Lung problems?

[ScubaRob0311]

Have a friend who is now interested in getting certified as well. They were asking me how to answer medical question on form and if it was worth pursuing diving?
Basically they went to drs a year or two ago for some shortness of breath that is gone. They did some breathing tests, first time it showed restrictive pattern so they did it again with additional tests that didn't really show restrictive pattern anymore but definitely showed some abnormal results including reduced TLC. I guess other then those abnormal results pulmonologist didn't find anything wrong and said it was possibly from (I forget word they told him) him not being active.
My advice to him is to obviously go back and talk to pulmonologist but he doesn't have health insurance at moment and if it's an obvious no go he doesn't want to waste money making appointment.
Anyone have experience with this?

 

[Pedro Burrito]

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[fmerkel]

First - can you get a much better scan of that PFT (pulmonary function test)? Can't make out the numbers, which are critical to interpretation.
Second - there are a number of discrepancies in your report that don't add up, further complicating figuring this out.
- Being inactive does not change most of your PFT results, the critical ones. Being out of shape can make you SOB (short of breath) but that would show up with activity. If SOB shows up with normal activities....that is not good.
- What can change PFT results is a poor coach which might not be that uncommon in a primary physician's office but I would not expect it in a pulmonologist's office. So...which did he see?
- Not understanding the instructions can mess up the PFT test. Again, a good coach would be able to see and correct this. A poor coach might not.

Either a restrictive or obstructive lung condition would not be conductive to diving unless the condition is diagnosed and treated (if possible), or goes away and can be shown to have done so.

 

[ScubaRob0311]

Hopefully this is better. I guess coaching was presumably good, had them do it a couple times to verify consistent results. They have sleep apnea and had to increase pressure while sleeping to prevent hypoxia even though lower pressure adequately controlled the apnea events. The pulmonologist (not primary) said there was nothing they could find wrong. Person also had long standing cough and was getting spasms in torso area around that same time which I guess is better now.
Just found out they had a chest CT after the fact when seeing a different pulmonologist who also said they were fine and to exercise more but did not do another PFT. Here is text
"
TECHNIQUE: High resolution scanning with supine and prone imaging
without intravenous contrast
FINDINGS: There is some mild linear density at the lateral left
base on series 3 image 170 and series 7 image 189 in the lingula,
likely scarring. This was seen on chest x-ray as well.
The chest x-ray linear density at the medial right base is seen
currently.
There is a 5.5 mm nodule in the right lower lobe adjacent to the
major fissure as seen on series 7 image 153, series 9 image 91
and series 10 image 141.
Lungs otherwise clear. Central airways patent.
Few nonspecific thoracic lymph nodes. No adenopathy is suggested.
There is some residual thymic tissue.
No pleural or pericardial effusion. Unenhanced central pulmonary
arteries and thoracic aorta are unremarkable.
Regional bones intact. Few included unenhanced images of the
upper abdomen are grossly unremarkable.
Impression:
Small linear density lateral left base likely a scar that was
seen on chest x-ray.
A 5.5 mm right lower lobe nodule adjacent to the major fissure is
nonspecific. Follow-up recommended for this in 6 months time."
Pulmonologist said no need to do follow up CT Because they quit smoking over 5 years prior to this CT.
They also had unexplained fever for 8 months and tachacardia and blood work found a very slightly underactive thyroid. Started on 25mcg synthroid and surprisingly fever and tachacardia went away.

 

[fmerkel]

Pretty overweight? Common problem in obstructive sleep apnea (80-85%). That would account for some of the PFT results.

Note - if more pressure was required to prevent hypoxia, the apnea was not properly controlled. A major part of the therapy is hypoxia prevention. Getting the pressure right to start is part science, part art, and part luck. It's not unusual to have to tweak it a little. The sleep test is always a bit weird for everyone, so 'normal' sleep is often elusive during the test procedure.

A couple of the key readings, FEV1 and FEV1/FVC are OK/good enough. Poor readings there would be indicative of lung results that would probably exclude him, notably asthma and COPD. Obesity can be a contributor to restriction. How would you do if a medium sized kid was sitting on your chest while you tried to do a PFT?

How is exercise tolerance? Humping scuba gear around is not light work. OTOH, some overweight people take to scuba because they feel unweighted in the water.

 

[Duke Dive Medicine]

@ScubaRob0311 , all of the results shown say, "Pre-bronchodilator". Did he have a post-bronchodilator test done as well, with an inhaled medication given between tests?

Best regards,
DDM

 

[ScubaRob0311]

@fmerkel
I would say about 6 foot probably around 230ish lbs so overweight but not morbid by any means. Recently he started running doing the couch to 5k and has been able to keep up with that.

@Duke Dive Medicine
No inhaled medications given between tests. Pulmonologist originally thought asthma was possibility even though restriction was seen and was given symbicort and was taking that for a few weeks prior to the full PFTs shown above. He said taking the symbicort didn't make any difference in symptoms and stopped taking it after about a month.

 

[fmerkel]

[Symbicort contains a combination of budesonide and formoterol. Budesonide is a corticosteroid that reduces inflammation in the body. Formoterol is a long-acting bronchodilator that relaxes muscles in the airways to improve breathing.]

Both of those are long-acting drugs, generally given for asthma, so if he was taking it up to and just prior to the PFT he was effectively 'post-medication'. I wondered about no post-medication readings.
Running is an encouraging sign of motivation in the right direction.

What is the timeline in regard to being treated for OSA, and this PFT evaluation? OSA can definitely screw up a lot of body functions. Kind of like stopping smoking you can get some immediate results from the start but it can take awhile for more optimal changes to occur. Lots of men think they are going to take up exercise and lose weight when they find out they have OSA. Pretty much that is 100% failure until they do get treated. Then they approach the same levels of adherence to those goals as non-OSA males, which ain't so hot.

You realize no one here can clear him for diving? All we can do is encourage or discourage toward that goal.

 

[Duke Dive Medicine]

@fmerkel
I would say about 6 foot probably around 230ish lbs so overweight but not morbid by any means. Recently he started running doing the couch to 5k and has been able to keep up with that.

@Duke Dive Medicine
No inhaled medications given between tests. Pulmonologist originally thought asthma was possibility even though restriction was seen and was given symbicort and was taking that for a few weeks prior to the full PFTs shown above. He said taking the symbicort didn't make any difference in symptoms and stopped taking it after about a month.

Thanks. I think it would be reasonable for him to seek medical clearance to dive. One concern would be whether the scarring and the nodule they visualized could cause any gas trapping, which a radiologist should be able to determine, but aside from that possibility I don't see any show-stoppers here. The fact that he's working out and getting into better shape is a plus.

Best regards,
DDM

 

[ScubaRob0311]

@fmerkel
Totally understand no one here can clear him. Again if it's a definite no go then he doesn't want to waste time and money on Drs visits at this time.
He says he was treated for sleep apnea for 3 months prior to the PFTs and was/is 100% compliant. AHI was under 2 during that time but he thinks the hypoxia wasn't taken care of until after the PFT's. I guess he bought his own pulse oximeter and saw oxygen levels still dropping at night and then had a oximetry test done at home while using APAP and AHI that night was around 1 but oxygen was under 88% for 93 minutes.

@Duke Dive Medicine
Thanks, I'll let him know that and that he should make an appointment and that it's not a definite no go.

What I am kinda curious about is how low his residual volume is, if at depth would that further decrease it and if so could that cause any issues ?