First Steps
The Basics
Stories
Articles
Quit Smoking
BBLW Community
Links
BBLW Team
Bookstore

Learn more about Jane Martin

Contact BBLW
BBLW Home

 

 

Ask Dr. Adams - Part 1 & Part 2

*** Note that this is general information and is not intended as medical advice.
If you have questions about the topics in this Q&A, take this information to
your next appointment with your own physician and decide with him or her
how best to serve your needs.

Dr. Francis V. Adams believes that an informed patient is a healthier patient and he proved that when he took the time to answer questions on our own Breathing Better Living Well Community forum.

Dr. Adams is a pulmonologist in private practice in New York City and is the author of The Asthma Sourcebook and The Breathing Disorders Sourcebook – comprehensive guides for patients with lung disease – and Healing Through Empathy. He is also a Police Surgeon with the NYPD.

More about the doctor can be found at AdamsMD.com.

These questions and answers were posted on the BBLW Community page from Dr. Adams on his first “Ask Dr. Adams” visit.

Is Asthma COPD?
Short of Breath with Allergies
Asthma and COPD
Medication Sequencing?
FEV1 (Forced expiratory volume – how much air you blow out in the first second of exhaling)
Exacerbations
Pneumonia
Spiriva
Airway Remodeling - Can asthma episodes cause permanent damage?
New here with many questions
Rescue inhaler  
Thank you

The following questions and answers were posted on the BBLW Community page from Dr. Adams on his second “Ask Dr. Adams” visit.

What is pneumonia?
Inflammation
Xopenex
Oxygen at Night
Does Stress or PTSD Affect or Worsen COPD?
Progression of Lung Disease
SOB With Exertion
COPD with the Strength Loss in Legs
O2 - Sleep Apnea
Oxygen and Exercise
Belly Breathing
Pulmonologist
Gray Around the Gills... ?
What does it mean when "too much oxygen becomes toxic"?
What causes the redness?
Thanks to Dr. Adams


Is Asthma COPD?

Hello Dr. Adams,

Welcome to the board and Thank You for joining us here at BBLW.
There has been a lot of discussion lately about which diseases fall under the umbrella term "COPD." We all know that Emphysema and Chronic Bronchitis are included but some
include Asthma and some don't.

Is asthma also one of the diseases listed under COPD?

Thank You,
Tim

* * * * *

Hi Tim:

Thank you. It's good to be here.

No, asthma is no longer listed under COPD. The reason for this is that although there is overlap between asthma and COPD, there is also a fundamental difference.

Asthma is now defined as an inflammatory disease of the airways of the lung, which produces narrowing or constriction. This narrowing produces obstruction to air flow. The key point is that this process is completely reversible. COPD is also characterized by airflow obstruction but this is not completely reversible. Some people with COPD have partial reversibility but this does not approach the improvement that asthmatics may experience.

I hope this is helpful.

Dr. Adams

Back to the question list


Shortness of breath with allergies

Hello Dr. Adams,

I have a question regarding allergies and shortness of breath.

I have mild intermittent asthma and rarely need my albuterol inhaler. I have pretty severe allergies to grasses, pollens and dust. My symptoms were always limited to a lot of sneezing, stuffiness, itchy eyes and throat and fatigue. But when my allergies are really flaring up like they have been lately, I notice that I am short of breath when exerting. I never have wheezing, and I've never notice this shortness of breath until the last couple of years and I've had severe allergies all my life.

With the symptoms not in my chest, but "in my head" how can the allergies be making me short of breath. Or are they?

Thank you!
Jane M. Martin

* * * * *

Hi Jane:

That's a question I am asked frequently. There are two possibilities.

The first is that your shortness of breath may be due to severe nasal congestion. It may sound odd but researchers have shown that if you close the nasal passages, this results in the sensation of shortness of breath. This is in part a reflex and I believe partly due to the fact that with the nasal passages closed or narrowed we are forced to mouth breathe. Mouth breathing is unnatural and also dries out the upper and lower respiratory passages. Our noses are really built in humidifiers and mouth breathing does not have this benefit. There are a number of good treatments for allergic nasal congestion including antihistamines, Singulair, and nasal steroid sprays. If you feel very stuffed, see if additional treatment relieves the congestion and shortness of breath.

The second possibility is that your shortness of breath may be due to asthma. Not all asthmatics wheeze or are aware of wheezing. You might use your albuterol when you experience shortness of breath and see if it resolves quickly. If it does, asthma is the most likely answer.

We are in and will continue to have a bad allergy season so I expect to hear your question alot.

Best wishes,
Dr. Adams

Back to the question list


Asthma and COPD

Hi Dr Adams, it's good to have you here - welcome to BBLW!

We have many members with asthma who have also been diagnosed with COPD. I know you said that asthma isn't classified as COPD anymore, so I was wondering how asthmatics come to be diagnosed with COPD. Is it an additional lung problem or a misdiagnosis?

Thanks!
Eileen

* * * * *

Hi Eileen:

That's an important question. It is my personal belief that a number of asthmatics are misdiagnosed as COPD. It goes back to that feature of reversibility that I discussed in Tim's question.

When a patient has pulmonary function tests and the results show airflow obstruction with little or partial reversibility after the use of a bronchodilator (usually albuterol), the diagnosis of COPD is applied. If there is marked improvement or reversibility these patients are diagnosed as asthmatic.

The problem here is that the airways of an asthmatic can be so swollen and constricted that the single application of the bronchodilator in the PFT lab may not produce the marked improvement so typical of asthma. This may also happen if someone is overusing their bronchodilator spray since the too frequent application of the drug may produce a decreased response of the beta receptor that controls how open the air tubes are. This is how an asthmatic may end up misdiagnosed as COPD.

In order to reach the correct diagnosis of asthma I recommend a few additional tests. First, it helps to look for allergy by checking the blood for an increase in allergy cells (eosinophils) as well as the allergy protein (IgE or immunoglobulin E). Asthmatics are often allergic so if I find evidence of allergy increases my suspicion that my patient is truly asthmatic. I also recommend a chest CT scan since it is an excellent test to prove that there is emphysema (destruction of the air sacs or alveoli of the lung). If the CT demonstrates emphysema, the diagnosis of COPD is clearly the correct one.

When a physician is not sure if there is asthma or COPD, a trial of oral corticosteroids would be the next step. Steroids are very effective in asthma (less so in COPD) so that a course of oral medication may in fact "unmask" an asthmatic by reducing the swelling in the bronchial tubes. After a course of steroid a patient who had little reversibility or improvement after bronchodilator on initial testing may now show marked improvement confirming that asthma was in fact the correct diagnosis.

I hope this is helpful,
Dr. Adams

Back to the question list


Medication Sequencing?

Good Morning Dr. Adams,

Like many of our members, I have an asthma component along with COPD.

My asthma is usually very well controlled by my maintenance medications. I use Advair 500/50 2X daily, Spiriva 1X daily, and Theophylline 100Mg ER Tabs 2X daily. I have Albuterol inhaler for an escape medication and also Albuterol for neb treatments during exacerbations.

I normally do not need to use my Albuterol unless I am having an allergic reaction to tree molds or grass and during weather changes. During these times my inhaler works well.

My question is about sequencing of all of these medications.

I was told by my GP that it was ok to use my Inhaler first to "OPEN" my airways and then to go ahead and use the Advair then the Spiriva. I have been told recently that I should not use my Albuterol first. I was told not to take the Advair within two hours of the Albuterol and to wait at least 30 minutes after the Advair to use the Albuterol if I still felt the need for it.

Could you please explain this to me?

Thank You,
Tim

* * * * *

Hi Tim:

I'm glad you asked this question.

When the inhaled steroids were first released in this country (early 1970s) it was an accepted practice to ask patients to use their bronchodilator spray prior to the steroid to, as you said, open the airways, facilitating delivery.

This is no longer the recommended practice.

One reason is the use of long-acting bronchodilators (salmeterol or Serevent and formoterol or Foradil), which are taken on a regular basis. Advair contains Salmeterol which has a 12 hour duration of action. The current thinking is that if you are taking your Advair regularly you have a constant bronchodilator effect so adding Albuterol is unnecessary. You do not need to use it before Advair or Spiriva.

There is another important point and that is Albuterol should be reserved for "rescue" only. It works much better when taken "as needed" rather than on a regular basis. We also know that overuse results in a decreased effect.

In terms of the timing of the Albuterol and the other medication, you do not have to wait or adjust your medication. In other words, keep Advair on a set every 12 hour schedule. You do not have to alter it if your need for Albuterol arises; even if the albuterol falls right when the Advair is due. There is no evidence of any increased side effects if you use them at the same time.

I hope this is helpful.

Dr. Adams

Back to the question list


FEV1 (Forced expiratory volume – how much air you blow out in the first second of exhaling)

Hello Dr. Adams,

I am new to posting here but wish to ask a question.

When my doctor's office administers the spirometry test, my FEV1 is lower after the albuterol spray than it was before the spray. This has been the case for the last two times I have had the spirometry test. Why is this?

I have severe COPD with severe asthma.

Thank you,
Serra

* * * * *

Good morning:

That's a good question.

If there is a 5% or less drop in your FEV1 this would not be considered significant.

If you are dropping more than 5% it suggests that you are having an adverse reaction to the medication. This may occasionally be due to the preservative or propellant included in the medication and not the drug itself. Some aerosol solutions contain sulfites (good idea to check labels) which are used as a preservative (also used in foods) and these chemicals are known to produce asthmatic attacks is susceptible individuals.

With COPD, the response to albuterol is often minimal while it is much greater in asthma. Your lack of response suggests that your COPD component is greater than the asthmatic one.

In some patients it is useful to use an anticholinergic agent such as ipratropium bromide (Atrovent) in place of albuterol for PFT testing since this family of bronchodilator is much more effective in COPD. You could ask your physician to do this or to give the ipratropium after testing you with the albuterol.

Another important point is that the before and after bronchodilator PFT testing should be done with Albuterol out of your system. In other words, a valid test can only be done if you have not taken your bronchodilator spray for six hours. If you have Albuterol in your system you will not register any response to the drug in the laboratory.

Be well,
Dr. Adams

Back to the question list


Exacerbations

Hi Dr. Adams,

I've been told I have chronic bronchitis and some asthma. I've also been told I have asthmatic chronic bronchitis. First of all, have I ever been actually diagnosed with COPD if I've never been told I have emphysema? Once I was told COPD means you have both, but in pulmonary rehab I was told chronic bronchitis is one of the conditions under the umbrella of COPD.

My primary question of concern is about exacerbations. Over the past couple of years the exacerbations are becoming more frequent and harder to get on top of. Why is this? Especially in the past months I've had to have 3 courses of Prednisone and also several rounds of antibiotics to get rid of infection. I've been trying to ignore it that things are worsening, but my husband and kids often bring me back to reality. To be honest, I'm scared, too. Often I get so tired and suffocated I feel like I'm only half here. My mind gets so unclear. Should I be concerned or should I just learn to accept it as a very real part of my condition and make the best of it? Also, sometimes my ribs feel like they're being forced outward and talking makes my bronchial tubes feel swollen shut and it tires me out completely if I talk too much. Is all this "normal?”

Sorry, but I guess this is a jumble of questions! Thanks for all your help at this forum.

Thanks,
Trudy

* * * * *

Hi Trudy:

Yes, if you have been diagnosed with chronic bronchitis you do have COPD. It sounds like you do have an asthmatic component, which means that some of your airway obstruction or narrowing is reversible.

What you are describing (a downward spiral) is very common. This relates to what happens when you get an infection. The bronchial tubes, especially the smaller, more delicate ones, become red and inflamed, often congested with mucus. The mucus can become hardened and stay within these passages forming a breeding ground for germs so that infections keep coming back. This is why it is so important to treat exacerbations aggressively and as completely as possible. Very often people feel better and treatment is reduced or stopped too soon.

Aggressive treatment may mean a longer course of antibiotic or steroid. Unfortunately side effects may develop but again the benefits should outweigh these adverse effects.

I would certainly try to get a sputum culture done to see what organisms are present; look into chest physical therapy with postural drainage to mobilize secretions. If you do have mucus plugging (best seen on a chest CT scan) then you want to add the Acapella mucus mobilization device and consider taking guaifenesin (Mucinex) on a regular basis. I would also be sure that you are on the best possible medication regimen (I like the combination of a long-acting bronchodilator like Serevent or Foradil combined with Spiriva as well as an inhaled corticosteroid with the option to use a short-acting agent like albuterol as needed).

I hope this is helpful,
Dr. Adams

Back to the question list


Pneumonia

I have Strep Pneumonia. I have had this for 5 months. I had my shot in 2005. I should mention that I have had Emphysema for 11 years and due to a lung operation in 1996 got pseudomonas and have been on and off antibiotics and Predinsone for years and so most oral antibiotics do not work on me.

I have had 7 hospital stays this year with I don't know how many IV antibiotics and still cannot get rid of it. Any ideas??

Thanks.
Doan Ca.

* * * * *

Hi Doan:

The following things may have been done already but I would recommend having your blood checked for any weaknesses in your immune system. This would include levels of immunoglobulin G, immunoglobulin M, and immunoglobulin A as well as Immunoglobulin G subsets. In addition your CBC should be checked with a differential to make sure your white blood count is normal. I would also recommend having a sputum culture done once a month or every other month to see what bacteria or fungi may be living in your bronchial tubes.

When someone has COPD and surgery, the anatomy of the lung may become distorted or weakened so that germs begin to live in the damaged areas. This is called colonization if the germs just accumulate but do not invade the surrounding tissue. Once they invade you have an active infection, which must be treated.

The approach I would recommend would be to try to reduce the population of germs. First you need the culture to tell us what the organisms are. I would recommend daily chest PT with postural drainage to flush out mucus that has accumulated. Germs love the stagnant environment when there is plugging of the airways with thick mucus. You can also keep mucus moving with a few methods such as the Acapella mucus mobilization device, a home nebulizer, a medication called Mucomyst, and guaifenesin, which is now sold OTC (over the counter) as Mucinex.

If you culture pseudomonas from your sputum and you have had this infection develop into pneumonia, I would recommend inhaling an antibiotic called TOBI (tobramycin) on a regular basis to kill these organisms before they multiply into pneumonia. Unfortunately there is nothing similar to this for Strep and you need to rely on the IV antibiotics to kill that infection. You might want to involve an Infectious Disease specialist in your care.

I hope this is helpful,
Dr. Adams

Back to the question list


Spiriva

Dr. Adams,

I am currently taking Atrovent four times a day, but do not feel it is as effective as it was when I first started taking it.

I have heard so much good information about Spiriva and am wondering if I should ask my doctor about changing to it. I never had to use my rescue inhaler until the last few months and now I am thinking maybe I should look for a change in my medication.

What are your thoughts on Spiriva vs. Atrovent?

Dee

* * * * *

Hi Dee:

I have been very pleased with the results of changing my patients from Atrovent to Spiriva. They are both anticholinergic bronchodilators but Spiriva is much more potent and effective. It is also a once a day medication which I recommend taking in the morning. Several studies have shown a clear advantage over Atrovent in improving PFT’s and lung function. In addition, increases in lung function can continue up to 12 months after starting Spiriva.

I definitely recommend changing.

Best wishes,
Dr. Adams

Back to the question list


Airway Remodeling – Can asthma episodes cause permanent damage?

Dear Dr. Adams,

As a respiratory health care professional, I've heard about "airway remodeling," which I understand is that airways and lung tissue actually develop permanent damage (leading to COPD) if they continue to go through repeated pneumonias and bad asthma episodes.

Sometimes patients with severe COPD who come to our program tell me that they had pneumonia frequently as a child or they remember having asthma and struggling to keep up when playing with friends. Can you talk a little bit about this, and if I am understanding it correctly, address the importance of avoiding asthma episodes to prevent airway remodeling? In working with people having asthma attacks in the ER for many years, it seemed that some people took the episodes lightly, saying something like, "Oh sure, we come in here a few times a year and they open it up again and he/she's fine again for a while."

In other words, should those younger people out there today with asthma be concerned that their asthma attacks are not just fixed in the ER or with a burst of prednisone with no lasting effects?

Thank you for your time and expertise! This has been a great learning experience for all of us.

Jane Martin

* * * * *

Hi Jane:

This is a very important question.

Studies of the airways of moderate and severe asthmatics have shown changes that consist of scarring, thickening, infiltration of inflammatory cells, resulting in what is termed "airway remodeling." This occurs even in mild asthmatics but to a lesser degree. Clearly repeated asthmatic attacks produce chronic changes that may become permanent, especially attacks that are poorly or partially treated.

The most sobering fact in this area of research, however, is that many medications including the inhaled corticosteroids do not seem capable of reversing these changes. Once scar tissue is established it cannot be reversed.

This is why it is so important to prevent asthmatic attacks. This can be accomplished through avoidance of known allergens and the use of preventive or controlling medications that reduce the frequency of asthmatic attacks. For severe allergic asthmatics, the anti-IgE monoclonal antibody, Xolair, has the ability to prevent allergen-induced asthmatic attacks.

The attitude you describe is definitely a bad one. The best asthmatic attack is the one that never happens.

Thanks for having me in,
Dr. Adams

Back to the question list


New here with many questions

My husband has been diagnosed with IPF, Emphysema and Pulmonary Hypertension based on his CT scan. He is SOB even when sitting. Has what he calls "waves," where he is very dizzy, to the point he feels like he is going to pass out, severe chest pain, his pulse drops down in the 40s and 50s, he gets really sleepy and fatigued. His O2 level ranges between 89% and 94% when this happens. He is not on O2. He takes Spiriva 1X a day. Has Albuterol Inhaler as needed. He is also on Mucinex. That is all he takes.

He had an echo done that shows he has valvular regurgitation involving the pulmonary & tricuspid valves, listed as trivial. Normal left ventricular function with LVH, Diastolic function class: Relaxation abnormality (grade 1) correspondes to E/A reversal. No one has explained these results to us. Do you know what the echo report means?

The CT of his chest shows he has a 6 cm right apical bulla. Honeycombing is present. There is enlargement of the main pulmonary artery measuring 3.5 cm in dimension as well as enlargement of right and left pulmonary arteries with the right measuring 2.8 cm. He has IPF and Emphysema. Again, no one has explained these test results to us. Not even the pulmonary doctor he saw.

We have another appointment on June 21 with a new PD. Any light you can shed on this is GREATLY appreciated.

Thank you,
Susan - wife of John - DX 1/07 - IPF, Emphysema & Pulmonary Hypertension

* * * * *

Hello Susan:

IPF is idiopathic pulmonary fibrosis; it means scarring of the lungs; a disease which we do not know the cause of. It reduces lung capacity and when this becomes severe, oxygen levels fall. They tend to fall a lot during exertion or exercise but this can also happen with emphysema.

Unfortunately there are few good treatments. In fact in younger people, transplantation is considered the treatment of choice. A trial of steroids is often given for 3-6 months with repeat lung functions and CT scan but only 1 in 10 people respond.

The combination of this with emphysema must have reduced your husband's lung capacity so that the pressure in the blood vessels that supply the lungs (pulmonary circuit) have become elevated. This is what is called pulmonary hypertension. This puts a strain on the heart, which can then fail in a severe case. Medications have some effect on reducing this pressure but one side effect might be to reduce the general blood pressure, which could have severe consequences (dizziness, fainting). One important general measure to treat the pulmonary hypertension is to keep oxygen levels in a good range, preferably above 90% saturation. Oxygen levels usually fall during the night so I often obtain an overnight oximetry study. Quite often we find that the 02 saturation is low during the night and by treating this with oxygen the patient's general condition improves. Basically this takes a strain off the heart. Studies have shown that oxygen used in this way can prolong life.

I would be aggressive in treating the emphysema component and would suggest that Foradil be added to Spiriva. A REHAB program might also be of value to improve stamina and exercise capacity--this would be done with him using oxygen.

The valves of the heart quite often do not close completely. This allows some blood to go back through the valve. This is called regurgitation or insufficiency. It is quite common so a trivial amount of this is not a problem. The heart has a right and left ventricle. The right side connects to the lungs and the left to the general circulation. LVH means left ventricular hypertrophy which means enlargement--this is common when the heart works too hard as in hypertension (high blood pressure) but normal LV function means the muscle is performing normally (decreased function would mean heart weakness or failure). The heart pumps but it also relaxes. Diastolic dysfunction means that the heart is not relaxing normally--this is also common in hypertension and can lead to heart failure. High blood pressure is very treatable and there are medications that can be given for diastolic dysfunction. A cardiologist would be the best person to address the heart issues and can work with your pulmonologist on the pulmonary hypertension as well.

A 6CM bulla is a large cyst. This may occur due to emphysema and basically is an empty air sac that does not help with breathing. I don't think this is large enough to consider removing it. The pulmonary artery divides into a right and left vessel and enlargement is a sign of pulmonary hypertension. Honeycombing is a pattern of scarring that is common in pulmonary fibrosis.

I know this is a lot to digest. Please let me know if I can be of any further help.

Dr. Adams

Back to the question list


Rescue Inhaler

Dr. Adams,

You have mentioned that overuse of Albuterol reduces its effectiveness. I use it before exercise and for quick relief because it works so well for me. How often is too much?

Dee

* * * * *

Hi Dee:

I'm glad you asked that. The short-acting bronchodilators like Albuterol really work best when used on an "as needed" basis rather than around the clock on a regular schedule such as every six hours. Studies have shown that if albuterol is taken four times a day on a regular basis for two weeks, its effect begins to weaken.

You can safely use it before exercise on a daily basis but if you have exercise-induced asthma you should also consider an alternative treatment such as Singulair or a long-acting bronchodilator such as Serevent or Foradil.

You also want to be sure that you are on the best possible maintenance medication regimen (for asthma this would include Singulair or an inhaled corticosteroid and possibly a long-acting agent; for COPD this would include Spiriva and a long-acting agent). This might reduce your need for the "rescue" inhaler.

I would hope that you would not need albuterol for rescue more than twice a week.

Please feel free to follow up on your question,
Dr. Adams

Back to the question list


Thank you

I just wanted to thank you so much Dr. Adams for being here to answer our questions.

Sadly many of us have been left in the dark when it comes to the facts concerning our illness and the medications we need, and what we can do to help ourselves. We have come to the INTERNET for the help, information and support we need.

Your answers were very informative, honest and so helpful, and I wonder how we got along before you stopped by.

Thanks again,

Dee

* * * * *

You are most welcome, Dee, and I hope to be back.

Dr. Adams

Back to the question list


What is pneumonia?

Dear Dr. Adams,

I'll start us of with a question that, in spite of being a respiratory therapist, I really need to know. This is also a question that I hear a lot from my patients. What, exactly, happens in the lungs with pneumonia?

I know it has to do with more secretions / phlegm that get stuck in the lungs. And it also involves inflammation, right? I'm also asking how it is caused by inactivity, such as after chest or abdominal surgery when people are afraid to breathe deep enough and cough, or even when people aren't up and about like they once were. Finally, can having pneumonia actually damage the lungs and make a person feel like they "never got back to how they were" before the pneumonia? I often hear people say that.

Thanks so very much for being here and for answering our questions!
Jane

* * * * *

Good morning.

That a very timely question since this is the pneumonia season.

In pneumonia, an organism which may be a virus, a bacteria, or a member of a different group of germs such as the legionella organism (these are often called "atypical" germs since they don't fit into viral or bacterial groups), is inhaled. If the germ gets past our built in defenses (nasal passages) it enters the bronchial tubes where it begins to multiply. Our immune systems recognize the invader and defense cells are mobilized to respond as well as proteins (called immunoglobulins) in an attempt to kill the germ. This early phase is really a form of bronchitis in which there is considerable inflammation. Debris is also produced from the interaction of the cells and the immune system. This produces cough with increased sputum, which may be discolored. As the infection progresses it begins to involve the smallest bronchial tubes (called bronchioles) which enter into the air sacs of the lung (alveoli). Pneumonia means that the air sacs have become involved and what you see is the inflammatory material (mucus, cells, germs) clogging these sacs. This material in the air sacs is what produces the infiltrate on a chest x-ray, which is the most reliable means of diagnosing pneumonia.

Any condition that reduces the normal clearance of secretions (and germs) from the lung will increase the likelihood of pneumonia. This might be bedrest for another condition or a rib injury which limits cough which expels germs and sputum. We need to keep our airways clear so that germs do not have a greater chance of taking hold.

When a pneumonia resolves, all of the inflammation and the material including the debris, dead cells, dead germs must be mobilized and excreted. In some cases, this is not complete and the air sacs may be permanently damaged. This is often called post-inflammatory fibrosis and it is irreversible. Fortunately this is the exception and not the rule. Patients with COPD or other lung conditions are more likely to suffer this consequence, however.

Prevention is the best approach to pneumonia. Influenza is often complicated by pneumonia so a flu shot is a must. Pneumovax or pneumonia vaccine covers strept pneumonia, which accounts for about 40% of all pneumonia so it is also a must for anyone over 65 or with a chronic lung condition (including asthma).

Best,
Dr. Adams

Back to the question list


Inflammation

Good morning, Dr. Adams. It is nice to have you back here again.

I am just going to jump in here with a question. I have made a list, but I think I will just ask one at a time.

My first question concerns inflammation. I have read that inflammation could play a role in heart disease and for people with lung problems, lung cancer, and also other illnesses. I also know that joints and muscles can be inflamed due to different reasons.

Is the inflammation of the same type, or are there different kinds of inflammation?

Thanks in advance,
Dee

* * * * *

Hi Dee:

That's a great question.

Inflammation is a general term so there are a number of different forms depending on what is driving the reaction. For example, we have been talking about pneumonia or an infection this morning where the white blood cells (which are one of our immune defenders) respond to an invading germ. In the interaction between our cells and germs, cells and germs die, giving off chemicals, which produce inflammation.
Allergy can also produce inflammation. The best example here is asthma in which white blood cells and allergy cells break down producing inflamed airways.

Immune disorders such as Rheumatoid Arthritis also have inflammation. Again, immune cells drive the inflammation.

There have been reports that the arteries of the heart (coronary arteries) may develop plaque due to inflammation from infection, so this is a hot topic. Expect to see a lot writtten on this subject.

Dr. Adams

Back to the question list


Xopenex

Thank you for your answer to my last question, Dr. Adams.

I have another one about Xopenex inhalers.

My husband was given a Xopenex inhaler for a cold recently. I have knowledge of the Xopenex for nebulizer treatments, but had never heard of the inhaler before. When is it appropriate to use a Xopenex inhaler in treatment of COPD?

Dee

* * * * *

Dee,

Xopenex is levalbuterol which is available as a spray (Xopenex HFA) or nebulizer solution (comes in two strengths, 0.63MG and 1.25MG). It can be used every 6-8 hrs as needed.

Xopenex is derived from albuterol. Chemists have removed part of the albuterol molecule in an attempt to reduce side effects. I find that it is very similar to Albuterol.

Xopenex is a rapidly acting beta-agonist dilator that should be used for rapid relief of shortness of breath in COPD or asthma on an AS NEEDED basis.

It is more effective in asthma patients but is helpful in COPD as well. I like to combine it with an anticholinergic bronchodilator such as Spiriva which is used on a regular basis.

Dr. Adams

Back to the question list


Oxygen at Night

Dear Dr. Adams,

Here's another question I get a lot from patients in our pulmonary rehab program.

What's the advantage of using oxygen at night and not during the day? Is it because the breathing sometimes slows down and / or is more shallow during the night and the oxygen levels drop?

Here's another oxygen-related question I wonder about. We go by the magic number "88%," that is, if somebody has an oxygen saturation at 88% or lower on the pulse oximeter, they qualify for supplemental oxygen. My question is this: If they are 'living' at 89% or so much of the time, is that really enough for staying as healthy as possible? I've heard that there are findings telling us that by using this guideline we're letting our patients be "too low."

Thank you!

Jane

* * * * *

Hi Jane:

Another great question.

Oxygen levels are lower for everyone during sleep. This relates to a more shallow breathing pattern that we all assume during sleep. Some alveoli drop out of use so O2 levels fall. If you are starting out with an awake O2SAT above 94% it is unlikely that the sleep level will be below 88%. It is best, however, to do a sleep oximetry study and see the actual O2 levels at night. This is relatively easy with a pulse oximeter that has a printout or memory. Home care companies usually set this up with an order from the MD.

When O2 levels fall below 88% it constricts the blood vessels (pulmonary arteries) in the lung. This produces a higher pressure which is transmitted to the heart. The end result can be a weakening of the heart muscle or congestive heart failure so it is important to maintain O2 levels above 88% for the entire day.

Another common O2 problem is that O2 levels in COPD patients typically fall during exertion. Again an oximeter can document this and if levels fall below 88%, portable O2 is required.

I do believe that 89% is better than 88% although I understand that it doesn't seem significant. What we know is that the blood vessel constriction occurs at a certain level and it can be that at 1% higher O2SAT, constriction does not occur but at the lower level it does.

Dr. Adams

Back to the question list


Does Stress or PTSD Affect or Worsen COPD?

I've heard that stress or post-traumatic stress can directly affect asthma. How does it relate to COPD? How big a part do negative emotions or depression play in our fight with lung disease?

Thanks,
Trudy

* * * * *

Hello:

I'm glad you brought that up.

Stress is a well-known asthma trigger but stress, anxiety, and depression often accompany chronic lung disease (both COPD and chronic asthma). I feel these are aggravating factors and large studies have shown a high incidence of anxiety and depression in COPD. Anxiety will often aggravate shortness of breath and depression may also increase symptoms of fatigue and reduced appetite.

I encourage my patients to seek treatment for these problems. This may vary from person to person but I would include support groups, medication, and counseling among the best options.

Dr. Adams

Back to the question list


Progression of Lung Disease

Hi Dr. Adams,

Thanks for taking the time to visit with us here at BBLW!

My questions here have to do with the progression of lung disease. I have asthma, chronic bronchitis, and bronchiectasis. A doctor once told me that some day I'll have emphysema. Is this necessarily true? The progression of this disease doesn't actually mean I'll eventually have to deal with other lung diseases, does it? And if I take proactive measures, I can slow down the progression, right? Does every time I get an infection speed up the progression? Does pushing myself beyond my limits (not pacing, etc.) speed up progression?

Thanks,
Trudy

* * * * *

Hello:

There have been some reports of patients with uncontrolled asthma developing emphysema. I believe the key word here is uncontrolled. In other words, patients with severe disease that is not well treated may progress to emphysema. When I say uncontrolled I mean a patient who needs to use a rescue inhaler more than twice a week and who has more than one nighttime asthma attack per month. Anyone falling into this category should see their physician to adjust their asthma regimen.
With a good regimen and asthma that is well controlled, I do not feel that you have to fear progression to emphysema.

Infections do cause inflammation and congestion but are in most cases, reversible, so that progression to emphysema would be unlikely.

I also do not see any problem with vigorous exercise or pushing yourself as you say. In fact, exercise is in general beneficial for the lungs.

Dr. Adams

Back to the question list


SOB with Exertion

Hi Dr, Adams,

Thanks for joining us this week to answer our questions.

I recently completed the 12 week course of P. Rehab and am now continuing in the maintenance portion of the program. My Breathing and Oxygen usage has improved alot. When I started I was using 3 LPM of o2 at rest and 4 LPM with exertion. I'm now able to maintain my SPo2 Saturation in the mid 90's on 2 LP all the time. My questions is: Why is it that my Spo2 will be sitting at 96 and I am still so SOB? Normally this happens with any exertion.

Tim

* * * * *

Hi Tim:

That's a great question.

As you can see, a low oxygen is only one cause of shortness of breath. As you have experienced, air hunger can occur even with normal oxygen levels. A vivid example of this that I see frequently is someone having an acute asthmatic attack; breathing 20 to 30 times a minute but with a normal oxygen level.

In asthma and COPD you can experience shortness of breath if the airflow through your bronchial tubes is not free and easy. In other words if the bronchial passages are narrowed or constricted you have to work harder to get air through and this increased "work of breathing" is felt as shortness of breath.

Another example is a "stiff lung" as may occur with scarring or fibrosis of the lungs. In fibrosis, the consistency of the lungs changes from a sponge-like consistency to a more solid consistency. This triggers stretch receptors in the lungs to send signals to the brain that increase the rate of breathing, again increasing the amount of work needed to breathe. This is felt as shortness of breath.

Exercise and REHAB is a great way of strengthening the muscles of breathing. As they get stronger, the work of breathing is less tiring and your stamina increases.

Keep up the good work, it should help you become less short of breath.

Dr. Adams

Back to the question list


COPD with the strength loss in legs

Dr.Adams,

With severe Copd will 30% lung volume cause your legs not to work as good as they use to or tire out quicker? I have just started to notice it and my daughter thinks I should use the walker with a seat. Will this continue to get worse before I won't be able to walk? Guess that is a stupid question to ask.

Kitty

* * * * *

Hello Kitty:

No, that's a good question. In fact, researchers have been looking into this problem of muscle weakness or atrophy in COPD patients.

There are alot of leads. First, nutrition may be a problem. Many patients lose weight (energy consumption of breathing, shortness of breath during meals, decreased appetite due to depression) with COPD and with the weight goes muscle mass producing weakness. Muscles also need fuel which is oxygen to function and as we have been discussing O2 levels may be low or may drop during exercise. There may be hormonal problems also such as reduced testosterone which is an anabolic steroid. In fact, patients with COPD, particularly men, have been treated with anabolic steroids with some success. I have a few patients I have treated this way and I believe it is helpful. The problem is the adverse effects, especially in men if there is prostatic disease and the masculizing effects that would be evident in women. Another muscle problem in COPD is due to the use of metabolic steroids like prednisone. This would be oral or injectable, not the inhaled. Unfortunately these potent drugs can weaken muscles. This is called myopathy.

What to do? First, improve nutrition and consider seeing a nutritionist to guide you. If there has been weight loss, try to get back to your ideal weight, using supplements that are rich in protein as well as carbohydrates. Check the O2 levels and use O2 for exercise if your level drops on exertion. Talk to your MD about a conservative trial of anabolic steroids. If you are maintained on oral corticosteroids (prednisone) see if you and your MD can wean you off or at least to a lower dose.

Most importantly, use your muscles and keep going to REHAB to build muscle mass.

Good luck!

Dr. Adams

Back to the question list


O2 - Sleep Apnea

Hello Dr. Adams, Thank You for visiting with us here at BBLW. My questions is this, I have sleep apnea and sometimes I wake up gasping for air and pull of my mask, I know now that I can not sleep with out it, nor can I sleep with it! is there a solution to this predicament...

Thank You for your time.

Sandy

* * * * *

Hi Sandy:

I hear the same thing from my patients with sleep apnea. There has to be an explanation and I'm afraid the only way to sort this out is by having another sleep study using your own equipment to see what it producing this.

I can tell you what we have found in some of my patients. Clearly there can be a malfunction of the CPAP device itself. One patient needed more humidity and the drying out of his throat caused him to awaken suddenly. We have found some patients who had a drop in O2 and needed to have an increase in O2 added to their sleep setup. It is also possible that the CPAP setting has to be changed and that your current setting is no longer effective.

I am sure that the cause of your problem can be found. Talk to your MD about setting up a new study.

Best,

Dr. Adams

Back to the question list


Oxygen and Exercise

Dr. Adams,

When would you recommend using oxygen with exercise? Are there guidelines for this, or should you just watch your levels and back off on exercise when they get too low?

Dee

* * * * *

Hello:

I like to check the oxygen saturation at rest and again during exercise. In COPD and fibrosis, O2 levels commonly drop during exertion. If the level goes below 88% during exercise I would place O2 before the exercise session begins to prevent this drop.
I would again check the level with 02 on to make sure that the liter flow is enough to keep O2 saturation above 88%.

Dr. Adams

Back to the question list

hr

Belly Breathing

Dear Dr. Adams,

I have a question about Diaphragmatic, also belly, or abdominal breathing.

When a person has a lung removed, or a lower lung lobe removed, it that half of the diaphragm then unattached to anything, just floating? In other words, can a person with a lung removed still do effective abdominal breathing on that side, or is it compromised just using the other half?

Also, when a person has quite severe COPD and a really flattened diaphragm, can we still work on using it for more efficient breathing, or is it too flat to do much of the work?

I think for a lot of people, mastering diaphragmatic breathing is pretty difficult. I know sometimes I see patients become kind of frustrated with it, but when they "get it," it really does help. It is a hard concept to grasp.

Thank you!

Jane.

* * * * *

Good morning:

That's an interesting question.

The diaphragm is the most important and strongest muscle of breathing. It has its own nerve supply so although removing the lung or just the lower lobe of the lung affects its position (the diaphragm will move upwards when the lung or part of the lung on that side is removed) and movement (may move less after surgery) it remains an effective muscle of breathing.

Diaphragmatic or belly breathing is still worth performing after surgery. Yes, it may be difficult to accomplish but just the effort alone helps to improve respiration.

In COPD the diaphragm may be overworked and fatigued. In fact, studies have shown that muscle fibers may be lost. In COPD the overinflated lungs push down on the diaphragm so it becomes flattened and therefore is unable to move normally.

This is part of the reason that lung reduction surgery or procedures may improve breathing in COPD. I would not give up trying to work the diaphragm. Like any muscle, it is capable of strengthening through exercise.

Dr. Adams

Back to the question list


Pulmonologist

Hello Dr. Adams,

My question is a little different. I would like to know from you, as a medical professional, what I should look for in a top rate pulmonologist to help me in my battle against COPD? Would you mind sharing that with me? I am having a hard time finding one that is really good and would sincerely appreciate any guidance you can give. For example, the last time I was in to see mine I had fever and was very sob and wheezing. The only thing he checked was my blood pressure and gave me a spirometry test. He also rushed me out of there. This does not seem right to me. Not good enough or am I mistaken?

Thank you,
Serra

* * * * *

Hello:

I have to agree with you. You want a physician who takes the time and addresses your complaints. Finding the right person can be difficult. You can certainly check credentials since you want a board certified physician. One of the best ways to find the right doctor is through someone you know who has been satisfied with his or her care.

Best,
Dr. Adams

Back to the question list


Gray Around the Gills... ?

Gray Around the Gills...?

Hi Dr. Adams,

There are times when I get grayish around my mouth area. It's usually after I've pushed myself perhaps too long in exercising or after exerting myself a lot with shopping, etc, and I get extremely tired. Kind of those times when my mind talks me past what my body tells me I can handle... What causes this?

Thanks!
Trudy

* * * * *

Hello:

Although this is not the bluish discoloration we call cyanosis I suspect this may be explained by a drop in oxygen. If I am right, it will correct after a few minutes rest. You could confirm this with an oximeter, which would show your oxygen level during exercise and recovery.

Dr. Adams

Back to the question list


What does it mean when "too much oxygen becomes toxic?”

Dr. Adams,

I have oxygen at night, because according to a sleep study, my oxygen level lowered at night. It has happened that when I'm going through a bad exacerbation, I've been put on it during the day for a limited time. I've been told that if a person gets too much oxygen, it can get "toxic". What does this actually mean? How would a person know if they're getting too much? Is getting too much as bad as getting too little oxygen? I'm sometimes confused by this paradox. Will you please explain this?

Thanks so much for all your informative answers, Dr. Adams! I hope I'm not too late to get this one more in yet.

Trudy

* * * * *

Hi Trudy:

This is an important point so I am glad that you brought it up.

It is best to think of oxygen as a drug. You can take too much or too little.

Too much (or high concentrations of) oxygen can produce two important problems.

The first relates to the concentration itself. The air we breathe is 21% oxygen. When you are breathing 2 or 3 liters per minute with your nasal cannula the concentration is between 28 and 35%. If someone is given 60% or greater O2 for more than 24 hrs, it can directly damage the lungs. This is called "oxygen toxicity". This happens alot in an ICU where a critically ill person often needs high, even 100% O2 to survive. Fortunately, alot of this is not permanent if the concentration is reduced soon enough.

The second problem related to too much oxygen has to do with how we breathe. One mechanism that stimulates breathing is related to oxygen, the other to carbon dioxide (CO2). If an individual's CO2 level rises and remains elevated, the primary drive to breathe is the O2 level. Too much oxygen can then reduce this O2 drive, resulting in a further increase in CO2 which can then produce a coma. This can be avoided with monitoring of O2 and CO2 levels. This is best done with a blood gas (blood must be taken from an artery) although less invasive methods of monitoring CO2 (like oximetry for O2) are becoming available.

Best,
Dr. Adams

Back to the question list


What causes the redness?

What causes the redness?

Trudy asked about the gray color appearing on her face. My face gets quite red sometimes while walking and doing things and, once in a while, just while sitting. My doctor tells me prednisone causes this but it seems to be more related to movement, increased heart rate maybe? Can you shed some light on this for me please as to why my face flames red all of a sudden? It never did this before COPD.

Thank you,
Serra

* * * * *

Hi Serra:

That's a good question and a common problem.

Your MD is right since some medications definitely promote flushing or facial redness and prednisone is high on the list. The higher the dosage, the more striking the effect. Beta-blockers which are used for blood pressure, heart irregularities also produce flushing. Hormone replacement can do it too.

There are some medical conditions that could also be responsible. The most common is an elevation in blood pressure. BP naturally increases with exercise or exertion so this is quite common. It would help to know your blood pressure when this happens so you might want to check this during the episode.

My guess is that it is a combination of the steroids and blood pressure. As a general rule, your MD will try to bring you to the lowest steroid dose that is effective and he may also treat your BP if it is elevated.

It's been a pleasure being with you. Your questions have been great and challenging. I hope to be back,

Best wishes,

Dr. Adams

Back to the question list


Many thanks to Dr. Francis Adams for taking the time to spend with us at BBLW to answer our questions. Take time to look at these great questions and answers for a wealth of information and excellent answers by a caring physician.

Happy Learning!
Jane.

Back to the question list


© Copyright 2009, Jane M. Martin, CRT
http://www.breathingbetterlivingwell.com

 

Return to The Basics page.

 

 


Dr. Francis Adams

Dr. Adams hosts Doctor Radio on SiriusXM satellite radio every Tuesday morning from 6 to 8 AM (Eastern time). You may also listen at Sirius.com. Look for Doctor Radio, Sirius channel 114 and XM channel 119. The show welcomes phone calls (1-877-698-3627) and e-mails to docs@sirius-radio.com

 

 

   
 
 


Material presented on this website copyright ©2017 Breathing Better Living Well

site design by monkeyCmedia
Site Meter