dr. Peter salgo welcome to Second Opinion where each week our Healthcare Team solves a real medical mystery. When we close this file in a half an hour from now, youll not only know the outcome of this weeks case but youll be better able to take charge of your own healthcare and doctors will be able to listen to patients more effectively. Im your host, dr. Peter salgo. And youve already met our special guests who are joining our primary care physician, dr. Lisa harris. Lisa, its good to see you back. dr. Lisa harris good to see you, peter. peter now nobody on this team knows this case and im going to get right to work. Let me tell you a little bit about elaine. Elaine is fiftysix years old and shes been a smoker for thirty years. Three years ago, elaine went to her primary care physician, lisa, and she had the following symptoms. She said, im short of breath with even small amounts of activity. Ive got trouble climbing stairs. I have to stop and catch my breath. Im coughing all day long. I wake up at night coughing. Now im coughing up sputum she says, especially in the morning and its increasing and i cant seem to clear it. Shes 56 and 128 pounds. Her Blood Pressure is 138 74. Her pulse is 98. Her respiratory rate is 24. And when her doctor listens to her chest the description here is course rales and scattered wheezing. What are rales . lisa well rales are defused sounds that you hear within the lung that tell you that theres something happening. Its not very specific but it tells you that theres something happening within the lung tissue itself. peter okay. lisa im just a little curious as to, was this a sudden onset that she decided to come in now. If shes been smoking that long, she clearly must have had some symptoms prior to this. Im just wondering. peter just trying to get a flavor from the chart here, it sounds as if shes been having some trouble and it finally got the point where she said this is the day im going to see my doctor. lisa right. Absolutely. peter does that make a difference to you . lisa well sure. I mean for patients that come into my office. Anybody who presents with a respiratory symptom in my office will get a spirometry as well as an examination of me listening to their lungs and checking to see their saturation and what the oxygen looks like. peter okay. You mentioned spirometry. lisa yes. peter got a lot of lung doctors here but youre the one doing the spirometry, so you tell me what it is. lisa well the spirometry is actually a test that allows us to look at what is the flow of oxygen through the airways and how quickly someone can expire the volume of oxygen out of their lungs at a certain amount of time. And it tells us a little bit about the function of the lung. If theres restriction or if theres bronchospasm or a little bit more about whats happening within the lung. peter bronchospasm is tightness in the chest. lisa tightness. So it tells you a little bit about the function of the lung. peter and youre worried about the wheezing . lisa absolutely worried about the wheezing. peter anything else anybody else wants to do . dr. Make peter, id be very concerned about. Lisa mentioned this. About whether this was, the onset was acute or was chronic. Those lung sounds indicate to me she might also have pneumonia now and so i think its important to figure out whats happening right now. peter okay. dr. Make in terms of the acuity of the presentation. peter what else do you want to do . dr. Levy not to jumto any conclusions but when you hear a story of tobacco use over thirty years and shortness of breath on exertion you immediately start thinking of obstructive lung disease. But rales on physical exam, as barry was pointing out, are peculiar and you start wondering about does she have an acute pneumonia thats going on right now. lisa or does she have congestive heart failure. dr. Levy right. lisa theres a lot of other things that youd want to. peter but they did do a spirometry. lisa okay. peter and the results from the spirometry, ive got the actual numbers. Fev1 over fvc, whats that . dr. Make thats how fast the air comes out. Its a general measure of how much air comes out in the first second when you blow out hard and fast compared to the total amount of air. peter alright, fortyeight percent predicted and hers was fifty percent. dr. Levy so the ratio is fifty percent . peter correct. dr. Levy between the one second value and the total amount. peter aha. dr. Levy so thats markedly reduced and the normal patient will generally be able to get at least seventy percent of their total lung volume out within that first second. But for her to be cutting off at fifty percent, thats really a sign of obstructed. dr. Make so if you think about it this way, the air passages are like tubes or pipes. The smaller they are, the less fast the air comes out. The bigger they are, the faster it comes out. And this indicates the airs coming out pretty slow, so theres some problem with the air passages being smaller than they should be. peter well elaines doctor makes a diagnosis on the basis of this alone. Ill tell you what the doctor said. Said, elaine, youve got asthma and im going to treat you for it. Is there enough information here to say youve got asthma . dr. Make no, not at all. peter anybody happy with this diagnosis . dr. Make no, no. This is actually a very common problem. And in fact its more common in women than men. peter was it the wrong diagnosis or is there simply not enough information to make a diagnosis . What do you think . lisa this is not enough information here. I mean the other thing that i would do, you know, if she had the spirometry and showed restriction of flow i would give her a nebulizer treatment, listen to her lungs again and repeat the spirometry to see if there was any reversibility or response. peter now grace anne, i noticed during this conversation you were beginning to smirk. grace anne that should be enough for a general practitioner or an internist to send the individual to a pulmonologist for a full range of pulmonary function tests. peter did Something Like this happen to you . grace anne well yes, except that my Family Doctor did not have spirometry in his office and didnt recommend that i go somewhere else. So i, i left the office. Was not asked to come back and i still couldnt walk half a block without stopping to catch my breath. dr. Levy theres a very important point here that just. Spirometry, we talked about the mechanics of doing it. Its no different than a Blood Pressure cuff measures Blood Pressure. You cant assess Blood Pressure by feeling someones pulse or looking at someone. You cant assess someones lung function without measuring it with a spirometer. And thats why we advocate in a symptomatic patient, thats the real, only way to figure out how good their lung function is. peter but youll forgive me. Her doctor did spirometry. And then said you got asthma. And ill go further. Her doctor sent her home with a diagnosis of asthma. And i can tell you, sent her home with a combination inhaler, albuterol, a steroid, and oral pills, prednisone. dr. Levy i mean i got to ask barry, as a fellow pulmonologist, with rales on exam, with the wheezes, im not so sure id feel comfortable kind of jumping ahead without either more information, a chest x ray, a temperature. lisa as a primary care physician, i wouldnt feel comfortable doing that, so certainly i would measure her temperature. Absolutely shed get a chest x ray to make sure there wasnt acute infectious process going on. And then if all of that was negative, i might consider starting her on therapy for the symptomatic wheezing and. dr. Make and i would get an ekg to assure that she didnt have a heart attack recently. lisa well shes my patient, so shes already had this. peter she has the perfect practitioner. Now shes home, albuterol, steroids, inhaled steroids, oral steroids. And i tot to tell you the indicates that she says shes feeling better. Shes doing great. lisa her physician gave her some very acute, quick acting medications that would mask some other chronic symptoms without really investigating more clearly what the underlining problem is. She already gave you a very significant part of the history. Shes been smoking for years. But id want to know some other occupation history. Was she exposed to fumes . Where does she work . People dont just jump up with asthma out of the blue. That is a chronic, ongoing problem. peter youre sitting there like the conscious of the panel just sort of drinking this in. What are you thinking . dr. Fisher whats striking to me about the smoking history is that shes been smoking for thirty years but she didnt start until she was twentysix, which is sort of late. And so im not sure what that means. But from the prospective of the smoking id certainly be curious about that. peter her doctor makes no note in the chart about, you know, stopping smoking. At least not a lot in here, so she still smokes. Sometimes her breathlessness and coughing are worse, sometimes it feels worse for days on end. But she keeps renewing her prescriptions, including the steroids and going back to the doctor. And as time goes by, her symptoms begin to get a little worse and a little worse. Shes beginning to gain weight now. And shes starting to get a little depressed. Now whats happening. dr. Make so i think one of the things thats not in the chart you havent told us about, is follow up. You know were very good at treating patients acutely and then we say, okay this will make you better but dont think about the chronicity of the process that we all talked about. And i think the key here is having her come back, first to make sure shes better. And second, to see whats going on more long term. dr. Levy and then youd love to get a repeat spirogram on her. lisa absolutely. dr. Levy to see how is her lung function going to settle out after this acute episode has been solved. peter by spirogram, you mean do the spirometry again . dr. Levy a second spirometry. peter so one is not sufficient . dr. Levy its no different than if you measured high Blood Pressure today and treated a patient, you have to have them come back and make sure its normalized. peter grace anne, i want to go onto you. You initially got a diagnosis which was not satisfactory and eventually you were lead to the correct diagnosis. grace anne i got no diagnosis. I was. I was told after what was considered to be a full physical exam. I got blood work. I got chest xrays, ekg, proctology, and was told that if i lost ten pounds id feel like a new woman. peter i can tell you a little bit more about elaine. Three years have lapsed since the chart indicates she came to see her physician and her kids have brought her to the emergency room because she is lethargic, she is confused, shes having trouble breathing, and they think her skin looks a bit blue. A little cyanotic. Is this all from asthma . lisa yes shes a little cyanotic and im concerned that now she has end stage emphysema or end stage lung disease. peter what do you want to do, lisa . lisa well shes in the emergency room. We absolutely need to get a temperature, vital signs. We need to know what her respiratory rate, what her oxygen saturation is. She needs a chest xray and they are not going to do a spirometry in the ed. We might get a peak flow that will. peter i can give you some of the information that youre asking for. Shes using accessory muscles to breath. That is shes breathing with her shoulders and her abdomen. Her chest looks really hyper inflated, kind of barrel looking. Her heart rate is fast. She does not have pink frothy sput. Im going to make a note of that. They also say therefore shes not in pulmonary edema. They say she doesnt have an s3 and they conclude thats a heart sound, she doesnt have congestive heart failure. Her oxygen saturation on room air is about seventyfive percent. She has rales again but this time theyre localized in her right lower lobe. Diminished breath sounds all over the place. You asked for a cardiogram and it showed right heart strain. Im going to give you everything here. Chest xray right lower lobe pneumonia and yes she has a fever, one hundred and one. Her white counts nineteen six. And who wants a blood gas . You can all raise your hands. lisa absolutely. peter im sure you all want a blood gas. This is a measure of the oxygen in her blood on the arterial side, not on the veins. Her ph is 728, shes a little acidotic. Her oxygen on room air is 60, its low. Her pco2, the Carbon Dioxide in her blood is 55 and her bicarbonate is 34. There. Theres a battery of stuff. Who wants to chew on this one . dr. Make she has pneumonia. And she has pneumonia, which has caused significantly more respiratory compromise in her baseline condition, because she probably has underlying copd. And now those blood gases say that she has respiratory failure, which is a medical term to say shes severely ill. peter elaines been told she has asthma. Suddenly im hearing is chronic obstructive pulmonary disease. You want to give me a quick definition and well move forward, because i can tell you more about elaine. dr. Make so copd stands for chronic obstructive pulmonary disease. Largely its related to disorders that people think about and may know best about called emphysema but its not only emphysema. A better term is copd. And a lot of it is caused by smoking. In fact 85 of people who have copd is related to cigarette smoke. Copd is a syndrome and its not only related to the lungs. Often people have other disorders at the same time that we actually think now are part of copd. Depression, for example, which is very common in patients with copd. Osteoporosis. Heart disease. Now a lot of these diseases are caused by smoking but some of them may be caused by the inflammation of the lungs spilling over to the rest of the body. grace anne when i was diagnosed with copd, much to my surprise i had ischemic heart disease. This is, you know, these are bed fellows. Lung cancer. All. These are the natural ones that any physician should think of. dr. Levy the lungs themselves in copd are not the whole picture. When you look at causes of death of patients with copd, only about a third of it is associated with lung disease. A third of it is tied in with heart disease, and then you move into cancer, and other comorbidities. So. grace anne yeah. dr. Levy it is a spectrum. Its a systemic disease as barry would. grace anne and thats why its so hard to get an adequate number. I mean there are twelve million americans who have this disease, have been diagnosed and are getting some form of treatment, maybe not optimal. And twelve million who are not yet diagnosed. We must reach these people. They are lost americans. And theyre suffering. peter youve heard enough about elaine. Have you heard enough to give her a diagnosis right now, there in the emergency room with all the labs and Everything Else . What are you going to say shes got . dr. Levy i think people would most likely agree that she probably has copd at this phase of it, because its unlikely that her lung functions is entirely normal. To get to those pco2 levels and to be in the state shes in. peter your doctor, if i remember what you told me, told you lose weight. grace anne i believe that he said that because he knew the disease that i had but he believed it to be irreversible. The definition now, according to the best medical practice, is very different from what it was then. It is not fully reversible, but it is highly treatable. And thats the message that has to get out to patients so they dont lose heart and to doctors who see 90 of, Family Doctors, of all people who have copd. Theres hope. There is hope and if you follow directions and take your medicines properly and exercise. You must begin to get your life back. peter the fastest rising group . Men, women . Its women right . grace anne women. They have a susceptibility. We have a susceptibility. And no one knows why. peter fourth leading cause of death in the United States. grace anne yes. peter and growing. dr. Levy well in fact as cardiovascular and cancer moralities have improved, copd has doubled in the past i forget if its three, four, five years. But the death rate associated with copd has been going the wrong direction. peter how does cigarette smoking cause copd . dr. Fisher well there have been a whole host of studies that have shown a relationship between smoking and copd, cardiovascular disease, lung cancer, etc. The list grows almost every month. And those studies are controlled studies, epidemiological studies that have various ways of piecing together the puzzle. So i dont think too many people have too much question at this point that copd is largely caused by smoking. peter we have to pause just for a moment here and sum up what weve covered, which is a lot. But i think we can boil it down to this. Copd is chronic obstruction of airflow through the airways. It is common but its often incompletely diagnosed or even misdiagnosed. And by misdiagnosed people are going to lose time. Lose time when they might otherwise have had therapy that might have helped them. Is that fair . lisa thats absolutely fair. dr. Levy thats fair. peter alright, heres elaine. She has copd. We agree. dr. Levy yes. peter okay. What are you going to do now . dr. Make lets take the most severe consequence of any disease and thats death. So you can talk about more or less of these treatments but we have treatments that can prevent death in patients with copd. We have treatments that can prevent exacerbations or periods of worsening like lead her to the hospital. And we have medications that help patients every day be less short of breath. Be able to do more and feel better. And so thats the gamete of what our objectives and our goals are for these patients. We can improve them a lot. peter grace anne, what did you do when you were told you had copd. What was the kind of regime that you followed . grace anne well fortunately my doctors, and there were a team of doctors, recommended a very aggressive treatment plan. And i implemented it to the best of my ability, so i went to pulmonary rehab. I took all my medicines on schedule. I tried to change my life. I had stopped smoking fifteen years before but thats another quirk of this disease. Youve done what the Surgeon General asked. Youve done what your family and friends want. Youve given up the cigarettes and it only strikes in your middle life, in 40s, 50s, 60s. So there youve been reformed and youre still hated for it. peter how did your lung capacity change on it . grace anne i exercise six days a week and i do everything by the book. I have, over these last eight years, ive gone from 26 of predicted to between 60 and 65 of predicted and ive maintained it despite surgery for lung cancer in 2005. An hour a day, six days a week and im lifting weights and im doing what i can to preserve what is left of me. peter how on earth do you tell somebody who cant breathe to get on a treadmill . How does that work . grace anne sure you do. You can get on with oxygen and you can sta