Tidal Volume question

Sludge · Post by **Sludge** » Sun Mar 30, 2014 1:47 am

nmbugs wrote:Let me see if I can explain why my SOB doesn't feel like asthma....
First I don't wheeze and second the SOB starts to happen upon exhale not inhale. Because I cannot exhale all the air in my lungs I cannot inhale. Again there is no wheezing and the pain in my chest is on exhale then not being able to empty my lungs out I cannot take enough air in.

OK, but asthma is a disease of exhalation, and these numbers:

Code: Select all

Spirometry:

                Pre:    Post:
FVC             2.23    2.57
FEV1            1.14    1.27
FEV1/FVC%       51      49
FEF25-75%       0.37    0.36
PEF             3.50    3.79

certainly suggest there is a significant asthmatic component (i.e., there is more than one thing going on).

However, we can call that "unresponsive obstruction".

BTW, is your FVC normal? What is your age and height:

http://www.cdc.gov/niosh/topics/spirome ... lator.html

Can you upload the PFT results (you can upload the document to Dropbox, GoogleDocs, etc.) to look at the Flow-Volume Loops and Volumes (RV) to see if there are any clues there?

nmbugs · Post by **nmbugs** » Mon Mar 31, 2014 12:57 pm

Okay hopefully this works:

Since I cannot get that image to load using the img tags I will just put the link here: https://docs.google.com/file/d/0B-ELU_v ... FpT2NrMjA/

Also the link for the calculator was pretty close to the reference values listed on my report.

Sludge · Post by **Sludge** » Tue Apr 01, 2014 3:57 am

nmbugs wrote:Okay hopefully this works:

You need to create a Public Folder in Dropbox (in instructions I have previously posted elsewhere) in order to see images.

No Flow-Volume Loops?

Regardless, the significant increase in FRC and RV and the FEV1/FVC < predicted with FEV1 < 50% > 34% of predicted demonstrates severe obstruction, but the normal diffusion seems totally out of place (especially since you're on supplemental oxygen and desaturate severely with exercise).

That said, even if they messed up doing the diffusion, it still should have dropped like a rock, which returns to the thought of multiple issues. Precipitous and otherwise unexplained oxygen desaturations certainly suggest right to left cardiac shunts (PFOs, ASDs and the like). This could also create pulmonary capillary distention (affording more opportunity for diffusion) and offer an explanation to the "normal" diffusion.

Ever have echocardiograms?

At any rate, I'm sure NJ will thoroughly explore that.

nmbugs · Post by **nmbugs** » Tue Apr 01, 2014 10:58 am

Maybe this is more what you are looking for: https://docs.google.com/file/d/0B-ELU_v ... hmeUs3aWM/

That PFT was done 3 months prior to my last one and was done at the hospital where the other was done at my doctors office.

Edit: Forgot to answer the question about Echo yes, I will get that posted tomorrow, just got home after the long trip and back to the pulm. I mentioned to him about the right to left cardiac shunts and he said that could be a possibility but the only way to know is to repeat the R heart cath (which NJ is doing anyways) and take blood gases. Is that correct, that's it is diagnosed through blood gases. I have no clue why my cardio didn't do blood gases when he did my cath, does oxygen effect blood gas results? Just curious.

Sludge · Post by **Sludge** » Wed Apr 02, 2014 2:15 am

nmbugs wrote:I mentioned to him about the right to left cardiac shunts and he said that could be a possibility.

Possibility?

Here, we evaluate the prevalence of right-to-left shunting (RLS) through transcranial Doppler ultrasound (TCD) in a large patient group with obstructive sleep apnea (OSA).

METHODS:
One hundred consecutive patients (mean age 59.5 y) with OSA underwent TCD with intravenous injection of agitated saline. The grading of right-to-left-shunts was in accordance with the Spencer PFO Grading Scale.

RESULTS:
RLS was detected in 72 of 100 patients (72%). Thirty-four out of these 72 patients (47%) had a shunt grade I or II; 15 (21%) had a shunt Grade III or IV; and 23 (32%) had a large shunt (Grade V or V+). In 47 of 72 patients (65%), a right-to-left shunt was detectable at rest without Valsalva maneuver.

http://www.ncbi.nlm.nih.gov/pubmed/22893767

Sludge · Post by **Sludge** » Wed Apr 02, 2014 2:32 am

nmbugs wrote:Maybe this is more what you are looking for:

No, I need the thing that looks like this:

nmbugs · Post by **nmbugs** » Wed Apr 02, 2014 11:54 am

So sorry, I thought those graphs just showed what the number meant so I chopped them out. Here are the other graphs too that was with the Dec study and the one from the Sept study too: https://docs.google.com/file/d/0B-ELU_v ... ZSaFBUWW8/

So if that much of the OSA population has RLS then would I be having so many additional problems, like needing oxygen, increased pulm pressures, tachycardia and all the other crap going on? Is that because of the various grades? It just seems like if this is common with OSA these docs here would have suggested this back from the very beginning. Granted I know, and I hate to say this, the best of the best doctors do not pick SE NM or El Paso (I should have gone to the University there, I know but didn't!) as places where they say, hey that's a wonderful area where I want to spend the rest of my life in practice .

Now my doctor yesterday said something about a gas being really high, my memory sucks but I thought he said nitrous oxide but that doesn't sound right does it. And how that points to how severe my asthma is and how if I don't get it under control there will come a time when my rescue inhalers won't work (seems like from the test that's there already). So now I am trying another inhaler pulmicort flexhaler and so far my lungs don't feel like they are on fire :knock on wood:. Anyways the reason I ask is because if I heard him wrong and it's carbon dioxide that is high, could the oxygen be doing more harm than good? I can't imagine being off of it especially when walking but maybe they rushed me on it too fast perhaps? Now, before I was put on oxygen my regular blood work was showing my CO high in my blood, not sure what that means/if anything.

I really appreciate all your help. You have helped me more here than the doctors have that charge me out the wazoo. My husband doesn't even call them doctors anymore just says are you going to the (makes duck noise) today? Frustrating to live in an area where the local hospital had to file bankruptcy because of this: http://www.alamogordonews.com/alamogord ... source=rss (a must read to understand the level of care here) and sadly that is the hospital that did most of my tests

nmbugs · Post by **nmbugs** » Wed Apr 02, 2014 12:21 pm

Here is the echo which was done over a year ago: https://docs.google.com/file/d/0B-ELU_v ... hzcjVmaUU/ and I included the holter too which that was just done 12-13. Granted that echo was done at the hospital linked in that article and I have had other tests done where I got the CD and the doctor reading it came to a different conclusion or told me that the tests were screwed up and needed repeating, so who the heck knows! I do have the CDs from all my studies and xrays.

Oh and the docs keep talking about a LBBB that keeps showing up in my EKGs. When I had my stress test they wouldn't allow me to do the treadmill because of the LBBB and made me go through the chemical. Back at that time the LBBB was intermittent but now apparently it's constant.

Thanks again!

Sludge · Post by **Sludge** » Thu Apr 03, 2014 3:19 am

nmbugs wrote:So sorry, I thought those graphs just showed what the number meant so I chopped them out. Here are the other graphs too that was with the Dec study and the one from the Sept study...

The numbers just select key points, but the graphs show all points. The shape can tell you a lot about disease conditions:

as well as if the test was done correctly.

Indeed, the post-bronchodilator loop on 12/13 looks a little schmutzy, so using 9/13:

2 things that needed to be looked at were:

That effort was performed technically well; and
There was no evidence of intrathoracic/extrathoracic obstruction (like tumors)(which would not be a good thing)(although i imagine you would have guessed that).

nmbugs wrote:Now my doctor yesterday said something about a gas being really high, my memory sucks but I thought he said nitrous oxide...

Yeah, that would have been funny...

Can you post those blood gas results? "Really high" may mean you need to change your xPAP therapy completely.

nmbugs wrote:Anyways the reason I ask is because if I heard him wrong and it's carbon dioxide that is high, could the oxygen be doing more harm than good?

Theoretically, too much oxygen can create respiratory depression, but that tends to happen only when somebody's totally decompensating. You treat both factors separately, and never let a low oxygen remain untreated.

Did you ever get measurements of Respiratory Muscle Strength (Negative Inspiratory Force/Positive Expiratory Force)(NIF/PEF)? Ever do an MVV (Mandatory Minute Ventilation) maneuver?

Sludge · Post by **Sludge** » Thu Apr 03, 2014 4:30 am

Sludge wrote:
That effort was performed technically well..

Proper coaching, having the same (or equivalent) technician, and and insuring the laboratories all use the same predicted values are critical to PFT interpretation.

But if the tests were performed nearly identically, and I have the dates correct (the inherent hazard in getting "snippets" of information)

the Inspiratory Capacity ("OK, take a BIG breath in!") has dropped nearly a liter in 3 months (1.41L vs. 2.37L).

nmbugs · Post by **nmbugs** » Thu Apr 03, 2014 9:32 am

Sludge wrote:
Can you post those blood gas results? "Really high" may mean you need to change your xPAP therapy completely.

Did you ever get measurements of Respiratory Muscle Strength (Negative Inspiratory Force/Positive Expiratory Force)(NIF/PEF)? Ever do an MVV (Mandatory Minute Ventilation) maneuver?

That's what was strange I have never had a blood gas test! I thought he was gleaming this "insight" from my PFT or something. Maybe he was just trying to scare me into taking these inhaled steroids (which I have been a pita about because a. the cost b. they burn like crazy).

Neither of those tests sound familiar.

Yes the dates are correct on the pfts, to be exact the first was done on 9-20-13 and the second 12-06-13. I will say the first tech worked the heck out of me, I was exhausted after the test. The second one was way different and much easier so maybe the 2nd tech didn't push me as hard I don't know. The first tech made me repeat the tests over and over, that test took a good 40 min. The second test was maybe 20 min long.

Sludge · Post by **Sludge** » Thu Apr 03, 2014 5:51 pm

nmbugs wrote:That's what was strange I have never had a blood gas test! I thought he was gleaming this "insight" from my PFT or something.

UFB.

Do you have a recent Total CO2 or HCO3- from labwork? We can calculate pCO2 from that.

nmbugs · Post by **nmbugs** » Thu Apr 03, 2014 11:42 pm

Sludge wrote:
nmbugs wrote:That's what was strange I have never had a blood gas test! I thought he was gleaming this "insight" from my PFT or something.
UFB.

Do you have a recent Total CO2 or HCO3- from labwork? We can calculate pCO2 from that.

I thought I had my latest results but the ones I have are almost a year old. I have to run errands tomorrow so I will stop and get my most recent blood work, the "post op" for the cath. I looked through the crap my pulm ordered and I see nothing on there for CO2 or HC03 but he did test me for HIV! He also ordered c-reactive protein which was high at 3.46, when I asked what that meant he said that test really didn't tell them anything. Well why the heck order it?? Grrrr. Anyways on all the older blood work I don't see any test called HC03 or blood bicarbonate so I doubt that has ever been done, I am guessing it should have been done. I feel like I am living in medical hell here.

Sludge · Post by **Sludge** » Fri Apr 04, 2014 4:09 am

nmbugs wrote:I do have the CDs from all my studies and xrays.

Want to put up your most recent chest x-ray?

Sludge · Post by **Sludge** » Fri Apr 04, 2014 4:14 am

nmbugs wrote:The first tech made me repeat the tests over and over, that test took a good 40 min. The second test was maybe 20 min long.

PFTs are very effort-dependent, stressing the need for good technicians.

Besides, at that level of deterioration, you would be posting from The Great Beyond, and wouldn't be worried about further testing (OK, I suppose there is The Last Test. I sure hope They grade on a curve).

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