Bronchoscopy indicated?
Question:
> The Centers for Disease Control and Prevention (CDC) has > developed a set of diagnostic criteria for Lyme disease for > surveillance purposes [1.3]. These criteria are also applicable to > the clinical diagnosis of Lyme disease." > http://www.acponline.org/journals/annals/15dec97/pplyme2.htm > CLINICAL GUIDELINE, PART 2 > Laboratory Evaluation in the Diagnosis of Lyme Disease
The guidelines for surveillance purposes was never meant to be used for diagnosis. Thank goodness that finally this misinformation has been corrected legally through Public Law 107-116 signed by Pres. Bush on Jan. 10th of this year. The law reinforces that the CDC’s Lyme Disease Case Surveillance Definition is not valid as a standard of care for the diagnosis & treatment of Lyme Disease. It also reinforces that medical protocols that use the CDC LD Case Definition to base diagnosistic and /or treatment standards misuse this protocal and are invalid. A letter from David Satcher, MD, Dir. of the CDC to Sen D’Amado reinforces that the case survellance definition is not to be used for any medical protocol or as a standard of care. Dr. Satcher’s letter takes precedent over "Guidelines for laboratory evalution in the diganosis of LD" (Annals of Internal Medicine 12/97) which misstates, "These CDC criteria are also applicable to the clinical diagnosis of Lyme Disease". Lyme Disease Foundation Feb. 2002 **We needed this Public Law because the antibody test criteria were only meant for tracking purposes only. Not everyone makes antibodies to this disease (for a variety of reasons). It does not mean that they are not infected. Kara Tyson Lyme Disease Support Group Of AL
Response:
> After a nasty bout of pneumonia last year, my 10yo daughter has had > persistent sometimes severe asthma. She has also had 2 subsequent > pneumonias and a follow up chest X-ray that had not returned to normal. > After a recent second pulmonologist opinion, she had an autoimmune blood > workup and a CAT scan. The CAT scan revealed a persistent patchy right > upper lobe infiltrate. Autoimmune workup was all okay – except 3 out of > 10 bands were positive for Lyme. She was started on antibiotics for > presumed Lyme (the Lyme probably explains her complaints of joint pain). –cut– > I know this is obviously not asthma under good control. The > pulmonologist said there is not much room to move with the asthma meds, > since she failed Serevent twice and I hate to see her take oral > steroids. I’m not even thrilled about the inhaled steroids.
Regarding joint pain; more likely due to oral steroids. There are a lot of false positives with Lyme testing. Link: http://www.nlm.nih.gov/medlineplus/druginfo/corticosteroidsglucocorti… Corticosteroids Glucocorticoid Effects (Systemic) http://www.rxlist.com/cgi/generic/pred.htm prednisone PI Trying to determine the pathogen that may be causing the infiltrate can be very difficult. I have an infiltrate, the doctor says it could be any of 50 different things; bacterial, fungal, viral, cancer, mycoplasma, pulmonary embolism, etc. After sputum cytology, CT scan, bronchoscopy biopsy, we are still looking. My case is different, I’m an older guy, walking 3 mi/day. Asthma under control at Pulmicort 2 pf x 2 plus Serevent. Just added Singulair back in due to seasonal allergies causing rhinitis. Singulair is great for allergies; marginal improvement for asthma. Ellis
Response:
- Hide quoted text — Show quoted text – > Hi, > After a nasty bout of pneumonia last year, my 10yo daughter has had > persistent sometimes severe asthma. She has also had 2 subsequent > pneumonias and a follow up chest X-ray that had not returned to normal. > After a recent second pulmonologist opinion, she had an autoimmune blood > workup and a CAT scan. The CAT scan revealed a persistent patchy right > upper lobe infiltrate. Autoimmune workup was all okay – except 3 out of > 10 bands were positive for Lyme. She was started on antibiotics for > presumed Lyme (the Lyme probably explains her complaints of joint pain). > So now we await a follow up appointment with the Pulmonologist. > My questions are this: If this were you, would you want a bronchoscopy > done?
Well obviously that decision is up to the Pulmonologist. But I would ask the Pulmonologist whether there’s already enough info to proceed without a bronchoscopy for the time being. From your description, you already have some good clues: the history of recurrent pneumonia, the abnormal CT scan, the positive Lyme test and joint pain. It sounds like she has some kind of infection (possibly more than one). If the infections can be brought under control with antibiotics, then maybe the bronchoscopy won’t be needed. I can see how such infections could exacerbate asthma. > She has been almost exclusively on nebulized albuterol with Flovent 110 > 2 puffs bid inhalers (3 puffs tid on flares) since October. She still > uses an inhaler at school. She takes Singulair, and she takes Zyrtec > before bed. An Allergist diagnosed vasomotor rhinitis – but that was > after only doing the standard scratch tests.
If she didn’t test positive for allergies, then there’s no reason for her to take Zyrtec. > She certainly looks like > someone with allergies with dark circles under her eyes, chronic runny > nose and she gets absolutely awful if off the Zyrtec – so I wonder if > more precise allergy testing should be done. I know I’ll probably ask > the pulmonologist that on follow up. Can chronic vasomotor rhinitis > kick up severe asthma? Is there something to nip this?
Has she been evaluated for chronic sinusitis? Symptoms of sinusitis can resemble those of non-allergic rhinitis. (I was repeatedly misdiagnosed myself.) And sinusitis can definitely exacerbate asthma. — Steven D. Litvintchouk
Response:
–cut– > She has been almost exclusively on nebulized albuterol with Flovent 110 > 2 puffs bid inhalers (3 puffs tid on flares) since October. She still > uses an inhaler at school. She takes Singulair, and she takes Zyrtec > before bed. An Allergist diagnosed vasomotor rhinitis – but that was > after only doing the standard scratch tests. She certainly looks like > someone with allergies with dark circles under her eyes, chronic runny > nose and she gets absolutely awful if off the Zyrtec – so I wonder if > more precise allergy testing should be done. I know I’ll probably ask > the pulmonologist that on follow up. Can chronic vasomotor rhinitis > kick up severe asthma? Is there something to nip this?
Zyrtec is an antihistamine; antihistamines only help those with allergies, so that would be puzzling if no allergies can be found but Zyrtec helps. Or do you mean Zyrtec-D, which also contains the decongestant pseudoephedrine. Vasomotor rhinitis is a type of nonallergic rhinitis. Postnasal drip could get into lungs exacerbating asthma. There might also be the possibility of sinusitis; an ENT can diagnose. Link: http://www.NationalJewish.org/medfacts/allergic_rhinitis.html Allergic & Non-Allergic Rhinitis http://www.vh.org/Providers/ClinRef/FPHandbook/Chapter20/06-20.html Otolaryngology: Nose > As soon as she gets a virus, her asthma bottoms out – literally. She > was completely incapacitated by an asthma attack for about 4 days about > 2 weeks ago and we had to use oral steroids (this is the third time in a > year she needed a short burst of steroids).
Viruses tend to exacerbate asthma. > I know this is obviously not asthma under good control. The > pulmonologist said there is not much room to move with the asthma meds, > since she failed Serevent twice and I hate to see her take oral > steroids. I’m not even thrilled about the inhaled steroids. > She cannot run at all. She gets short of breath on a flight of stairs. > And she defintely gets gray/blue around the lips – which is THE symptom > that scares me the most.
How about the fingernails? when they show blue it can indicate low oxygen. http://www.nlm.nih.gov/medlineplus/ency/article/003215.htm Skin discoloration – bluish http://www.healthcentral.com/peds/top/003215.cfm Pediatric Health Encyclopedia Skin discoloration, bluish "Mild cyanosis is difficult to detect. Usually the oxygen saturation of the blood has to drop below 80% before it can be detected." However, her last oxygen saturation while sick > was 98% – although that was sitting still, which I question the > usefullness of (but that may just be me and my stressed-out sick of all > this uncontrolled asthma state of mind). I don’t know if the doc is > gonna say to her that this is as good as it gets. It seems an awful > thing to tell a 10 yo.
For difficult cases like this you might consider consulting National Jewish Center in Denver. www.njc.org free advice–800-222-LUNG Ellis
Response:
> After a nasty bout of pneumonia last year, my 10yo daughter has had > persistent sometimes severe asthma. She has also had 2 subsequent > pneumonias and a follow up chest X-ray that had not returned to normal. > After a recent second pulmonologist opinion, she had an autoimmune blood > workup and a CAT scan. The CAT scan revealed a persistent patchy right > upper lobe infiltrate. Autoimmune workup was all okay – except 3 out of > 10 bands were positive for Lyme. She was started on antibiotics for > presumed Lyme (the Lyme probably explains her complaints of joint pain).
All about Lyme Disease: http://www.acponline.org/journals/annals/15dec97/pplyme1.htm CLINICAL GUIDELINE, PART 1 Guidelines for Laboratory Evaluation in the Diagnosis of Lyme Disease "In the classic presentation, patients develop a distinctive rash, erythema migrans, which is accompanied by such constitutional symptoms as fatigue, headache, mild stiff neck, musculoskeletal aches, and fever. Some weeks after initial exposure, untreated patients may develop symptoms and signs of disseminated disease, particularly neurologic, cardiac, or articular disease. The Centers for Disease Control and Prevention (CDC) has developed a set of diagnostic criteria for Lyme disease for surveillance purposes [1.3]. These criteria are also applicable to the clinical diagnosis of Lyme disease." http://www.acponline.org/journals/annals/15dec97/pplyme2.htm CLINICAL GUIDELINE, PART 2 Laboratory Evaluation in the Diagnosis of Lyme Disease
Response:
> Also, regarding Serevent – since it’s a long acting bronchodilator – > wouldn’t the object be to get the asthma in control and then not need > the Serevent?? Since so many people are maintained on Advair – isn’t > that really not reaching the object of good control?? I’m confused on > this. > SL
The advantage of using a long acting bronchodilator is that studies have shown it can cut the need for inhaled steroids by a factor of 2. Steroids are immunosuppressants and have other undesireable side effects so should be used in the minimum dose to control the problem. Advair combines Serevent and Flovent in one convenient dry powder inhaler. [However I prefer to use Serevent and another steroid inhaler, Pulmicort, separately, so as to be able to adjust the Pulmicort dose independantly to correspond with symptoms.] Ellis
Response:
- Hide quoted text — Show quoted text -> >My questions are this: If this were you, would you want a bronchoscopy > >done? > From your recounting, probably not. What is the doctor’s opinion? > Sheldon > I don’t know the pulmonologist’s opinion yet – he wanted CAT scan and autoimmune > workup results first. Follow-up appointment is coming up. Our pediatrician > thought a bronchoscopy should be done though, and that’s what prompted the > pulmonology visit. > SL
Normally a CT scan would precede a bronchoscopy as it’s less invasive. The pulmo doc would make the call on this, as he would be doing the bronchoscopy. Biopsies can be taken during the procedure. I just went thru this; chest x-rays, CT scan, a few days ago a bronchoscopy which found a blocked right segment 6. Next step if it doesn’t show improvement on the next chest x-ray, is a hollow needle biopsy thru the chest wall into segment 6 using CT to guide the needle. Next appt and x-ray–Tues. The bronchoscopy is no fun; lots of coughing. Here’s a link on pediatric bronchoscopy where they seem to use a smaller bronchoscope [mine was 5-6 mm dia] http://peds-www.bsd.uchicago.edu/ucch/healthpages/pulmcrit/bronchosco… Guide to Pediatric Bronchoscopy Ellis
Response:
> >My questions are this: If this were you, would you want a bronchoscopy >done? > From your recounting, probably not. What is the doctor’s opinion? > Sheldon > "Life would be devoid of all meaning were it without tribulation."
I don’t know the pulmonologist’s opinion yet – he wanted CAT scan and autoimmune workup results first. Follow-up appointment is coming up. Our pediatrician thought a bronchoscopy should be done though, and that’s what prompted the pulmonology visit. SL
Response:
Hi, After a nasty bout of pneumonia last year, my 10yo daughter has had persistent sometimes severe asthma. She has also had 2 subsequent pneumonias and a follow up chest X-ray that had not returned to normal. After a recent second pulmonologist opinion, she had an autoimmune blood workup and a CAT scan. The CAT scan revealed a persistent patchy right upper lobe infiltrate. Autoimmune workup was all okay – except 3 out of 10 bands were positive for Lyme. She was started on antibiotics for presumed Lyme (the Lyme probably explains her complaints of joint pain). So now we await a follow up appointment with the Pulmonologist. My questions are this: If this were you, would you want a bronchoscopy done? She tried Serevent twice (once in Advair). Both times she gradually declined to a full-fledged asthma flare. If this were you, would you want to try Advair again. She has been almost exclusively on nebulized albuterol with Flovent 110 2 puffs bid inhalers (3 puffs tid on flares) since October. She still uses an inhaler at school. She takes Singulair, and she takes Zyrtec before bed. An Allergist diagnosed vasomotor rhinitis – but that was after only doing the standard scratch tests. She certainly looks like someone with allergies with dark circles under her eyes, chronic runny nose and she gets absolutely awful if off the Zyrtec – so I wonder if more precise allergy testing should be done. I know I’ll probably ask the pulmonologist that on follow up. Can chronic vasomotor rhinitis kick up severe asthma? Is there something to nip this? As soon as she gets a virus, her asthma bottoms out – literally. She was completely incapacitated by an asthma attack for about 4 days about 2 weeks ago and we had to use oral steroids (this is the third time in a year she needed a short burst of steroids). I know this is obviously not asthma under good control. The pulmonologist said there is not much room to move with the asthma meds, since she failed Serevent twice and I hate to see her take oral steroids. I’m not even thrilled about the inhaled steroids. She cannot run at all. She gets short of breath on a flight of stairs. And she defintely gets gray/blue around the lips – which is THE symptom that scares me the most. However, her last oxygen saturation while sick was 98% – although that was sitting still, which I question the usefullness of (but that may just be me and my stressed-out sick of all this uncontrolled asthma state of mind). I don’t know if the doc is gonna say to her that this is as good as it gets. It seems an awful thing to tell a 10 yo. Also, regarding Serevent – since it’s a long acting bronchodilator – wouldn’t the object be to get the asthma in control and then not need the Serevent?? Since so many people are maintained on Advair – isn’t that really not reaching the object of good control?? I’m confused on this. I’m hoping some of you will give your opinion and give me some ideas on what to do or try or request from the Pulmonlogist. Thanks for any opinions. SL
Response:
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