EFFORTS Home

Respiratory Practioners' Q & A's

Mark Mangus
Mark Mangus, Sr.
BSRC, RPFT, RRT, RCP

John Richter
John Richter, RT
Swedish Covenant Hospital


EFFORTS wishes to thank Mr. Mark Mangus, Mr. Larry Conway, and Mr. John Richter for devoting
their time and EFFORTS in providing answers for our members to some of our most important questions. 

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Disclaimer: The information provided herein, is not intended to be of a diagnostic nature or to question treatment by your own physician. It is meant strictly as information and education based on what is disclosed in the questions submitted by our membership. Any response by Mr. Mangus, Mr. Conway, or Mr. Richter is based solely on his training and knowledge and of course might be subject to correction or difference of opinion.

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Buteyko Breathing

Q. I just wanted to learn about Buteyko Breath and what is opinion of this method. Dusan

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A. Theoretically it doesn't jibe with western/mainstream biophysiological theory. Yet, it has received some positive assessment in regard to completely reversible airways disease - - - the fancy name for "Asthma". I came across some information over the past year that indicated it is receiving empiric study, at present. Other than that, I know of no peer-reviewed studies that either support OR dispute its veracity.

I CAN tell you that those with consequential COPD should steer WAY clear of Buteyko, since it encourages breathing methods that promote retention of carbon dioxide, a significant problem for those with advanced COPD and disturbed pulmonary gas exchange. Regards, Mark Mangus

DLCO Pre or Post Meds

Q. On all of my PFT tests, the DLCO percentage is listed under the 'pre' medication column. Is the DLCO test usually done pre-medication, and if so, would the values and percentages possibly improve after medication? Thank You Angie

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Yes it is common practice to do the DLCO and also the lung volumes on the "pre-bronchodilator" series of measurements. While we can sometimes see a significant change in lung volumes if they are repeated after bronchodilator, it is not considered the standard to do such measurements. The DLCO 'can' change, too. But, any change would likely be small and insignificant. It is not as sensitive a measurements as are the others. In other words, if it were to change 3 %, that wouldn't translate into anything meaningful in terms of the clinical picture. Regards, Mark Mangus

Loss of Time

Q. I have no memory of my ambulance ride, nor the ER, nor x-rays or blood draws. I have some vague memory of saying bi-pap! , athough I've never been on one before. I have little memory of the 1st day (monday) in ICU, except for constant neb treatments. I remember someone saying I had staph pneumonia (MRSA) which I've had before, someone else saying respiratory distress, and, later on, acute bronchitis. Then, it was not MRSA but MSSA (don't know that one).

My concern is the lost 24 hours. My Pulmo says I wasn't unconscious, or in a coma. I just have zero memory of anything-which I'd like to know. I have applied for a copy of my records. Any comments Mark, or other Medical people? Although I was in ICU for 5 days, I was feelng well in 4 days, and, when sent to a room, did fine. What happened ???? Susan

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A. There is a phenomenon I have seen thousands of times - - - and it's been written about in the medical literature in numerous publications, as well as described in the popular literature in various ways. When someone gets severely ill, such as what you describe, their brain kind of lets their consciousness take a vacation, so to speak. You can be awake and lucid, with regard to responses and a lot of things, yet, for some sort of primal and/or instinctive (my description) reasons, you do not store memory of the time period. I saw this when working intensive care for more than 18 years. Folks would be deathly ill for some period of time. When they recovered and regained their orientation to time and place AND were 'recording/retaining memory' again, they'd have lost sometimes many days. It seems to be some sort of 'defense' mechanism - - - kind of as if the conscious realization of what's going on could be so overwhelming it could cause you to react in such a way as to be counter productive to what your body needs to do to heal. So it simply hits the "off button" on memory and lets you babble on and interact without recollection or account.

Don't worry about it. I've never seen it cause any kind of permanent consequence - - - AND - - - I've seen many hundreds of patients long after their episodes. They were just fine! Best Regards, Mark

Weight and FEV1

Q. Have any studies looked at the relationship between weight and FEV1? I mean a person like yours truely type male, 6 ft and 200 lbs age 62. I should weigh 170 or so, but now that extra FAT is in my belly and probably crowding my lungs.

I ask because I have lost about 10 lbs and my FEV1 max has increased slightly.. (I take it weekly and doing a running average for a trend). Another question on my mind is the way the medical community rates COPD by FEV1. Wouldn't a better method to be to take other phyiscal data into the rating. Example: Take the 6 or 12 minute walk time and convert thats to MET's, divide by weight and the mulitiply by FEV1 ? It certainly would give people a incentive for getting in better shape and helping themselves. Smiles Bob

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A. A couple of interesting questions you ask. I am aware of a number of studies done over quite a stretch of years that have looked at the specific relationship of weight to FEV-1. Across the breadth of them they have found that there is a positive correlation between weight and FEV-1 - - - BUT - - - NOT in the manner, or to the degree with which you suggest a potential correlation.

As best I can recall, until one has increased their weight by MORE than about 30 % over what should be ideal for them, body mass in the form of excess body fat does not tend to interfere with ventilation IN AND OF ITSELF. Conditioning has most to do with what interference additional or inadequate body mass will have upon FEV-1. If one is in poor physical condition, the impact is amplified,on both sides of the weight issue. In fact, as body weight DROPS below ideal , mortality increases as a direct correlate to weight and FEV-1. FEV-1 is found to fall as body mass drops below ideal, independent of condition. So, contrary to what you might have suspected, being too heavy has much less 'raw' impact on FEV-1 AND survival rate/duration than does not weighing enough! It is striking to see that survival drops sharply as body mass drops below 90 % of "ideal". So, in the end, even those who are significantly above ideal body mass and have COPD turn out to have a better survival rate than those who are on the light side.

Insofar as why FEV-1 alone is used to classify folks - - - and especially now, under the GOLD standard - - - is because of ALL the different individual measurements, factors and other data, FEV-1 has been shown through "decades" of extensive "worldwide" research to correlate best with 'degree of severity', in terms of symptoms AND in particular, 'survival rates', independent of many ofther factors. What you suggest, in terms of synthesis of several factors would 'actually' confound and obscure the very product you wish to produce, by interjecting exceedingly variable 'subjective' information into what is shown already to be a simple and clean single factor. The 6 or 12 minute walk test is NOT any kind of measure that would add clarity to assigning one's condition. It's veracity is dependent upon too many factors that are subjective - - - good day, bad day, more or less symptoms than usual, subject's effort, etc. The FEV-1 is already the best of all those that you mention. Putting FEV-1 into and equation and factoring in a whole bunch of subjective information would only confuse things further, not provide any better information, I'm afraid!

Insofar as the question of METS is concerned, that is good for those who know what they are and can equate them to tangible measures and practical application. For the average person they are too esoteric, IMHO and that of most others with whom I talk about it. Further, because metabolic rates are so skewed in those who have significant COPD, METS are all but impossible to calculate with any meaning. Lastly, the exercise load of which most with significant COPD are capable provide METS so low that they are not helpful in quantifying anything meaningful about what the subject did. Again, as with the multifactoral calculation to figure out how bad someone is, METS would serve to further confuse the "practical" information provided by other measures. Heart rate and blood pressure for a big part are ALSO equally confounding in many of those with advanced COPD. That is why for many of us, they are not helpful in determining to to do or not to do for and with our pulmonary disease patients.

I'm sorry to burst any bubbles, you might have had in these regards. I applaud your effort to think about these questions and to pose them with suggestions. It is when we quit thinking and asking questions that we are doomed! ! ! Keep thinking and asking, Bob! Best Regards, Mark Mangus

How Come My Emphysema Is So Different?

Q. Have been reading letters from Emphysema patients and so many have mucus > problems? I have Emphysema &am on oxygen 24/7 and take 1 nebilizer a day with Xopenex levabuterol HCI and take Spiriva once a day. I nearly ever cough and if I do-nothing has to come up?? I am wondering why my illness is so different? Please answer. Doris

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A. It is indeed related to WHETHER one has Chronic Bronchitis or Emphysema and 'how much of a mix' of the two they have.

Those who have more purely emphysema generally will not produce mucus. Those who have more purely Chronic Bronchitis will generally produce mucus. Yet, this is not the beginning and end to the case for Chronic Bronchitis. Some 'bronchitis' are what I call "dry bronchitis" - - - similar to the post that suggested there are those who produce mucus and those who don't, going so far as to label them "wet" and "dry". There are those with bronchitis who produce gobs of mucus. I refer to them as "wet bronchitis" or "fulminant" - - - a fancy term for "profuse" or "lots". These are by no means universal, medical terms, just "MY" labels from throughout the years of my practice.

Generally speaking, one who has a smoking history can be expected to have "some" degree of chronic bronchitis. While their emphysema can be severe, simply because they don't produce mucus doesn't mean they don't have Chronic Bronchitis. The ONLY SURE way to tell exactly that one has or doesn't have Chronic Bronchitis is to biopsy the bronchial tissue. Chronic Bronchitis (CB) poses classic and characteristic changes in the structure and tissues that form the bronchial tubes. If those changes are present, then the diagnosis is made.

What differentiates the mucus producers from those who don't produce mucus is the presence of - - - and number of - - - increased "goblet cells" and "mucin glands". These are the mucus factories within the airways. In S-O-M-E folks with CB the number of these structures does NOT increase as destructive changes occur on the way to clinically significant and worsening of their disease. In others, these structures proliferate at a high rate and become disproportionately abundant compared to their normal ratio/numbers. THESE are the folks who become the wet/fulminant CB'ers.

So, while you can certainly ascertain whether or not you have more emphysema than CB, according to the amount of mucus you may produce, if you've got a 'significant' smoking history (more than 20/day for more than 20 years), the only way you can truly rule out chronic bronchitis is by direct examination of the bronchial tissues (histologic examination). Regards, Mark Mangus

FEV1 Measurement Before or After Meds

Q. When referring to the FEV1%, as we often do, is it standard to use the % predicted BEFORE medication or AFTER medication ? Which number is everyone else here using when they give their % ?? If you have a lot of reversibility - which number is used to determine true lung function, or even eligibility for SSDI ? In addition, my DLCO seems to have been taken BEFORE medications, would this number change at all AFTER medications ?? I'm sorry if this seems like a stupid question, but I truly do not know which of the two sets of numbers are used. Thank You !

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A. The FEV1 necessary to qualify for disability is < 60 %. If one can reach greater than 60 % after bronchodilation, then they wouldn't qualify UNLESS they had additional conditions or circumstances that would factor in to make the FEV1 hold less weight in the determinating equation. For instance, folks with pulmonary fibrosis can have great FEV1's but lousy oxygenation. What qualifies them is their hypoxia, not their difficulty (or lack thereof) in moving air. Generally speaking, folks who have COPD that is mild enough that their FEV1 is greater than 60 % - - - even those whose FEV1 requires bronchodilator medication to exceed 60 % - - - do not have breathing limitations that would impede their ability to function for most tasks of moderate to significant vigor.

Lastly, what is better to do than to simply state your FEV1, is to add the qualifier that the number you quote is either "before" or "after" bronchodilator. That way, no one has to guess which one you are quoting. When you run into an unqualified quote, ask the individual if the number they put forth is before or after bronchodilator medication. Regards, Mark

Do Oximeters Need Calibrating?

Q. I have been using the same pulse oxi for 5-6 years now. Do they need to be serviced/calibrated/battery changed? June-NJ

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A. They do not need to be "calibrated". As long as they are functioning with presumed or proven 'reasonable' accuracy, they do not need service. One should gently wipe the light emitter and pick-up sensors with isopropyl alcohol at intervals to keep them free of oils and dirt that can distort the signal and impose error into the measurement.

I would think that if you have a "battery-powered" model, you'd have had to change the batteries long ago and several times in a 5 - 6-year period. But, if you haven't had to change batteries in that time AND your oximeter still works, then I have to ask what brand and model of oximeter you are using before I can offer any definitive information in your particular instance. Regards, Mark

Waking Up with a Headache

Q. I have been waking up every morning this week with a headache. I am on oxygen at night at level 2. I read something somewhere or someone told me that it has something to do with my oxygen. Do you get the headaches because of to much oxygen or not enough oxygen? I want to know if I am doing something wrong. Some times at night when I have the oxygen on I take it off while I am sleeping, and then when I wake up I have a headache. So if someone could please help me with this I would appreciate it. Viola-NV

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A. You can be getting headaches from a couple of different causes related to what your gas exchange is, Most often, when folks are experiencing morning headaches, it is because their oxygen is going too low, if the reason is related to oxygen at all. While there are rare instances when folks can develop a headache from getting "too much" oxygen, the evidence and documentation on this phenomenon is very scant.

Folks can be experiencing elevated CO2, as well. High CO2 (low pH) causes the blood vessels in the brain to dilate and hold more blood. The increased pressure inside the head that results from this is what causes the headache. A combination of elevated CO2 and decreased O2 can cause the problem, as well. Frequently, these three scenarios occur when one is suffering from sleep apnea. If you snore or have 'periodic breathing' or pauses when you don't breathe that last more than 20 seconds and have not been evaluated for sleep apnea, I would advise you to seek evaluation. If you know that you DO have sleep apnea and are being treated for it - - - say with oxygen and CPAP or BiPAP - - - then you should let your doctor know, so (s)he can evaluate you and maybe adjust your therapy, if needed.

Yet another possibility that is unrelated to your lung disease can be blood pressure. You may be experiencing high blood pressure. In any case, all prospects point to calling your doctor and seeking evaluation. Your complaint is a fairly definitive one and warrants investigation. Regards, Mark

Emphysema Progression Question

Q. Could someone tell me if there is a procedure (tests) a doctor can do to tell how far Emphysema has progressed. In other words, I would like to know where I stand with this disease. All that's been done is a lung capacity test (I think that's what it's called when you blow into a machine) and X-Rays. I've been told that I have E, to use the medicine that's been given and to quit smoking. I have no idea what percentage of damage I have to my lungs. Monte Miller

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A. The Pulmonary Functions Test (where you blew into the machine and it measured what you did when you blew) is a fairly definitive test, in terms of telling how much "structural damage" you have done to your lungs. Your blood gas tests and finger oximetry can show what - - - if any, to this point - - - deficits you have developed in regards to exchanging oxygen and (indirectly/estimated) carbon dioxide. But, there is not much more you can know that those tests don't tell you. "Quantifying" one's lung disease and loss of lung function is far from being "cut 'n' dried" in mathematical and percentage terms. As you will learn as you read stories and information from our members, some have HORRIBLE "n-u-m-b-e-r-s" and yet "f-u-n-c-t-i-o-n" quite remarkably. Others have good numbers and percentages but have horrible gas exchange, which slows them down to a crawl. A lot of what determines what folks can or cannot do, with regard to function and activity often has more to do with their ability to tolerate discomfort and" keep on keepin' on", versus NOT being able to tolerate the hardship and finding themselves sitting more and more and functioning less and less AND when they DO have to exert, finding that even the least demanding tasks can become nearly impossible to do - - - at least not without horrible breathing difficulty.

So, the numbers are what YOU make of them. How you live with COPD is what YOU are able to make of it and of what function you retain and maintain. It is only loosely dependent upon measurements and percentages. You need to do as your doctor suggested and then get moving and pushing and see what the future hold for you AS IT HAPPENS. No one I've ever met has a good crystal ball to tell you what IS GOING to happen in your future. It WILL be what you make of it! Best wishes and regards, Mark

Oxygen: How High is Too High?

Q. Mark the other day I asked a question about raising my oxygen when I exercise on the treadmill well I raised it to 4 today and my sats stayed at 95-96 throughout my 35 minutes. When I had it on 3 my sats were going down to 92 at times. My question is how high is too high to raise during exercise. thank you francine, texas

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A. According to Dr. Richard Casaburi, a guru in exercise and oxygenation in folks with COPD, you can't raise it too high! He recently did a blinded and randomized study on folks who weren't considered to need oxygen and found that their performance improved by a statistically significant margin when they were given oxygen to raise or maintain their oxygen saturations at greater than 96 % during exercise. We have a lot of data that shows that folks who exercise at saturations of 88 - 92 % do a lot worse (performance and tolerance) than they do when their oxygen saturation is 92 - 96 %. When I oxygenate folks here in the clinic, I do not hesitate to boost their oxygen saturation to 96 %, especially if it allows them to go faster, farther and longer!

So, I would suggest that if you do better when your oxygen is 95 - 96 % on the 4 liters, then by all means do so, especially if it gives you wiggle room to go faster, farther and/or longer! Best Regards, Mark

Steroid Inhalers and Thrush

Q. I get constant thrush from any inhaled steroid even if I rinse. So this brings up a question that I have had for a very long time,,,,,last year I had a bronchoscopy (sp?) ... and it showed a substantial yeast growth in my lungs, voice box & esophagus. I had to take diflucan for 2 weeks to get rid of it. After finishing the medication, my lungs cleared out & breathing became much easier.

Now my question ... EVERY time I try to use inhaled steroids, I seem to get this thrush and ny breathing gets worse little by little. We can rinse our mouths, yes, but how do we keep the thrush / yeast out of our lungs ?? Wouldnt it stand to reason that if the thrush populates the mouth & esophagus, that it would also populate the lungs ? Maybe this is a stupid question, but Ive been worried about it for a very long time. I had always noticed a gradual decline in my breathing after using flovent or pulmicort - This seems to be a problem for me - and I think its related to thrush - but the docs dont believe me. I try to adhear to the doctors orders to use the steriod every day (I have a strong asthma component) .. but I am wondering if it is doing me more harm than good ?

I am now on Nystatin again, for thrush in the back of my throat, and I wonder how far the thrush has gone .... any input ? Thanks. Angie

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A. Your concerns AND questions ARE most legitimate, and far from possibly being stupid! Generally, the organism that causes thrush (Candida Albicans) does not cause pulmonary infections. HOWEVER, you say you have had a yeast infection in your lungs which cleared up with Diflucan. Whether or not the organism was Candida or another yeast, you have a specific history of yeast infections in your lungs. That alone should be reason for your doctors to be suspicious about your complaints AND ongoing difficulties, let alone trying to do more about them.

Check with your doctor and see if vitamin and mineral supplements targeting enhancement of your immune system might not be an option. How about yogurt? Have you tried a daily intake of one or two servings?

The problem facing you and your doctors is that as you relate, you have a strong asthmatic component. That 'should' be effectively kept at bay by the steroids. HOWEVER, you also relate that you feel you breathe worse with the steroids. There are those who don't respond as we'd like, or expect when they take steroids. You could ask for a PFT done while on steroids and another after two weeks off steroids. That should tell the story about whether or not you need the steroids so much that (other dilemma/consideration) that they are worth the grief they cause you. You are still faced with the question of benefit out-weighing the drawbacks and difficulties. Don't take their brush-off. Keep at them until you receive satisfactory answers and/or results. Otherwise, consider an additional opinion and seek it. Regards, Mark

Inhalers and the Heart

Q. Is it possible to weaken the heart by over-medicating with combivent via inhalers? If so, how does one know how much is too much? Thanks, Mike

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A. It is indeed *possible* to "over-use"/"over-dose" on the Albuterol component of Combivent. HOWEVER, the amount that it would take - - - FOR MOST FOLKS - - - is rather large. The 'red flag' point is usually when one is using in excess of two inhalers per month. When use approaches or exceeds three inhalers per month, then we are looking at very certain danger. That is in the neighborhood of 20 inhalations and more, per day - - - for a lot more than a few days! This is also just a general answer. For some folks, the overdose point may be lower. For others, higher. For folks with certain additional vulnerabilities and conditions, it changes even more to a lower level.

My recommendation is that if you find that your inhaler OR nebulizer isn't carrying you for more than two hours at a time, with two to four puffs then you should be on the phone with your doctor to determine additional action to take. I hope this answers your question. Best Regards, Mark Mangus

Getting Oxygen Too Fast??

Q. Is there such a think as getting the o2 to fast to make you sob?  I  was having trouble with the regular size hose so they gave me a smaller one (the part of  the hose to your nose)  Now it comes out fast and I can hear it all the time.  Everyone keeps telling me I have an O2  leak! God Bless, Debbie

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A. When you take the same amount of flow you were putting through tubes of a larger size and push it through tubes of smaller size, the rate (speed) at which it comes out the tubes will necessarily increase.   So, for it to 'feel' like it is coming out faster is exactly what is happening.   That the increased speed, or "jet-like flow" can make you MORE short of breath is unlikely.   Naturally, with it coming out faster, it WILL make more noise. It can also cause increased irritation within your nose, too, depending upon your oxygen flowrate.  What was your problem with the "regular-sized hose? Regards, Mark Mangus

TTO Advice

I only use 02 part time but find the nasal cannula thing, a nuisance, awkward and embarrassing in public. I going for a TTO, what is the hospital issue, time, etc.?   If I wanted to swim, how could I block the opening ?   The process seems so slick, I wonder why more people don't have it done? Your advice on this would be sincerely appreciated. Warren H.

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A. I want to caution you, Warren, the TTO is *NOT* recommended as solely a "cosmetic" maneuver.   TTO, is most often recommended for those whose oxygen requirements are high enough that standard portable oxygen systems cannot easily accommodate their needs.   TTO allows reduction in oxygen flow AND in the case of conservation devices, allows them to work better than they might with a cannula as the delivery device.   Unless recommendations have changed in recent years - - - and having spent considerable time at the TTO exhibit this past weekend at our AARC national conference, NO recommendations were forthcoming to the effect that TTO is now recommended solely for cosmetic reasons and considerations - - - TTO should be reserved for those who have a specific indication and need for it.
 
These recommendations are so because of the fact that, while it is neat and convenient and a wonderful means to deliver oxygen and conserve to prevent avoidable waste of oxygen, it STILL involves an "invasive" procedure that, while not requiring hospitalization - - - it can be done in a matter of minutes in an outpatient setting - - - can involve complications like bleeding, infection, airway obstruction and subcutaneous emphysema (a benign problem of air leaking between skin and supportive tissue and muscle layers).   
 
So to characterize it as a "slick process" would be to make too light of what is not a easy worry-free prospect, IMO.   Further, it requires diligent and careful care - - - though, as Tom and others can attest, is NOT difficult, once you get the hang of it and develop your routine.  But, my point in response to Warren's comment: "I wonder why more people don't have it done?" is that it's NOT so nonchalant a prospect that folks would "decide to "have it done" as a matter of fact course of action!
 
I will be the first to loudly complain that TTO is sadly under-utilized in my experience and in the case of a good many folks, who would benefit from it.   But, at the same time, it is not something that I would recommend pursuing simply for convenience and looks, without the key elements of need being present. Best Regards, Mark Mangus

Recuperation Time During 6 Minute Walk Test

Q. Idid the six minute walking test and accomplished a very decent distance, according to the physiotherapist at the Pulmonary Rehab Center..My 02 sat dropped to 89%...HOWEVER, she clearly pointed out that the RECUPERATION time was a key factor as to whether I needed oxygen for exertion. I recuperated within ONE MINUTE , back to 93% or so, on ROOM AIR..She was very happy with that and said I did not require oxygen at this point.

Therefore, I would like to pose the question to MARK and/or Gary as to what their take is on the "recuperation" factor is in these tests. Best, Melody in Montreal

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A. I have heard a lot of medical professionals talk about "recuperation time" as if it makes a difference in whether and when one needs to begin using supplemental oxygen.   I have serious concerns about the whole notion for a number of reasons.  

First, there is NO data to support the notion, or to establish a reasonable desaturation pattern or duration that can be considered safe.   Second, every proponent of that notion seems to have different levels of tolerance, insofar as how low they will let folks go, how long they think is safe for recovery and WHEN the point of intolerance has been reached.   Next, there are NO standards or consensus to establish the notion as a desirable practice.   Instead, there are just a number of clinicians who place themselves 'in that camp'. 
 
The data that ARE available contradict the acceptability of such a notion.   Among those data are the fact that when measured, pulmonary artery pressure is observed to be significantly elevated (to > 35 mmHg pressure) in more than 50 % of those who desaturate to the 88 - 90 % range.   The degree of elevation varies too much to be able to characterize it in a broadly applicable sense - - - a needed component of a broadly applicable policy.  
 
To force folks to meet some kind of 'criteria of crisis', before declaring them in need of supplemental oxygen - - - and especially by standards such as these - - - all in the face of NO data or evidence to suggest that it is even a good idea, let alone acceptable and non-harmful practice - - - flies in the face of the "do no harm" ethic by which we are 'supposed' to be practicing our various forms of medicine.   Now that more and more data are coming in to show the benefit of earlier, more aggressive intervention with oxygen therapy, it seems more and more incongruous to me that clinicians continue to adhere to the "not until the last possible minute" approach to treatment with oxygen.   I truly believe it is costing a great many lies and untold suffering for those who suffer through without it. Regards, Mark Mangus

O2 Use At Night and Daytime Sats

Q. My question relates to a post that said sats should stay around 93. I'm on 2L O2 during sleep, but not during 'regular' house-type activity, but use 2L when trying to exercise at rehab or when taking outdoor walks.  My normal daytime level is usually 88-89.  If I do PLB it goes up to 91 or 92 but doesn't stay there.  Before I used O2 at night my usual daytime level was 91.  So it seems to me that by using O2 at night and having levels of 94-97, my daytime level has dropped.  Does this make sense?  Also, I've heard the 'old wives tale' that once you go on oxygen, you never go off -- but, but, but -- I've also heard that some people need O2 for a number of months or a year while they exercise and build up the healthy part of their lungs.  Is this actually possible?  Finally, if sat starts dropping, even with oxygen use, what then?  What's happening and how does one recover from this episode??  Yes, I'm newly diagnosed and have ALL the questions a lot of you are bored to tears with, but still I must ask.

Another question is WHY do some people have extremely low values on PFT, yet good enough value on DLCO so they do not need oxygen?  Does this have something to do with 'diffusion' -- which I don't understand yet.  Is there any web site that actually answers this?  I'm really good at researching on internet but haven't run across this answer. It's too cold in Colorado right now to get outside and walk in the park, so I hooked myself to O2, put in a 'Riverdance' CD, watched my oximeter and managed to exer-dance for 23 minutes -- even worked up a few droplets of 'glow'.  Felt so good to take charge and NOT feel trapped in my house.  We are all creative and smart people, except for believing the tobacco companies.  We can find the 'little' ways to make life happier and bless our days with joy. Much love to all, Carolyn H

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A. It is trickier to make a call on one's saturations when they live at 5000 feet elevation AND have COPD.   88 - 89 and 90 - 92 might be good for someone - - - even with COPD - - - at that altitude, though I'd have to yield to the person's doctor, who knows them better.   I CAN say that there is no reason to think that because Carolyn is using oxygen at night that it would somehow make her saturations WORSE during the day.  that just doesn't follow any kind of physiologic pattern that we see or know in pulmonary disease and its progression.   Carolyn doesn't say if she has polycythemia or not.   THAT has a bearing on potential changes and expectations.   She doesn't use her oxygen during the day with activity, despite relating information that suggests she desaturates sufficiently to warrant its use.
 
Insofar as folks needing oxygen temporarily and then not - - - versus those who need it and then have to use it for the rest of their lives - - - there are FAR more in the latter category than in the first category.   In many many hundreds of patients I've seen over the years, the number who had significant COPD AND only needed oxygen for some temporary period of time are very few - - - say less than 50 of more than 1500 - - - and their reduced need for oxygen was expected and very predictable.   BUT, for the most part, when a person's disease progresses sufficiently to affect their diffusion capacity sufficiently to cause hypoxia, they have gone on oxygen as a "for life" kind of treatment.   That is the reasonable expectation - - - even if we DON'T like the idea of it!  In any case, there NEVER SHOULD or NEVER HAS TO BE anything even close to myth or legend with respect to going on oxygen.   It is easy to 'empirically' establish the need for oxygen.  There is little doubt that it is needed, how much is needed and WHEN it is needed.   The myth enters when folks try to find reason to avoid using it when they REALLY need to use it! ! !
 
I know of no site to direct Carolyn to for a specific answer to her specific question.   I don't believe we have more than a slew of theoretical possibilities that can explain why some folks can have a better DLCO than others and still need oxygen when the other person doesn't.   Here again, often we find that the person with the "worse" DLCO DOES desaturate and by all rights SHOULD be using oxygen.   But, because their doctor has 'looser' requirements for when his/her patients MUST begin using oxygen, they are not using it.   It doesn't meant they don't need it.  It just means that by arbitrary decision, they are not being given the option of oxygen therapy. Best Regards, Mark 

Diffusion: What Does This Mean?

Q. If my diffusion is 57, what exactly does that mean? I am  really confused. Thank you.....Diana in Ohio

* * *

A. I will assume the 57 is "57 %" and is what you possess in regards to what you "should" possess, according to equations that predict what your 100 % maximum would be.   In diffusion, one can exchange oxygen reasonably well until they drop below 50 %.   Some experience hypoxia (low blood oxygen levels) with a diffusion of as high as 40 %.  Others can have a diffusion that drops to 30 % and still not exhibit hypoxia.   The value is relative to the rest of your pulmonary functions and some anatomical factors, like matching of where air goes in your lungs to where it comes in contact with blood flowing through your lungs.  There are other factors associated with breathing and circulation that can influence diffusion, both positively and negatively.
 
You and/or your doctor know(s) better than I "exactly what that means" for you, specifically, IF you know what your oxygen saturation is when you are at rest AND what it does when you move around, you have your answer.  If you don't have that information, that would be what you need to discover next.   In and of itself, the diffusion number provides only limited and not often specific information about your ability to oxygenate your blood as it passes through your lungs.
 
Regards,
 
Mark Mangus

Is Coughing Damaging to the Lungs

Q. When you do a lot of coughing does it do any damage to the lungs or is it just uncomfortable and exhausting.? I am on atrovent and advair the coughing is much better but not all gone yet. I go back to get checked next Friday. Thanks for any info you might have.

* * *

A. The short answer to this question: We don't know for absolutely sure. The likely answer; probably NOT.

While in theory, a cough CAN cause damage to the lungs, it would likely happen only under the most extreme or unusual set of circumstances. AND, any damage that 'could' occur, would be expected to be restricted to the immediate moment - - - say in the form of a "pneumothorax" - - - a collapsed lung; from popping open a breach (tear) to the outside of the lung, allowing air to leak into the chest and compress the lung, rather than to a cumulative effect over years of coughing.

The lungs have very unique and effective defense mechanisms, not just from a functional standpoint, but also from a physical and mechanical standpoint, too. When we cough, many 'counter forces' are activated to keep us from 'busting a gut', so to speak. While tremendous 'amounts' of pressure are generated in the coughing (and sneezing, too!), opposing and 'splinting' forces and mechanisms keep them from doing structural harm/damage.

So, while we can't say that 'without exception', coughing doesn't contribute to emphysema, we have many reasons to believe that it indeed doesn't. Regards, Mark

Borderline Oxygen Levels and Flying

Q. This question has probably been answered before but ...... I am facing a business trip for work requiring air flight. I am not on O2 yet, but close to borderline on needing it. I am really worried about going on a plane and what it might do to my breathing status. Haven't been on a plane in 4 years, and I was nearly as bad then. You thoughts please ? Thank You

* * *

A. Get a walk test before going. If you drop into the upper 80's as your lowest saturation after walking more than 4 minutes, I'd say you can squeak by without having to use oxygen in flight. If you drop below the upper 80's with less than four minutes walking, then I'd say think about it hard and would recommend using it. Saturation changes any worse than those - - - you should definitely use oxygen in-flight. I can't get any more specific about or speculate any better than these limits. Regards, Mark

What % Does DLCO Become a Problem?

Q. At what % does DLCO become a problem ?? What values on a PFT determine trapping from Asthma vs E or Bronchitis? If a person has E + Asthma, and is very over weight, could their PFT values, specifically the DLCO improve ?? Thanks in Advance !!

* * *

A. Usually at less than 30 %. It is different 'among' individuals as a factor of how bad the 'air distribution' within their lungs happens to be. If their emphysema/air-trapping is worse, they will start to have oxygenation problems at a higher DLCO than those who ventilate better. There is no 'hard-set' threshold number.

There is no way to tell exactly how much air-trapping is from each. There is no informative value in knowing the difference, either. If it were possible to know, it wouldn't have any bearing upon choices of treatments, any way.

To your last question/scenario, "anything's possible!" It certainly 'c-o-u-l-d' happen. Yet, it's one of those things that you can't know until you 'look over your shoulder' at the past. (as in 20/20 hindsight). Regards, Mark

Does Emphysema Cause Pneumonia?

Q. I have had pneumonia every year for the past 5 years since I was diagnosed with emphysema. That is how my doctor originally found out I had emphysema. This year my doctor advised me to get the flu and pneumonia injection, which I did, but I had the worst bout of pneumonia ever. Is getting pneumonia a common consequence of emphysema? Karen (Australia)

* * *

A. The pneumonia shot covers over 20 varieties of pneumococcal pneumonia O-N-L-Y.   It does NOT cover "all" pneumonias.   There are M-A-N-Y other organisms NOT covered by the pneumonia shot that can give you a pneumonia.    So even though you get the pneumonia shot, you can STILL suffer a bout of pneumonia.   It just won't likely be causes by one of the pneumococcus strain of bacteria.

The reason the several pneumococcal pneumonias are covered and so important to cover is that THAT strain of bacteria are responsible for the greatest number of pneumonias that kill older folks, infants and those with chronic/other health problems, like COPD. Regards, Mark

Acceptable Level of Oxygen at Rest

Q. Can someone please tell me what an acceptable level is for my oxygen at rest? When I went to the doctor last week, she was not very happy because me oxygen was at 95% at rest. It is lower today to > about 92%. Is that normal? I have been coughing a lot today and cannot seem  to "catch my breath".

* * *

A. I think she is concerned about the drop compared to prior levels. The levels you quote are not troubling in and of themselves - a 92% SaO2 is quite good for a COPD patient, and a 95% is about what mine runs without COPD.

Directly to your question: An SaO2 above 90% is acceptable for a COPD patient. That is a level at which we would consider weaning you from oxygen (or lowering the amount of oxygen you are on) in a hospital.

As with so many things in medicine, the issue is not the "snapshot" number, but the trend over time. That may be what has your doctor concerned. Larry Conway, RRT

Dampness in Basement Apartment

Q. Just moved into a basement appt.which is cheap but discovered I have to use a Dehumidifier which fills with water very quickly especially when it rains. Is a wet/humid atmosphere good for my lungs Fev....44%COPD or damaging.I seem to be much more bronchial/wheezy since moving in 12 days ago. Will appreciate any advice Mark or whosoever can help. Peace ...life and breath to us all Jonathan

* * *

A. It sounds like you might be getting more than humidity. Molds and fungus like that environment, too. If the humidity alone isn't bothering you, then it could be the molds. Are you able to get the environment pretty well dried out with that de-humidifier? You might need to think of a move to a better location from the standpoint of breathing. The cheap price may be easy on your pocketbook, but hard on your breathing! Regards, Mark

Dad Not Doing Well...What Can He Do?

Q. Hi, my name is Peg, my dad is 78 yrs. old, he has emphysema, do you know of anyone that could tell me if this might be something my dad could try? He is not doing very well, I think that anything that may work would be worth a try. I would like to keep my dad for a while longer, as long as he is not struggling to stay alive. Any info would be greatly appreciated. Thanks

* * *

A. More than any magic potions or medications, the core action to survival IS "struggling" . . . struggling to move . . . struggling to breathe . . . struggling to keep on keepin' on. It is those who seek only comfort who succumb sooner to this disease AND suffer worse along the way, in so many instances! The more comfortable you try to make your father, the more you will NOT be helping him - - - strange as that may sound. By him not getting up and struggling, he is becoming weaker and actually losing strength and stamina.

As many folks here on our list can tell you, even though he may seem VERY debilitated, weak and frail, hope is not lost or absent. On the contrary, he may have a whole lot more to gain than y'all can imagine, from where you stand at this time. If it is possible, see if he can be evaluated for entry into a pulmonary rehabilitation program. They can help him get on track to really make some progress, if that is a possibility.

I'm not trying to discourage you from trying alternative treatments. But, I'd like for you to know that drugs and alternative treatments to "make him feel better" may not be indicated, or of potential benefit, much less be enough to do what you hope they can do. If you have more questions, or we can help, please post again and we'll see what we can do.  Regards, Mark Mangus

Exercise: How Much, How Often

Q. Tell me, someone, what is a general rule-of-thumb for how often and how long we should be exercising? Daily for 6-hr workouts (:- } (prepping for US Open) or every 5 days for 5minutes?  It has to fall somewhere in between, correct? I have somewhat advanced E, am on O2 24/7, and was diagnosed about 6-7 yrs ago.  I went thru rehab but forgot exercise formula.  I didn't do a lot of exercise as my work kept me hopping until retirement 6 months ago.  Thanks for your response.  erlyn in az

* * *

A. Studies show that a minimum of 3 days-per-week is what's needed to achieve and maintain benefit.   That considers a fairly vigorous exercise plan of cardiovascular-targeted aerobic exercise of at least 20 minutes and up to one hour, burning around 1000 calories.   This is for "healthy" people to maintain a reasonable baseline level of fitness.   This also generally fits the recommendations of the ACSM (American College of Sports Medicine)    This really presents a wide range, when you think about it.   But, people are different among each other and requirements vary.
 
The bottom line is, it's awfully difficult to exercise "too much"! ! !    Conversely, it's awfully EASY to exercise too little! ! !    . . . especially if you have a chronic disease, are elderly and have mobility or other physical limitations, like pain and difficulty breathing.   None of these difficulties are, in and of themselves, reasons NOT to exercise.   Rather, they present all the more reason why you should exercise as much as you can, doing anything that will produce benefits commensurate with your functional needs.  
 
Extrapolating from recommendations for those who are "healthy" to those with COPD, I would say that we recommend that you exercise for relatively more time and more than three days per week (4 - 5 should be better by far, IF possible) since you must exercise at such a reduced "load" from those who are healthy.   While strength-building (lifting weights, working against specific resistance) and flexibility (stretching and movements to work joints) are indeed desirable forms of exercise and should be a part of your comprehensive exercise program, by far, aerobic exercise (walking, biking) should be the core element in any workout and should comprise no less than 50 % of the total exercise time, if you exercise for an hour, and 100 %, if you exercise as little as 20 minutes.  Without a significant component of aerobics, symptoms will only be reduced by a fixed amount, not eliminated and still be able to adversely affect your performance in daily function.
 
A common error in thinking is that because your job keeps you up and about, you don't need some component of, or as much time exercising.   Nothing could be farther from the truth.   Unless your job is doing aerobic fitness exercises all day long (US postal delivery - ON FOOT!, gas/water meter-reader, ditch-digger, etc), it certainly isn't enough to qualify as sufficient aerobic exercise.  I've had burly masons come in who were strong as an ox, yet had horrible cardiovascular fitness.   Yes, it was all a big surprise to them, as well!
 
So, bottom line, try to exercise for at least an hour at least three days-per-week.  If you can do more, do so.   If what you are doing isn't enough to give you the conditioning to do what you need/want to do, then increase your duration and/or load until you get to the level of condition you need/desire to be at. Regards, Mark

Needing Assistance Flying Overseas with Oxygen

Q. My wife and I would like to travel to Japan next year ,but I understand the airlines will not let you carry your own oxygen on the plane and I cant find anyone that knows how I can get oxygen refills in Japan. And all I have now is an home oxygen concentrator and the portable one's I have found on the computer are to big for me to carry.I use oxygen only at night at 2lpm.Is there anyone there that can help me.? Ed

* * *

A. Try contacting VGM and Associates (Van G. Miller) (1-800-642-6065)   They have helped many folks whom I've referred to them for overseas oxygen services.   The man answering at this number may even be Brad Workmeister, who answered when I called a few months back.
 
They won't make arrangements for you.    That is not what they do.   They will give you contact information for companies who provide the services so that you can make your own arrangements.   The companies they refer to are those who have asked to be included, have been used by others in the past and have given service good enough to be included in the listing, according to user customer-back.   They have put my folks in contact with oxygen providers in many reaches and corners of the world. Regards, 
Mark Mangus

Getting Oxygen When Needed

Q. Can oxygen be beneficial to help breathing with a FEV1 of less than 25% even when the blood saturation is mostly over 90 %, PO2 between 54-65? Do you have some information on this? Marie from Germany

* * *

A. It most certainly CAN!   Those numbers are at the low end of clinical acceptability!   In deed, here in the US, one qualifies for government (Medicare) reimbursed oxygen when their pO2 is 55 mmHg or less.   So the 54 you relate falls within our guidelines.   Also, in the report of a substantial study, in Chest, last December, Dr. Richard Casaburi, a pulmonary specialist, prominent for his research here in the US, found that even folks whose saturation averaged in the low to middle 90 %'s exhibited clinically/statistically significant improvement in exercise tolerance and performance when given oxygen sufficient to raise their saturation to normal (> 96 %).  
 
FEV1 is not considered a good indicator for need of oxygen, though in those below 25 %, we see increasing accuracy in predicting need for oxygen/presence of hypoxia - - - at least with exertion.   There are a surprising number of folks who maintain a normal (> 95%) saturation while breathing ambient air, even though their FEV1 is < 25 % of predicted. Regards, Mark

Why Do We Take Steroids?

Q. I was on Advair and Spiriva.  Had thrush so bad and the meds my Dr. gave me would not clear it up.  Previous to Advair I was on Serevent & Qvar with a Aero-chamber.  Never had any problem with thrush. (I did rinse and all that!!)  Am now on Foradil & Spiriva with no steroid.  What exactly is why we take steroids? My Dr. said a lot of us don't need them.  I don't feel any different without them.  Should I be taking some kind?  I know this has been kicked around before but I'm still now clear. I live in a small Ok. town that don't have a pulmonary Dr. so rely on my GP and you for answers. Also I use my handihaler for my Foradil too.  I order my Spiriva from Canada and so far have not had a bad one.  Guess that shows we are all different !  I don't post often but read everything. Loved Mark's answer on the 8 minute treadmill.  Tried it yesterday and sure enough I didn't get so winded.  Thanks Mark.  Donna Sullivan OK

* * *

A. You ask some good questions.   Steroids are prescribed for their anti-inflammatory effect - - - inflammation not always being a component of the "narrowed airway" problem for many with chrinic bronchitis and especially emphysema.   That you don't feel any different without the steroid on board than you do with it indicates (anecdotally) that you don't need it.  
 
It is interesting that you had no problem with Qvar (beclomethasone - a steroid), yet you had big problems with Advair.   It certainly could be that the Aerochamber made the difference, since all the 'extraneous' medication was captured and held within the chamber and NOT in yoour mouth, as happens with Advair, or other steroids taken without a holding chamber.
 
Small town or not, you are fortunate to have a "GP", as you say, who is up on treatment enough to have you on drugs like Foradil and Spiriva, let alone Qvar.   It is also good that you two work together to 'try' things and are not afraid to abandon that which causes trouble or does not help, in favor of trying other things to find that which works for you.  Regards, Mark

Can You Improve Your DLCO?

Q. Is there any way to improve your DLCO readings?  Other than quitting smoking, of course. Since this seems to relate to whether or not you need 02 in your life, thought I'd ask. Joy/MO

* * *

A. There is nothing you can "do" to change or improve your DLCO.   It is one of those things in COPD that is solely based upon physical and physiological changes that, once altered, do not return to normal.  Loss of lung tissue, destroyed with the progression of emphysema, along with the blood vessels that accompany that tissue reduce the number of oxygen molecules that can pass through the remaining viable tissue.  Add to that any "thickening" of the tissue between the gas-holding alveoli and the blood vessels in contact with for exchange of gases, or from scarring and you have even more difficulty with regard to getting oxygen molecules to pass into the blood.
 
Quitting smoking is of great help to reduce the chances of aggravating the situation.   So, yes, that is an effective means to thwart further inducement of deterioration.   It is when DLCO gets bad enough that we see the need to begin supplemental oxygen therapy.
Regards, Mark

Using Helios at Night

Q. On Monday I was put on the Helios system and just love it. I now have the freedom I need to be as active as possible. My 02 prescription reads 2L at rest and 3L on exertion and sleep. Yesterday when I was in Pulmonary Rehab and they asked me what I was doing for nighttime 02, and I told them I am using the Helios. I am suppose to use 3L at night, because my levels drop. The Helios is only able to be used with the conserving device at 3L and I have no concentrator to use at night. I do hook up to the large tank so that I don't run out during the night. The 2 gals in the Pul Rehab now say I should have the overnight complete sleep study (in the hospital 2 yrs ago I had the night test ,but it was just my finger hooked to the oximeter while sleeping and it showed at that time I dropped to below 80 several times during the night). I guess what I'd like to know is just how important it is to have the complete sleep study done and do I need to have them provide for me a concentrator for overnight use? thank you, Lorraine - ND

* * *

A. When I was in home care our policy was to never set one of our patients up with the Helios for use while sleeping without an overnight oximetry study. This way we had documented proof that the system worked for them. When a person sleeps they usually breathe more shallowly than they do when they are awake. If one's breathing is too shallow to trigger the pulse of oxygen during the night, then you won't get anything from the Helios. That is why most Helios users (that I have talked to anyway) have a continuous
flow system for use during sleep. If your supplier does not want to give you a concentrator, there is a continuous flow flow meter that can be attached to the Helios reservoir. If you got the manufacturers instruction book with the reservoir I think you will find a picture of it on one of the last pages in the book.

The people at your Rehab obviously know your needs better than I do, so there may be additional reasons they feel you need a full sleep study, but at a minimum if you are sleeping with the Helios system I (and the manufacturer) recommend that you have an overnight oximetry study while using the Helios. It is for your safety. John A. Richter RRT

LVRS Qualifications

Q. I'll hopefully be having LVRS - as soon as I can choose a surgeon. My dilemma and question is: Is it better to go with a surgeon who is said to be top-notch  but has stringent rules about no smoking  and prednisone for 3 months, (both of which may be a problem) or another very good surgeon (but not first choice) who will likely be more open in his  qualifications? What's the deal with no prednisone? I'm hoping to decide in 2 days. My emphysema is very serious,  I live with SOB all the time now. The Dr. thinks it's LVRS or nothing. Thanks for your opinion.

* * *

A. The no prednisone rule is because you'll heal better AND the integrity of your tissues is likely to be better after three months off steroids.   Those are extremely important considerations in success of the procedure.   They could make or break survival, so I wouldn't compromise them, were I in your shoes.   The smoking is also a concern, because if you don't quit for three months, at least - - - solid - - - no cheating, then the likelihood of recidivism is extremely high, especially if you really have a good result in breathing improvement.
 
The bottom line from where I stand is why risk failure and possible death for a month or two of toeing the line and letting prednisone's influence be diminished.   We're talking about your life and future, here!   The procedure is hard enough on you as it is, without making it any worse! Regards, Mark

Target Heart Rate During Exercise

Q. I need your advice on a subject that came up today at rehab. Each of us has a different target heart rate which they tell us is determined by our resting heart rate. They have told us that our target heart rate is 30 beats higher than our resting heart rate. We are told that when we are on the treadmill we should not exercise to the point that our heart rate is higher than this. They feel that 'slower and longer' is the best way to exercise. I know that you have expressed your reasoning on this before but would you be so kind and explain again how you do it at your hospital? I was told that only the cardiac patients are urged to push themselves past their target heart rate. Thank you and God bless, Jeanette in Ohio

* * *

A. For the reason that you are confused about what it 'should' be, is why I dislike "target heart rates" for any populations other than cardiac rehab patients.   And while I'm mentioning them, they are set target heart rates that are NOT to be exceeded, so either you might have misunderstood the information, or you were told wrongly about cardiac patients.
 
My position is that because folks with pulmonary disease have so many different co-morbidities (other things wrong with them at the same time), that standard predictors are not reliable sources for such information as a general application or rule.   Your program staff and policies, probably acknowledge and agree with my premise to some degree, anyway,  hence, why they have decided that 30 beats above resting is their "comfort level" cut-off.  They are arbitrary in their choice.  AND, it is not a bad thing, necessarily.   Yet, to hold you back from going faster - - - IF you can ALSO go longer - - - simply because your heart rate has increased more than 30 beats - - - especially in the face of YOU feeling GOOD with the increase (i, e; no discomfort or symptoms because of the increase) goes beyond what I would do, were you here at my clinic.   I have lots of patients who have resting heart rates of 80 and rise to 125 on the treadmill - - - sometimes at LOW speeds!    That is 45 beats increase.   Yet, they are perfectly comfortable, walking on the treadmill for 30 - 40 minutes at 2.7 mph and even talking, though maybe in spurts and while winded quite a bit.   At the same time, if one's heart rate gets up to and above 140, then I assess them and assure myself that they are safe to continue.  I do this by questions and eyeballs while they continue to exercise.   I don't stop them unless I find reason to.    Another point I have to consider is that I give my patients all the oxygen they desire and keep their sats. high (> 93 %, 96 % not being unusual, at all), while other programs use the "only enough" approach, keeping sats only > 89- 90 - 93 % range).   If oxygen is being restricted, then I'm not opposed to being more conservative on other parameters, like heart rate.   So it's all relative, to some degree.
 
My feeling is, if you can't exert enough to ACHIEVE windedness, regardless of what your heart rate does, then you are NOT achieving the greatest level of benefit/conditioning you could be with the use of that time. Regards, Mark

Should Patients Have Oximeters?

Q. I can see why some Drs. do not want patients to have an oximeter. My wife consults it all the time.  She shows it to me whenever it is low. That is after walking across a large room , or getting out and into the car. On her conserver she wants it on continuous feed instead of pulse because it might dip to high eighties. I don't think dips are serious, especially if it comes back to nineties shortly.  Who is correct ??

* * *

A. You did not indicate how long your wife has been diagnosed or how long she has had the pulse oximeter.  It IS human nature to focus on any new information source when either the problem or the information source is new.  Also, if she is newly diagnosed, her concern is reasonable; she has not yet learned to be comfortable with the feedback she gets from her own body and how to correlate that to the readings.  That will take time.

In general, I believe that more information is better than less information.  Having the device and ignoring it would be silly. Therefore, I would not recommend any firm guidelines such as "check it only 2 or 3 times weekly."  She needs to work with the pulse oximeter to learn how to tell when how she feels indicates problems growing.  This will help her know when she needs to increase
the frequency of checking the oximeter.

One posted response seemed to compare the constant "oximeter-watching" to constantly weighing during a diet.  I doubt that is an appropriate analogy.  As one poster mentioned, the oximeter can be a valuable means of telling if they are reaching dangerous levels of desaturation.  She will become better at this the longer she works with the oximeter.

At the same time, she needs to realize that there IS normal fluctuation on exertion.  Not every minor and rapidly reversed drop is a crisis.  Knowing when it is and when it is NOT is not always easy.  One of my concerns about the widespread possession and use of pulse oximeters by patients is that patients are often given the devices without the training and support to make sense of them.  Oximeters are NOT efficient as complete replacements for arterial blood gases, their values can be rendered incorrect by certain interfering material and physical conditions, and one needs to realize this so as not to hang one's hat on the oximeter alone.

Therefore, I would encourage your wife to watch not just the specific numbers, but the pattern of change, the pattern of decline and rebound of the values, and how she feels during both.  Slow rebound of her level might indicate she should talk with her physician.  Have her check the oximeter when she feels SOB, when she is using pursed-lip breathing, etc.  It not only can help her know
if a problem is coming, but it can also help her become more aware and confident of the effect of the tools she has at hand to improve her breathing.

Above all, have her ask her physician for guidance on what she should expect as far as oximeter changes, what changes he would want reported to him, etc. If he does not know/can't say/won't say, then I believe you need to seek another physician who will, or who will refer her to a respiratory therapist or specialist who WILL and CAN help guide her.

I'm sorry this is so long, but this is not a simple matter, no matter how easy it may seem.  The human body is very complex and variable, a little knowledge can be disquieting, and information or data without understanding can be frightening and confusing.  It is impossible and unwise to characterize her either as overly concerned or appropriately focused without more detail than any of
us on the list have.  I would be happy to try to help you and her better understand the information, data, and limitations of the oximeter - within the limits of my ability to help due to distance and lack of specific personal contact - either through postings through the list or privately.

I personally would always err on the side of more information rather than less. Larry

Exercise Question

Q. I have been walking 2 miles a day in my warehouse at work.  Most days  I do it in segments separated with a minute or so when I feel I should stop and catch my breath.  My question is this, if I get disturbed during this  routine, as in having to go answer a few phone calls, and end up doing the two  mile in bits and pieces throughout the day, does that diminish the value of the exercise?     John in NJ

* * *

A. The simple answer is "YES!"; Spreading a 2 mile walk out over the course of the day, done in spurts of short duration, will yield a significantly diminished result over doing it without stopping, or even the way you describe you do it, with short pauses along the way to catch your breath.
 
In considering the benefit of exercise, something is always better than nothing.   If a little is all you can squeeze in, then better that than nothing at all.   But, in considering the return on any exercise, total time is important, as is duration of individual segments of the total exercise time, but uninterrupted duration is the prevailing determinant of "how much" conditioning will occur at a given load.    Lastly, intensity is a huge contributing factor, in that it determines the potential for expected level of condition to be achieved.   
 
A person who does 90 minutes of exercise with little to no interruption, from start to finish, will realize benefit that is significantly greater than a person who exercises that same 90 minutes, doing the same exercises at the same intensity as did the person who did it all in one stretch.    Hopefully, this comes as no big surprise.  Endurance and cardiovascular/pulmonary fitness require endurance-targeted exercise.   That, by definition, is repetitive motion over the course of a significant uninterrupted duration.  
 
In your particular scenario, John, your two miles each day would yield a return that is significantly greater than it is now, if you walked it without stopping along the way.   After that, if you walk it all in one session with stops along the way to catch your breath, you significantly reduce total potential benefit from that which you would achieve if you didn't stop.   Cut that even further with interruptions that spread that 2-mile walk over the course of several hours, and your benefit drops even more.   Indeed such a walking pattern could yield and estimated 25 % or less conditioning than would walking 2 miles non-stop, when both are walked at the same relative speed. Regards, Mark

Is Paint Harmful?

Q. I know this might have been  talked about but I'd like to get this straight about paint.  Is it  harmful permanently or just an irritant?  The smell of paint never  bothered me or at least I thought it didn't.  I have severe Emphysema,  but am wondering if I can still paint if I can get up the energy to do so.  How about painting outdoors?  Does this make a  difference?  Please let me know, as I am getting ready to paint the  baseboards in the basement and maybe paint the fence.  Thank you in  advance for any advice. Mimi, Pa

* * *

A. If you don't react negatively to the odor of the paint, then "Go for it! ! !"   Most paints today don't carry additives that caus harm, like those of days gone by.   Stains and solvents are another thing altogether.   But, latex base paints are generally safe.   It's all in what your nose likes, after that. Regards, Mark

Swimming and Breathing

Q. My kids bought a swimming pool for my grandson for his birthday and put it right next to my porch since he's here 99% of the time. It one of those easy set 1 2 3 pools. Anyway, I almost drowned when I was little and have stayed clear of water over my ankles ever since but he wanted me to get in with him so I did. I LOVE IT! I don't understand it but I can stay in there for 2 or 3 hours moving the whole time and not get out of breath. I still wheeze but I feel fine. When not in the water I can't get from one room to the next without getting out of breath. I just don't want to get out and my husband was kidding about putting it in the living room this winter because he hasn't seen me laugh so much in years. I just can't get over how much better I feel in there. The first time I got out I thought I would have to go to the hospital because it hit me like a ton of bricks, couldn't get a breath but it passed. Now, I use my nebulizer before I get in, my husband brings my inhaler to me before I get out and he put a chair right next to the ladder so I can sit right away. The porch is only 20 feet away but I just can't go that far when I get out. I also noticed that I stay blue in there. My nails are blue, they say my lips are blue, my husband said my face is snow white and when I get out it looks like my legs and feet are kinda blue. Nobody else gets blue in there. I think maybe because my circulation isn't the best? Everybody worries about me when I'm in there and I don't want to worry them but I don't want to stop going in. I'm hoping somebody will know why I have tons more trouble breathing when I get out and why I get so blue and will it be ok? Thanks! Kay in West Virginia

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A. It is well documented that because of buoyancy in the water (90 % of your body mass is supported by buoyancy) that less energy is expended to move about.  ALSO, because of the density of water, exercise is more effective, pound for pound and easier to do!   I send my most deconditioned patients into our pool when land-based exercise is beyond their condition of the moment.    The reason why you have so much difficulty getting out and back into the house is because you lose the buoyancy when you leave the water.
 
The blueness could be from any number of things, from peripheral blood vessel constriction due to the cool water, to hypoxia (not enough oxygen).  You need to be assessed for that with pulse oximetry DURING WALKING!   If you need oxygen, you can still use it while in the pool.  I just set up tanks here in my pool with extra-long oxygen tubing! Regards, Mark

Why Do Some Need Oxygen and Some Don't?

Q. Just recently, I seem to have read of several members whose  FEV1 is much higher than mine, and yet they are on supplementary oxygen 24/7 and  I'm not on it at all. Could the RRTs explain why some people need to have supplementary  02 in these circumstances, please.  Are there other factors that make the  FEV1 reading unimportant? Ann

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A. The short answer is that there are several factors that influence whether you need supplemental oxygen at a given FEV1.  The biggest single factor is what kind of physical condition you are in beyond your COPD.  If you exercise and stay in good condition, your body is more efficient in using whatever oxygen your lungs are able to provide to it.  This means that you can function comfortably without supplemental oxygen (or with less supplemental oxygen than if you were in worse physical condition).

Another factor can be the presence or absence pulmonary fibrosis, interstitial edema, or any other disorder that makes it more difficult for oxygen and carbon dioxide to pass from the lungs to the blood and from the blood to the lungs.

Remember that FEV1 is only a measure (only one of several) of the mechanical ability of the lungs and chest system to move air in and out.  There are three other parts to the oxygen delivery and use process:
- Oxygen getting from the lungs into the blood (and carbon dioxide getting from the blood to the lung).
- The blood getting pumped around effectively to the body.
- The body being able to use the oxygen effectively.

Anything that negatively impacts any of those can increase your need for oxygen beyond or independently of the degree of FEV1 reduction.  All of your other factors must be in pretty good shape. Whatever you are doing - keep it up!!! Larry

Suddenly Falling Asleep

Q. My husband has copd, emphysema, cor pulmonale and congestive heart failure. He will suddenly fall into a deep sleep without any warning that he is sleepy. His sats are usually in the normal range for him ( 88 -92%). Is this normal for his condition?

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A. Regardless of his pulmonary diagnoses, what you describe is NOT normal, nor acceptable to continue without effort to find the cause and resolve it if possible.  What you call "normal for him" at 88 - 92 %, is not good, for someone who has cor pulmonale and CHF!   B-e-c-a-u-s-e of his CHF and cor pulmonale, he should be allowed to drop no lower than 92 %.  He should be getting more supplemental oxygen, IMHO.  I would recommend asking the doctor about turning up he oxygen flow.   In any case, there are folks who have a severe form of "narcolepsy", where they suddenly and without warning, drop into a deep sleep.   It can be a primary problem caused by neurologic or pulmonary or a combination of factors from each system.   It can be secondary to something like severe OSA (Obstructive Sleep Apnea). In any event, I would strongly suggest you consult with his doctor about this and be sure it is thoroughly investigated! Regards, Mark,

Oximeter Use While Still Smoking

Q. The number you read on an oximeter ,(any number) is supposed to be the percentage of oxygen in the blood stream. I have also heard that the number may be including other gases as well like Co2 and/or carbon monoxide or any other present gases. Is this true?  If a person smokes the gas from the burning tobacco gets into the blood stream. Does this gas displace, or take up space that O2 would normally be? A person that smoked 2 packs a day may have a reading of say 95.If he were to quit smoking would that number change?...Rusty

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A. Oxygen saturations measurements represent the percentage of hemoglobin that is available to carry oxygen compared the actual amount that it is carrying.   So, a saturation of 95 % means that of the hemoglobin's capacity to carry oxygen, it is carrying 95 % of what it CAN carry.    While the oximeter is able to detect "oxygen", but is NOT able to distinguish between "types" of oxygen, it picks up ALL of the oxygen that is bound to carbon as carbon dioxide (CO2 =  a VERY small percent), to carbon as "monoxide" (CO = also a VERY small percent - - - unless you are a smoker) as well as the good stuff - plain old bi-molecular oxygen - O2.   While the "percentage of carbon monoxide increases in an active smoker, the saturation itself, as a measurement, is NOT affected by it.  So, when the person stops smoking, the percentage of carbon monoxide carried on their hemoglobin drops and is replaced by bi-molecular (the good stuff) oxygen without any change occurring in the overall saturation.  The only way you can tell the shift has occurred is to run a sample of arterial blood through a co-oximeter, which DOES distinguish between 'types' of oxygen carried on the hemoglobin.
 
So, the answer to your question would be no, the smoker who quits would NOT see a change in his/her saturation.   BUT, there WOULD be a measurable change (for the better) in the good oxygen being carried at whatever saturation they ARE running. Regards, Mark

Is Oxygen Dangerous?

Q. I'm  confused about oxygen and the different references to it regarding it being  flammable. A while ago, someone said that it (ox) did not catch fire.   Isn't being flammable and "catching fire" the same thing?  (I guess  I'm referring only to pressurized oxygen, not that which I'm right now  breathing in). When one has oxygen in the home, what happens if there is a  leak?  Can it catch fire? How about explosive qualities?  And  if it can't catch fire or explode, what does flammable actually  mean? What makes oxygen dangerous? I know I sound like a new student in  freshman science but I never had reason to wonder about this stuff  before.  Any answers and/or insight into oxygen would be  appreciated.

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A. I know it can be confusing.  Many doctors and nurses are confused  about it to some degree as well, so don't feel alone.

Here is the deal, regardless of the various terms applied to oxygen:

1 - Oxygen itself DOES NOT BURN.
2 - Oxygen SUPPORTS the burning of any other flammable material.
3 - Without oxygen, other materials will not burn.
4 - The higher the level of oxygen around it, the faster, hotter, and more vigorously a material will burn.
5 - In higher oxygen concentrations, the burning of a material can be so intense that it essentially becomes a flash fire with explosive results.
6 - The other major risk associated with oxygen in a cylinder is that it is at high pressure (a full tank is at about 2000 psi (pounds per square  inch!).  If that tank is dropped or the valve knocked off, it can act as a  missile
or a bomb.

So, as far as fire hazard is concerned, here is a description of a demonstration I used to do for nurses as far as the effect of oxygen:

If you take an ordinary oxygen cannula (prongs) and try to light it with a lighter, it will burn a second or two and then go out.  It will not sustain burning in room air oxygen (21 percent).  However, if you run oxygen  through the same cannula at just 1/4 to 1/2 liter per minute (most of you on  oxygen are using 1 to 3 liters per minute), the cannula burns like a torch, with  flame shooting out 2 to 4 inches (imagine that stuck up your nose!).

So, just remember:
1 - No open flame around oxygen (especially near the face!).
2 - No spark source around oxygen.  Friction toys, you know those  little cars that you push and then they keep rolling, they cause sparks, and  they have set off several oxygen tent fires with kids.  Obviously, no  matches, no electric razors (some battery powered are OK).
3 - Protect your cylinders from falling or sharp hits.  This applies  to small and large cylinders, because the working pressure in a full tank is  about the same regardless of size.

See if this helps.  Let me know if there are other points you need  clarified.Larry Conway, Registered Respiratory Therapist

New Doctor Experience

Q. My new doc was seen today for the 1st time.  My records were not in order...sigh.... but he found the info he needed  (I hope) and looked things over and determined that I not only had E but asthma.  Maybe we all do but i didn't know that.  Said my numbers were not very good.  Will be putting me on a new (very old med with rare side affects) to help with the asthma component.  The nurse put the oximeter on my finger and the reading  was 93.   Usually 97 98 when at rest for me.  So i asked him about that and he took it again and it was 97.  Said well now that you are resting it is up.  I wanted to know about exertion as i am very  SOB on exertion.  He said"  Do you want to drag an o2 tank around???   I said no but I would if i needed it to breathe.  So then he said ok we will schedule a 75 minute rest exercise test. My question is: Should I do the test?  Is he giving me a CHOICE as to whether or not i will use o2.  Whether I need it or not???   I am very confused about this.  Can anyone like one of the docs or the RRT's shed some light as well as any members who have experience with this attitude or whatever. Thanks so much for any replies. Hugs..and yes I am frightened...Diana

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A. I always figure tests are how we get information. To me the question should be: Do I NEED to drag an oxygen cylinder around?, not: Do I WANT to drag an oxygen cylinder around? Comprehensive testing will give you an honest answer to the first question, a look at some of the compact, lightweight portable systems available today will give you an answer to the second (if it needs to be answered at all). I thought the days of dragging an oxygen cylinder around were over. I find that one of the most important things I can do for some people in Pulmonary Rehab is help them see the benefits of using supplemental oxygen if they need it.

I had a lady tell me she didn't want to be restrained by using oxygen. I asked her how often she got out other than to come to rehab and go to the doctor, she said almost never because she was too short of breath. When she saw how much she could do with the oxygen on in rehab she tried it at home too. Now she is happy with her more active lifestyle. She doesn't run marathons or anything, she does her own grocery shopping, and goes out to lunch with her friends. Oxygen set her free, it didn't tie her down.

They tell me in the army they used to say "Smoke 'em if ya got 'em", When it comes to oxygen I say "Use 'em if ya need 'em."
Don't be scared, be informed, John A. Richter RRT   (uh oh, I think that's my new tag line)

PFT Results

Q. What if on your earlier tests there is a marked difference between the two (pre-med vs post med)  maybe 15%, then maybe 2 years later they do another spirograph & there is no little difference between the two? (Pre/post) Joy

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A. When one has a PFT and the 'post-bronchodilator' result represents a significant % improvement, is THEN put on medications to maintain the improvement and THEN, when re-tested later shows NO improvement, the physician needs to ask himself/herself three questions:  (1) Did the patient take their bronchodilator medications too close to being tested?  (2) Does the "lack of significant improvement mean medication is no effective or necessary, or does it show the medication is having the desired effect?   (3) How does this test compare to the one on which the significant improvement was observed?   Is it the same as the "post-bronchodilator" measurement from the earlier test?   Or is it the same as the "pre-bronchodilator" measurement from the previous test?   Without answering at least 'these' questions, to make the decision to stop the medication does not consider enough to support it as the best direction in which to go.   These are all important facts to consider before stopping a medication that could indeed be the reason the test DOESN'T show significant change.  Otherwise, you could end up right back where you began before the earlier test.   AND, you could end up enduring a lot of unnecessary discomfort and suffering. Regards, Mark

Inhaled Steroids and Osteoporosis

Q. Previously I was on several breathing medicines. Two years ago I threw them all away and went on Spiriva. I am very happy with Spiriva. Now my new Doctor tells me at my first appointment I should add Advair. (not Pulmo)  What do you think?? I kind of agree with him when  I heard it had steroids: However I have osteoporosis so I worried.   The Doctor says only oral steroids cause osteoporosis.

Concerning rehab and the procedures. I always thought it was funny how the people in charge say  "don't overdo"  BUT----"Push yourself"  Appreciative for your informative thoughts. in EFFORTS. Don

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A. The influence on osteoporosis from inhaled steroids is significantly less than for oral steroids, by a factor of several times.   If you already have osteoporosis, you have reason to be concerned.   BUT, you probably should consider if or not the steroid helps your breathing more than it could be hurting your osteoporosis.   If you can exercise more and more vigorously because of the added beta-agonist and steroid, then perhaps you can override the negative influence of the steroid.   But, while I agree with your doctor that oral steroids doses - - - being SOOO much higher (relatively) than inhaled steroids and influencing systemically rather than locally targeted - - - can "cause" osteoporosis, the incidence of inhaled steroids "causing" osteoporosis is g-r-e-a-t-l-y reduced, but nevertheless still there.   If I were in your shoes, I'd probably try Advair.  If it helped significantly, I'd accept the risk on the osteoporosis consideration.   That's "my" opinion on what "I'd" do.   Take it for no more than that, please.
 
I hear you loud and clear on the mixed messages conveyed by pulmonary rehab staff, doctors and others.   It's kind of like the 'hurry up and wait', idea; or 'take your time, but hurry', I like to chide my folks with.   Yet, it's not totally oxymoronic, when you consider it properly.   You need to be careful not to go too far, yet, not be so cautious that you under achieve!    I think it is far easier to do too little than to do too much.  My observations over the last 15 years pf pulmonary rehab have borne that out, again and again. Regards, Mark

Exercise Pushed Too Hard?

Q. Is there an age and severity level at which a person will NOT benefit from moving a little more each day?  Is it smart to allow the very severe and or aged to sit back and not exercise. Lyn

* * *

A. Essentially, there is NO age or level of severity of COPD at which we say one shouldn't try to exercise or improve.   There is only one condition that I know of that is prohibitive to being able to exercise or realize improvement from it.   That condition is the one where you have no pulse or respirations!   Until you are afflicted by that eternal ailment, the only thing standing between you and improvement are your imagination or any excuses you may have conjured up.   There are doctors and others out there who will impose their opinion on you and say you can't or shouldn't or something.  
 
You CAN hurt yourself trying to go about it without proper knowledge or training.   That is where pulmonary rehab comes in.   I have seen some R-E-A-L-L-Y B-A-D folks do some R-E-A-L-L-Y  R-E-M-A-R-K-A-B-L-E things in my experience of 15 years of pulmonary rehab.    I learned a LONG time ago never to underestimate a determined person, no matter HOW hopeless they may appear to be! ! !   That's why I love this job!   I have patients who come in really debilitated, work hard, get better and go on with their lives - - - albeit often with our maintenance exercise program as part of that life - - - and when they get all the compliments on how good they are doing, BINGO, "I" get all the credit! ! !   What a deal!
 
Again and seriously speaking, this applies most specifically to those who have COPD and only up to a point.   That point is individualized and can't be predicted, only ascertained upon arrival.   for folks like Rodney, I cannot say that my blanket statements cover them.  Folks like him, I believe, have other things going on that may or may not allow for exercise, improvement, etc.  I am dialoguing with Rodney, privately and hope to learn more about his unusual condition in relation to being so young and having such bad numbers.   I'm not convinced that his only lung problem is COPD. Regards, Mark

FEV1 Doesn't Change with Bronchodilator

Q. My FEV-1  has always been the same before and after using a bronchodilator yet nothing  helps me as well as albuterol when I'm SOB.  If it doesn't change my  airways to improve the FEV-1, how does it improve my breathing?  I've  been treating copd for 24 years and it seems I have more questions about it  now than ever!! Virginia n  Va

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A. A possibility is that it reduces your air-trapping enough that you can feel the difference there.   Yet, it doesn't have to show up as an FEV-1 change to be significant. Regards, Mark

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