Calling Dr. Bauer ...

Dear Dr. Bauer:
What criteria do you use to make the determination to prescribe oxygen round the clock for your patients? Can oxygen harm a patient without severe hypoxia?
Marion Vaughan
Sarasota, FL

Yours is an excellent question. Oxygen should be considered like any prescription drug: it needs to be given only when indicated and in the right dose. When given to people who don't need it or when prescribed at too high a dose (flow-rate) it can be a waste of money and medical resources. Fortunately, we have quite specific guidelines that help us to use this "medicine" appropriately.

Technically, a patient with lung disease should have a recent oxygen saturation test that is 88% or less. Most of you know that this test is very simply performed in the hospital or doctors' office with a lighted finger probe (called a pulse oximeter). Alternatively, an arterial blood gas (a blood test requiring a needle puncture of an artery in the wrist) must show a partial pressure reading of 55 or less. Although quite technical, these criteria must be met for your insurance to pay for the oxygen and equipment.  Some patients need oxygen 24 hours a day, some only at night while sleeping, and some only with strenuous physical activity during the day. Your doctor or respiratory therapist can easily test for all these situations to tailor the right prescription for you.

It is unlikely that oxygen prescribed at flow rates coming out of standard plastic "nasal prongs" will be harmful. The air we breathe contains about 21% oxygen. The usual prescription for oxygen is for 1,2,3 or 4 liters per minute flow out of the plastic tubing. This can result in a boost of oxygen delivery up to a 40% concentration at best. People with normal lungs cannot perceive this difference. Paradoxically, those with extremely bad COPD and very low oxygen levels may be harmed if they are treated too aggressively with high flows out of their nasal prongs. This is another reason why oxygen flow needs to be adjusted or "titrated" by trained medical personnel.

We still do not have a cure for most cases of pulmonary fibrosis. Occasionally, when we know the cause such as an infection or drug reaction, the disease is easily treated. Usually this is not the case and the fibrosis or scarring process worsens over time. Several drugs are available to slow this disease process and each patient reacts quite differently from the next to treatment programs. Prednisone, a drug used for many lung diseases besides ILD is probably the most common medicine used to treat this disease. Each month I read about new drugs and treatments that are being researched in our country’s large medical centers. I have confidence that some day in the not too far future, we will have more effective medicines and even a cure for this disease.

Dear Dr. Bauer:    It seems like when people sing in church, they are exercising their lungs at the same time. What do you think? Bill

Dear Bill:

You have made an excellent observation! Singing is a form of controlled breathing and in this way, is similar to another controlled breathing pattern called pursed lip breathing. When we exhale forcibly through a partially closed air passage like a "pursed lip" or a "singing vocal chord," the air pressure in our lung increases. This keeps the bronchial tubes (air passages) and alveoli (air sacs) open longer and more effectively. A proper exercise program including breathing exercises is a cornerstone for an emphysema treatment plan. Maybe I should prescribe all my patients to sing their favorite song QID (four times a day.)

Thank you Bill!

Dear Dr. Bauer:
I have been disabled since 8/95. My diagnosis is moderate COPD. I have been advised by my doctor to use 2 liters oxygen. I have attended Pulmonary Rehab and was advised by my home therapist and rehab therapist that my saturation readings are between 92% and 95% after 30 minutes of exercise, therefore they feel I have no need for oxygen. I also had a consultation with another rehab which felt I did not need oxygen at this time. I do better without it as it makes me dizzy, fatigued, and weak. When I ask my doctor about this he says my blood gases are reading in the 50's and I need the oxygen. I'm confused. Can you help me?                                                                                                                              Thank you, BD

Dear BD:
Physicians need to follow strict guidelines when we prescribe oxygen for our patients. These guidelines have a sound scientific basis. In addition, Medicare and other private insurers will rarely pay for the considerable expense of oxygen unless coverage guidelines are met. All patients must have their blood oxygen level tested with by an arterial blood gas (a blood test) or pulse oximetry (a simple finger probe.) This test should be done with 30 days immediately proceeding the prescription date and is optimally performed while the patient is breathing room air in a resting state. A partial pressure level of less than 55 (this is the PaO2) or an oxygen saturation level of less than 88% (this is called the SaO2) is necessary. Occasionally, PaO2 levels between 55-59 or a saturation level of 89% may be adequate if the patient also has evidence of heart disease. Sometimes oxygen levels will be fine when the patient is resting but will clearly drop with exercise activity or perhaps while sleeping at night. These specific situations can qualify patients for oxygen use during exercise or with sleep. Oxygen can be life saving. It certainly can relieve that shortness of breath that results from severe lung disease, but only if prescribed with the type of guidelines I’ve outlined above.

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Dear Dr. Bauer:
My husband was just discharged from the hospital following treatment for a condition the doctors called a "blood clot to the lungs." What exactly is this?
Karen Stroup
Exeter, NH

Blood clots that travel to the lungs are a serious and fairly common problem that affects approximately 500,000 people each year and results in over 50,000 deaths. The more technical term for this condition is pulmonary embolism (or PE). Why do people get a PE? Small and sometimes large blood clots form in the veins in our legs. Risk factors that predispose patients to this problem include lying in bed for prolonged periods of time; recent surgery; a stroke or sometimes an underlying diagnosis of cancer. A portion of the blood clot in the leg sometimes breaks off and travels through the circulation where it will most often end up being caught up in the blood vessels in the lung. When it happens, patients usually become short of breath and develop chest pain and a rapid heart beat.
When recognized early on, a pulmonary embolism can almost always be treated successfully with blood thinners. However, about two-thirds of cases remain undiagnosed! Although we have many good tests to help sort out this problem, there is still no simple and accurate way of making this diagnosis with certainty. I suspect that the mortality risks of this disease will markedly decrease in the years to come as soon as we can develop an accurate warning test.

Dear Dr. Bauer:
I have bad emphysema and often become quite short of breath. I asked my doctor if oxygen would help. He performed some test and told me that right now, oxygen would not improve my breathing. How can this be?
Jennifer Donovan
Melbourne, FL

Although almost everybody with a low oxygen level in their blood feels quite short of breath, not everybody with a breathing problem has a low oxygen level. Often patients with emphysema, COPD or many other lung conditions feel short of breath. This frequently occurs with activity or exercise. Everybody's lungs need to work harder with exercise to move air in and out of the chest cavity. With bad lung disease, the breathing muscles try to work harder but air movement is inefficient and ineffective. It's no wonder you may feel short of breath.
We do have specific guidelines or criteria for prescribing oxygen for our patients. Insurance companies and/or Medicare will usually not reimburse the costs for home oxygen unless these strict guidelines are met. A simple blood test called an arterial blood gas, or a non-invasive test, such as a pulse oximeter, can determine whether or not you are a good candidate for home oxygen. If low oxygen levels are not the problem, many other remedies such as medication changes or breathing exercises may make a big difference in your breathing symptoms.

Dear Dr. Bauer:    I don't need oxygen during the day, but recently my doctor recommended that I start using oxygen by nasal prongs at night while I sleep. Why should this help me?               Mark Lynn, Ormond Beach, FL

It may seem surprising, but the amount of oxygen in our blood actually decreases in all of us when we sleep. During the night, our breathing patterns become more shallow and irregular. Many adults, especially those who are overweight, can have blocked breathing passages in the back of their throats during sleep, which may impair delivery of air to the lungs. Patients with heart disease often have more difficulty breathing while lying down in bed.

For these reasons, some patients with lung disease may have adequate oxygen levels during the daytime, but at nighttime, oxygen levels may decrease to the point where supplementation by a home delivery system is appropriate. Sometimes patients with low nighttime oxygen levels cannot sleep well, but this is usually a problem that is very difficult for the patient to feel at all.

The most accurate way to diagnose this problem is to check your oxygen level with a home monitoring device called a pulse oximeter. Physicians can arrange for this test through their office, hospital or a local home care company. All patients who use oxygen during they day should continue to use their oxygen when they sleep.

I personally would like to prescribe pleasant dreams to all of you!

Dear Dr. Bauer:    I quit smoking six years ago. At first my breathing improved. I coughed less and was more active. Now I am having more problems with shortness of breath. Why?           Pam Parker , Binghamton, NY

Each of us, whether we smoke or not, loses a bit of lung function every year. This is part of the normal "aging process" and, unfortunately cannot be prevented. Persons who smoke are at increased risk of an accelerated loss of lung capacity. Some smokers lose lung function very quickly; these are the ones who develop emphysema at an early age and who need oxygen early on. I am glad you quit six years ago.

Smokers who quit their habit, very quickly slow their rate of lung decline to normal, just like nonsmokers. Symptoms such as cough and sputum production quickly improve. However, after twenty, thirty or more years or smoking, some of the damage to the lung is permanent and cannot be reversed. As you become older, this impairment can become more symptomatic. The moral of the story is twofold: one, don't start smoking and two, it's never too late to quit!

Dear Dr. Bauer:    What is the difference between pneumonia and bronchitis?                                  Just Wondering

Bronchitis signifies an inflammation of the larger bronchial passages  in the lung. When this occurs, patients typically have symptoms of cough, chest congestion and lots of sputum production. The most common cause of  chronic bronchitis is smoking, but anything that can irritate the bronchial tubes such as air pollution, strong fumes or odors can cause bronchitis  in susceptible individuals. Sometimes an acute bronchitis may be the result  of an infection of the bronchial tubes. This is usually caused by a bacteria  or virus and may get better without any specific antibiotic treatment.  Pneumonia, on the other hand, is a more serious infection that attacks  the lung tissue itself. Many, but not all pneumonias, result in lots of  sputum production. In general, patients with pneumonia appear more ill  than those with common bronchitis. Faster breathing patterns, higher temperatures, worsening blood oxygen levels are all hallmarks of pneumonia. A pneumonia  can frequently be heard and localized by your doctor listening closely  with a stethoscope. Ultimately, a chest X-ray is needed to diagnose a pneumonia  with accuracy. The typical pneumonia shows up as a localized white area  on a chest X-ray, pneumonias may be caused by a variety of infectious agents  including bacteria, viruses, and other less common microbes. Tuberculosis  can also cause pneumonia. Not everybody with a pneumonia needs to be hospitalized.  The decision to whether or not to be admitted to the hospital depends on  many factors including how sick the patient appears, what the sputum and  patient’s blood test show, and what kind of antibiotic treatment is appropriate.  Fifty years ago, there were very few antibiotics available to treat pneumonias.  Fortunately, today we have scores of antibiotics to chose from and most  all pneumonias can be treated quite effectively.

Dear Dr. Bauer:    My friend told me about a new breathing pill called Accolate. Please tell us more about this.

Recent advances in research have led to the production of new  medications that seem to be effective in treating the causes of asthma.  Most of the inhalers and oral medications used to treat asthma symptoms  reverse the acute spasm that occurs in the bronchial tree during an attack.  This can result in a quick improvement in symptoms of cough, wheezing and  congestion, On the other hand, asthma is now thought of as a disease that  results from chronic ongoing inflammation of the bronchial passages.  Previously,  inhaled and oral steroids as well as inhaled chromolyn were the main stay  of anti-inflammatory treatment. Many different chemicals produced in the  bloodstream and in the lung itself may trigger the process of inflammation in the lung.  A class of chemical compounds called leukotrienes have been  identified as playing a crucial role in triggering of asthma. In a typical  asthma attack, leukotrienes are released in the lung. This results in prompt  bronchial swelling, mucus production and powerful bronchoconstriction.   A new oral medication zafirlukust (Accolate) can block the release of leukotrienes in the lung. When taken twice a day, this medication seems to be effective in treating signs and symptoms of mild to moderate asthma. Other oral medication  of the same type should also be on the market in the near future. The exact  role of these medications in the treatment of mild to moderate asthma still  needs to be sorted out by practicing physicians and their patients. This  new medication is not an anticipated new drug for emphysema patients.  I  think it is fortunate that new inhalers and new medications are continuously  being introduced to help us manage our patients with breathing problems more effectively.

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The Pulmonary Paper    PO Box 877     Ormond Beach, FL 32175

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