Reduction in Opioids for Pain: Could This Make My Breathing Worse?

Reduction in Opioids and Breathing is Worse

Dear Dr. Mahler:

I have COPD-my Dr. has taken me completely off the Fentanyl patch which I used for years – I have several issues that cause me a lot of pain. I have also been on Vicodin – 8 each day. They are now cutting back on it.
My problem is my breathing has worsened and I have had increased breathing exacerbations with these cut backs. Do you think there could be a connection?
Do you have any suggestions for me? Between the pain and breathing issues my quality of life is bad and I am depressed that I can’t do the things I used to. I use the Stiolto Respimat and Albulterol when I have a bad breathing situation.
Would really appreciate if you would have any suggestions for me. THANK YOU.

Sandra from Little Rock, AK

Dear Sandra:

Your experience is not unusual.

opium poppy is source of natural opiods

Opium poppy

Both fentanyl and vicodin are opioids that act on receptors in the body to relieve pain. Opioids include opiates that found in the resin of the opium poppy (incluidng morphine) as well as medications made in laboratories that are called synthetic drugs. These include fentanyl and vicodin [hydrocodone and acetaminophin (brand name is tylenol)] which you are or were taking.

Opioids are also helpful to relieve shortness of breath. Usually, they are used for those with advanced disease for palliation. It is quite possible that your worsening in breathing is related to the reduction in opioids. Remember that opioids may cause side effects including tiredness, low energy, sleepiness, and constipation.

water exercise may help shortness of breath due to reduction in opioids

Seniors doing Water Aerobics

exercise may help with shortness of breath due to reduction in opioids

Man pedaling stationary cycle being supervised by rehabilitation specialist.

Could the combination of your COPD and use of fentanyl/vicodin led to an inactive life style? If so, is it possible for you to do more activities to improve your breathing, or does your pain limit activity level? Is participation in a pulmonary rehabilitation program a possibility for you? Are water activities possible with your pain problem?

Another question that I have relates to your report of exacerbations with reduction in opioids. Are you experiencing chest congestion and coughing up yellow or green mucus with these episodes? If so, I suggest that you ask your doctor to check for bronchiectasis (see post on April 21, 2017, under COPD News) and acquired immunodeficiency (see post on November 23, 2016, under COPD News). Both of these conditions may lead to frequent flare-ups.

Finally, you may wish to ask your doctor about starting an inhaled corticosteroid medication to help reduce the risk of future flare-ups. Your current use of Stiolto Respimat as a maintenance medication is excellent as it contains two different types of long-acting bronchodilators. The 2017 GOLD recommendations suggest that an inhaled cortiosteroid be added to a medication like Stiolto if you continue to experience exacerbations.

I hope this information is helpful. Best wishes,

Donald A. Mahler, M.D.

Chinese Herbal Product for Clear Lungs and Better Breathing

Chinese Herbal Product – ClearLungs

Dear Dr. Mahler:
I have recently been taking the Chinese Herbal product, “ClearLungs.”  I have felt my lungs clearing up but I cough a lot, I take no other medication.  Should I keep taking it, what is your opinion?
Lynn from Chattanooga, TN 

Dear Lynn,

Before discussing the Chinese herbal product, I have a few questions for you. You describe that “I cough a lot.” There are many causes for coughing and thus it is important to find out why. When you cough, is it a “dry cough” or do you raise mucus? Do you have allergies, asthma, or chronic obstructive pulmonary disease? Have you mentioned your coughing to your health care professional?

Chinese herbal product may help with coughing

Female with COPD coughing

 What is the Chinese Herbal Product – ClearLungs? As I am not familiar with this product, I searched the internet. The website stated that ClearLungs is a brand name that “contains 13 perfectly balanced herbal ingredients designed to help keep airways free of phlegm and mucus while supporting clear lungs and free breathing.” The website did not mention the actual names of the 13 herbal ingredients.

Who Makes ClearLungs? ClearLungs is manufactured by Ridgecrest Herbals, Inc., a Utah corporation.  The company makes over two dozen formulas, including both herbal supplements and over-the-counter (OTC) homeopathic medicines which contain herbs.

What is the Cost? Sixty tablets of ClearLungs cost $21.99 if ordered on the website.

My Comments Lynn – I can not recommend this product as I don’t know what are the actual 13 herbal ingredients. With most medications, studies called randomized clinical trials are performed to evaluate how good the medication works (efficacy) and safety.  It would be interesting to learn if the manufacturer has performed any such studies to evaluate ClearLungs.

I hope that this information is helpful.


Donald A. Mahler, M.D.

What is the Best Maintenance Bronchodilator Therapy for my COPD?

Maintenance Bronchodilator Therapy – Four Combinations Available in a Single Inhaler

Dear Dr. Mahler:

I have severe COPD and I was wondering roughly how long does it take to get on a maintenance program that works. This May will be a year and I still use my nebulizer with a duoneb every 4 hours and my emergency inhaler (Ventolin) when needed. My pulmonologist knows this. Should I see another pulmonologist??? I figure I should of been getting some relief. I have been smoke free for 3 months and will not go back to smoking again. Could you please point me in the right direction???

Jeff from Lubbock, TX

Dear Jeff:

DuoNeb is a very good short-acting combination of two different bronchodilators – albuterol and ipratropium. They work in different ways to open the breathing tubes by relaxing the muscle that wraps around the tubes. Short-acting bronchodilators last approximately 4 – 6 hours, and then the breathing tubes return to previous narrowing. Also, Ventolin is a brand name for albuterol delivered in an inhaler.

Maintenance bronchodilator therapy keep the breahting tubes open for 12 - 24 hours.

View of smooth muscle wrapping around the outside of the breathing tubes

All studies show that long-acting bronchodilators are more effective in keeping the breathing tubes open for a longer time and making it easier to breathe compared with short-acting medications. There are many choices of long-acting bronchodilators to use that are delivered in different types of inhalers.

In the past few years four different combination of long-acting bronchodilators in a single device have been approved for use in the United States by the Food and Drug Administration. I have several posts describing these medications used as maintenance bronchodilator therapy. They include in alphabetical order of brand names: Anoro Ellipta – a dry powder inhaler; Bevespi Aerosphere – a metered-dose inhaler; Stiolto Respimat – a soft mist inhaler; and Utibron Neohaler – a dry powder inhaler. Anoro and Stiolto are used once a day as their effects last for 24 hours, while Bevespi and Utibron are used twice a day because they last 12 hours.

Jeff – I suggest that you ask your pulmonologist about a trial of one of these dual long-acting bronchodilators instead of taking DuoNeb. In my practice, I give samples to be used for 2 – 4 weeks as a trial, and then schedule a follow-up appointment to assess whether the medication is helping the person “breathe easier.”

You may wish to share this post with your pulmonologist. If he or she is unwilling to try one of these long-acting combination medications, then I would consider seeing a different health care provider.

Best wishes,

Donald A. Mahler, M.D.

Ventolin Inhaler Recall in April 2017 Due to Defect – Delivers Fewer Puffs

Ventolin Inhaler Recall – How Does It Affect You?

Dear Dr. Mahler:

I read last week that Ventolin inhalers were recalled by the company. I don’t know if I need to do anything or not? My COPD has been stable for the past few years as I take Spiriva in the morning and use Ventolin whenever I need some relief of shortness of breath.  I usually use Ventolin once a day, especially if I am going shopping or helping to babysit my grandchild. What should I do?

Susan from Silver Springs, MD

Dear Susan:

On April 4, 2017, GlaxoSmithKline (GSK), the pharmaceutical company that makes Ventolin, issued a recall of more than 593,000 Ventolin inhalers from U.S. hospitals, pharmacies, retailers and wholesalers. The reason was a defect that may cause the inhalers to deliver fewer doses of the medicine than indicated.

GSK has issued a Ventolin Inhaler Recall

Ventolin Inhaler contains albuterol – a quick-acting bronchodilator

What is Ventolin Inhaler?  Ventolin is a a brand name for albuterol sulfate – a quick-acting bronchodilator that relaxes the muscle that wraps around the breathing tubes. It is used by patients who have asthma and COPD as a “rescue medication” to provide quick relief for breathing difficulty. The usual does is two puffs at a time, and it can be used every 4 – 6 hours “as needed.”

ProAir can be used as a substitute because of the Ventolin Inhaler Recall

ProAir inhaler contains albuterol

There are two other brands of albuterol sulfate – ProAir and Proventil. The different bands of albuterol should be able to be used interchangeably. Pharmacies may give you the brand of albuterol based on a contract

Proventil inhaler contains albuterol

with the pharmaceutical company for a lower cost. Whether you receive any reduced cost is dependent on your local pharmacy or mail order pharmacy.

What Is the Problem with Ventolin Inhalers? GlaxoSmithKline said it had received a number of product complaints about a bulging of the outside wrapper, indicating a leak of the propellant that delivers the medicine. The recall involves three lots of the Ventolin HFA 200D inhalers manufactured at GSK’s plant in North Carolina.

The U.S. Food and Drug Administration approved the voluntary “Level 2” Ventolin inhaler recall, which only affects products in the United States.

What Should I Do? The Ventolin inhaler recall does not pose a danger to you or other patients, so you are not being asked to return your Ventolin inhaler. However, it is possible that your Ventolin inhaler may not provide the expected 200 doses. If you do not believe that you received the full 200 doses, you might wish to discuss this with the pharmacist where to bought the inhaler. Consider asking for a free replacement or another brand. Certainly, there is no guarantee that this will happen, but most retail pharmacies want to help their customers and have them return for future business.

Best wishes,

Donald A. Mahler, M.D.

Smoking Marijuana: Is It Safe for Someone with Mild COPD?

Smoking Marijuana and the Lungs

Dear Dr. Mahler:

I live in Massachusetts where marijuana was legalized for recreational use this past November. What are your thoughts for smoking an occasional joint to “chill?” My primary care doctor has told me that I have mild COPD. I smoked cigarettes for about 20 years, but quit two years ago. I am currently taking Tudorza Pressair twice a day, and may use ProAir a few times a month. How safe is smoking marijuana for my lungs?

Brian from Wooster, MA

Dear Brian:

Marijuana is the second most commonly smoked substance after tobacco.

Plant used for smoking marijuana

Marijuana plant

Although the harmful effects of tobacco smoke are well known, there is less information about the health effects of smoking marijuana. As most people know, marijuana can be inhaled in many ways – a joint, vaping, and water pipes – are the most common. It is impossible to predict if you will experience any lung damage from smoking an “occasional joint.” Here is some health information for you to consider.

How can smoking marijuana damage my lungs? Smoke of any kind can cause bronchitis – inflammation and swelling of the breathing tubes. Marijuana smoke contains many of the same harmful chemicals as in tobacco smoke. We do not know if light users who smoke an amount equal to 1 – 2 joints a month over a long time may worsen your mild COPD. 

Smoking marijuana may cause a lung bullae

Arrows shows a lung bulla in the right upper lobe of the lung

There is evidence that smoking marijuana can cause large air sacs, called bullea, to develop in the lung. This is more likely to happen in younger marijuana smokers (less than 45 years of age). A bulla can cause someone to be short of breathe and may rupture or “pop.” Air leaking from a ruptured bulla can lead to a collapsed lung called a pneumothorax.

For anyone with asthma or COPD, smoking marijuana can cause a “breathing attack.”

What symptoms indicate that smoking marijuana is affecting my lungs? Like tobacco smoke, marijuana smoke can cause coughing, mucus, wheezing, shortness of breath, and swelling in the throat.

Does smoking marijuana increase my risk of lung cancer? The answer is unclear, but it may increase the risk of lung cancer as marijuana smoke contains over 450 unique chemicals including those that can cause cancer (called carcinogens).

Can marijuana increase my risk of a lung infection? Marijuana smokers can develop a lung infection from a mold called aspergillus. The mold, or fungus, lives on marijuana plants and is inhaled in smoke. 

Has marijuana been used to treat some medical problems? Yes, marijuana has been used to treat many conditions including nausea and chronic pain. Several states allow health care providers to prescribe marijuana for health reasons. However, the Food and Drug Administration (FDA) has not approved marijuana for any medical condition. The FDA has approved medications that contain tetrahydrocannabinol (THC), the active ingredient in marijuana, for treatment of pain and nausea.

In summary, smoke of any kind has the potential to damage your lungs, and is not recommended for anyone who has a lung condition. I hope that his information is helpful for you in making an informed decision.


Donald A. Mahler, M.D.



Inhaler Medication Reaction – Lightheadedness and Nausea with a Once Daily Bronchodilator

Inhaler Medication Reaction: What are the Alternatives?

Dear Dr. Mahler:

My doctor’s office asked me to try a ‘new’ inhaler – ANORO – which worked great for 2 days but I had a reaction when I first inhaled it – lighted-headed and nauseated.  That lasted for about 2 hours.  They will not let me continue on this .  Is there not something comparable?


Beverly from Avon, CT

Dear Beverly,

View of smooth muscle wrapping around the outside of the breathing tubes

An inhaler medication reaction to – Anoro Ellipta – with a feelings of lightheadedness and nausea is uncommon, but certainly can occur.

To answer your question, let’s first consider the anatomy of the the breathing tubes (airways). Smooth muscle wraps around the outside of the breathing tubes (see figure on right).  The smooth muscle can constrict which causes narrowing of the breathing tubes and reduces air flow. Certain medications can relax the smooth muscle allowing more air to move in and out during breathing.

Anoro Ellipta enables patients to breathe easier with two bronchodilators

Anoro Ellipta dry powder inhaler

Anoro Ellipta is a dry powder inhaler that contains two different classes of bronchodilators – one is called a long-acting beta-agonist and the other is called a muscarinic antagonist. These medications work in different ways to relax the smooth muscle that wraps around your breathing tubes (airways). By relaxing the smooth muscle, the tubes can open more (dilate) allowing more air to move during breathing.

Side effects can occur with any medication including inhalers. Fortunately, there are three other approved inhalers that are similar to Anoro as they also contain both classes of bronchodilators. Two of these are available at the present time – Stiolto Respimat and Bevespi Aerosphere.

Stiolto Respimat – a soft mist inhaler

Stiolto is a soft mist inhaler and releases a fine mist

Bevespi contains two different bronchodilators in a single device

Bevespi Aerosphere – a pressurized metered-dose inhaler

when you press down on the release button. The dose of Stiolto is two inhalations once a day. Bevespi is a metered-dose inhaler; the delivery system is the same as albuterol metered-dose inhaler. Bevespi delivers an aerosol after pressing down on the canister. The dose of Bevespi is two puffs twice a day about 12 hours apart.

I suggest that you contact your health care professional to ask about these other dual bronchodilators.


Donald A. Mahler, M.D.



COPD Severity on Breathing Tests: To Find Out Your Grade, Ask Your Health Care Provider

COPD Severity on Lung Function Tests

Dear Dr. Mahler:

I want to learn more about COPD severity. On the breathing tests, there are numbers to tell how well you are breathing. I’m still confused with moderate, severe, to very severe and what it means. Thanks.

Joseph of Kansas City, MO

Dear Joseph:

Your question about COPD severity is a common concern among many patients that I see in my practice at Valley Regional Hospital.

First, the grading of severity is based on how much air that you exhale in one second. This is abbreviated FEV1.  Here is a graph that shows what FEV1 represents.  

FEV1 is used to grade COPD severity

Diagram of spirometry to diagnose COPD. FEV1 is the amount of air exhaled in one second.

Your best value is then compared with what it is expected to be for someone your age, sex (female or male), and your height. This is called FEV1 percent predicted.

To add to the complexity of the grading of severity of COPD, testing should  be performed before and after inhalation of a bronchodilator. Albuterol is almost always used for testing.  This is called post-bronchodilator FEV1 percent predicted. Your health care provider may or may not order testing with albuterol.

Guidelines and strategies for COPD describe the following four grades for COPD based on breathing tests:

                                        Post-bronchodilator FEV1 percent predicted


MILD                                                 80% or higher

MODERATE                                         50 to 79%

SEVERE                                                 30 to 49%

VERY SEVERE                                   less than 30%

It is important to remember that your current inhaled bronchodilators can affect the results of testing. For example, if you took your inhalers at 8 am and had testing at 10 am, this likely represent the peak effect of many long-acting bronchodilators. However, if the testing is done at 3 pm, the results will not be as good.

As you can see, higher numbers for lung function are better. However, it is important to recognize that the test results are just numbers and don’t reflect how you feel or how you are breathing.

These grades are most useful in describing the types of patients with COPD in research studies. It allows comparison of different medications in similar types of individuals based on breathing test results.

Joseph – I hope that this information is helpful. Finally, you can move up or down in these grades based on more effective treatments (may go up) or following a flare-up or exacerbation (may go down).


Donald A. Mahler, M.D.

Coffee (Caffeine) Can Block Inflammation in the Body: New Research Findings

New Research Study Shows that Coffee (Caffeine) Blocks Inflammation

Dear Dr. Mahler:

I recently read in our local newspaper that researchers claim the coffee drinkers could live longer. What are your thoughts? I am 70 years old and have had COPD for eight years. I try to eat right and do some physical activity for 20-30 minutes each day. My doctor has prescribed Advair for me which I take twice a day. Thanks for answering my question.

Shannon from Birmingham, AL

Dear Shannon:

I have received many questions about drinking coffee (caffeine) and possible benefits. Also, my post “Will coffee help my COPD?” on January 18, 2015, is the most viewed topic on the website.

coffee beans contain caffeine

coffee seeds commonly called beans

Before discussing the recent study, here is some brief information about inflammation (redness and swelling). In Latin, inflammation means “set afire.”  It is an important part of the body’s immune system to heal an injury or fight an infection.

However, if this persists and is chronic, inflammation plays a key role in various diseases – like asthma, diabetes, heart disease, bowel disease – in addition to COPD.

In a recent study published in the journal Nature Medicine, researchers at Stanford University analyzed the genes of 114 individuals who were part of an aging study. They found that older people between the ages of 60 and 89 tend to increase the production of inflammatory cells. Too much of these over a long time has been linked to heart disease, cancer, and Alzheimer’s disease.

Cup of Coffee (caffeine) that reduces inflammation

cup of coffee

Based on what the subjects reported in a questionnaire, those in the less inflamed group consumed more caffeine drinks like coffee, soda, and tea. The researchers also looked at the effects of caffeine on inflammatory cells in a culture (like a test tube). The cells soaked in caffeine produced far lower levels of inflammatory cells compared with those not soaked in caffeine.

In summary, the study showed a correlation between caffeine consumption and older people with low levels of inflammation in the blood. One of the authors, Dr. Mark Davis, commented that, “That something many people drink – might have a direct benefit came as a surprise to us.” While the researchers did not prove that caffeine causes better health, they came up with a possible way (mechanism) it could be doing so.

In the mean time, enjoy your coffee or tea. There are many proven benefits. For someone who has COPD, caffeine relaxes the muscle that wrap around the breathing tubes that hopefully might make it a little easier to breathe.


Walking a Dog: It Helped Me Be More Active and Lose Weight

Walking a Dog – Helped to Lose Weight

Dear Dr. Mahler:

I am 79 years old and was hospitalized last month for a flare-up of COPD. Usually I have 1-2 episodes of bronchitis during the winter and need an antibiotic and prednisone. I usually get short of breath clearing snow off of my car and drying off my dog when he gets wet from rolling in the snow.

The reason that I am writing is to share my “secret” for losing weight.  I live alone in a trailer, but last May I got a dog for company and activity. He wants to go out at least 6 times a day, and I need to walk him with a lease. There isn’t enough space for him to run around in my small yard. To care for my dog, I walk several times a day, up to 20 min at a time. Although I had not planned on this, I have lost 18 pounds since last May. I feel so much better being more active and it is easier to breathe losing my belly fat. Please share my experience walking a dog with your readers.

Sally from Bennington, VT

Dear Sally,

Many thanks for you note. Congrats on losing 18 pounds and make sure to give your dog a treat for helping you lose weight.

Woman walking a dog

Woman walking her dog

Here is some information about walking a dog and health benefits. In general, dog owners get twice as much exercise as those who do not have a dog. One survey reported that on average dog owners walked with their dog 24 minutes twice a day which adds up to 5 hours and 36 minutes a week. Studies show that those who walk their dog have the following health benefits:

  • Lower blood pressure
  • Increased mental attitude and sharpness
  • A lower risk of heart disease

The amount of exercise required for your dog will vary depending upon their breed and energy. Your dog can be a great incentive to get outside.

Here are some suggestions for those who have dogs. Set a daily routine with your dog. Try to walk at the same time each day. Also, find a dog park for fun and variety.

Sally – thanks again for your email. Hopefully, your experience will help others have a new friend and find a way to lose weight.

Best wishes,

Donald A. Mahler, M.D.


Cleaning Inhalers: Is It Necessary? How do I Clean My Inhalers?

Cleaning Inhalers – Helps to Prevent Infection

Dear Dr. Mahler:

I recently read that I should clean my inhalers to make sure that they work correctly and to prevent infections. However, I can’t find any information that describes how to do this. I use Symbicort inhaler and Spiriva powder every day and ProAir as my rescue inhaler. What do you recommend?

Gerard from San Juan, Puerto Rico

Dear Gerard:

You ask an important question about keeping inhaler devices clean and working properly. Unfortunately, this topic – cleaning inhalers – has not received a lot of attention.

As I am sure that others with COPD have the same question or concern as you do, here is information for cleaning inhalers as well as nebulizers.

Metered-dose inhaler (abbreviated MDI)

Cleaning inhalers is important for metered-dose inhalers

Diagram of metered-dose inhaler

When you press down on the top of the chamber, the aerosol spray comes out of the metering chamber and enters the nozzle  (see above). There is concern that the spray might accumulate over time and clog the nozzle. Cleaning the actuator with running water and air drying is recommended periodically to reduce this possibility.

Dry-powder inhaler (abbreviated DPI)

Dry-powder inhalers

A clean, dry cloth should be used to wipe away any powder from the mouthpiece. This should minimize any contamination with bacterial or fungus. This should be done periodically.

Soft mist inhaler (abbreviated SMI)

Soft mist inhaler

All that is required with the soft mist inhaler is to clean the mouthpiece with a damp cloth. It is recommended that cleaning be performed periodically.


The main source of nebulizer contamination is the patient. People of all ages tend to drool into the mouthpiece which explains why bacteria are frequently found in the reservoir (cup) after use.

nebulizer is one delivery system in which cleaning inhalers is important.

Hand held nebulizer

Any liquid that remains in the cup after you have finished inhaling leaves a wet environment with potential for growth of bacteria. This has led to the recommendation that the nebulizer be rinsed, washed, and air dried after each use.

Here are specific recommendations: Detach the medicine cup and mouthpiece from the tubing. Wash the medicine cup and mouthpiece with warm soapy water and rinse them with water. Place the equipment on a clean towel to fully air dry. Make sure to do this after each treatment and daily.

  • Don’t wash the tubing. If it gets wet, replace the tubing. Also, don’t put any parts of the nebulizer into a dishwasher to clean it because the heat can warp the plastic. Tubing should be changed periodically, usually every two weeks.

Here is a way to disinfect the mouthpiece and cup every other day. Mix a solution of 1 part distilled white vinegar and 3 parts warm tap water in a clean bowl. Soak the nebulizer parts (except the tubing and mask) for 60 minutes, then rinse thoroughly and air dry.


Playing a Harmonica: A Breathing Exercise for COPD

Benefits of Playing a Harmonica 

Dear Dr. Mahler:

I recently read about a pulmonary rehab program that includes playing music on a harmonica in addition to usual exercises. What are your thoughts? I haven’t tried it, but it sounds like fun.

Claudia from Jackson, MS

Dear Claudia,

I found several stories on the internet about the benefits of playing a harmonica for those with COPD.

Woman with COPD playing a harmonica

Woman with COPD playing a harmonica while breathing oxygen

There were several stories about how patients with COPD enjoyed the harmonica and found it made their breathing easier.  These anecdotes came from pulmonary rehabilitation programs at hospitals in Mountain View, CA, Austin, TX, Jacksonville, FL, and Chicago, IL. A group of patients with COPD in Colorado found their own musical group which they call the Harmonicats.

The COPD Foundation lists the following benefits of Harmonicas for Health program.

♦ Learn better control of breathing

♦ Exercise the muscles that help to breathe in and breath out

♦ Strengthen abdominal muscles for a more effective cough

♦ Relieve stress

♦ Socialize with others and have fun

One individual with COPD commented, “While I am playing the harmonica, I am enjoying it and not thinking about my breathing. I have found that playing different tunes has gradually improved my breathing capacity.

I also searched for studies evaluating the use of harmonicas in patients with COPD on PubMed. There is one study published in the July-August 2012 issue of the journal Rehabilitation Nursing (volume 37; pages 207-212) that compared usual pulmonary rehabilitation (16 subjects) with the same program plus harmonica playing (9 subjects practiced 5 – 20 minutes, twice a day, for 5 days per week). The authors found no differences in functional or psychosocial outcomes between the two groups enrolled in pulmonary rehabilitation.

Claudia – despite the findings of this one study, you might consider trying a harmonica. Remember, it is one of the few musical instruments that is played breathing both in and out.  It is likely to help with better control of your breathing. Let me know how it goes if you decide to give it a try.


Donald A. Mahler, M.D.

Flu this Winter 2016-17: Important Treatment Information

What Should I Do if I get the Flu this Winter?

Dear Dr. Mahler:

I am concerned about what to do if I get the flu this season. My doctor has told me my COPD is severe, but I am doing pretty good. I use Anoro in the morning, and have Combivent as my rescue inhaler. I try to walk or do some activity every day depending on the weather. However, I worry about the flu this winter, and how I might get very sick. What is your advice?

Cecilia from Salinas, CA

Dear Cecilia:

Signs and symptoms of the flu

People who have the flu often feel some or all of these signs and symptoms:

  • Fever or feeling feverish/chills
  • Cough
  • Sore throat
  • Runny or stuffy nose
  • Muscle or body aches
  • Headaches
  • Fatigue (feeling tired)


How Flu Spreads

People with the flu can spread it to others up to about 6 feet away. Flu viruses spread mainly by droplets made when someone with flu coughs, sneezes, or talks.  A person might also get flu by touching a surface or object that has flu virus on it and then touching her or his mouth, eyes or possibly their nose.

Coughing can expel the virus and cause flu this winter

Man coughing flu virus into the air.

When is Flu Contagious?

The flu can be passed to someone else before you even know you are sick as well as when you are sick. Most adults are able to infect others starting 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Some people, especially those with weakened immune systems, might be able to infect others for an even longer time.

When do flu symptoms start?

The average time is 2 days from when a person is exposed to flu virus to when symptoms begin. However, the range is 1 to 4 days.

How to prevent getting the flu?

You should stay away from sick people. Wash your hands often with soap and water, or use an alcohol based hand rub. Avoid touching your mouth, nose, and eyes with your hands.

Certainly, it is important to get the flu vaccine. If you haven’t received it yet, make sure to the shot as soon as possible.

Can the flu be treated?

Tamiflu capsules for treating flu symptoms


There are prescription medications  called antiviral drugs for treating the flu this winter. Since you have COPD, you are considered in the high risk group. Contact your health care provider as soon as symptoms start. Tamiflu is an antiviral pill that is used to treat acute, uncomplicated illness due to influenza A and B infection if you have symptoms of the flu for less than 48 hours.

When used for treatment, antiviral drugs can lessen symptoms and shorten the time you are sick by 1 or 2 days. They also can prevent serious complications like pneumonia.

Complications of the flu

Sinus and ear infections are examples of moderate complications from flu, while pneumonia is a more serious complication that can result from either influenza virus infection alone or from co-infection of flu virus and bacteria. Other possible serious complications triggered by flu can include inflammation of the heart, brain, or muscle tissues.

I hope that this information is helpful. Be safe and stay healthy.

Donald A. Mahler, M.D.

Are Cannabinoids Effective Therapy for Those with COPD?

InMed Researching Use of Cannabinoids for COPD

Dear Dr. Mahler:

I have been reading a lot about the use of marijuana as a treatment for COPD. What is the science behind cannabinoids as a possible therapy? I was diagnosed with COPD about five years ago. My pulmonary doctor has told me that my condition is “severe.” She has recently changed my inhaler to Stiolto which has helped my breathing, but I still cannot do all the things that I want. I completed pulmonary rehabilitation 2 years ago, and go 2-3 times a week for maintenance. I live in Colorado and can use marijuana products legally. Thanks.

Gay from Fort Collins, CO

Dear Gay,

Here is a brief description of the science of marijuana. Hopefully, it is easy to understand.

Cannabinoids are chemical compounds that are the active parts of marijuana. They alter release of neurotransmitters in the brain. Neurotransmitters relay signals between nerve cells (see diagram below).  Psychoactive drugs like marijuana exert their effects by altering the actions of some neurotransmitter systems. The primary psychoactive compound in marijuana is tetrahydrocannabinol (abbreviated THC).

Diagram whereby cannabinoids alter neurotramsmitter release in the brain

Diagram of two nerve cells. On the left, neurotransmitters are released and cross the space to bind to receptors on another nerve cell.


There are two known cannabinoid receptors called CB1 and CB2. CB1 is found mainly in the brain (in the limbic system where pleasure and pain are experienced). CB2 receptors are found in the immune system with high numbers in the spleen (an organ in the abdomen). CB2 receptors are responsible for the anti-inflammatory and possibly other therapeutic effects seen in animals.

InMed Pharmaceuticals is a pharmaceutical company located in Vancouver,
British Columbia, Canada, that specializes in developing novel therapies through the research and development of cannabinoids. It began its COPD program in June 2015. Research has shown that THC can dilate breathing tubes (bronchodilation) for up to two hours after use. Additional research shows that cannabinoids have anti-inflammatory effects by inhibiting two inflammatory enzymes (COX-1 and COX-2).

Cannabinoids are active part of marijuana plants.

Marijuana plant

Gay – as you have COPD, I advise against smoking marijuana which could be harmful for your lungs. Certainly, you can choose other options such as mixing marijuana with food.
Hopefully, future research will provide more information as to benefits of cannabinoids for relief of breathing difficulty.
Best wishes,
Donald A. Mahler, M.D.

Why am I More Short of Breath with Daily Activities?

More Short of Breath in Past Five Months

Dear Dr. Mahler:

I am writing because I am more short of breath with my usual activities. It has gotten bad enough that I have placed a chair between the kitchen and TV room to sit down and catch my breath.

My doctor has told me that I have “very severe COPD” based on my last breathing tests. I am taking Stiolto Respimat every morning, and use ProAir puffer 3 to 4 times a day, depending on how active I am. I have not had a chest infection for over 3 years, and am up to date on flu and pneumonia shots.

Pulmonary rehab can help with feeling of being more short of breath

Woman with COPD doing arm curls with hand weights.

This past summer I completed 10 weeks of pulmonary rehab, and really felt good and was able to do a lot more than before the program. Since then, I have been unable to exercise because my husband isn’t able to drive me to the hospital for maintenance phase of rehab. At my last visit, the PA told me that I had gained 7 pounds since August, and she could not find any evidence of a chest infection or a heart problem. Do you have any thoughts?

Marci from Rio Rancho, NM

Dear Marci,

Feeling more short of breath is a common problem for those with COPD. A chest infection or inhaling irritants in the air can cause breathing difficulty, but this should not last for five months as you report.

The five major causes for an increase in breathing difficulty in those with COPD over several months or longer are: anemia (low number of red blood cells); anxiety; deconditioning (or being “out of shape”); heart disease; or a gradual worsening of COPD.

Based on the information that you provided, it sounds like your reduced activities (deconditioning) and weight gain are the most likely reasons for the worsening in your breathing. To check for anemia, I suggest that you ask your doctor or PA whether it is reasonable to order a blood test called a complete blood count (CBC) that can determine whether you might have anemia.

These leaning positions help with feeling of being more short of breath

Leaning forward positions can help with breathing difficulty (figure from COPD: Answers to Your Questions, 2015; Two Harbors Press, Minneapolis)

Using a chair as a rest station is a good strategy. You might also lean on the back of the chair to help with breathing just as the man on the right is leaning on the end of a table. This leaning forward position stabilizes the shoulders and enables the neck muscles to assist the diaphragm with breathing.

Best wishes on being able to breathe easy.

Donald A. Mahler, M.D.

Frequent Exacerbations of COPD and Bronchiectasis on CT Scan

Why Am I Having Frequent Exacerbations?

Dear Dr. Mahler:

I recently had a CT scan without contrast which shows no increase in several bullae, but now shows bronchiectasis.  My doctor said this was common with copd (emphysema FEV1 = 26% predicted), but not what classification. 

I have never had a cough or sputum even with exacerbations, which I have every 4 – 6 weeks for 3 years.  Should I ask for further clarification of this?  My doctor prescribed azithromycin every other day, but after several weeks always get diarrhea.  Thank you for your input.

Marie from Saco, ME

Dear Marie,

It sounds like your doctor ordered the CT scan of your chest to look for a reason for your frequent exacerbations. As I sure that you know, it is unusual to have flare-ups every 4 – 6 weeks as you are experiencing. It is important to figure out the reason.

On October 28, 2016, I posted the findings presented at the 2016 CHEST meeting that bronchiectasis was a risk factor for frequent exacerbations. If you have not read it, I encourage you to review the information (under the heading COPD News).

Bronchiectasis is a chronic condition in which the walls of the breathing tubes are thickened from long-term inflammation and scarring. It usually develops as a result of pneumonia which can damage the lungs and provide a reservoir, or space, for bacteria or mycobacteria. Over time, the number of bacteria increase in number leading to symptoms such as cough, yellow-green mucus, chest congestion, and difficulty breathing.

CT scan shows cystic bronchiectasis which can cause frequent exacerbations

A slice of the chest on a high-resolution CT scan in a 62 year old with cystic bronchiectasis. The cysts are seen on the lower portions of both lungs.

Bronchiectasis is common in those with COPD. In one study, bronchiectasis was found in 29% of 110 patients from 40 – 80 years old who were diagnosed as having COPD by their primary care physician (O’Brien. Thorax. year 2000; volume 55; pages 635-642).

Even though you are not coughing up any phlegm, I suggest that you ask your doctor to see if it possible to try to obtain a sample of mucus from your lungs. The reason is to find out if you have a chronic lung infection that is causing repeated exacerbations. The sample should be sent to the microbiology laboratory at the hospital for culture of bacteria, mycobacteria, and fungi.

The easiest approach is to breathe a solution of saline (salt water) from a nebulizer to see if this can cause you to cough something up. A respiratory therapist can help with this.

If this is not successful, you may want to ask your doctor about

Diagram of scope passed thru mouth into the lungs (called bronchoscopy)

Diagram of scope passed thru mouth into the lungs (called bronchoscopy)

bronchoscopy. This is an out-patient procedure in which a tube is placed through your mouth and then passed into the breathing tubes. Sterile water can be passed through a channel in the scope; the water can “capture” possible infectious organisms. The fluid is then suctioned back into a container for culture. I have done this in some individuals to successfully identify whether a bacteria, mycobacteria, or fungus is contributing to repeated flare-ups.

Finally, have you been tested for alpha-1 antitrypsin deficiency? Bronchiectasis is common in those with this hereditary type of emphysema. A simple blood test is used to test for this condition.

Also, I suggest that your doctor consider measuring immunoglobulin levels (A, G, and M) in your blood to evaluate for acquired immunodeficiency. Immunoglobulins are proteins in the blood that fight infection. Low levels may make it more likely for infections to occur. Replacement therapy is available for low Immunoglobulin G (abbreviated IgG) levels which can help the body fight or prevent infections.

Best wishes on finding an answer.

Donald A. Mahler, M.D.



How Can I Boost My Immune System to Prevent Chest Infections?

Foods to Boost the Immune System

Dear Dr. Mahler:

I want to know what I can do to prevent chest infections this coming winter. Each winter season I seem to get 1 or 2 flare-ups of my COPD which are due to bronchitis. Each time I am treated with an antibiotic and prednisone, and it can take up to a month for me to recover completely. I have had COPD for about 8 years, and take Symbicort inhaler in morning and evening along with ProAir for breathing problems. I get a flu shot every fall and have received both pneumonia shots. I am willing to try new things. Many thanks.

Ralph from Morris, IL

Dear Ralph:

Your question is important for everyone who has COPD. Avoiding chest infections is “key” for feeling well and keeping active throughout the winter months. Some people who have a flare-up (called an exacerbation) find that recovery from an episode may take weeks to months, and that prednisone may need to prescribed for longer than the usual 5 – 10 days.

You didn’t mention whether you smoke or not. Remember, cigarette smoking and inhaling irritants in air damage the lining of the breathing tubes (airways) that make it easier for viruses and bacteria to infect the chest. So, it is important that you do not smoke and avoid inhaling smoke, dust, fumes, etc.

Here are some foods to consider which can boost the immune system:

Button mushrooms can boost the immune system

Button mushrooms

  1. Button mushrooms – contain selenium, riboflavin, and niacin
  2. Blueberries, elderberries, and acai berries – have antioxidants
  3. Oysters – contain zinc
  4. Watermelon – has glutathione, an antioxidant
  5. Low fat yogurt – contains probiotics, or good bacteria, which may ease the severity of colds.
  6. Spinach can boost the immune system


    Spinach – has folate and vitamin C

  7. Tea – contain polyphenols and flavonoids
  8. Sweet potato – contains beta carotene
  9. Broccoli – has vitamins A and C as well as glutathione
  10. Garlic – contains allicin, a sulfur compound responsible for health benefits
  11. Miso – has probiotics
  12. Chicken soup – contains carnosine
  13. Pomegranate juice – contains punicalagins, an antioxidant, and folate
  14. Ginger – has antioxidants

I encourage you to try 1 or 2 of these different choices every day in order to boost your immune system. Also, stay active and avoid touching your face with your hands.


Donald A. Mahler, M.D.



Sweet potato

Sweet potato

Nebulizer Therapy – Can It Help Me Breathe Easier?

When to Consider Nebulizer Therapy

Dear Dr. Mahler:

I have severe COPD and attend pulmonary rehab sessions at the nearby hospital.  I take Advair in the purple disk twice a day and Spiriva powder in the capsule each morning. One of the other patients at rehab told me that she uses medicines in a nebulizer machine and this helps her breathe much better than when she used different inhalers in the past. Do you think that nebulizer therapy might help me?

Tracy from Bellingham, WA

Dear Tracy,

There are four different delivery systems for inhaled medications to treat those with COPD: metered-dose inhalers (commonly called puffers); dry powder inhalers; soft mist inhalers; and nebulizers. Some examples are shown below. In general, pharmaceutical companies have mainly been developing new bronchodilator medications as dry powders.

Metered-dose Inhaler

Metered-dose Inhaler

Examples of dry-powder inhalers

Examples of dry-powder inhalers

With dry powder inhalers, you need to take a hard and fast breath in – in order to pull the powder out of the device and overcome its internal resistance. Some individuals, especially those with more advanced COPD, may not have enough strength to successfully break up the powder packet in the inhaler device and then inhale the powder particles deep into the lower parts of the lungs.

Nebulizer therapy is used frequently to deliver bronchodilator medications to those with COPD who are experiencing a flare-up (exacerbation) both in the Emergency Department and in the hospital. Many patients with COPD find that this approach works better because you just breathe in and out normally when inhaling the medications from the nebulizer, and you don’t have to have to hold your breath as you do with the other delivery systems.

Inhaler machine for nebulizer therapy

Hand held nebulizer

There are four major reasons why your health care provider might prescribe nebulizer therapy: you have difficulty using the other inhaler devices [because of arthritis of the hands and wrists or because of difficulty following instructions (dementia)]; you have difficulty coordinating the steps to release the medication from the device, inhaling correctly, and then holding your breath for as long as possible; you are not able to breathe easier with inhaler devices; AND you do not have adequate force when breathing in to pull the powder out of the inhaler.

I suggest that you ask your health care provider whether a trial of nebulizer medications is appropriate, especially since you don’t feel it is easier to breathe with your current inhalers. Both types of bronchodilators (beta-agonists and muscarinic antagonists) as well as an inhaled corticosteroid are available in solutions for use in a nebulizer. These three different types of medications are similar to the Advair and Spiriva dry powder inhalers that you are currently using.

Best wishes,

Donald A. Mahler, M.D.

Is Fatigue due to My COPD? I feel Tired Most of the Time

I Have Fatigue Almost Every Day

Dr. Mahler:

I am 57 years old and feel fatigue and tired every single day. Although I have had shortness of breath for some time, my COPD was diagnosed four years ago before my hip replacement surgery. I take Advair and Spiriva daily and might use ProAir 1-2 times a day depending on activities. I work as a teacher’s assistant for 2nd graders, and am married to a supportive husband. The physician’s assistant whom I see doesn’t seem that interested. He simply says to stay active. Can my tiredness be due to my COPD or could it be due to something else?

Charlotte from Daytona, FL

Dear Charlotte,

Fatigue is a term used to to describe the general overall feeling of tiredness an a lack of energy. It is a common complaint and may be due to either a medical or psychological problem. Possible medical problems include a low number of red blood cells (anemia), an under active thyroid (hypothyroidism), an active infection, a sleep problem like insomnia or obstructive sleep apnea, and chronic fatigue syndrome. Anxiety and depression may also cause someone to feel tired.

A recent study evaluated factors associated with feelings of fatigue in 101 individuals with COPD and 34 healthy adults. The study was published in the October 2016 issue of Therapeutic Advances in Respiratory Disease (volume 10; pages 410-424).

Woman with fatigue

Woman with fatigue

Fatigue was more common in those with COPD (72%) compared with healthy individuals (56%). In general, those with COPD who had fatigue reported more shortness of breath with activities, had more anxiety and depression symptoms, and experienced worse quality of life compared with COPD patients who did not report feeling fatigued. Insomnia was also common in those who noted tiredness.

Charlotte – I suggest that you make an appointment with your health care provider to discuss your feelings of fatigue and tiredness. Ask to be tested for anemia, hypothyroidism, and an active infection. If these test are normal, then I suggest that you explore whether you have sleep difficulties, anxiety, or depression that might be contributing to your lack of energy.

I hope that this information is helpful. Best wishes,

Donald A. Mahler, M.D.



New Inhaler with Ectoin® Protects Against Effects of Air Pollution

Inhaled Ectoin® Provides Natural Barrier in Airways

Dear Dr. Mahler:

I live in London where there we have air pollution. My COPD is fairly stable, but I have breathing problems when I go outside and walk my dog. I check the air quality index each day, and try to limit activities to early AM and late afternoon. However, both my dog and I have to get out of the apartment several times a day or else we go crazy. Is there anything else that I can do?

Willie of London, UK

Dear Willie,

As you know, outdoor air pollution is a global health issue that kills over 3 million people a year. Research is showing new impacts on health in addition to lung and heart disease, such as Alzheimer’s, mental illness, and diabetes.

A new inhaler has been developed by a German medical device company called bitop AG. The inhaler has a molecule called Ectoin® which was discovered in the 1980s in a desert bacteria. According to Dr. Andreas Bilstein at bitop, “It is quite an inert molecule that does one main thing, which is bind water, which stablizes cell membrane tissues against physical or chemical damage.”

Ectoin may help to reduce damage to airways from air pollution

Particulate matter coming out of smokestacks in city

When inhaled, Ectoin® provides a natural barrier to help prevent damage caused by air pollution particles that can lead to inflammation of the breathing tubes (airways).  Dr. Bilstein stated that the perfect situation is that the person inhales it in the morning and evening at home.

So far, the inhaler has been tested in small groups of patients with asthma, COPD, and bronchitis considered to be at risk from air pollution.

Ectoin® does not interact with cell receptors so it is classified as a medical device rather than a drug. This means that large clinical studies are not required for official approval and the inhaler could be on sale soon. The estimated cost will be 17 pounds ($22) per month.

Bitop AG is the worldwide producer of Ectoin®. The company has about 35 employees with headquarters in Witten, Germany.

I suggest that you keep an eye out for when Ectoin® will be available. In the meantime, considering eating a lot of fruits and vegetables. These foods contain antioxidants which can provide some protection from inhaling air pollutants.


Donald A. Mahler, M.D.

What is Oral Thrush? With Which Inhalers Should I Rinse My Mouth?

How To Prevent Oral Thrush

Dear Dr. Mahler:  

I am concerned about getting thrush. I was diagnosed with severe COPD, and have improved with Stiolto Respimat. My pulmonary doctor said that I am now in the moderate category.  A nurse who works at a community college with me asked if I was rinsing my mouth with water after inhaling the medication. She said that I should do this to prevent thrush. Is that correct?

Sophia from Key Biscayne, FL

Dear Sophia:

Oral thrush is a commonly used phrase for a fungal infection of the mouth and throat (oral cavity). The fungus is called Candida albicans, and the medical condition is called oral candidiasis. This happens when the fungus – Candida albicans – accumulates in your mouth and throat.

Oral thrush with white plaques on the tongue

Oral thrush with white plaques on the tongue

 Candida albicans is a normal organism in your mouth, but sometimes it can overgrow and cause symptoms. Oral thrush causes creamy white lesions, usually on your tongue, the sides of the mouth, and/or the back of the throat. Although oral thrush can affect anyone, it’s more likely to occur in the elderly, in people with suppressed immune systems, or  those who take certain medications. Inhaler medications that contain a corticosteroid (prednisone-like medication) increase the chances of oral thrush developing.
Symptoms of oral thrush include:
1. loss of taste or an unpleasant taste in the mouth
2. redness inside the mouth and throat
3. cracks at the corners of the mouth
4. a painful, burning sensation in the mouth
Oral thrush is diagnosed by an examination of the tongue and mouth

Oral thrush is diagnosed by an examination of the tongue and mouth

 Sophiayou are taking Stiolto Respimat – which contains two different types of bronchodilators. There is no inhaled corticosteroid in Stiolto. Therefore, it is not necessary for you to rinse your mouth after using the medication. Advair, Symbicort, and Breo are approved medications for those with COPD that do contain an inhaled corticosteroid. After inhaling these medications, it is recommended to rinse the mouth with water and then spit out the water.
Donald A. Mahler, M.D.

How Long do I Need to Use Nocturnal Oxygen?

Nocturnal Oxygen: Is it Still Necessary?

Dr. Mahler:

I am writing to ask you if I should continue nocturnal oxygen during sleep. A few months ago I had a flare-up of COPD and was in the hospital for 3 nights. I am feeling better and have resumed all of my previous activities. The hospital doctor said to use oxygen at a setting of 2 with activities and during sleep. However, my breathing is fine when I go shopping and do laundry, and I have not been using the portable oxygen system for the past 2 weeks. However, I am afraid to stop the oxygen during sleep at night even though I don’t think that I really need it. What should I do?

Janet from Silver Springs, MD

Dear Janet:

Your situation is quite common. Someone with COPD can get a respiratory infection, and then need to use oxygen when discharged from the hospital. Oxygen is prescribed when the oxygen saturation level is 88% or below at rest, with walking, and’or when sleeping. Many doctors recommend use of oxygen during sleep if it is also needed with walking activities.

Oximeter which measures the percentage of oxygen being carried by hemoglobin in the blood

Oximeter which measures the percentage of oxygen being carried by hemoglobin in the blood

I assume that the oxygen supply company provided both a portable system (for activities) and a concentrator (for sleep).

At your next appointment, I suggest that you ask your health care provider to measure your saturation level at rest and while walking in the hallway for at least 2 minutes. This will determine whether you will need to use oxygen at rest and during activities.

To check whether you require oxygen during sleep, your health care provider can order a test called nocturnal oximetry. This system (shown above) measures your oxygen saturation while you sleep breathing room air (not using oxygen that evening) and records the results on a computer chip. You return the device the next day and the results can be viewed on a computer screen and/or printed on paper.  Generally, if your oxygen saturation is consistently above 88% during sleep, then you should be able to stop nocturnal oxygen.

I hope this information is helpful.

Best wishes,

Donald A. Mahler, M.D.

When will Bevespi Aerosphere be Available for my COPD?

Bevespi Aerosphere – a Dual Bronchodilator

Dear Dr. Mahler:

When will bevespi aerosphere be available?
Kenneth from Orange, MA
Dear Kenneth:
Bevespi Aerosphere is an inhaler approved on April 25, 2016, by the U.S. Food and Drug Administration for use in those with COPD.
What is Bevespi Aerosphere?  It contains two different bronchodilators that act to relax muscles that wraps around breathing tubes. One medication is called glycopyrrolate – a muscarinic antagonsit – and the other medication is called formoterol – a beta agonist. The two medications are delivered using a unique co-suspension technology. It is to be used twice a day, 12 hours apart.
Bevespi contains two different bronchodilators in a single device

Bevespi is a pressurized metered-dose inhaler

AstraZeneca is the pharmaceutical company that makes Bevespi.  Current plans are that Bevespi will be available in the U.S. in early 2017.

Contact AstraZeneca

Here is information from their website. If you are in the United States and would like additional information regarding AstraZeneca products, or you are a third party with an offer of services for AstraZeneca, you can contact the AstraZeneca Information Center by phone at 1-800-236-9933 (Monday – Friday 8 a.m. – 6 p.m. ET, excluding holidays).

Why will it take that long?

For the past several years medical insurance companies decide which medications they will cover (pay for) and what medications they will not cover (pay for). These companies have contracts with health care programs like Medicare, Medicaid, Anthem Blue Cross, and many others. These contracts typically start in January and last one year.
It is common that insurance companies have new contracts for preferred bronchodilators each year. This may require those with COPD to change their medication(s) when scheduled to be refilled early in the year.  Either you agree to change or else you may have to pay full price out of pocket or have a higher co-pay.
Finally, there are two other dual bronchodilators currently available in the U.S. One is Anoro Ellipta™, a dry powder, and the other is Stiolto Respimat™, a fine mist.
Donald A. Mahler, M.D.

Reduced Exacerbations with Two Bronchodilators

11% Reduced Exacerbations with Dual Bronchodilators

Dear Dr. Mahler:

I recently read about the results of the FLAME study on a COPD website.  As I understand the post, two different bronchodilators were better for reducing flare-ups of COPD than Advair.  I am 59 years old and have had COPD for four years. My doctor started me on Advair Diskus when I was diagnosed along with ProAir as needed. I have been doing pretty good, but had pneumonia this past winter. Should I ask my doctor about the two bronchodilator combination instead of taking Advair? Thanks for your advice.

Sam from Boulder, CO

Dear Sam:

The results of the FLAME study were presented at the International Conference of the American Thoracic Society in San Francisco in May 2016 and published in the New England Journal of Medicine on May 15, 2016 (doi:10:1056/NEJMoa1516385). Dr. Jadwiga Wedzicha is the first author of the study.

The FLAME study was a head-to-head comparison of: ♦ two different types of bronchodilators [indacaterol – a long-acting beta-agonist and glycopyrronium – a long-acting muscarinic antagonist] – brand name is Ultibro AND ♦ a bronchodilator [salmeterol] and an inhaled corticosteroid [fluticasone] – brand name is Advair.

3,300 patients from 43 countries participated in the study. After one year, the rate of COPD exacerbations (“flare-ups”) was 11% lower with indacaterol-glycopyrronium compared with salmeterol-fluticasone. Patients who received the two bronchodilators also had better quality of life and used albuterol as rescue medication less frequently.

Dr. Wedzicha commented that, “I think we can say that . . . a dual bronchodilator is the first choice combination that can be used in patients with COPD.”

Sam – I suggest that you discuss these findings with your doctor. You should be aware that an inhaled corticosteroid medication (such as fluticasone as found in Advair) is associated with an increased risk of pneumonia. For this reason alone, it would be reasonable to stop Advair since you had pneumonia this past winter. The reduced exacerbations (flare-ups) with indacaterol/glycopyrronium (Ultibro) is another reason to consider a dual bronchodilator inhaler. At the present, Ultibro is not available in the US.

Anoro Ellipta dry powder inhaler

Anoro Ellipta dry powder inhaler

Stiolto Respimat delivers a fine mist.

Stiolto Respimat delivers a fine mist.

However, Anoro Ellipta and Stiolto Respimat are dual bronchodilators available in the US and are similar to Ultibro used in the study. Neither of these medications contain a inhaled corticosteroid.


Once again, I encourage you to talk to your doctor about the results of the FLAME study and ask her/him about replacing Advair with one of the two combination bronchodilators.

Best wishes,

Donald A. Mahler, M.D.

Ozone Pollution Can Cause Respiratory Symptoms

Effects of “bad” Ozone on Lung Health

Dear Dr. Mahler:

I live in the Los Angeles area and am concerned about air pollution, especially ozone levels in the air. I was diagnosed with COPD about 4 years ago, and did pretty good until this past winter. It seemed like I had one chest infection after the other and received several different antibiotics. My breathing has not recovered completely. I notice that when there are air quality alerts this summer, I need to stay inside and “lay low.” What can you tell me about ozone?

Sally from Anaheim, CA 

Dear Sally,

Ozone is one of six common air pollutants. The other pollutants are: particulate matter; carbon monoxide; lead; sulfur dioxide; and nitrogen oxide.

Smog in Los Angeles

Smog in Los Angeles

Ozone is a gas that occurs in the Earth’s upper atmosphere and at ground level. It extends about 6 – 30 miles in the upper atmosphere and is considered to be “good” because it protects life on earth from the sun’s harmful ultraviolet (UV) rays. It is a main ingredient of urban smog – a word that comes from a combination of smoke and fog.


Formation of ozone

Formation of ozone

Ozone is created by chemical reactions between nitrogen oxide (NOx) and volatile orgnic compounds (VOC) in the presence of sunlight. Emissions from industries and electric utilities, exhaust from cars and trucks, gasoline vapors, and chemical solvents are some of the major sources of NOx and VOC.

How does “Bad” Ozone affect health? Breathing ozone can cause chest pain, coughing, throat irritation, and congestion. It can inflame the breathing tubes and worsen asthma and COPD, even causing a “flare-up” or exacerbation. Anyone who spends time outdoors in the summer may be affected, especially for those who work outdoors and for people exercising.

What is being done? On October 1, 2015, the U.S. Environmental Protection Agency (EPA) strengthened the standard for ground-level ozone from 75 to 70 parts per billion in the air. Stricter controls on industry, electrical utilities, and vehicles can also help.

Here is what you can do for your lung health. Check the air quality where you live. If the Air Quality Index (AQI) is forecast to be unhealthy, stay indoors and limit physical exertion outdoors. As ozone generally peaks in mid-afternoon to early evening, try to do shopping and run errands in the morning. Keep windows closed and use air conditioning and/or a fan to keep cool if it is hot outdoors.

Do your best to reduce air pollution from cars, trucks, gas-powdered lawn and garden equipment, and other engines by keeping them properly tuned and maintained. Reduce driving, carpool if possible, use public transportation, and walk as much as possible. 

I hope this information is helpful.

Best wishes,

Donald A. Mahler, M.D.



Tapering Pain Medications and Shortness of Breath

Tapering Pain Medications

Dear Dr. Mahler:

I am 72 yrs old. I have been on fentanyl and Norco for approx. 10 years for pain. I was born with a degenerative hip disease, had back surgery and was given this to help relieve pain. I was not told consequences of this. Now my Dr. Is lowering my dosage. I have been diagnosed with COPD had several bouts of breathing exacerbations-I now use Spiriva and it has helped until they lowered my RXs.

My question is, Could withdrawals cause my COPD to flare up? I seem to be having breathing trouble again. Appreciate any info you can give me. Thank you.

Anthony from Jackson, MS

Dear Anthony,

Both fentanyl and Norco (contains hydrocodone) are pain medications. They are called opioids that act on receptors in the body to relieve pain.  Opioids include opiates, an older term that refers to such drugs derived from opium, including morphine, and semi-synthetic and synthetic drugs, such as hydrocodone, oxycodone, and fentanyl.

Opium plant

Opium poppy. The Sumerians referred to it as “joy plant”

It appears that you are taking two similar pain medications for your chronic pain. So, it seems reasonable to reduce and hopefully stop one of these two medications.

In addition, opioids relieve breathing difficulty and are used in palliative care for persistent shortness of breath. So, it is possible that reducing your dose of either fentanyl or Norco is causing you some breathing difficulty rather than an actual exacerbation or flare-up.

You mentioned that you are taking Spiriva for COPD. This medication is a long-acting muscarinic antagonist. I suggest that you talk to you doctor and ask about adding a long-acting beta-agonist to Spiriva. This should open your airways even more and make it easier to breathe.

Anoro Ellipta enables patients to breathe easier with two bronchodilators

Anoro Ellipta dry powder inhaler

At the present time, there are four approved LABA/LAMA combinations in a single inhaler. However, only two of these – Anoro Ellipta and Stiolto Respimat – are currently available for use in the US.

Stiolto Respimat delivers a fine mist.

Stiolto Respimat delivers a fine mist.

Since you are currently using Spiriva (which is one of the two medications in Stiolto), it is quite reasonable for your doctor to stop Spiriva and to start Stiolto. You can also use albuterol inhaler as needed for quick relief of any shortness of breath.

Best wishes,

Donald A. Mahler, M.D.


Can Depression Affect my Breathing and COPD?

Depression Occurs in 25% of those with COPD

Dear Dr. Mahler:

I wanted to know your thoughts on whether depression can affect my breathing. I am 57 years old and have had COPD for about 3 years. I seem to be tired all of the time and get short of breath with little activity. I was treated for depression when I was in my 20s, but have been fine until about 3 months ago. I work as a teacher’s aide in a grade school in my town, and am now off for the summer. I quit smoking soon after I was told that I had COPD. I have an appointment with a nurse practioner in a few weeks. What do you think?

Karen from Tupper Lake, NY 

Dear Karen:

I encourage you to discuss your concerns with your health care provider. Being tired and feeling short of breath may be due to various causes including a low red blood cell level (anemia), low thyroid function (hypothyroidism), another medical problem, and a psychological condition. I suspect that the nurse practioner will order tests to check for these possibilities.

Man with depression

Man with depression

Depression is considered a mood disorder caused by changes in chemicals within the brain. According to the World Health Organization, it is estimated that 21% of women and 12% of men in the U.S will experience an episode of depression at some point in their lifetime. Recent reports from the United Kingdom and from the U.S. found that about one in four (25%) of those diagnosed with COPD suffer from depression over a three year period.

The risk of an episode of depression is related more to how may episodes you have had in the past rather than life stresses. Your previous treatment in your 20s simply means an increase in risk for another episode. That is why is important that your health care provider do a complete evaluation of all possible causes of your symptoms.

Effects of depression

Effects of depression

This condition can affect your thoughts, emotions, behaviors, and overall physical health. Typical feelings are sadness, hopelessness, guilt, moodiness, and loss of interest in friends and family. You may find that it is hard to concentrate or make decisions. It is common to withdraw from others, use drugs or alcohol to “numb yourself” in order to temporarily feel better, and miss work or other commitments. Other symptoms are lack of energy and changes in appetite resulting in weight gain or weight loss.

Depression is usually diagnosed by excluding other medical conditions and by your answers to a questionnaire. Once again, tell you health care provider how you are feeling and that you were treated for depression in the past.

Best wishes,

Donald A. Mahler, M.D.


Emphysema on CT scan – What is my prognosis?

What is my outlook for emphysema?

Dear Dr. Mahler:

I am 43 year old female who was diagnosed with chest ct mild emphysema. 3 years ago my pft was in normal range. I have since then quit smoking and gained a lot of weight. Also, I suffer from anxiety and I am terrified I will progress to end stage. I do not have the alpha tripsan defiency. Everything I read is doom and gloom and I feel as though Im doomed. I currently use symbicort 2x a day and albuterol as needed. Any advice would be greatly appreciated.

Val from Portland, OR

Dear Val:

You have a somewhat unique situation  You have emphysema on the CT scan of your chest, but normal breathing tests (PFTs). This generally indicates that your past cigarette smoking caused damage to your air sacs (alveoli), but

Microscopic view of the air sacs (alveoli) in the top right showing emphysema (destruction and enlargement).

Microscopic view of the air sacs (alveoli) in the top right showing emphysema (destruction and enlargement).

there is no narrowing or obstruction of your breathing tubes (airways). Remember that emphysema is one of two types of COPD – the other type is chronic bronchitis (coughing up mucus most days).

CT scan shows emphysema in the left lung. Arrows show "dark" areas in periphery of the lung with no blood vessels due to emphysema.

CT scan shows emphysema in the left lung. Arrows show “dark” areas in periphery of the lung with no blood vessels due to emphysema.

You wrote that everything that you read about emphysema is “doom and gloom.”

However, that is quite unlikely in your case as you quit smoking. As long as you don’t smoke, you should not have further damage to your lungs.

It is common that many people gain weight when they quit smoking. I encourage you to start an exercise program either on your own (walking daily) or join a community health and fitness center. I don’t believe that you qualify for pulmonary rehabilitation as your breathing tests are normal.

Finally, I encourage you to think positively because your condition should not get worse as long as you don’t smoke and don’t inhale irritants in the air.

Best wishes,

Donald A. Mahler, M.D.

Why is my COPD getting worse even though I quit smoking?

COPD Getting Worse – What are the Possibilities?

Dear Dr. Mahler:

Why does my COPD seem to be getting worse?  After my doctor pushed hard, I quit smoking 4 years ago. I have been doing pulmonary rehabilitation at the local hospital. However, my breathing seems to be getting worse and I have 1 – 2 chest colds each year, usually sometime between fall and spring. I take Advair and Spiriva regularly, and use ProAir 2 – 3 times a day when I am active. What do you think?

Hank from Appleton, WI

Dear Hank:

That is great that you quit smoking 4 years ago. As you know, it is important not to smoke or to inhale irritants in the air.

Respiratory system - quitting smoking can prevent COPD getting worse

Diagram of respiratory system

Have you had breathing tests that demonstrate that your numbers are going down? If not, it is important to ask your health care provider to order pulmonary function tests to find out if the results have changed.

Here is one possibility for your “COPD getting worse.” It is generally believed that inhaling toxic gases and particles from cigarette smoke causes inflammation in the breathing tubes that seems to persist even if someone quits smoking. However, damage to the lining of the breathing tubes (airways) may allow bacteria to get into the walls of these tubes. The presence of bacteria causes the body to call in white  blood cells (inflammation) in an attempt to kill the bacteria. This may also explain why you have chest infections each year.

A recent study published in Nature Communications (doi:10,1038/ncomms11240) in mice supports this concept. As author Dr. Bradley Richmond stated, “This may explain why inflammation persists in COPD even after patients stop smoking.” Of interest, the researchers were able to stop the damage in the mice by using roflumilast, an anti-inflammatory medication approved to reduce the risk of an flare-up (exacerbation) of COPD.

Other possible reasons for your “COPD getting worse” are anemia, anxiety, and a heart condition. Low fitness (called deconditioning) is unlikely as you are participating in pulmonary rehabilitation. Make sure to continue your exercise program.

Once again, I encourage you to talk to your health care provider about your concerns.


Donald A. Mahler, M.D.

Prednisone for A Worsening (Exacerbation) of COPD

The Good and Bad of Prednisone

Dear Dr. Mahler:

My problem is that I seem to need prednisone for a long time after every cold or chest infection. I am 76 years old, have had COPD for about 3 years, and take Spiriva HandiHaler and the higher dose of Symbicort inhaler along with ProAir when needed.  Since January when I caught a chest cold, I have been on different doses most of the time. My doctor has tapered me off prednisone, but within about 3-4 days, my breathing turns bad again. Do you have any suggestions? I am concerned because I am hungry all of the time and have gained about 10 pounds since January.

Thanks for any help.

Ida from Piscataway, NJ

Dear Ida:

The body responds to any infection by calling in (recruiting) inflammation cells to fight the

A microscopic view of a blood smear shows an eosinophil (an inflammatory cell) n the center surrounded by smaller red blood cells.

A microscopic view of a blood smear shows an eosinophil (an inflammatory cell) in the center surrounded by many smaller red blood cells.

virus or bacteria. However, in a chest infection, the inflammation (appears as redness and swelling) causes the walls of the breathing tubes to thicken.  This causes narrowing of the breathing tubes (as shown on the right of the figure) making it harder to breathe.

Photo on right shows chronic bronchitis due to inflammation and there is yellow mucus inside the airway

Photo on right shows redness and swelling (inflammation) of the wall of the breathing tube. Prednisone is used to reduce inflammation for a worsening (exacerbation) of COPD.

Prednisone is frequently used to treat a chest infection that causes you to be more short of breath. It is an anti-inflammatory medication that is used to treat a lot of inflammatory conditions including a worsening of asthma and COPD. Prednisone is effective in reducing the number of eosinophils. Based on results of different studies, it is usually given at a high dose (like 40 mg) for a total of 5 days.

For unclear reasons, in some individuals the inflammation persists for weeks to months, and 5 days of treatment is not enough.  In such cases, your breathing gets worse within a few days of stopping the medication. If this is happening, you will likely need a longer course of prednisone that is tapered slowly. Because long term use may cause side  effects, you need to work closely with your health care provider to figure out the dose of prednisone and how long you will require it.

The goal should be to get you off prednisone. If this is not possible, then the goal should be the lowest dose of prednisone to allow you to breathe comfortably and function.

There are many possible side effects of prednisone.  If used short term ( a few days to a few weeks), prednisone may cause difficulty sleeping, extra energy, change in mood, a “hyper” feeling, and an increase in blood glucose (sugar).  If used long term (more than a few weeks), other problems may occur such as an increase in the risk of an infection, a feeling of fatigue, high blood pressure, weight gain, swelling of the legs, and thinning of the bones (osteoporosis). Certainly, you should discuss the benefits and possible side effects of prednisone with your health care provider.


Donald A. Mahler, M.D.


Is Pulse Flow of Oxygen Enough?

Dear Dr. Mahler:

My pulmonary rehab coordinator encouraged me to write to you. I use oxygen from a small tank with activities at 3 that has pulse flow. Whenever I do anything, my oxygen saturation falls quickly to the low 80s and then comes back to the low 90s after I stop and rest.

I have severe COPD and am on “triple therapy” according to my pulmonary doctor. I have a stationary oxygen concentrator at home also set at 3, but I don’t seem to have the same drops in my saturation level when doing things at home.

I know that I could breathe better if I could keep my oxygen level above 90% with daily activities. Any suggestions?

Crystal from  Brooklyn, NY 

Dear Crystal:

Your problem is not unusual.

Here are the basics. The concentrator in your home delivers oxygen at a continuous flow. You said that your portable oxygen tank is set at pulse  flow. This means that the oxygen is flowing only when you first start to breathe in and then stops flowing when you stop inhaling. This is also called oxygen on demand. This pulse flow system allows you to use the tank longer before it runs out of oxygen.

In some individuals the pulse flow does not provide enough oxygen for the demands of your daily activities. I suspect that you will require a portable oxygen system that delivers continuous flow rather than pulse flow.

Woman using portable oxygen concentrator with continuous flow of oxygen

Woman using portable oxygen concentrator with continuous flow of oxygen

I suggest that you ask your pulmonary doctor to have your oxygen saturation measured in the office or pulmonary function laboratory doing the same activity such as walking with both continuous and pulse flow of oxygen. This will indicate whether you will require continuous flow of oxygen when you are active. If so, this means that the tank will not last as long as it currently does when you are using it.

You may need to carry an additional tank if you are away from home for a long time. Or, you might consider asking for a portable oxygen concentrator that provides both continuous and pulse flow.

Best wishes,

Donald A. Mahler, M.D.


How can I get a portable oxygen concentrator?

Dear Dr. Mahler:

I want to know your thoughts on a portable oxygen concentrator. I am 72 and have some trips planned this summer. Two people at my pulmonary rehab program have these and like them very much.

My doctor has told me that I have severe COPD, and I use two different inhalers. My oxygen is set at 3 on pulse with activities and when I exercise. When I sleep, I use a home concentrator at a setting of 2. I have talked to the company that provides my oxygen, but the man said that they do not carry portable oxygen concentrators. He said that I will have to buy one. Please help. 

Patrick from Albany, NY

Dear Patrick,

Your question about a portable oxygen concentrator is a frequent one that I receive in my practice. I will first address the situation how Medicare pays companies for providing oxygen to those who require it. This information helps you to understand how things work. Then, I will briefly describe some issues that you should consider if you decide to buy a portable oxygen concentrator. I will try to keep it simple even though is somewhat complicated.

How Medicare Pays for Oxygen

All types of oxygen are rented from a respiratory supply company. Once you qualify for oxygen by your health care provider, the company provides the oxygen to you, and then bills Medicare a monthly fixed rental fee. Medicare pays the oxygen company a monthly rental fee (from $140 to $200 per month depending on where you live) for 3 years and then a small “service fee” for the next 2 years. The oxygen company is required to maintain the equipment for a total of 5 years.

In 2013, Medicare reduced payment for portable oxygen concentrators by almost 50%. Due to this reduction in payment, many oxygen supply companies have told some individuals that Medicare does not cover a portable oxygen concentrator. The bottom line is that some oxygen companies do not believe that Medicare pays enough for the costs of a portable oxygen concentrator and therefore do not deal with them.

So, you should first talk to the respiratory supply company as you have done. If the company cannot provide the system, then you may to buy a portable oxygen concentrator.

Types of Portable Oxygen Concentrators

Airsep Focus POC that weighs 1.75 pounds.

Airsep Focus weighs 1.75 pounds.

The key features that you should consider are: weight; type of oxygen flow – pulse or continuous; available oxygen flow rates; how long the battery lasts; and cost.

One of the smallest is called the Airsep Focus that weighs 1.75 pounds, allows 2 liter/min pulse flow, and the battery lasts 3 hours.


Respironics SimplyGo POC that weighs 9.5 pounds and can be carried over the shoulder.

Respironics SimplyGo weighs 9.5 pounds and can be carried over the shoulder.


A medium sized concentrator is the Respironics SimplyGo which weighs 9.5 pounds and can be carried with a strap over the shoulder. It provides pulse flow rates of 1 – 6 liters/min and continuous flow at 1 – 2 liters/min. The battery lasts about 3.5 hours at 2 liters/min pulse flow and 1 hour at 2 liters/min continuous flow.



Bigger oxygen concentrators allow higher flow rates and longer battery time. They can be placed

Front view of SeQual Eclipse 5 POC.

SeQual Eclipse 5 POC weighs 18.4 pounds.

Cart with wheels and handle to pull POC.

Cart with wheels and handle.

on a cart with wheels and can be pulled. One of the heaviest ones is the SeQual Eclipse 5 which weighs 18.4 pounds, allows 1 – 9 liters/min pulse flow and up to 3 liters/min continuous flow. Battery time is up to 5 hours if pulse flow is used and 2 hours for continuous flow.


These are only three examples of many available portable oxygen concentrators. You should consider which features are most important for your use. Also, you may wish to rent one from a respiratory supply company before buying.

Good luck on finding the best portable oxygen concentrator for your needs.

Donald A. Mahler, M.D.


Stem Cell Therapy for Advanced Emphysema: Does It Work?

Here is a typical question among many that I have received about stem cell therapy to regenerate new lung tissue in emphysema.

Dear Dr. Mahler:

I hope that you can provide an update on stem cell therapy for emphysema. I am 53 years old and have been told that I have Stage 3 COPD /emphysema. Although I quit smoking and my lung doctor has me on the “best” medications, I find that I am slowly getting worse.  I attend pulmonary rehab 2-3 times a week, and have a normal weight. I want to be around to see my granddaughter get married. Is there hope?

Sally from Boulder, CO

Dear Sally,

It is good to hear that you are doing all of the “right things” for your COPD.

You and many others have asked about stem cell therapy. Certainly, it is an attractive option in theory – to regrow new lung tissue to replace damaged emphysema.

Unfortunately, stem cell therapy remains experimental at the present time for advanced COPD.

What are stem cells?  Stem cells have the potential to develop into cells that serve many different functions in the body. In addition, in many tissues they serve as a sort of internal repair system, dividing essentially without limit to replenish other cells as long as the person or animal is still alive. When a stem cell divides, each new cell has the potential either to remain a stem cell or become another type of cell with a more specialized function, such as a muscle cell, a red blood cell, or a lung cell.

Types of Stem Cells There are two types of stem cells. 1. Those that come from a human embryo – obtained by in-vitro fertilization in a laboratory. They cells can take on the function of any part of the body including cells in the lung. 2. Those that come from developed organs and tissues in the human. They are used by the body to repair and replace damaged areas.

Current Status of Research  Here is a summary of what is happening in research laboratories. Stem cell therapy has been used successfully in the treatment of blood (hematological) and orthopedic conditions. This technology will hopefully be used to advance knowledge as a potential treatment for those with advanced emphysema. The goal would  be to regrow functional lung tissue where there is currently disease or damage.

At the present time there are over 30 trials focusing on lung disease; 7 of these are in emphysema. Of the emphysema studies, only a few are taking place in academic medical centers in the US. The major challenges are: 1. finding a appropriate source of stem cells; and 2. finding the correct dose.

At Brigham and Women’s Hospital in Boston, a stem cell research program is underway. Researchers are taking a biopsy of the lung in someone with emphysema, growing these cells in a tissue culture, and then at a later time placing them back into the individual. If this approach is successful, it will likely take many years before this type of stem cell treatment is ready for use.

To summarize, current information does not support the benefits of stem cell therapy in treating those with advanced COPD. Hopefully, that will change in time.

Keep active and stay positive.


Donald A. Mahler, M.D.