After "Nodule Week" maybe we should have "Dyspnea w/up week"...
Anyway, I see a lot of older patients with no obvious structural pulmonary or cardiac abnormalities and just want to compare notes.
To ilustrate it, yesterday I saw this 60 y/o woman with "episodic DOE". She is fairly healthy, exercises regularly on a treadmill and was sent by the cardiologists after a normal radionuclide stress test (normal EF too). She notices dyspnea with chest tightness when she tries and exerts herself "faster than usual" like racing up the stairs. Her daughter got married a few weeks ago and everytime she went up to get something she would get dyspneic. No F/C/NS/cough.
No TOB. Occ social ETOH.
On a PPI, Calcium and prn Tylenol.
Normal exam (normal BMI!).
Normal PFTs (FEV1 and ratio, TLC, no air trapping and DLCO~101%).
She had had a normal chest CT and we did a Mathacholine test which was negative (~10% change in FEV1 after 25mg).
What would you do next in this case? Do you see a lot of this less obvious cases of DOE?
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MVV, MIPs and MEPs were normal?
Similar to you, Carlos, I have a lot of patients with similar presentations.
I started to get frustrated with them, so I decided to start getting CPETs on them.
I found that a large percentage of them had air trapping with exertion.
Try getting full PFT's before and after exercise to see the RV and TLC.
They respond remarkably to tiotropium and rehab.
If you do not get any significant changes on the CPET, rehab works in a number of these individuals.
Like Mike I send many of these pts to rehab but it is even hard how to chart/bill them (dyspnea? dynamic hyperinflation?)
I think that's interesting Mike. I'm a little surprised that you see so much exercise induced hyperinflation-(I don't doubt it, just wonder why...). Given that, I think tiotropium would be as good as anything. It would be interesting to repeat the testing after 6 months or so to see if that air trapping improves with intervention...
It surprised me as well. I just got so frustrated with one patient that I decided to get a CPET. When I saw the post exercise PFT's and compared them to full PFT's I obtained before the decision was made to order the CPET, I thought this may be more common that I initially perceived.
I have since gotten 4 more CPETs with dynamic hyperinflation (actually the last 2 I just had them walk on the treadmill until they became dyspneic and obtained lung volumes).
Rehab is a nightmare to get for these individuals because they do not have FEV1 < 65% predicted. The billing people need a letter of medical necessity, a treatment regimen, a candy bar and $1000 to consider them. It is really difficult to enroll people at times.
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