What causes hemoptysis? There are many causes for hemoptysis, the most common being bronchitis, lung cancer, pneumonia, lung abscess, tuberculosis, bronchiectasis, and pulmonary thromboembolism (blood clot).  Conditions that cause massive hemoptysis (see discussion below) are diseases that erode into the bronchial circulation, which is under higher pressure than the pulmonary circulation. Common causes of massive hemoptysis are chronic infections or conditions complicated by infection (such as lung abscess, tuberculosis, bronchiectasis, or cystic fibrosis), as well as cancer. Many times the cause remains undetermined despite extensive work-up.

Other causes  of hemoptysis include: trauma, vasculitis (inflammatory disease of the blood vessels), aspiration of foreign body (especially children), Systemic Lupus Erythematosis, Goodpasture’s Disease, Sarcoidosis, over-anticoagulation, congestive heart failure, mitral stenosis, aspergilloma (fungus ball), and severe coughing.

What happens if I have hemoptysis? In general, hemoptysis requires a systematic and thorough evaluation to discover its cause.  (Hemoptysis in a patient with chronic bronchitis during an acute exacerbation is a possible exception because it is usually mild and self-limited).  However, if the hemoptysis is massive, recurrent, or won’t go away, then further evaluation is indicated.

• Is it really hemoptysis? The history in most cases will suggest that blood is actually being coughed up from the lungs, but it may be difficult at times to distinguish hemoptysis from bleeding in the upper respiratory tract (such as the nasopharynx or sinuses), or blood from the gastrointestinal tract that was regurgitated or vomited.

• Is the bleeding massive (i.e. life-threatening)? This is important not only for necessitating a different approach to management, but will often alter the differential diagnosis, or list of possible causes.  Massive or life-threatening hemoptysis is more than 200 ml (or a little under a half pint) total in one day.  Any amount of bleeding at a high rate, even over a short period of time, should be managed as being potentially life-threatening because  blood will flood the airways and cause asphyxiation.

• What does the medical evaluation consist of? Generally, the initial evaluation will consist of a careful history and thorough physical examination. The doctor will ask about any acute or chronic pulmonary symptoms, including cough, shortness of breath, wheezing, or if you have had any previous lung disease. The history or physical may uncover findings suggesting a certain cause, such as underlying heart disease, vasculitis, or pulmonary thromboembolism. Systemic symptoms, such as fever, night sweats, weight loss, and malaise may be present in chronic infection, cancer, or inflammatory diseases.

• What tests might be done? Generally, the first test will be a two-view (front and side) chest x-ray. (The chest x-ray can be unrevealing despite the presence of an important disease as the cause for the hemoptysis.) The doctor will often obtain blood tests, including  complete blood count (CBC) and coagulation studies (PT/PTT). Depending on the patient age and clinical circumstances, sputum testing for infection and/or cancer may be obtained. Chest CT scanning (contrast, high-resolution, or spiral) is a non-invasive and sensitive x-ray technique that can help the doctor determine the cause of hemoptysis. Ventilation-Perfusion (V/Q) scan is useful in evaluating for thromboembolic disease. The decision whether to perform fiberoptic bronchoscopy should be made in consultation with a lung specialist (pulmonologist). An echocardiogram can help examine the functioning of the heart and heart valves. On rare occasions, more invasive testing is required, including surgery (such as thoracoscopy, mediastinoscopy, or thoracotomy).

What should you do if you have hemoptysis? If you have unexplained hemoptysis, especially if it is more than a few teaspoons total in a day, call 9-1-1 and go to the nearest Emergency Department. If you have other symptoms, including chest pain, severe shortness of breath, dizziness, or fainting, you should go to the ED. You should not ignore this symptom, as it can be life-threatening. If in doubt, call your doctor right away.

How is hemoptysis treated? The main treatment for hemoptysis targets the underlying disease process. For example, an infection will be treated with the appropriate antibiotic or antimicrobial agent. Otherwise, the treatment is nonspecific. If massive hemoptysis is present, the treatment might require surgery.

Where can I learn more?
National Institutes of Health
National Center for Biotechnology Information (pdf)
Rakel RE. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders; 2005:402-413.

What causes wheezing? The potential causes for wheezing are many. The most common cause is asthma, but “not all asthma patients wheeze and not everyone who wheezes has asthma.” Any condition that causes a narrowing of the airway caliber, including bronchospasm, edema, tumor, secretion, foreign body, external compression, or dynamic compression, can produce wheezing. Even healthy people can produce wheezing if exhaling hard enough.

More common causes for wheezing include:

1. Asthma
2. Emphysema/COPD
3. Pneumonia/pneumonitis
4. Tracheobronchitis
5. Bronchiolitis
6. Foreign body in the lungs (aspiration)
7. Smoking
8. Heart failure/pulmonary edema (“cardiac asthma”)
9. Severe allergic reaction (anaphylaxis)
10. Medication-induced bronchospasm
11. Vocal Cord Dysfunction
12. GERD
13. Certain viral infections

Less common causes of wheezing include:

1. Tracheo-bronchial tumor
2. Aortic aneurysm
3. Carcinoid
4. Tracheal stenosis
5. Post-radiation stenosis
6. Tracheomalacia
7. Amyloid deposition
8. Sarcoidosis
9. Post-lobectomy

What are the characteristics of wheezing? Wheezing is usually most noticeable during exhalation. This usually results from significant reduction of expiratory flow rates (how well you can quickly exhale). On the other hand, inspiratory wheezing often signifies permanent airway stiffness (such as from stenosis, scar tissue, or tumor) or foreign bodies. The location of wheezing may also aid in the diagnosis. For example, wheezing heard all over the chest is more likely due to underlying diffuse lung condition, whereas localized wheezing suggests a more localized process, such as tumor or foreign body obstructing an airway. Wheezing is usually louder than the underlying breath sounds and can sometimes be heard without a stethoscope.

When do I call the doctor? You should call your doctor right away if you have:

• Wheezing for the first time
• Wheezing accompanied by shortness of breath, chest pain, bluish discoloration of the lips or nails, altered mental status or confusion
• Wheezing caused by allergic reaction, including insect bite or sting, food, or medication
• Wheezing that keeps occurring without explanation
• Wheezing associated with swelling of the face, tongue or lips

If wheezing is severe or occurs with severe shortness of breath, you should go directly to the nearest emergency room.

What will happen at the doctor’s office? Your doctor should take a detailed history and then perform a physical examination, particularly of the head & neck, lungs, and heart.  Additional testing might include chest x-ray, breathing tests, and blood work (including arterial blood gases). Your doctor may prescribe drugs to relieve narrowing of the airways. You might require hospitalization.

Where can I learn more?

National Institutes of Health
European Respiratory Journal reprint on wheezing
WebMD

How does the predictive value the blood test compare to TST? Although there have been studies confirming the increased future risk of active TB in individuals with positive TST, the same was not true for those with a positive Interferon Gamma Release Assay (IGRA) result. In 2008, a study from Germany demonstrated that a positive IGRA result is predictive of future active TB risk (Diel R, Loddenkemper R, Meywald-Walter K, Niemann S, Nienhaus A. Predictive value of a whole-blood IFN- assay for the development of active tuberculosis disease after recent infection with Mycobacterium tuberculosis. Am J Respir Crit Care Med 2008;177:1164–1170). Moreover, IGRA was at least as sensitive and was more specific compared to traditional TST. Negative IGRA results do not require confirmation, but results can be confirmed with either a repeat IGRA or TST if the accuracy of the initial test is in question.With any of the testing methods, persons who have a negative test result can still have LTBI.  Individuals with a negative IGRA result but who are likely to have LTBI and who are at greater risk for severe illness or poor outcomes if TB disease occurs might need treatment or closer monitoring for disease.

What are the currently approved IGRA tests? Currently approved (by the FDA) IGRA tests in the US are QuantiFERON TB Gold, QuantiFERON TB Gold In-Tube, and T-Spot.TB. The current CDC guidelines allow for the use of IGRA in all circumstances in place of PPD skin testing.

What are the advantages of IGRA testing?

• Single patient visit (no need to return in 48-72 hours)
• No anamnestic (“boosting“) response
• More specific (better able to separate those who might have had a false-positive PPD from prior BCG vaccination or many non-tuberculous mycobacterial infections)
• Results available in 24 hours
• No reader bias or error

What are the disadvantages of IGRA testing?

• More costly
• May be less available in certain locales
• False positive can occur in individuals with certain non-tuberculous mycobacterial infections
• Collection/Transporting/Laboratory errors
• Performance in immunocompromised individuals and children not completely determined
• Blood must be tested within 8-12 hours

Additional Information: Due to insufficient available information, IGRA is not recommended for screening of children under 17 years, pregnant women, or for those with diseases that increase the risk for progression of LTBI to active TB (e.g., HIV/AIDS). There is no reason to follow a positive IGRA with PPD testing. It is important to note that active TB cases can have a negative IGRA and a positive IGRA cannot differentiate between LTBI and active disease.

Where can I learn more?

Centers for Disease Control (CDC)
National Center for HIV, STD, and TB Prevention

Dr. Steven Dubinett, Professor of Medicine and Pathology and Director of the Lung Cancer Research Program at the David Geffen School of Medicine, University of California, presented research on the use of a blood test to detect lung cancer. Using a panel of 40 biomarkers, protein substances measurable in the blood and thought related to lung cancer development or progression, the testing was accurate in detecting the presence of lung cancer (scientifically termed sensitivity) 88% of the time. The testing had a 79% specificity, or ability to correctly identify those without lung cancer. The testing was also sensitive enough to be able to detect lung cancer at early stages.

Reducing the requirement for invasive testing, such as lung biopsy, is very useful, especially if the blood testing permits diagnosis at an earlier stage, when biopsying is more difficult and treatment is potentially more beneficial.

Further testing and clinical trials will be necessary, but the current research results are promising. If this methodology holds up, look for clinical availability in 3-5 years.

What are the types of pneumonia? Doctors classify pneumonia by the (1) cause, (2) location in the lung, or (3) clinical setting.

• Causes: Pneumonia can be caused by bacteria, viruses, fungi, parasites, chemicals, and other agents. 
• Location: Lobar (confined to a specific location, or lobe) versus interstitial (more widely spread throughout the lungs).
• Clinical Setting: Includes Community-acquired Pneumonia (CAP), Hospital-acquired Pneumonia (also called nosocomial pneumonia), Ventilator-associated Pneumonia (VAP), Aspiration Pneumonia (from gastric content entering the lungs), Opportunistic Pneumonia (in people with defective immune systems), Atypical Pneumonia (based on symptoms and infectious cause), and Occupational/Regional (some jobs or places may predispose you to a certain type of pneumonia).

What are the symptoms of pneumonia? For some pneumonias, such as Pneumococcal Pneumonia (from Streptococcus pneumoniae, the most common cause of CAP), the symptoms develop very rapidly- hours rather than days. Common symptoms of pneumonia include:

1. Fever (often after a shaking chill)
2. Chest pain (on the side of the pneumonia), particularly when coughing or breathing deeply
3. Shortness of breath
4. Cough (often with darkened mucus)
5. Nausea, vomiting, and muscle aches

Elderly patients with pneumonia may have fewer symptoms or less rapid onset, and experience confusion or lethargy. Atypical Pneumonia characteristically has more slowly progressive symptoms (often with flu-like symptoms first), dry hacking cough, and less severe chest pain.

How is pneumonia diagnosed? Your doctor will take a thorough history from you, and perform a physical examination. Listening to the lungs with a stethoscope, palpating your chest, and percussing your lungs (tapping with fingers) help your doctor determine if you have pneumonia. The chest x-ray (or maybe chest CT) will give your doctor a visual image of the location and type of pneumonia. A sputum test might be ordered to help identify the cause. Blood tests, such as CBC (to look for abnormal White Blood Cell count) or blood cultures (to look for infection spread to the bloodstream) might be taken. Sometimes, your doctor might need to do invasive testing, such as bronchoscopy, thoracentesis, or lung biopsy.

How is pneumonia treated? The treatment approach in patients with pneumonia involves several decisions by your doctor:

1. Do you need to be in the hospital, or can you be treated at home?
2. What type of pneumonia is it or is the most likely?
3. Do you have any underlying health issues?
4. What is the best choice of antibiotic (or antimicrobial), if any?

What are the complications of pneumonia? Although the vast majority of pneumonias respond well to treatment, some cases develop complications. These include:

1. Lung abscess (a thick-walled, pus-filled cavity in the lung)
2. Atelectasis (deflated lung)
3. Respiratory failure (inability to keep up the demands of breathing)
4. Bacteremia (bacteria spread to the blood)
5. Pleural effusion (fluid in the space between the lungs and chest wall)
6. Empyema (pus in the pleural space)
7. Pneumothorax (collapsed lung)
8. Dehydration
9. Hypoxia (low oxygen)
10. Kidney complications and electrolyte imbalances
11. Heart problems, including arrhythmia (abnormal heart rhythm) and heart attack

Is there prevention? Yes, there are things you can do to help decrease your chance of getting pneumonia.

1. Good hygiene. Wash your hands and don’t touch infected surfaces. Using ordinary soap is sufficient. Alcohol-based gels are also effective for everyday use.
2. Avoid transmission. Stay away from sick people (if possible).
3. Vaccination. A single dose of the Pneumococcal Polysaccharide vaccine works for most adults in protecting against Pneumococcal Pneumonia. A revaccination after 6 years may be needed. Yearly Influenza vaccination (“flu shot”) may reduce your risk of pneumonia.
4. Healthy lifestyle. Eat a well-balanced diet, and don’t smoke, use illicit drugs or drink alcohol excessively.

Where can I learn more?

National Institutes of Health/National Institute of Allergy and Infectious Diseases

Centers for Disease Control and Prevention (CDC)

American Lung Association

National Heart Lung and Blood Institute

 

What are the different ways inhalers deliver medicine? The two main systems are Metered-Dose inhaler (MDI) and Dry Powder inhaler (DPI). The MDI has a pressurized canister with medicine inside, fitted to a boot-shaped plastic holder. Typically, the medicine is released when you actuate the canister by pushing down on it. Some actuate automatically when you inhale. Dry Powder inhalers release the medicine when you take a deep, fast breath, rather than using a gas propellant like the MDI.

What are the commonly prescribed medicines used in inhalers? Inhalers usually contain bronchodilators (medicines that relax and open the airways), corticosteroids (medicines that reduce the airway inflammation), or some combination.

Bronchodilators: “airway openers”

• Short-Acting Beta Agonist (SABA)- These work rapidly (seconds) to open the airways, but typically only last 4-6 hours. Commonly prescribed SABAs include albuterol (Proair, Proventil, Ventolin), levalbuterol (Xopenex), and pirbuterol (Maxair).
• Long-Acting Beta Agonist (LABA)- These keep the airway relaxed and open for about 12 hours, but do not begin rapidly like SABAs. LABAs are better for maintenance therapy and should not be used for “rescue” or acute asthma symptoms. In the US, commonly prescribed LABAs include salmeterol (Serevent), formoterol (Foradil) and aformoterol (Brovana).
• Anticholinergic- These also open the airways, but by a different mechanism than the beta agonists. The main short-acting drug is ipratropium bromide (Atrovent) and long-acting drug is tiotropium bromide (Spiriva).

Inhaled Corticosteroid (ICS): These medicines have no significant effect on relaxing smooth muscle like bronchodilators, but instead work to reduce airway swelling and mucus production. Commonly prescribed ICS inhalers include beclamethasone (Qvar), fluticasone (Flovent), budesonide (Pulmicort), mometasone (Asmanex), flunisolide (Aerobid), and triamcinolone (Azmacort).

Combination inhalers: In the US, the most commonly prescribed combination of bronchodilator (LABA) and corticosteroid are Advair (fluticasone and salmeterol) and Symbicort (budesonide and formoterol). The combination of beta agonist (albuterol) and anticholinergic (ipratropium bromide) is called Combivent.

How can I be sure there is medicine remaining in my inhaler? Many newer inhaler brands include a counter but for others the best way is to keep track of the number of inhalations used and discard when you have reached the total number indicated on the box and/or inhaler. People using MDIs may mistakenly keep using an inhaler with only propellant inside (no drug). In other words, inhalers can still generate a “puff” sound or “feel” like there is something inside, but the drug has been completely used up. This is a serious problem if you depend upon the inhaled medication. Be sure to get a new inhaler before you used all the doses of the old inhaler.

How do I properly use my Metered-Dose inhaler?

• Closed Mouth Technique:

• Open Mouth Technique:

How do I use my Dry Powder inhaler?

• Aerolizer

• Diskus:

• Flexihaler

• HandiHaler

• Twisthaler

Where can I learn more?

American College of Chest Physicians (pdf instructions in English and Spanish)

National Institutes of Health (closed mouth technique)

National Institutes of Health (with a spacer)

Strep throat is most common in the winter months or around winter time. It is most commonly seen in school-aged children and teens but also occurs in adults and children under three. Most sore throats are viral, not Strep.

Group A Streptococci are found all over and are the most common bacterial cause of acute pharyngitis in humans- accounting for up to 30% of cases in children and 10% in adults. In addition to acute pharyngitis, GAS can cause impetigo (skin disease), and less commonly, pneumonia, cellulitis (skin infection), otitis media (inner ear infection), sinusitis (sinus infection), bacteremia (blood stream infection), necrotizing fasciitis (severe infection of the tissues below the skin), meningitis (infection around the brain), and Toxic Shock Syndrome.

S. pyogenes has an outermost capsule that helps it escape detection by the human immune system, allowing it to colonize in your upper respiratory tract. At any time, it can overwhelm your host defenses and cause disease.

What are the signs and symptoms of Strep throat? The “classic” findings for Strep throat are:

1. Fever (above 100.4 F)
2. White or gray patches on the tonsils
3. Tender and swollen lymph glands in the neck
4. Absence of cough

These symptoms and signs (the Centor Criteria) are non-specific and even if you have all four, the odds are only about 60% probability of Strep. Symptoms of Strep throat start 2-5 days after exposure, usually rather suddenly.

Other findings in Strep throat include: headache, malaise, red and swollen tonsils, difficulty or pain on swallowing, chills, loss of appetite, rash, bad breath, abnormal taste, and nasal congestion. Children may experience nausea, vomiting, or abdominal pains.

You should call your doctor if you develop signs or symptoms of Strep throat, even if you don’t know if you were exposed to someone with it.

How is Strep throat diagnosed? In addition to a physical examination, your doctor can take a mucus sample from the back of your throat using a long cotton swab. Using the Rapid Strep Test, he/she can have the test result in about 15 minutes. Your doctor can also take a sample of your throat mucus and send it to the lab for culture. This is more reliable but it takes up to 2-3 days. Sometimes the Rapid Test comes back negative (meaning you don’t have Strep throat) but your doctor may do the culture to be sure, because sometimes the Rapid Test can miss a case. If the Rapid Test is positive, there is no need to culture. Most cases of sore throats are viral and Strep cannot be diagnosed accurately by symptoms alone.

How is Strep throat treated? Although Strep throat usually gets better on its own, your doctor will treat you with antibiotics, to shorten the course of disease, decrease the time you are contagious, and to decrease your chances of getting a serious complication of strep infection, such as Rheumatic Fever or kidney inflammation. Not all antibiotics will kill S. pyogenes, so it is important for you to take the one prescribed by your doctor for this infection, and not one for another infection that you still had in your medicine cabinet. It is also very important to completely finish the full course of antibiotic and not stop once you start to feel better. Nearly all symptoms of Strep throat are gone within a week. Viral sore throats do not require or respond to antibiotics.

If you don’t start getting better after 1-2 days of treatment, call your doctor.

Is Strep throat contagious? YES! Until you have been on antibiotics for several days, you can still spread the Strep germ to others. You can help prevent the spread by frequently washing your hands, covering your mouth when coughing or your nose when sneezing, and not sharing eating utensils or drinking glasses. Properly dispose of used tissues. Avoid close contact with others who have been diagnosed with Strep throat until their symptoms are gone. Since bacteria can survive for a short time on doorknobs, water faucets, and other objects, it’s a good idea to wash your hands regularly. You should probably stay home from school or work for 24-48 hours after starting antibiotics.

Important tip:  Get a new toothbrush after you are no longer contagious but before you finish the antibiotics. This will keep you from reinfecting yourself. Also, keep your toothbrush separate from other family members.

What else can I do to feel better? Most important, get plenty of rest- this will help your body fight the infection. Drink several cups of water each day to stay well hydrated. Take acetominophen (like Tylenol) or ibuprofen (like Advil or Motrin) for fever or pain. Avoid giving aspirin or any salicylate product to children under 19, as they may develop a serious condition called Reye’s Syndrome. Eat soft foods, and drink cool drinks or warm liquids. Avoid eating acidic or spicy foods. Gargling with warm salt water (1/4-1/2 tsp salt in 8 oz water) several times daily may help. Lozenges or popcicles will help soothe the throat. Avoid smoking.

Where can I learn more?

CDC/Dept of Health and Human Services

American Academy of Family Physicians

About 80-90 percent of Malignant Mesothelioma cases start in the pleura. Peritoneal Mesotheliomas make up most of the rest. Very rarely, Malignant Mesotheliomas start in the lining of the heart (pericardium) or testicles (tunica vaginalis).

Malignant mesothelioma is a rare cancer. In the US, there are only about 2,000-3,000 new cases diagnosed annually (compared to about 200,000 cases of lung cancer each year). Worldwide, the incidence appears to be on the increase. Malignant mesothelioma is usually a disease of the elderly, with the vast majority occurring in those over 65.

Causes of Malignant Mesothelioma: A risk factor is something that affects your chances of getting a disease, but does not mean that you will get the disease. Risk factors for Malignant Mesothelioma include asbestos, zeolites (such as erionite, a mineral found in the soil in parts of Turkey), radiation (high doses used in the past for certain cancers), thorium dioxide injections (“Thorotrast”) used for certain x-ray tests until the 1950s, and possibly SV40 virus (a simian virus that contaminated some vaccines about 50 years ago). Unlike lung cancer, smoking cigarettes does not cause Mesothelioma.

In the US, the main cause of Malignant Mesothelioma is asbestos. After someone breaths in the asbestos fibers, they can travel to the mesothelial cells and cause DNA damage that result in cancerous growth.

Most cases of Malignant Mesothelioma involve workplace asbestos exposure, but household or environmental exposure can cause this disease. The risk of Malignant Mesothelioma increases with increasing asbestos dose (“dose-response”), but even very small doses can cause this cancer. Malignant Mesothelioma takes a very long time to develop, with time between first exposure to asbestos and diagnosis (“latency period”) often 20-50 years, or longer (even if exposure stopped long ago).

Types of Malignant Mesothelioma: There are three different types of Malignant Mesothelioma, based upon how the tumor cells are arranged when examined under a microscope: Epithelioid, Sarcomatoid (Fibrous), or Biphasic (Mixed). The Epithelioid type have the better prognosis and comprise about 50-60% of Malignant Mesotheliomas.

What are the signs and symptoms of Malignant Mesothelioma? The symptoms, especially early on, are non-specific (could be from other reasons) and many people wait months before seeking a doctor. Depending upon where the cancer arises, signs and symptoms include: unexplained weight loss, chest or abdominal (belly) pain, shortness of breath, fatigue, cough, fluid around the lungs, nausea, or swelling or fluid in the abdomen.

How is Malignant Mesothelioma diagnosed? If you develop signs or symptoms of Malignant Mesothelioma, go see your doctor. He or she will take a thorough history, including any exposures to asbestos, and perform a complete physical examination. If your doctor still suspects Mesothelioma, you will likely undergo further testing, including blood tests, x-rays, scans, and other procedures. Your regular doctor may refer you to a lung specialist (pulmonologist).

Chest x-ray or chest CT scan can reveal thickening of the chest lining and the accumulation of fluid in the pleural space. There may also be evidence of previous asbestos exposure, such as pleural plaques, pleural calcification, or asbestosis.

Other imaging techniques used include Positron Emission Tomography (PET scan), Magnetic Resonance Imaging (MRI), or Abdominal CT.

Blood tests, in addition to commonly ordered tests like Complete Blood Count (CBC), electrolytes, kidney function, or liver function tests, might include osteopontin or soluble mesothelin-related peptides (SMRPs).

Other testing might include Pulmonary Function Tests (PFTs), bronchoscopy (insertion of a scope into the lungs), thoracentesis or paracentesis (removal of fluid from the chest or abdomen) or closed pleural biopsy (taking a piece of tissue through a needle). More often, your doctor will send you to a surgeon for biopsy through a scope (thoracoscopy, mediastinoscopy, or laparoscopy), or surgical open biopsy.

The diagnosis of Malignant Mesothelioma is then confirmed by the pathologist who examines the fluid or tissue using a microscope and specialized lab tests. Sometimes the pathologist needs more fluid or tissue before confirming the diagnosis.

Treatment Decisions: After your doctor diagnoses Mesothelioma, he/she will discuss treatment options. This might involve other physicians, such as a cancer specialist (oncologist), thoracic (chest) surgeon, or radiation specialist. Unfortunately, this cancer is almost always incurable. Without treatment, the mean survival is about 9 months. Treated, survival time could double. Your age, general health, type of cancer, and spread of cancer affect your prognosis.

Most cases are not surgically removable and not many patients are able to tolerate the surgery. Combination chemotherapy seems to prolong survival but is not a cure. Radiation may reduce symptoms. Consider participation in a clinical trial, particularly at a major cancer center. Current research includes gene therapy, new targeting chemotherapy, multimodality treatment, photodynamic therapy, and new radiation therapy techniques.

 
Where can I get more information?

National Cancer Institute
American Cancer Society
Mesothelioma Applied Research Foundation
National Institutes of Health

 

What does the ABG test? The ABG measures the pH of the blood and the partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2). It is used to determine the bicarbonate level, and can measure hemoglobin, carboxyhemoglobin, and methemoglobin levels.

Why order ABG testing? Your doctor might order ABG testing to assess for certain respiratory (lung), metabolic, or kidney diseases. Patients receiving supplemental oxygen, especially those on ventilators (breathing machines), and patients undergoing prolonged general anesthesia often undergo ABG testing. Patients with uncontrolled Diabetes Mellitus, heart failure, sleep apnea, kidney failure, or drug overdose might require ABG testing. Patients with lung diseases such as COPD, asthma, cystic fibrosis, pulmonary embolism, or pulmonary fibrosis might have ABG testing during the course of their illness.

How is ABG testing done? Drawing arterial blood for blood gas analysis is usually done by a doctor, nurse, respiratory therapist, or phlebotomist. Most commonly, the blood is taken from the Radial artery (in the crease of the wrist) using a thin needle and syringe. The Radial artery is easily accessible, can be compressed to control bleeding, and has less risk for occlusion. The Femoral artery (in the groin) or the Brachial artery (in the fold at the elbow)  is sometimes used, especially during emergency situations or with children. Blood can also be taken from an arterial catheter already placed in one of these arteries.

Arterial blood gases are more painful than having blood taken from a vein because the artery is located deeper from the surface.

To take your blood gas, the healthcare professional will:

• Palpate the area for your pulse and to check for alternative circulation
• Look for signs of skin infection at the potential puncture site (if yes, look for alternate site)
• Clean the site with alcohol (or sometimes betadine)
• Inject a local anesthetic, like lidocaine (not always done)
• Insert the needle into the artery (sometimes more than one attempt needed)
• Allow the blood to fill the syringe, then remove the needle
• Compress over the needle site to prevent bleeding
• Check for complications

How are ABGs interpreted? The “normal” pH of the blood is 7.4. In most laboratories, the normal range is from about 7.35-7.45. Below 7.35 the blood is abnormally acidic (“acidotic”), and above 7.45 it is abnormally alkaline (“alkalotic”). The normal range (at sea level) for PaO2 is 80-100 mmHg and the normal range for PaCO2 is 35-45 mmHg. Hypoxia is a low PaO2 and indicates that the patient is not respiring properly. Under most circumstances, at a PaO2 of less than 60 mmHg, supplemental oxygen should be administered. An abnormal carbon dioxide level usually indicates a respiratory problem. For a constant metabolic rate, the PaCO2 is determined entirely by ventilation. A high PaCO2 indicates hypo- or underventilation (respiratory acidosis),and a low PaCO2 indicates hyper- or overventilation (respiratory alkalosis). PaCO2 levels can also become abnormal when the respiratory system is working to compensate for a metabolic issue so as to normalize the blood pH (metabolic acidosis or alkalosis with respiratory compensation). There are online guides available to help interpret the results.

What are the risks? The risks of having an ABG include bleeding, clotting, bruising, pain, fainting, hematoma (blood accumulating under the skin), arterial damage (rare), and infection.

How do I prepare? There is no special preparation needed. Be sure to tell the doctor or person drawing the blood if:

• you have a bleeding disorder
• you are taking aspirin or blood thinners
• you have an allergy to local anesthetics, such as lidocaine

If you use home oxygen, check with your doctor if the test is to be done on or off your oxygen.

Where do I get ABG testing? Most doctor’s offices are not set up to perform this test. Usually, you will go to the hospital if this test is ordered by your doctor as an outpatient test. Most blood gases are performed on hospitalized patients.

Is there an alternative test? There is a non-invasive (no needle stick) test for oxygenation, called pulse oximetry. In this test, a small clip-like device is placed on the fingertip (or sometimes the ear lobe), and a sensor reads light that is transmitted through the skin. This test has the advantage of continuously making measurements of oxygen saturation (how much of your hemoglobin is carrying oxygen), which correlates with PaO2 levels, but there are factors that can affect its accuracy. These include abnormal forms of hemoglobin, poor detection of pulse, severe anemia, and certain colored nail polishes (especially reds and dark blues). The pulse oximeter does not measure the PCO2 levels.

 

 
Where can I read more?

• National Institutes of Health

• Fischbach FT, Dunning MB III, eds. (2004). Manual of Laboratory and Diagnostic Tests, 7th ed. Philadelphia: Lippincott Williams and Wilkins

• Pagana KD, Pagana TJ (2006). Mosby’s Manual of Diagnostic and Laboratory Tests, 3rd ed. St. Louis: Mosby

Pulmonary Embolism (“PE”) is a medical condition wherein a lung artery (or arteries) develops a blockage from a substance that traveled through the bloodstream to the lung. Venous thromboembolism (“VTE”) is a common medical term for pulmonary embolism and DVT. Click here to see a video animation of DVT and PE.

What causes PE?

The most common cause (over 90% of cases) is from a blood clot (“thrombus”) from a deep vein, usually in the leg (“deep venous thrombosis” or “DVT”). If the blood flow in the legs becomes slowed, clots may form. This can happen during periods of immobility, such as after a surgery, during long car or airplane trips, or because you are bedridden. Damaged veins, such as from an injury or previous surgery are more prone to forming blood clots.

Other lesser common causes of PE are air (such as from an air bubble in an IV catheter), fat (such as from fat in the bone marrow during a leg fracture), tumor (such as from cells of a cancer breaking off into the bloodstream), infected material (such as from IV drug abuse), or amniotic fluid (such as during a delivery).

What are the symptoms or signs of PE?

Unexplained shortness of breath, chest pain, cough, and hemoptysis (coughing up blood) are some of the most common features of PE. The chest pain is often “pleuritic” or more painful with breathing. Patients may also experience arrhythmia (abnormal heartbeat), especially rapid or irregular heartbeats. Other symptoms or signs may include feeling of dread or anxiety, severe sweating, low grade fever, lightheadedness, rapid breathing, fainting, and cyanosis (bluish discoloration of the lips and finger tips). Multiple and smaller clots may lead to pulmonary hypertension. Not all persons with PE have these signs/symptoms, and some have none. In about 5% of cases, PE can also present with circulatory collapse and “sudden death”.

Sometimes the only signs and symptoms come from the clot in the leg (DVT). DVT can cause swelling, warmth, redness, and pain of the affected leg.

It is important to see your doctor immediately if you have signs or symptoms of VTE.

How is VTE diagnosed?

First, your doctor will take your medical history and examine you to look for risk factors for VTE, look for signs of DVT or PE, look for other causes to explain your signs/symptoms, and to decide the likelihood that you might have VTE.

Next, your doctor will do testing to help diagnose or exclude VTE. There are a number of available tests. Your doctor will decide how to evaluate you depending upon your condition, other health problems, how likely it is that the doctor thinks you have VTE, and local testing preferences/availability.

Some of the diagnostic options include:

1. Ventilation/Perfusion Lung Scan
2. CT Angio with PE protocol
3. Pulmonary Angiogram
4. Ultrasound/Doppler of the legs
5. D-Dimer blood test

In addition, your doctor may obtain a regular chest x-ray, EKG, Echocardiogram, complete blood count (CBC), tests of clotting status (PT/PTT), other blood tests (such as kidney function, liver enzymes, electrolytes, and sedimentation rate), and arterial blood gases.

Who is at risk for VTE?

VTE affects both men and women equally. The risk increases with increasing age, doubling with each ten years after age 60.

Known risk factors include:

• Immobility- this can occur in just hours, such as sitting still on an airplane or long car ride.
• History of previous DVT or PE.
• Persons with congestive heart failure
• Patients with cancer or recently treated for cancer.
• Estrogen-containing hormones (including oral contraceptives)
• Those with certain inherited conditions (such as Factor V Leiden, Protein C or S deficiency, antithrombin deficiency, and others)
• Being overweight or obese
• Pregnancy or just after pregnancy
• Cigarette smoking
• Recent major surgery
• Previous deep vein injury or those with central venous IV catheter
• Bedridden persons
• Burn victims
• Older persons, especially over the age of 60
• Injury to the pelvis, hip, or leg

How is Pulmonary Embolism treated?

In most cases, the treatment consists of medicines aimed at stopping the clot from growing and preventing new clots from forming. These medicines are called anticoagulants (“blood thinners”).

Blood thinners come in pills, IV injections, and shots under the skin. The pill is called warfarin (trade named “Coumadin”). The injections include heparin and enoxaparin (“Lovenox”). Often, your doctor will start the injectable treatments (which are faster acting) at the same time as the pill, which can take several days or more to reach a satisfactory level in your blood. Once the Coumadin is working, the injections are stopped and you can go home on Coumadin. Coumadin is taken once a day. In some patients (such as pregnant women), the treatment is only injections.

Your doctor will monitor your Coumadin treatment by a blood test (“protime” or “PT” and “International Normalized Ratio” or “INR”). Initially, you may have this test daily, but eventually only weekly or biweekly. The ideal is an INR of 2-3. Coumadin is inhibited by Vitamin K, so you should not eat foods rich in this substance (such as certain leafy green vegetables, broccoli, Brussels sprouts, okra, sauerkraut, asparagus, certain onions, and cabbage).

Anticoagulants do not break up the clots already formed. Over time, the body dissolves most clots. If your symptoms are life-threatening, you might need treatment with medicine to quickly dissolve the clot (“thrombolytic”), or rarely, surgery to remove it. These have added risks and are not used unless absolutely necessary.

Treatment for VTE typically continues for 2-6 months, depending upon the cause and circumstances. If you’ve had clots before or if you have cancer, you may require longer treatment. Some patients require treatment indefinitely.

In some people, the medicines don’t work or they cannot take the medicines. In those cases, the doctor may have a device (or “filter”) inserted into the large vein below your lungs (“vena cava”), to interrupt the passage of further clots passing from the legs to the lungs. These vena cava filters do not stop clots from forming and may not entirely prevent clots from reaching the lungs.

Treatment of pulmonary embolism also includes treating the symptoms. Oxygen is administered. Analgesics are given to relieve pain. Intravenous fluids are given, and sometimes drugs that increase blood pressure, if the blood pressure is low. Mechanical ventilation (“breathing machine”) may be necessary if respiratory failure develops.

What is the prognosis?

In general, the prognosis depends upon how much lung is damaged by clots, and the existence of other medical problems (especially of the heart or lungs). At least 100,000 cases of PE occur each year in the US and if left untreated, about 25-30% of patients who have PE will die. In the US, PE is the third most common cause of death in hospitalized patients.

What can be done to prevent VTE?

The main goal is to prevent the development of DVT. Steps you can take include:

• Get out of bed and move around as soon as possible after surgery
• Exercise your legs or walk around if you are on a long car trip or airplane
• Don’t smoke, especially if you have other risk factors, such as estrogen supplements
• Take medicines (if prescribed by your doctor) before/after surgery
• Wear specialized stockings if recommended by your doctor (especially for those with a history of DVT)

Living with VTE

• Most importantly, take your medicines exactly as prescribed. Taking too little does not protect you and taking too much can cause bleeding.
• Ask your doctor about your diet, because certain foods can inhibit the function of Coumadin. It is best to maintain a balanced and regular diet.
• Check with your doctor about drug interactions, including antibiotics and certain over-the-counter drugs.
• Take the blood tests as ordered by your doctor and make sure you thoroughly understand any directions for changing the dose.
• Call your doctor immediately if you experience any bleeding from the skin or nose that will not stop in 10 minutes after you apply pressure, any bleeding from the digestive tract (such as vomiting blood or vomit that looks like coffee grounds, bloody stools or black tarry stools, or abdominal pain), any sudden neurological problems (such as severe headache, sudden loss of vision, sudden loss of movement in your arms or legs, or confusion).
• Call your doctor if you symptoms recur after they had resolved

Where can I learn more?

NIH/MedlinePlus
American Medical Association
NHLBI
ATS 2009 Reading List