Dr. Divakara. P
Internal Medicine
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I have a signal arthritis. Rib cage hurts when I breathe. I had a clear chronic obstructive pulmonary disease (COPD) four years back and normal pulmonary function test (PFT). I stopped smoking ten years ago. I am a swimmer and have breathing problem. I also have suspected connective tissue disease. I am currently taking Humira, Methotrexate and daily I take Nexium. I recently did PFT tests. Forced vital capacity (FVC) is 126 %, FEV1 is 126 %, FEV1/FVC 99 % predicted, Residual volume/Total lung capacity (RV/TLC) is 100 %, diffusing capacity of lung for carbon monoxide/alveolar volume (DLCO)/(VA) 100 % predicted. Are these results fine?
Hi,
Welcome to icliniq.com. Well, your pulmonary function test (PFT) values are totally fine. Any value above 80% of predicted value is considered as normal. So, your values are too good.
Patient's Query
Thank you doctor,
My total lung capacity (TLC) is 125 % of predicted, but the residual volume/ total lung capacity (RV/TLC) is 100 % predicted. Why is my total lung capacity (TLC) so high?
Hello,
Welcome back to icliniq.com. A high percentage is not a matter of concern. A high total leukocyte count (TLC) could be due to high vital capacity (VC). In a patient with past history of chronic obstructive pulmonary disease (COPD), such a high value could be considered with suspicion.
Patient's Query
Hi doctor,
I had a high resolution computed tomography (HRCT) scan last year as I have an autoimmune disorder. I stopped smoking ten years ago or may be twelve. The scan showed very mild centrilobular emphysema. I went to a pulmonologist who carried out the necessary pulmonary function test (PFT)s. He also looked at the CT scan and told me it is so mild that it is almost nonexistent. He went on to assure me my PFTs were excellent and I did not have chronic obstructive pulmonary disease (COPD). I am just very nervous. I know I smoked and damaged my lungs. But, I have exercised competitively for years since I stopped. He said it would not progress being so mild and to continue exercising. My oxygen levels are 97 to 98 at rest. During heavy exercise my heart rate is about 80% and it drops to 96 on rest. In a sprint on a hill, I have seen it drop to 94 for a moment but within two minutes there was recovery and it shot up to 98. He also said that, if I had COPD I could not recover so fast. Can you give me your opinion on this? My vital capacity (VC) is 128 % predicted.
Hello,
Welcome back to icliniq.com. Chronic obstructive pulmonary disease (COPD) is a progressive disease because the causative factors (smoking and air pollution) cannot be eliminated completely. But in your case, you had mild emphysema and more over you have stopped smoking since 10-12 years. So, the causative factor of COPD is eliminated in your case. Also COPD is not diagnosed only based on computed tomography (CT) scan. Pulmonary function test (PFT) also is important in diagnosing COPD. If PFT is normal, then it is definitely not COPD. As your values are more than 100 %; I am a bit skeptical about it. If possible, kindly get a repeat PFT done and revert back with the report. But, as of now there is nothing you need to worry about.
Patient's Query
Thank you doctor,
What you say makes sense. When you say you are skeptical what do you mean? I know that the value is above normal. This is the second one I have done since last year. Figures were basically the same. I have attached and sent you my last year reports. Kindly have a look at them. I also have a photo of the slice on computed tomography (CT). Shall I send that too? It might be of some help. Thank you.
Hi,
Welcome back to icliniq.com. I went through the attachment (attachment removed to protect patient identity). Well, if in your separate readings they are showing high normal values then it is fine. I said I was skeptical, because you were smoker though you have left it for 10 years. And your computed tomography (CT) showed someemphysematous change though mild. With this background, we can expect some (mild) reduction in your lung capacity. But, instead it is higher than normal. This made me think if there was any mistake or error in testing and hence I recommended a repeat test. But, if you have tested it twice on separate occasions and both show high normal values then it is good for you that you have a very healthy lung and definitely there is no chronic obstructive pulmonary disease (COPD).
Patient's Query
Hello doctor,
Thanks for your response. I have not been totally honest and I should tell you that initially I stopped 12 years ago and got into heavy sports this went on for about seven years. I got sick six years back with a rheumatic condition known as a spondyloarthropathy. Because of which I had to stop all my activities. Then I started smoking on and off, not heavy and not consistent. Then four years back I was checked for emphysema. The computed tomography (CT) scan was clear and pulmonary function test (PFT)s were good. So, I was assured that I had no emphysema. After a year, I smoked briefly and stopped permanently. Depression and anxiety got the better of me. I have stopped since four years. However, on another scan this time with contrast they saw that I had emphysema. That is when I went to the pulmonologist last year and returned again eight months later. He has assured me that it is very mild and said that it should not affect me. He also advised me to continue exercise and never smoke again. Now, I am into swimming and cycling. My PFTs were good, but all over 100 % and my residual volume/total lung capacity (RV)/(TLC) is 100 % predicted. I too wondered about the large values. I know it is a progressive disease and I know that I should never have started back. If I had quit 12 years ago and stayed so, I would be fine. Now, I am not so sure. I hope it is not too late.
Hello,
Welcome back to icliniq.com. Well, first of all thanks for the information. Still, there is no need to worry. Your recent pulmonary function test (PFT) is very normal which rules out chronic obstructive pulmonary disease (COPD). The emphysema seen on computed tomography (CT) could also happen due to your rheumatic condition, but again nothing needs to be done. I need to know whether you are on any medications for the rheumatic condition. And whether your rheumatic condition is active or not?
Patient's Query
Thank you doctor,
Yes, my condition is active and I have been on both Methotrexate and Humira. I have stopped Methotrexate about eight weeks now and Humira for about three weeks. I know that Methotrexate can affect the lung as well.
Hi,
Welcome back to icliniq.com. Thanks for the information. If your disease is still active then why did you stop Methotrexate and Humira (Adalimumab)? I think more than your pulmonary function tests, you need to be concerned about your rheumatic condition. Yes, Methotrexate do cause lung problem and it might have caused mild damage which is seen in the computed tomography (CT). But, as advised there is nothing to be worried of. I recommend you to consult your doctor again, who is treating your rheumatic condition, and get your medicines restarted.
Patient's Query
Hi doctor,
I am going to start back my medications. I would like to know, whether the Humira can cause emphysema changes in your lung as well. I have contacted my doctor about restarting the Humira and Methotrexate. I read about Methotrexate and it says pneumonitis is possible. Can it cause emphysema? Five years back, I was checked at a clinic and my computed tomography (CT) scan was totally clear. I started medications three years back and emphysema was discovered last year. Five years back, I smoked slightly for a few months and quit. I wonder whether the medication that has put me in this state. Please advise.
Hello,
Welcome back to icliniq.com. Well, there isno evidence that Humira causes emphysema. But yes, it can cause damage to lungs like pneumonia, interstitial lung disease but not emphysema. The same holds good for Methotrexate. Methotrexate causes interstitial pneumonitis and increases the risk of pneumonia. In one record, I came across that the long-term usage of Methotrexate may cause mild degrees of air trapping and significant increases in residual volume. This can give rise to emphysematous change and increased values in pulmonary function test (PFT). So, we can reduce, but not with 100 % surety, that your emphysematous changes and increased PFT values could be due to Methotrexate. But, still there is no harm in continuing or restarting Methotrexate.
Patient's Query
Hi doctor,
I will be speaking with my doctor about restarting the Humira and Methotrexate. What I am concerned about is the change in lung volumes and other values. My forced vital capacity (FVC) and FEV1 have increased. My total lung capacity (TLC) has increased from 6.35 to 6.72; Vital capacity (VC) has gone from 4.35 to 4.44. My inspiratory capacity (IC) has gone up a lot from 3.28 to 3.94 and my residual volume/total lung capacity (RV/TLC) is exactly as predicted. Is this hyperinflation of my lungs? Is that why the values have increased. I am attaching a photo of my computed tomography (CT). Can you explain this to me? Also, my diffusing capacity of the lungs for carbon monoxide/vital capacity (DLCO/VA) dropped from 110 to 101. I am worried. Please help.
Hi,
Welcome back to icliniq.com. Well, in my previous reply, I have said that Methotrexate causes air trapping. This air trapping causes hyperinflation of the lungs and gives high pulmonary function test (PFT) values. There is nothing to worry about Methotrexate, it can be restarted.
Patient's Query
Hello doctor,
I understood your point. I have attached several files with pictures of my lungs. The diaphragm is not flattened as you would see in emphysema. Can you comment on the severity of the lung? Do you think this will progress? I will never smoke and will continue exercise. I am due to go to hospital in a month or two for further evaluation of my arthritic condition. Thank you for all your time and help you have been of great service to me. Keep well.
Hi,
Welcome back to icliniq.com. I have gone through the scan (attachment removed to protect patient identity). Scan is pretty much normal. Yes, diaphragm is not flattened, but flattening of diaphragm is seen only in severe cases or long standing cases. I say the scan is good based on the lung parenchyma structure which is quite good. As of progression is concerned, it will not progress as long as you do not smoke. Since there is also a possibility of Methotrexate induced emphysema and if you continue taking Methotrexate for long time then it may progress. But, as of now do restart Methotrexate and do a repeat pulmonary function test (PFT) and computed tomography (CT) chest after six months. If the scan and PFT shows progression then you need to get an alternative for Methotrexate from your doctor.
Patient's Query
Hello doctor,
Thank you so much. Will take your advice and keep well. Did you see the emphysematous changes?
Hi,
Welcome back to icliniq.com. No, I am very much convinced that there were no emphysematous changes.
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Internal Medicine
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