Pneumonia

[Mave]

Last week I posted in the nodule forum as a recent chest CT scan showed a nodule on my right lung. My doctor was been baffled as to the reason none of the treatments/antibotics, nebulizers, prednisone etc., weren't having an effect on the illness. I posted in the forum and asked for suggestions to the ongoing pneumonia I've had since December 07 and the nodule.

The person ( think it was Davy) suggested a sputum history and a TB test. I printed this out and showed it to my doctor and he complied. I was able to cough up a small amount of sputum from deep in my lungs and it went to the lab.

Within 2-3 days my family doctor called and I was asked to come in. He showed me my lab report which I have a copy.

I have Pseudomonas +4 (heavy). It says white blood cells +2 (few), Epithelial cells +1(rare) Organisms +4 negative bacilli, +1 Mixed oropharyngeal flora. I haven't a clue as to what any of this means???

My doctor contacted a specialist and was advised I have (3) IV treatments per day of Tazocin 4.5g every 8 hrs. along with Cipro taken orally 750mg.

I've been on this course of treatment for one week now and I haven't noticed any improvement with my peak flow which has stayed at 400 since this all began.

Is this the right course of action now? Also what further tests do I require to know if the bacteria is gone from my body?

Also is it possible that the bacteria has damaged my lungs after three months of fighting it?

Should I have a liver and kidney function blood test? Also is it a good idea to be on acidophilus?

I look forward to hearing from you!

[Davy9]

They have identified a heavy growth of pseudomonas aeruginosa bacteria from your sputum sample. It is a gram negative bacteria. They will have also identified which antibiotic this particular organism is sensitive to which they will give you. Your are getting the correct course of treatment, in the correct manner.

Your peak flows are not just reflective of where this infection maybe localized. They reflect the ability of the lungs to blast air out as fast as possible. They are more related to airways resistance. That said, this infection may be keeping them inflamed or irritated enough to keep them compromised. Or they could just be tight for other reasons. I'll suggest this. If you conduct peak flow measurements frequently the trauma of that effort can keep airways irritated. Give them some time to calm down. Do you also use inhaled aerosolized medications like bronchdilators and/or inhaled steroids?

Complete your course of antibiotics. Symptoms like the nights sweats and fatigue should improve. They should conduct a follow up chest Xray to assess the status of the nodules. Pseudomonas can cause permanent lung scarring so the nodules may remain but not be acute. If all else is well just think of them like you would any other scar on you body. If you continue to remain symptomatic with fevers, sweats, nausea, light headedness, etc..., then let your MD know.

But, you now have a specific infectious culprit identified that can be targeted for treatment and that is good news.

[Mave]

Hi Davy

To bring you up to date on things. For 3 weeks I had IV's every eight hours along with Cipro. I'm now off the IV's and just finished Avelox for two weeks, now I go on Zithromax for two weeks. I also had my TB test and my chest x-ray has been sent away to the TB Center.

I was informed I'll always have the Pseudomonas Aeruginosa and not allow myself to get run down, under stressful conditions, catch a cold etc. As soon as I see my sputum change color I take it in to the lab as I have a standing order. I recently had a pneumovax booster as well.

With the bacteria and bronchiectasis is it possible to have my lungs washed out with an antibacterial solution? Would that get rid of the bacteria? My doctor told me because of all the scarring and pitting the bacteria stay hidden and I will always have it.

With my pulmonary functions tests I was 79% which is good, although I still feel I lack air and puff and pant considerably. Should I have an oxygen test as well?

I wanted to thank you for suggesting the course of action. Without the sputum history I still would be suffering and mostly likely in a very bad state.

[Davy9]

Hi Mave,

They certainly have attacked the Pseudomonas aggressively. If the organism has pocketed in that nodule or in areas of airway pocketing (bronchiectasis) then the blood bourne antibiotic may not have had access to all of the offending bugs. They can go into the lungs with scopes and try to lavage specifically sites of infection, but they can only go so far. They can do lung lavages but I'm not certain that they would do them with antibiotics. They do them in conditions where the lungs have a generalized need to have something removed and they use the least irritating stuff they can. They are done in surgery so that they can access one lung at a time. More radically if they can be certain that that nodule is a source for this organism and that antibiotics are not reaching them they can employ surgery to move that area. Lobectomies are recommended for patients with hard to treat TB and they also work for chronic, localized, encapsulated infections from other organisms.

The advice to keep healthy and to be aware of early signs of lung infection is just plain common sense. Perhaps you have a predilection for lung infections because of asthma, prior smoking or just because of chronic lung problems. Pay attention to your health and learn what is normal lung behavior for you. In winter wear snoods to warm up inhaled air. Eat well, stay well hydrated (assuming no kidney or heart problems). Just maintain good health and learn what those early signs of lung infections are so you can intervene on them ASAP.

There are many values on a PFT so I don't know what you refer to as 79%. But they do have this study for future comparison if they should need to. Shortness of breath with exercise can be low oxygen or just a poorly conditioned body. An easy way to see if the oxygen is impacting your exercise is to use a pulse oximeter under work load. A pulse oximeter measures O2 saturation through the skin (usually through a finger sensor). Normals would be above 95% and they become problematic when at around 85%. What you do is get the value while at rest then do some work that tires you out while wearing the sensor (they are usually portable). If the value drops when you work then you need to have the cause of that assessed. That can be caused from lung or heart conditions. If it is from your lungs then they might consider supplementing O2 while you exercise and while you sleep. If you tire out and do not desaturate dramatically then you're just poorly conditioned and can recondition yourself to enhance your physical durability. In any case you should get a structured conditioning program so as to not overly stress your system while rehabilitating. Your want to get stronger but you do not want to harm yourself getting there.

[Meave]

When I had the PFT they showed me the test result and it was 79% which they felt was very good. I feel my problem is trying to get more air into my lungs rather then exhaling it. I'm glad you replied as I have an appt. with my doctor tomorrow. I'll mention the pulse oximeter. I've been inactive for 5 months. Before becoming sick I used to hiking or walk 4-5k's each day without problem. Now the simpliest tasks cause me to run out of breath. I become very fatigued, lightheaded and no energy. I have to literally force myself to do something then I fall in a deep sleep for several hours, which is abnormal for me.

From the chest ct scan it also showed a hiatal hernia. I wasn't aware I even had one. The doctors feel acid reflux, along with asthma and several bouts of pneumonia have scarred and pitted the lungs over the years. I'm on Nexium twice aday for the acid reflux. I didn't feel like I had stomach aliments either.

I'm also getting some sort of gadget to monitor my sleeping for one night as well.

Thank you for your advice about the scoping. That sounds like something I would want to avoid unless necessary. I am very interested in the pulse oximeter as I want to get fit without causing harm.

[Davy9]

Hello again Meave,

Your prior health status is encouraging. I would ask them to explain what they mean by "scarred and pitted" lungs. Having a hiatal hernia is one thing but to have one that has repeatedly resulted in aspiration events with lung damage is another. BTW aspiration does not lead directly to pseudomonas but it can pave the way to allow it to start. Aspiration of gastric content is just very acidic and it always results in immediate coughing and irritation. I can't imagine that you would not have experienced some discomfort under those circumstances.

Try and get a clear idea of the current status of your lungs, if they will heal, by how much and how you can help them do so. Let them know that prior to this event that were were active and that you hope to return to some level of that activity again.

The sleep study could be one to assess acid reflux which is often worse when people lie down (there is such a thing as anti-reflux posturing for sleeping). Or, the study could be one to assess the existence of sleep apnea. That is where breathing becomes impaired enough while sleeping to desaturate (again by pulse oximeter). This can be caused by upper airway obstruction or from other causes.

With the pulmonary function test there are so many different values they measure. You would be amazed at what can be learned from measuring what goes into and comes out of the lungs and in what fashion. Perhaps you've seen pictures of athletes on stationary bikes hooked up to full tilt breathing head gear. From that they know the work performed, when the work crossed from aerobic to anaerobic, what types of foods are being burned (carbs or proteins, etc) and many other things.

Anyway just keep learning more about your situation.

[LungDoc]

Bronchiectasis is a challenging disease to treat in some cases. It is actually scarring of the bronchial tubes, usually from old infection, recurrent aspiration or other chronic inflammatory diseases of the lung. While I cannot give you all the details here, it would be helpful to know if you had a high resolution CT of the chest and if the bronchiectasis was confined to one lobe or many.

Because the airways that are bronchiectatic are pulled open and the membranes on them are not very functional, you tend to pool secrestions, which is where the bacteria live and grow. There are no "pockets" of them that can be eliminated. By the way, the lungs are not a sterile environment, but are constantly under attack by microorganisms, dust, pollution and other contaminants of our environment.

Pseudomonas is one of the most common bacterial infections of the bronchiectasis patient, but not the only one. You are also prone to getting repeat bouts of infection. We try to use measures to promote airway clearance, such as flutter valve, nebulizer treatments with hypertonic saline, and occational a percussion vest. What you need to help reduce flares depends on how severe your changes are on the CT scan, to some degree. Not all patients need all of these things.

Bronchscopy is not a surgery, nor does it need to be done in the OR. It is a form of endoscopy where I look into your larger bronchial tubes and can take samples of tissue or the secretions. We can also remove mucous plugs that sometimes occur, but it is not like a vacuum cleaner, and we do not get all of the lung or bronchial tubes visiualized. Whole lung lavage is not the typical procedure for this. That is used for patients with a specific disorder known as pulmonary alveolar proteinosis. It is extremely rare and your description of your case does not fit that.

As an aside, a sleep study will not help you diagnose acid reflux, but a 24 hour pH probe would. Sleep studies are generally not done with that kind of monitoring. A sleep study would help diagnose obstructive sleep apnea or narcolepsy or sleep related movement disorders. Additionally, acid reflux is sometimes silent and will not always cause the classic symptoms of burning and throat irritation and cough.


Just wanted to clear up some potentail misinformation. Bronchiectasis is sometimes a little confusing to some, because its symptoms overlap with so many other medical conditions and not many are familiar with the ins and outs of therapy. As the Physician moderator of this forum, I would be happy to answer your other questions about bronchiectasis. I have met and worked with some of the leading experts in this field, and it is a personal area of interest for me.

[Meave]

Hello LungDoc

I appreciate you’re input and explanation of Bronchietasis. I had been diagnosed with it way back in 1988 when my lungs needed a Bronchscopy after a bout with pneumonia. It was back then I was informed I had Bronchietasis. I remember the bronchscopy vividly. A good part of my face and chest were frozen, I was hooked up to several monitors and I was blindfolded. It was the worst experience I’ve had it my life. It was conducted at a teaching hospital in a major city.

At that time I was informed I had Bronchietasis and Asthma. The lung doctor was more concerned I was made aware how dangerous asthma is if not controlled. I was told I must take 3 asthma inhalers each day, Ventolin, Flovent and Atrovent. That has been my meds since 1988. When I catch a cold in travels to my lungs right away and I’m prescribed antibotics, nebulizer treatments with Pulmacort etc., and prednisone.

For as long as I can recall I have never ever been able to run, play tennis, or enjoy activities where my heart rate goes up. I run out of air, feel faint and my heart goes crazy. What you mentioned about promoting airway clearance is a shock to me. All these years and with my quality of my life suffering are appalling. Not one doctor mentioned flutter valves, nebulizers with hypertonic saline or a percussion vest (which I don’t know what the it either). It was like “ oh by the way you have Bronchietasis, no big deal.”

I feel I have been cheated of the past 20 years because no one cared enough to offer a better solution for my breathing difficulties. This was the first time I had a CT scan for my chest. The pneumonia showed up, nodule, infection and Bronchietasis. I’ve never heard of CT resolutions either. I always have chest x-rays.

My last CT scan was back in January 08. Do you think it’s advisable to have another?

I normally don’t wheeze or have a raspy sound in my lungs when I’m ok or even when I’m sick. Most doctors feel because I’m not wheezing then it’s not serious, where as I feel when my lungs feel heavy and clogged I’m suffering from congestion.

I’ve printed your reply and bringing it to my family doctor to read on Wednesday. I doubt if he has heard of any of the measures you have mentioned to help patients with Bronchietasis.

Tomorrow is my last day on antibiotics for the Pseudomonas. I was on Zithromax for 2 weeks and then Avelox 400mg. for 2 weeks and so on. I felt a decline when I was on Zithromax and advised to stop using it. My doctor is in a quandary of what antibiotic to use on me after the Avelox. I hate to have a relapse in the meantime. I’m allergic to penicillins. Would you be able to suggest an alternative for Zithromax?

I sincerely appreciate you’re answer with so much information. If it wasn’t for this forum
my doctor wouldn’t have sent me for the sputum history, nor would they found out I have Pseudomonas.

Thank you so very much!

[Meave]

I had my appt. with my specialist the other day. I had alist of questions which you had asked me and I then asked him. I would never have thought of these things either.

The Bronchietasis is in both lungs as with the Pseudomonas. I had a high resolution chest CT scan.

I feel very tried and exhaust easily lately, coughing more each day it seems. The doctor has advised Cipro for 2 weeks and then Tobi in nebulizer for the 2nd weeks. Stay on this treatment until my follow-up with him in November. He also informed no need for further sputum histories.

When I went to have the prescription filled the pharmist had never heard of Tobi and looked it up as with the cost. I'm looking at $3500.00 for Tobi, not including Cipro and 3 asthma sprays I use. I'm not able to afford this, actually how many people can?

Would you or another doctor whom specializes in Pseudomonas Aeruginosa can advise on another antibotic that works as effectively but less money than Tobi?

I'm also to go for physio therapy...everything you mentioned before.

Help....

[LungDoc]

Inhaled tobramycin (Tobi) nebulized is an antibiotic that suppresses (but not cures) bacterial growth in the lungs. It is helpful for a few of the bacteria we worry about in bronchiectasis. The downside is cost. Typically, it is used one month on and one month off on a regular basis, although other options are available. Avelox should not be used to treat pseudomonas, because it is not an antipseudomonal agent. Cipro or Levaquin are preferred fluoroquinolones for this. Azithromycin is not antipseudomonal, but there are trials of it in bronchiectasis showing that it may have antiinflammatory properties. We usually dose it for that indication 3 times a week.

I would not expect your family doctor to have all the answers for you. Care of this requires people who are experienced with dealing with this problem, because of all of the nuances of treatment.

Your experience with bronchoscopy is unfortunate. We no longer keep you awake for the procedure. I do all of mine with conscious sedation. You sleep thru it and remember nothing. However, this is 2008, and in 1988 things were different and so was our understanding of bronchiectasis and testing for it and treating it. There were no high res CT scans then. You cannot look back that far and expect to have gotten the same kind of care we can offer 20 year later. That is not realistic. That said, you seem to be on your way to some of the therapies that should help make you feel a little better. I am glad you took my suggestions to heart and brought them up with your doctor.

You might want to ask about other forms of inhalers that might be more efficatious for you. Atrovent is not all that helpful for asthma, but does work for other kinds of lung disease. There are some newer inhaled powder forms of steroids that can sometimes help too. Talk to your doctor about all of this. I don't want to diagnose or treat you, but just keep you informed so you know the right questions to ask.