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Tuesday, July 29, 2014
Complex breathing issue
1) Why would the PIF of the PFT drop 14 percent after Albuteral? 2) Are the results listed below likely caused by a combination of more simple things: GERD + Asthma + Allergies? Or is it likely more serious? (Note: currintly in Iraq - US Army Officer)
38, male, 68.5 inches, 177 lbs PFT: FEV1 = 53% predicted (56 after 2 x Albuteral); FEV1/FVC also 53% - 56% (PFT was taken about 9 days after end of attempted treatment mentioned below)
Chest X-Ray = Major findings: Slight hyperinflation; 4 mm non-calcified nodular density in lower left lung
Difficulty breathing,. Activity does not seem to "cause" the problem; but becomes audible and noticeable by others upon moderate excursion.
Non-smoker (occasional cigar), active, active duty Army Captain
Started noticing the “chronic” problem about two years ago during first tour to Iraq. It progressively got worse while back in TX and now here in Iraq a second time. Also noticalbe at night while lying still or sleeping (by wife)—there is s sound of air being “forced” out of my lungs. It is not loud, but noticeable.
Can no longer sustain a 10 min/mile pace for even two min…despite repeated attempts at improving fitness.
Family History: Maternal: Grandfather died of Emphysema (also had lung cancer); Uncle has emphysema; mother chronic bronchitis/asthma, sister undiagnosed breathing problem; Paternal: Grandfather died of lung cancer, father died of lung cancer
Doctor attempted to treat breathing problem with a step wise approach Singular 6 days + Xopenex; then added to this 60 mg Prednisone + Advair 250 twice a day for five more days. Monitored by PEF increased baseline from about 420 L/min to 470. (Predicted norm for this device based on Age/Height is 630 L/min.
PFT was taken about 9 days after end of prednisone and other medications.
1. The peak inspiratory flow (PIF) is a highly variable measure and not a primary number that most clinicians view as reliable on a specific pulmonary function test. Therefore the fact it decreased after albuterol is difficult to interpret. The FEV1 is the most reproducible and reliable measure and as it did not decrease after albuterol it makes it more likely the PIF drop was due to the variability inherent in that measure. There are some people who react poorly to the propellents in the meter dosed inhalers (such as albuterol) and can have a drop in lung function after using albuterol but again these people would have a drop in the FEV1.
2. The symptoms described in combination with the PFT data provided suggest there may be a serious pulmonary disorder accounting for the symptoms. The low FEV1 is very concerning given its measurement after a course of prednisone and your age. There are several possibilities that could account for these findings including asthma, hypersensitivity pneumonitis, and others. I would recommend a complete evaluation by a pulmonologist which will likely include a high resolution chest CT scan and more pulmonary function testing. Treatment options really depend upon the diagnosis.
John G Mastronarde, MD
Clinical Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University