Oxygen at Night

AJ

Dear AJ:

Most people don’t realize that we all have lower oxygen levels while sleeping.

There are several reasons for this finding. Although we are “at rest”, our breathing patterns during sleep are much more shallow and slower compared to daytime. This is especially true during periods of deep sleep. Lying flat in bed can be a less efficient position for our lungs to transfer oxygen into the bloodstream. Those with lung disease and concurrent heart disease are at much higher risk for low nighttime oxygen levels. Finally, patients with sleep apnea have recurrent bouts of low oxygen levels while sleeping. This is due to intermittent blockages of the air passage in the back of the throat.

Criteria for initiating oxygen therapy are well documented. Medicare and most insurance companies will not cover oxygen therapy unless saturation levels fall below 88 %. With portable oxygen saturation recording devices, your doctor should be able to screen you, day or night, to determine with some certainty, the need for oxygen therapy. Pleasant dreams!

Lung Scarring

DJ

Dear DJ:

Scarring in the lung can have many different causes and can involve different areas within the lung itself. Idiopathic pulmonary fibrosis is a scarring or “stiffening” process that usually spreads throughout both sides of the lung. This commonly results in more difficult efforts at beathing and lowered oxygen levels.

Scarring can also occur in small, localized areas within the lung. Common causes for this would include a resolving or healed pneumonia (infection), lung trauma, or healing of a portion of the lung following surgery or radiation therapy. Sometimes the lining of the lung, called the pleura, can become scarred following infection or trauma. Exposure to occupational dusts such as asbestos has been shown to cause scarring of the pleura. Scarring of the lung may or may not be symptomatic for the patient. I hope this information is helpful for you.

Snoring

Bill Rice, Ormond Beach, FL

Snoring is the load sound we all recognize when parts of the upper airway vibrate with respiratory efforts. Swollen sinus passages, large tonsils, a large tongue or floppy soft palate may be the culprit. Snoring is usually the loudest when sleeping on your back, which explains why a nudge from your sleep partner temporarily fixes the problem. Unfortunately I can’t offer you an easy cure or magic “No Snore” pill. Please don’t fall for the TV offers for a simple spray. They won’t work.

Snoring in children or teens may often be cured by tonsillectomy. Since weight often plays a role, losing some extra pounds can be helpful, although for most of us quite difficult. A visit with an otolaryngologist (ears, nose and throat specialist) is a good idea. A deviated septum or swollen nasal polyps sometimes need surgical intervention.

There is a new surgical procedure called somnoplasty that can eliminate vibrating tissues in the back of the throat.

I recommend a consultation with a board certified sleep specialist for difficult snoring problems. Snoring can often be a warning or more serious sleep illness such as sleep apnea. This is a condition marked be long periods at night when breathing becomes completely blocked. This can cause low oxygen levels and very poor quality sleep. Special but easy nighttime sleep studies are needed to diagnose and properly treat this problem.

Best wishes for good sleep and happy dreams!

Inhalers and more Inhalers!

Edward Montwill, Niles, IL

The number and types of different inhalers currently on the market can be very confusing for our patients. Many of them sound the same (e.g. Flovent, Serevent, Atrovent and Flonase). Some inhalers, such as Flovent come in different strengths (e.g. 44, 110 and 220 mcg dosage). Some inhalers have different names and manufacturers, but are actually the same medication (e.g. Albuterol, Proventil, and Ventolin.) It’s even more confusing now with new inhalers that are combining two medications in one inhaler with different strength options (e.g. Advair).

I strongly urge all my readers to know the names and the strengths of their individual inhalers. When my patient tells me he is using his “orange inhaler” four times a day, I’m usually at a loss given the large number of inhalers that now look the same.

Some inhalers can be substituted for others. This depends on the class of medication and the duration of action of the inhaler. The actual inhalers chosen by your physician should depend on several factors. These include the nature of the underlying lung disease, convenience of use, activity and severity of underlying lung disease as well as cost.

Each time I visit with a patient in clinic, I review the names of each inhaler, the doses used and their effectiveness. Many people using inhalers are able to have some variability during the day in their inhaler program. I suggest you bring you medication list with you to your doctor each visit and ask if your program is appropriate for your current lung condition.

Do I Need Oxygen?

Billye H - Farmerville, LA

I have seen many patients in clinic with severe lung disease who are short of breath at rest or with physical activity, yet their oxygen levels show little or no decrease from normal levels. The breathing centers deep in the brain tell us we are “short of breath” for many reasons. A runner just finishing a mile race, clearly is short of breath but has quite normal oxygen levels. If a person with normal lungs holds his breath for a minute, he or she will be short of breath despite normal oxygen levels. A buildup of chemical mediators in the body with activity and activating stretch receptors in lung passages and respiratory muscles play important roles. Patients with obstructive lung disease such as asthma and emphysema have great difficulty exhaling air at adequate flow rates. The brain interprets this abnormality as a sensation of feeling short of breath. Patients with pulmonary fibrosis have stiff lungs. The increased effort and work of breathing for these patients is interpreted by the brain as “shortness of breath.” This uncomfortable feeling can be quite profound despite normal oxygen levels. This may help to explain why those with lung disease still feel short of breath even when they use oxygen and have normal levels measured at the doctor’s office.

Theophylline

A Concerned Reader

Just the other day, one of my patients asked me to call in a refill prescription for his favorite brand of theophylline. I was told by the pharmacist that it was no longer available.

I suspect that our big pharmacuetical companies have made a purely financial decision that manufacture of brand name theophyllines (i.e Theo-dur, Slo-Bid, Slo-Phyllin, Theolair-SR, Uni-Dur) are no longer profitable. If fact, this medication is being used with much less frequency the past few years. Theophylline was developed as an oral bronchodilator many years ago. It used to be the “standard therapy” for both asthma and COPD. There are three major reasons why theophylline has come a bit out of favor. First, we now have many short and long acting

inhaled bronchodilators that work much more effectively. Second, we now realize that inhaled steroids oral are a vital first line drug for many of our patients. Third, high doses of theophlline can be dangerous with serious, life threatening side effects. Theophylline is still available as a prescription generic medication. Many people are still use theophlylline and find it helpful without any problem at all. My general advice is to ask your doctor if this is still “the right medicine for you”.

[Some products will be still be available, Uni-phyl, T-Phyl, Theo-24, Theolair. Changing to a different form will require checking your blood concentration of the drug a few weeks later.]

Acute Bronchitis

Julie Bilinski, Florida

Bronchitis refers to an inflammation of the upper bronchial passages in the lung. When this occurs, symptoms of cough, chest congestion and sputum production are common. When this occurs in those of us without lung disease or chronic cough, it is called acute bronchitis. When an increase in cough or sputum occurs in patients with known lung disease such as COPD or in smokers who normally cough every day, a worsening of this condition is best called “an exacerbation of chronic bronchitis”.

Acute bronchitis is one of the most common reasons people call their doctor for help. By far, the most common cause of acute bronchitis are viral infections of the upper airway. Unfortunately, antibiotics are rarely effective here, just like they are of little benefit in treating the “common cold”. Those without lung disease usually find cough and sputum get better after a week or two regardless of the type of treatment offered.

I suspect, however, that many of our readers have rather significant lung disease that they deal with on a daily basis. For them, an acute exacerbation of bronchitis is a big concern. Possible causes include viral infections, air pollution, allergens, or an asthma attack. Occasionally bacterial infections can cause an exacerbation of chronic bronchitis. The role of antibiotics is a bit more controversial here, but I think most lung doctors would support prescribing antibiotics for our patients with bad lung disease who have severe symptoms, limited breathing reserves, especially when fever and nasty looking sputum is present. Usually five to seven days of antibiotics are sufficient. I think it is rare that some of the new, very costly, antibiotics are needed.

Sleeping with COPD

Insomnia, the inability to fall asleep or maintain good sleep throughout the night, is a very common complaint. Unfortunately, patients with lung disease may have many factors that promote poor quality sleep. Sleep disturbance commonly occurs in COPD with patients who note difficulty initiating sleep, frequent awakenings with respiratory distress, shortness of breath ot nighttime cough or a feeling of being unrested when first waking up.

Inadequately treated bronchospasm resulting in wheeze and cought are frequently the culprit. Low nighttime oxygen levels are also very common. All of us, with or without lung disease, breathe slower and with more shallow breaths while sleeping. This results in lower oxygen levels in everyone while sleeping. Those with reduced oxygen levels during the day are likely to have even further reductions while sleeping. Some patients with lung disease, who have adequate oxygen levels during the day, may benefit from nocturnal oxygen use to improve sleep quality if significant desaturations (low levels) can be demonstrated during sleep.

Obstructive sleep apnea syndrome may coexist with COPD. This is a common condition caused by blockage of the air passage in the back of the mouth during sleep as the muscles and soft tissues in this region become more lax with sleep onset. Warning signs for sleep apnea are snoring and sleepiness during the day.

Most often, sleep quality improves when the underlying medical issues, such as those mentioned above, are addressed. Sleeping pills are to be used with extreme caution in those with lung disease. Too much medical sedation can blunt respiratory efforts while sleeping. This could result in dangerous low oxygen levels or too high carbon dioxide levels. Pleasant dreams!

Runny Nose

Marion Vaughan - Sarasota, FL

One of the most common complaints of patients with nasal oxygen is a runny nose. The constant flow of oxygen and air in the nostrils can be drying and irritating to the skin. A natural response of sensitive nasal passages is to secrete lots of clear mucus. This is a particular problem during the cold dry months up North. I usually recommend my patients use a humidifier in their home, especially in their bedroom at night. Humidification systems can also be directly incorporated into most oxygen concentrators. You need to speak to your home care vendor about this. Finally, there are several prescription sprays such as Atrovent nasal spray, as well as many brands of topical nasal steroids, that can be a big help. Ask your doctor if these steroids would be appropriate for you.

Dental Work

Evelyn Jennings - Cackamus, OR

It’s not surprising the dentists may feel uncomfortable performing complicated dental work on their patients with severe lung disease. On the other hand, patients with COPD can still use their nasal oxygen in the dentist’s chair and the local anesthetics administered by injection should not interfere with respiratory efforts. If your dentist cannot help you, I suggest asking him if there are other dentists in your area who frequently see patients with lung problems. Often larger hospitals, especially big medical centers, will have affiliated dental clinics on the same campus. This is probably your best chance of having dental work performed by those familiar with the special problems of lung patients. Good Luck!