace of 2mph for 30 minutes a day....usually....I find if the air pressure is low I struggle to do 20 or 25 minutes.....I am wondering if I should strive to go further faster and what should my goal be?  I should add that I am 71 years old.....please let me know if you have ideas.. Thank you! and Happy New year!!


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(Note:  You can also purchase a finger pulse oximeter from FaCT Canada in British Columbia starting at  $59.95 if you're a COPD Canada Patient Network Member.  This also includes the carrying case and free shipping  Finger Pulse Oximeters)

Lung Volume Increase Question(s)           

Hi Mark, I had childhood allergies and Asthma. Nothing really significant that I didn't live with. I worked a as a Firefighter of 30 years and retired 2 and 1/2 years ago. One of the reasons I retired is because I couldn't t do the physical demands anymore. my breathing was getting worse and I had a few scary moments. I took in a lot of smoke over the years. I never smoked cigarettes. I see a Pulmonologists every 6months. My AM regimen is Spiriva, Advair, 1 81 mg aspirin, and 1 , 10 mg Loretadine, with about 16 ounces of water. I'm on 2 lpm of oxygen at night time for sleep hypoxia. Obviously I have COPD. my blood work has been good. I stay active as I can. Sometimes I have to work every breath to keep breathing. I use albuterol 2 or 3 x's a month as needed. I use a nebulizer every few months or so as needed. My PFT says I have the lungs of an 80 year old. OH yea, I'm 58 years old. I use a Netty pot every am with a baking soda and canning salt solution to cleanse my sinuses. I gat a bad cold and or flu every year at least a couple of times that require antibiotics. My PFT 2'xs ago showed that I lost 700 cc's of lung volume, however through hard work, and following my orders I gained back 200 cc's of volume. My question is there anything I' missing? Can I increase my lung volume through any specific exercises . How about breathing exercises. Are there any food supplements or herbs that are recommended?                 

Thank You Bill
 

Hi Bill,

There is nothing you can do to increase your lung volumes, per se.  They will fluctuate up and down in accordance with your exacerbations (colds, bronchitis events, etc).  Walking exercise is very good to maintain your best pulmonary function within the limitations you now have.  You are a tough guy as exemplified by the difficulty breathing that your report during activity.  While it's not fun or comfortable to sustain hard breathing work, if is a MUST to survive and thrive. AND, breathing hard, while it may 'seem' like it will 'do you in' is not a bad thing and WON'T hurt you AS LONG AS your oxygen saturation is > or = 90 % during those periods of activity.  So, if you don't have an oximeter, it would be a great idea to purchase one.  I have recommended Nonin as a source for a choice of several that are very good.  See my response to Heather for more information.

Staying on top of your condition - with attention to exacerbations as soon as possible is a must for continued good management of your disease.  You are a young guy, at 58, to have such severe COPD.  But, with your fire-fighter history, it unfortunately, is no great surprise.  It is sad that you suffer these consequences for your many years of saving lives and property.  I hope your community is appropriately appreciative and supportive of your sacrifice!

Many folks are finding additional benefit from adding NAC (N-Acetyl Cysteine) to their medication regimen.  It has anti-inflammatory and mucus thinning benefit.  It can be purchased over the counter and should be taken 1200 mg once a day, up to 2400 mg (1200 mg, twice a day) during bouts of bronchitis and colds)  Taks an addition 1000 - 2000 mg of vitamin C with the NAC which helps thwart the formation of kidney stones in some folks who take NAC (very rare occurrence/complication).

Other than those suggestions, the key to survival and staying in the best shape possible is to KEEP MOVING!  Exercise is of critical importance.  With that, adequate oxygenations a must to prevent damage to your heart over time.  You now use oxygen at night for sleep hypoxia.  I would wager that if you desaturate during sleep, you also desaturate with exertion.  And it may not take much exertion to produce dangerous drops in your oxygen level.  So, be sure to check out that factor as soon as possible so you can address and correct it as soon as possible, too.

Best Wishes,

Mark

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Breathing Test Explanations & COPD Understanding (2 Parts)

I was diagnosed with severe COPD/Emphysema in October  of this year. On my 1st pulmonary doctor visit on December 8th, 2011, my ABG's were :pH 7.49, PCO2 36.0, PO2 79.0, HCO3 27.2, BE 4.2, Hb 13.7, SaO2 97.5, HbCO 6.9. FIO2 21.00.

 I was diagnosed with Acute Pleurisy & Chronic Bronchitis, Dyspnea, COPD w/ALE (don't know what ALE means), COPD severe,  Emphysema, nicotine addiction, cigarette abuse. The physician stated that I was to return on the following Monday (5 days later) & if HbCO values remained the same he would admit me to the hospital. He started me on Bactrin DS BID, Prednisone 40 mg 4 x day, Tessalone Pearls PRN, Musinex BID, hold Advair and use DuoNebs QID, continue with Xanax and Trazadone..


When I returned on Monday 12/12/2011, he stated my HbCO was now 8.2% (didn't tell me the other values) but stated he wasn't as concerned with the 8.2 % now because of the fluctuation in the other values. He had me do the "timed walking test" which was ok. He discontinued my DuoNebs, continue Prenisone Titration for 4 weeks, added Advair daily & use Ventolin Inhaler PRN severe SOB. He made my return appointment for 4 weeks later ( 01/09/2012).


I have done a lot of research online concerning COPD/Emphysema and PFT's/ABG's. Everything I have read indicates that the HbCO level of 8.2 is dangerously high and can be life-threatening.
My question is should I be concerned about the 8.2% level? The doctor didn't seem alarmed at this high value. Since the last visit I have become more lethargic, have slight memory problems, frequent angry outbursts and increased urinary/bowel incontinence (especially when coughing hard).
Maybe I need a second opinion?
Thank you for your time.

Susan

Hi Mark,
I recently sent you a question concerning my ABG's (AT 8.2). But, I forgot to include my PFT report:
SPIROMETRY:

FVC              59%
FEV1            38%
FEV1/FVC   53 POST
PEF               35
FEF 25-75    19
FIVC               47
FIF50%           0.97 POST
MVV                32 POST

LUNG VOLUMES:

VC          52
TLC         77
FRC PL   101
RV            123
RV/TLC    57
ERV          059
IC               1.06

AIRWAY RESISTANCE:

RAX          290%
GAW         38

DIFFUSION:

DLCO          33%
DL ADJ        33%
DLCO/AV     92

Susan

Answer to part 1 -

Susan, I hope you have quit smoking.  The CO will remain elevated in folks who continue to smoke.  The only other cause of chronically elevated CO is exposure to heavy traffic, as in the city where lots of care exhaust is breathed in, or in jobs where CO is infused into the air from combustion or other chemical reactions that emit CO.

Your blood gas actually shows modest "hyperventilation", often seen with various lung disease conditions and in response to low oxygen.  But, your oxygen level isn't significantly decreased to explain why that phenomenon is occurring in you.  Yet, if you are continuing to smoke, it could be from your body's response to the elevated CO.  In any case, the 8.2 CO and the question of continued tobacco use remain a question for me as you didn't include that in your information.

I don't know what the ALE means, either, unless it's your doctor's abbreviation for "Acute Lung Exacerbation".  Ask him what it means.

I don't think your necessarily need a second opinion.  You need to know from your doctor what you should be doing to reduce your symptoms and improve your health and function within the limitations you cannot change.  If you are not confident with your current doctor's care or skills, that would be an indication to seek a second opinion.  But, you didn't allude to any concerns of that type.  So, it is up to you to decide.  Even then, you need to have a specific objective in seeking another assessment and opinion.  If you don't fully know what your current doctor wants you to do, then another doctor won't be in any better position to second guess the first one.

Part 2 answer -

Your PFT's show a combination of obstructive (COPD) and possibly restrictive elements to your lung disease. Your ability to diffuse oxygen is reduced at 33 % which, when combined with the elevated CO adds up to explain your low paCO2 on your blood gas.  It doesn't help much with advising you on what to do.  Again, the question still hangs about the tobacco use and the cause for the 8.2 CO level.  Answer that and we may have better direction to go in terms of advice.

Best Wishes, Mark

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Heather

Hi Heather,

You are doing well and on the right track to maximize what lung function you retain.  Indeed, you should strive to go further faster.  If 30 minutes is going to be your choice of maximum duration, you should work to increase toward 3 - 3.5 mph.  Ad 'interval' walking at some point, wherein you jump the speed be 0.5 - 0.7 mph - abruptly - and maintain the increased speed until you become as winded as you can stand.  sustain that windedness for a minute or two at which point you will drop the speed - again, abruptly - back to the lower level to 'recover' while continuing to walk - RATHER THAN stopping, altogether to rest.  You may have to drop your lower speed in order to maximize the approach.  So, say, for instance, you start at 2.0 mph and jump to 2.7 for your fast interval.  The  drop back to 2.0 for recovery.  It will seem slower when you drop back down to it - a good thing, as you want to keep moving while allowing yourself to regain more comfortable breathing.  As you do that more and more, you will see your fast interval increase.  When you get to where your fast interval is 20 of the 30 minutes (approximately) increase both speeds and work to increase the fast interval.  Over time (perhaps as much as a couple of months, you will see your overall speed increase to where maybe, 2.8 is your low speed, while 3.5 is your fast speed.  At that point, you can maintain those speed differences and add o1 or 2 % grade for the fast intervals, dropping the grade back to 0 for the recovery periods.

The most important factor in the mix will be to maintain the best oxygenation you can during your walking exercise.  You say you now use 3 L.  You may find you need 5 liters for exercise and to stay above 90 % saturation.  Be sure you have enough oxygen to supply your needs AND monitor your oxygen saturation with a personal oximeter.  If you don't currently have one, you can get a good one for $100 or a bit less.  Check out the Nonin line of oximeters  Look them up on-line)  (I have no financial interest in Nonin.  I just think it's about the best available.)

Let us know how you do over time.   Best Wishes,                 Mark

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November 18, 2012

 

Question Re: Hyperventilation Syndrome

Hi Mark:

My name is Ron, I'm a medical writer doing a piece on HVS (hyperventilation syndrome) and read with interest, your blog of 2009 on COPD and the 'myths' of diaphragmatic breathing. I had a few questions and was wondering if you could provide some insights? I'd appreciate it.

Specifically with regard to HVS, a popular commercial theory is that hyper ventilators breathe only from the 'upper body' or 'intercostals' and 'not' as much from their diaphragm/abdominal muscles. But as I read your blog, you're basically saying this isn't possible, because people have to use their diaphragms. However, is it also possible that people hyperventilating are not using the correct abdominal muscles? Or perhaps that in HVS, people are simply OVERBREATHING, PERIOD---muscles notwithstanding---as opposed to using the 'wrong' muscles (abdomen), or NOT using the abdomen/diaphragm correctly?

PS- Incidentally, my take is that PLB without 'thinking' about the belly or diaphragm will fill the lungs and prove as effective as 'concentrating' on the belly, correct?

In any case, I'm trying to diffuse some of the myths out there and bring accuracy to my piece. Any help is, again, appreciated.

Sincerely,
Ron F

Hi Ron,

Congratulations on the article you seek to write regarding “Hyperventilation Syndrome” (HVS). The following are my thoughts on your questions, presumptions and issues with the portion of HVS considerations that you included.

First, HVS, is considered a syndrome that is psycho-emotionally driven. That it results in abnormal distortion of body physiology is what defines it and confounds attempts to characterize it, much less define its abnormalities. Let’s agree that the distortion of physiology to which I refer has to do with the resultant reduction in carbon dioxide (CO2) in the blood, the result of too much ventilation – more ventilation than normal body functions require with regard to shedding the waste product, CO2 AND the abnormal elevation of blood pH that accompanies the reduction in CO2. As such, it DOES fit your characterization of one who simply “over-breathes” – muscles notwithstanding – and is wholly a separate consideration from what muscles may have been used in its cause AND whether or not they are used wrongly or abnormally.

That said, you should understand that HVS, as an entity, is NOT in any way comparable to the alterations in breathing dynamics we see in those with advancing/advanced COPD. So, any description that I have provided along the way with regard to abdominal muscle breathing and/or shifting away from respiratory accessory muscle breathing (upper chest, intercostal muscles and those of the neck) cannot be applied to HVS.

During normal breathing conditions, muscles contributing to ventilation vary as demand changes. When one is breathing quietly, they use the abdominal muscles as primary drivers to inflate and deflate the lungs. The accessory muscles are ALWAYS ‘some’ component of the total effort of ventilation even under ‘normal’ “quiet” breathing conditions. When exertion enters the picture, while the abdominal muscles continue to be the primary muscle group driving ventilation, there is increasing recruitment of effort from the respiratory muscles. They assume an increasing portion of the ventilatory work load. This all occurs with little to no “intention” or deliberate thought-and –action, on the part of the person. At maximum, both autonomic AND deliberate driving of ventilatory muscles occurs – the best example being the person who is running. There is a ‘coordination’ of muscle and muscle group effort to bring about the effective result of total muscle participation in maximum ventilation. One does not “decide” to use one group of muscles over another. That is a function of physiology and normal ventilatory mechanics.

In COPD, as the lungs become more diseased and normal mechanics of ventilation become altered toward the abnormalities we observe, respiratory accessory muscles are increasingly recruited to assume a greater portion of the ventilatory effort/workload because the downward shift in “neutral diaphragmatic position” results in a decrease in the power generated by the diaphragm during ventilation. Still, body physiology requires a certain amount of ventilation to keep body functions ‘normal’. AND that ventilation is time dependent. The lungs have to ‘get the job done’ in the same amount of time it always has, despite the increasing “time constants” that are imposed by the abnormal shift in the composition and function of the lung tissues and their effect upon airflow into and out from the lungs AND ventilatory muscle position(s) and function.

Now, some folks are taught (WRONGFULLY) to become more deliberate about using more muscles of the upper chest to ‘help’ with breathing. Some folks come upon the notion, on their own and begin following it. For most, though, the shift occurs without will or knowledge as an unknown or not/poorly understood phenomenon. It just sort of ‘happens’. In abdominal breathing methods, we discourage the willful or unintended use of those accessory (upper chest and neck) muscles through training and paying attention to ventilation, making it more a willful and deliberate action rather than the autonomic action it was under previously ‘normal’ circumstances and conditions. We attempt to cause the individual to shift effort back downward to the abdominal muscles. We know that use of the accessory muscles comes at a cost of geometrically more calories burned, in terms of effort AND is also significantly less efficient at actually moving air than the abdominal muscles.

At this point, I would remind you and everyone that pursed lips breathing (PLB) while incorrectly characterized as both and inspiration and expiration inclusive technique is, in fact, SOLELY an expiratory-effect action. How one gets the air “in” has nothing to do with PLB. Yet, you will read that almost everyone who describes their understanding of or favorite method for PLB will include all manner of “fluff” with action and effort devoted to various controlling measures for the “inspiratory phase” of breathing. I must state emphatically, that ANY and ALL effort to exert ANY kind of ‘willful’ influence or effort over “inspiration” is misguided and simply superfluous. It adds NOTHING helpful positive or useful to the process, in and of itself. The lips are “pursed” during EXHALATION, for a reason. Doing so splints the airways and allows for more complete emptying of the lungs against the tendency (due to pathology) for the airways to collapse, ‘trapping” air in the distal portions of the lungs. The “incidental” result of PLB during the expiratory phase is to prolong the expiration, relative to the inspiration, which allows more complete emptying of the lungs and resultantly, less collection of CO2-rich air at the end of each respiratory cycle. It also ‘incidentally’ reduces total respiratory rate by ‘some’ amount, in the process.

The recommendations to breathe IN through the nose, RATHER than the mouth is the absolute WORST part of the popularly touted method that can be included. Breathing In through the nose is recommended for the following reasons: (1) It warms the air coming into the lungs. (2) It filters the air. (3) It humidifies the incoming air. (4) It necessarily slows down the total respiratory rate, argued to be a primary benefit of PLB.

Benefit # 4 is based in truth with regard to slowing the inspiratory phase and reducing total respiratory rate – but NOT for good or beneficial reasons. Consider that many folks have nasal congestion which narrows the “cross-sectional” diameter of the nose as a pathway for air flow. Additionally, it is anatomically factual that the “cross-sectional” diameter of the nose is almost one-half that of the cross-sectional diameter of the oropharynx (= open mouth). Poiseulle’s law states that as the diameter of a tube is decreased by ½, resistance to flow through that tube increases by 2-to-the-4th power – or 16 times! ! ! So, the imposition of nose-breathing INCREASES the work to breath by about 16 times! That’s a LOT of energy added to the already difficult work of breathing for those with COPD. It’s a bad idea AND singularly the reason why PLB under conditions of ‘significant’ or ‘intense’ exertion does NOT work for the very folks who need its benefit the most. My point is that breathing IN through the mouth when the nose becomes an inhibiting factor to get the air in during inspiration should be abandoned in favor of breathing in through the mouth! I suggest that one ‘get the air IN’ in the most comfortable and natural manner possible.

Insofar as the question of professed benefits of #’s 1 – 3, above, the answer is this: There is insignificant ‘consequential’ filtering that is accomplished by the nose. There is insignificant warming and humidifying that occurs, as well. We have, within our lungs a unique feature we call the “isothermal layer”. That is the point within the lungs at which the gas in the lungs reaches 100 % of body temperature and is 100 % saturated with humidity. It is found several branches into the bronchial ‘tree’ and is a “mobile” layer in that as the incoming air is cooler or warmer, it will move up or down within the airways to accommodate the objective to condition the air to 100 % of body conditions (temperature and humidity, that is). Consider when a person jogs or runs outdoors, in the elements of the weather on a winter day. The air coming into the mouth/nose may be 0- degrees Celsius (32 degrees Fahrenheit). Were it not for the dynamics that control the isothermal layer, that air would essentially freeze the body. But, through increased circulation, increased heat and moisture transfer through mucus dynamics, air reaches the depths of the lungs at 100 % of body temperature and 100 % of body humidity requirement by the time it gets there, regardless of the temperature at which it started out. When the person goes inside their home where the temperature instantly increases to, say, 24-degrees Celsius (75 degrees, Fahrenheit), the isothermal layer rapidly changes to a higher point in the lungs and the lungs reduce the rate of heat and humidity transfer as appropriate for the conditions of the air coming in.

Additionally, the air is as ‘clean’ as it will get, regardless of through which route of entry into the lungs it navigated – mouth OR nose – by the time it reaches the isothermal layer. When air comes into the lungs, it is nominally filtered of large particles by the hairs and mucus in the nose. The balance of filtration occurs as mucus within the bronchial tubes traps and holds particles and subsequently transports them out of the lugs through normal mucus movement. The amount of filtration that occurs with respect to the total action of cleansing incoming air is nominal with regard to the contribution of the nose, the bulk of cleansing occurring as a function of mucus activity.

So, as evidenced by the information of the previous paragraphs, the “need” for breathing in through the nose is not based in “evidence”. Indeed, it is strictly a “perceived” benefit and is without any merit when you consider the ‘evidence’. As such AND because it creates such ADDED difficulty for the already challenged person with COPD, it ends up being counter-productive and imposes an unnecessary and limiting burden upon the individual who tries to follow the recommended method.

In summary, PLB is a maneuver that prolongs exhalation, reduces total respiratory rate AND increases efficiency of ventilation SOLELY through its influence upon the “expiratory” phase of breathing. It has nothing directly to do with what muscles participate in the ventilatory process with regard to “INSPIRATION. As hyperventilation is related to the abnormal INPIRATION of more air than is needed to normalize blood gases and pH balance, it is a phenomenon separate with regard to consideration, cause and remedy from any notion of muscle or muscle group function. That considered, I would strongly disagree with ANY theory that suggests that HVS could in any way be caused by “wrong-muscle” use or “wrongful use” of respiratory muscles, no matter where they may be found. Such suggestions illustrate a lack of understanding of the physiology of breathing from a basic level.

As to your last speculation about what PLB would or would not do in terms of which muscles are used, deliberately or not, for those with COPD, it becomes an essential necessity that they at some point learn to exert deliberate control over ventilation such that they become able to shift effort downward to the abdominal muscle group as the primary drivers, in the process, avoiding increased use of the respiratory accessory muscles of the upper chest, intercostals and neck.

To reiterate, HVS represents, as you correctly speculated, a phenomenon of “OVER-BREATHING - PERIOD”! It is that and only that, independent of any consideration of correct or incorrect use of the muscles of ventilation. AND, its cause is one of psycho-emotional origin. It does not and cannot occur through any intrinsic physiological effect, in and of itself.

I hope this is helpful to you. And, perhaps, if you have further questions, they would best be handled through direct correspondence, rather than through a medium like this forum, since I suspect the interest and applicability to our COPD population is not inherent to this topic. This response HAS offered me the opportunity to better explain PLB, however, a point I would think is indeed of significant interest to readers of this forum.

Best regards and wishes to you,

Mark

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Comments Re: Your Answer to Recent O2 Stats


Hi Mark.
I do respect your candor, and I know that your answers are 100% truthful, but please when you do answer also give the other side of the coin as well.

I know you keep mentioning that over time my symptoms will get worse as well as my 02 levels, and what you say is true. COPD is a progressive disease,
but I think you should have mentioned as well the other side.
It should read something like this.

”As you know Philip your disease is progressive, and the more exacerbations that you have the progression of the disease may accelerate , but by that time in your disease there may be many things on the market to assist you that were not available at the time you wrote to me.
Recently they have had some but limited success with " Lung coils ", as well as LVRS, and a new procedure where they spray a glue like substance into your lungs. New Medications are coming on the market as we speak, so by the time you reach the stage where you may see significant changes in the progression of your COPD, there will be many more options available to you to help you, that were not available at the time you are contacting me today.”

What I say mark is also very true.
As time goes on I sincerely hope that many will be helped, and that new treatments and medications will become available.
Stem cells look promising as well, but a bit more down the road.
And look Mark at the worse case scenario that if one need a transplant. Look at how much longer the recipients are living now as compared to years ago.
My point Mark is yes I am going to get worse, BUT!!! by that time I could also get much better.
From my mouth into gods ear.
Your great Mark. keep up the fine work you are doing .

Kindest regards Philip

Philip, Philip, Philip, my Friend,

As the recipient of the responses to your questions to me, I would urge you to be cautious about mixing ‘facts’ and predictions based upon ‘evidence’ with the propensity to try to mediate with what are no more than prognostications, especially when they are based upon no more than ‘wishful thinking’. While I will always support the notion of ‘hope’ – after all, without hope, we are doomed to cynicism – what you suggest is hopeful, but certainly not guaranteed more than through ’ maybe/if’ possibilities.

It is undeniable that COPD is a progressive disease that can be modified only in terms of the speed of progression for many and the hope that they will succumb to a demise sooner than and from different causes than their COPD. That is the fact based upon evidence. The conditions – both controllable and uncontrollable – of how that progression can be altered remain one’s best hope in living happily and productively throughout the course of their disease. That is also fact based upon evidence. But, also based upon evidence is the fact that one can suffer an exacerbation or bout of acute respiratory illness that drastically alters their rate of progression, changes their baseline disease at a ‘momentary’ point and results in a dramatic shift in what is predictably possible or likely for them from that point on. Your ‘revision’ of my comments to read as you suggest “I” ‘should have’ stated them is based upon the presumption that your, or even (maybe “especially”) most folks with COPD, will experience an unfettered disease course that entails no more than simple progression of ‘longevity’ with maybe the occasional uncomplicated exacerbation along the way. Such suggestion(s) is (are) based upon much presumption and NOT ‘necessarily’ upon evidence. So the question of whether or not what you say is “also very true” as you insist, remains open for debate. And that you can reasonably suggest to put words into my mouth is indeed arguable.

But, let’s take a look at some of the points you made that you feel I failed to include as “the other side of the coin” and try to put them into perspective and potential application. You speak of “lung coils, glue and LVRS and their “limited” successful application and positive outcomes – speaking as if they are options for the general COPD population. Unfortunately, as the NETT (National Emphysema Treatment Trial, in the USA) illuminated, those who are actually candidates for LVRS procedures – of ALL kinds – are limited to about 12 % of the emphysema population. Realize that among those with COPD, those with emphysema – as a primary disease – represent about 20 % of the total COPD population. THEN among those 20 %, only 12 % will lend to the procedure by having a “heterogeneous” disease pattern that can be treated with the “localized” effect and benefit of LVRS. It is true that perhaps as much as, even possibly more than 50 % of those with Chronic Bronchitis as a primary disease ALSO have significant emphysema. Yet, among them, there are very few who have that emphysema component that is truly heterogeneous. The fact is that for the overwhelming majority of folks with COPD, LVRS – in any form – is NOT a treatment option – at least not in its current form and practice. And, the future does not lend to optimism that ‘that’ fact will change any time in the foreseeable future.

While there is much research ongoing in the area of pharmacological treatment for COPD, still, the vast majority of it is concentrated upon singular effects or components of the “inflammatory cascade” that comprises the disease process of COPD – that cascade continuing to change as we – through research discoveries – learn ‘new’ facts about the disease process and how it works. Remember, that the more we study COPD, the more we are discovering that it is a systemic process that is also increasingly complex and that is influenced by many more contributors than simply lung deterioration and its resultant functional loss. Hoping for – no, as you suggest – “expecting” that there will be even a ‘few’, let alone “many” new drugs that will in some way not only alleviate, but also “mitigate” and/or “reverse” the disease process and its attendant damage is, IMHO, presumptuous and something that, were I in your shoes, would not ‘hang my hat’ on as “likely”. Sure, you MUST “hope” for such ‘breakthroughs’ – and lord knows, as I learned with Cystic Fibrosis, many years ago not to say “surely never” or, as I actually did: “It’ll be 30 years before the gene for CF will be discovered”, when it actually took only another 5 years from the point that ‘that’ fact was included in my CF Foundation-provided ‘speakers’ material’ – the fact remains that such hope must also be tempered with realism and what is reasonably ‘likely’.

In actuality, I think stem cell interventions may not be so far off as you might suggest. While it may not become a widespread or widely applied therapeutic in our life time, aspects of it may be brought to fruition and applicability in a surprisingly short time. You suggest that lung transplantation is the “worst case” scenario. While I would characterize it as the “last resort” possibility, I would also agree with you that it has come a remarkably long way in the last decade and as my daughter just passed 9 years in the post-transplanted life and is coming up on the 5th anniversary of her second transplant (and after yesterday’s PFT, has an FEV-1 of 82 % of predicted and an FVC of 96 % of predicted – both placing her within “normal” parameters for pulmonary function, though she is considered to be in ‘chronic rejection’ by her transplant team) – I know all too well, how positive the prospect of transplantation is in today’s treatment process. But, again, those who are eligible for transplant remain among an all too small pool of the total COPD population.

While I share your “hope” for breakthroughs and progress, you must appreciate my position with regard to giving people the advice and answers to their questions that they seek from me. I must deal with the evidence and facts as we know them to be today. If I take to the tack to temper my responses with unbridled hope in every instance, I cease to become the person who presents the ‘facts’ for what they are and stand to lose some amount of credibility and certainly helpfulness for those who hunger for ‘information’ that is both useful to them and based in the evidence as well as in realism. In that light, I lose my usefulness to them – NOT the result I intend or hope for.

So, while you have the luxury to speculate, as you are wont to do, I must continue, as I do, to give the best of what I ‘know’ and then ‘encourage hope’, thereafter.

My best regards to you, always.

Mark

 

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