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Dr. Chip
Dr. Chip, Board Certified Physician
Category: Medical
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Experience:  20 yrs. in practice, includinge surgery, general medicine, addiction medicine and pain.
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This question is about my son who is 17 years old. Throughout

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This question is about my son who is 17 years old. Throughout his childhood he has had frequent chest infections - approximately every 4 months. His GP's have always diagnosed them as a viral infection. At age 11 his GP diagnosed him with asthma and prescribed inhalers. He continued having the chest infections with the same frequency and the blue inhalers never made any difference to his symptoms when he was ill. Over the last year he has sometimes felt disproportionately out of breath when climbing stairs.
9 weeks ago he suddenly became aware that he couldn't take a full breath, ie. when he was breathing in he couldn't complete the breath in. He also became unable to yawn. Over the following weeks he developed a cough and began producing white or pale yellow sputum. His chest felt sore and uncomfortable and he felt unwell. There is frequently a whistling noise when he exhales. He still has all these symptoms up to today.
A few weeks ago he saw a respiratory consultant who said that he definitely does not have asthma. He did a spirometry test which showed impaired function in his small airways. He arranged for a HRCT scan and an ambulatory ECG.
The ECG was normal. These are the findings of the CT scan: "Minimal scarring and atelectatic changes with mild traction bronchiectasis is noted in the right middle lobe. The rest of the lungs appear unremarkable with no significant bronchiectasis. Mild emphysematous changes noted, consistent with small airway disease. No other significant findings are seen".
He has a consultation with the consultant next week which me and my husband will attend with him. I would like some opinions/advice before that consultation please. What I would like to know is whether the CT scan indicates something serious or potentially serious. I note that his left lung has no changes so I assume that it's not normal to have these changes in his right lung. Are these changes a result of the frequent chest infections throughout his life (he's never smoked nor has anyone in our family)? What further investigations would you expect the consultant to want to carry out? The findings indicate only minimal/mild changes and yet my son feels quite unwell - he's not been able to take a full breath in or yawn for 9 weeks now and his chest feels very uncomfortable. Is there any treatment he could have for his symptoms? His GP initially upgraded his inhalers but they didn't make any difference at all and the consultant told him to not bother taking them anymore. I really feel quite concerned about the findings as they indicate scarring, atelectatic changes, traction bronchiectasis and emphysematous changes albeit they are all mild changes. Am I right to think that it would not be normal to find all these changes, even to a mild degree, in the lung of an otherwise healthy 17 year old?
Hi. With the spirometry did he also have a methacholine challenge test--where he was given first a bronchoconstrictor inhaler or nebulizer and then a bronchodilator inhaler and the test was repeated? And what specific inhalers has he been given?
Customer: replied 3 years ago.

No he's not had a methacholine challenge test with the spirometry - he blew into the spirometry equipment and was told the recorded result. He's been given Bricanyl turbohaler, Pulmicort turbohaler and Symbicort turbohaler.

OK Julie--and we can continue after this if you'd like. First off I don't agree that he couldn't have asthma since his symptoms seem to indicate that he does and he needs the challenge spirometry to look for that. I would also check him for Alpha-1 Antitrypsin Deficiency, a genetic disorder that can begin to cause emphysema in young nonsmoking patients. As for the ct findings, some of that could be just from the prior infections but there is mention of some emphysematous changes so that's why I'd check the antitrypsin deficiency. It's possible that he needs a different set of inhalers and maybe also oral Singulair to help with his breathing problems right now
Customer: replied 3 years ago.

Hi. I'm very confused over this question of whether or not he has asthma. He never responded to inhalers throughout his childhood, also he never made any wheezing noises (my Dad had asthma and he made very distinctive wheezing noises) - the only noises he's ever made are whistling noises on exhalation and some bubbling noises. Also, he never "gasped" for breath but would only be unable to complete a full breath in when ill which is what he's experiencing now. Our GP told us that the turbohalers he's been prescribed since this illness started are the strongest ones that are available and yet they've not helped him one bit. He's been no worse since he stopped using the inhalers than he was when he was using them at the beginning of this illness. Whether or not he's had the challenge spirometry test, wouldn't the strongest inhalers be effective IF he does have asthma?? - so they should have helped his breathing by now? Doesn't the fact that the inhalers haven't improved his symptoms prove that he can't have asthma? Since these inhalers aren't effective then I am EXTREMELY concerned if he could actually have asthma as he's now had these symptoms for 9 weeks and the last couple of days has been coughing up more sputum. We've taken him to 2 GP's 4 times and A&E once prior to seeing the respiratory consultant and everyone has given us a different opinion on whether or not he has asthma. IF he has asthma and these inhalers haven't been effective, then my understanding from his GP is that there aren't any stronger inhalers available so I don't understand what treatment he can have to help his breathing?? Do you think steroids would help?

Are you saying that there is nothing on the CT scan which would account for him having these breathing problems, coughing up sputum and the discomfort and soreness in his chest? Would the mild emphysematous changes account for these symptoms? Can you please answer this particular question.

I note what you say about testing for the antitrypsin deficiency and this is something I'll ask his consultant about. Would you say that it's unusual to find these changes in a 17 year old?

First off if he does have the antitrypsin deficiency it would have been there all along and it could just now be exacerbating his symptoms. A course of prednisone could help at this point. This could also be an allergy problem and I'd have him see an allergist for evaluation and if that's the case desensitizing injections would help. I'm not saying for sure he has asthma, just that that hasn't been fully evaluated as yet. He might also benefit from terbutaline. The ct scan doesn't account right now for his symptoms but it is suggestive of the antitrypsin deficiency
Customer: replied 3 years ago.

Hi. Thanks for your comment on the CT scan not accounting for his current symptoms - this is something which I was wondering about. I appreciate what you're saying that he's not been fully evaluated for asthma and I agree with you. I just wish someone had done the challenge spirometry somewhere along the line.

With regards ***** ***** he did have an allergy blood test just over a year ago as his lips kept swelling up randomly (not associated with eating). He tested positive for allergy to house dust mites and his IgE was very high. He started taking cetirizine tablets and his lips have never swollen up since then and co-incidentally he's only had one chest infection since taking the cetirizine - until he became ill 9 weeks ago. So I've wondered whether his chest problems are allergy related and yet he doesn't respond to inhalers. Also, he's always found it difficult to breathe through his nose - could this have any bearing on his symptoms?

Other than checking for antitrypsin deficiency and possibly a challenge spirometry do you think it would be worthwhile for the consultant to carry out any other investigations? We need to know what is making our son have these symptoms which are showing no signs of going and are making his life very difficult. If the CT scan does not hold the answer to what is causing the symptoms and IF he doesn't have asthma - then what else could be causing them?

He still needs the full asthma workup but I might give him a course of orednisone and Singulair to look for improvement if it is allergies. As for his nose he might have a deviated septum so I'd have an ENT look for that. I don't think there are any other tests to do for this.
Customer: replied 3 years ago.

The scan results said: "Minimal scarring and atelectatic changes with mild traction bronchiectasis is noted in the right middle lobe. The rest of the lungs appear unremarkable with no significant bronchiectasis. Mild emphysematous changes noted, consistent with small airway disease. No other significant findings are seen"

Could you please give me your interpretation of the results of the CT scan?

No problem Julie. The scarring suggests previous infections. Atelectasis is collapse of the alveoli--the air sacs--and all of us have a bit of that from time to time so it really doesn't signify anything. Bronchiectasis is a widening or dilatation of the airways that can be infectious or allergic in nature but he doesn't seem to have that. As for the mild emphysematous changes, since I can see the scan, I can't narrow that down but usually it means there may be a little overinflation of the lungs or there may be a small area where the alveoli are enlarged. That one part is key in him since at his age he shouldn't have any emphysematous changes.
Customer: replied 3 years ago.

So - the only questionable part of the scan (as far as you can say without actually seeing it) is the mild emphysematous changes. Even this, if it indicates that he may develop emphysema in the future, is only mild at this stage so you don't think it could account for his current symptoms. So, the scan doesn't appear to answer why he has his current symptoms. The consultant was very confident that he doesn't have asthma. So, as far as I can see, there must be another cause for his symptoms which hasn't showed up on the scan or on the spirometry test. Is there a possibility he could have cystic fibrosis? I believe this is diagnosed with a sweat or blood test? He has also had a normal chest x-ray a few weeks into this illness. Do you think cystic fibrosis should be considered?

Cystic fibrosis is a thought Julie and he can be screened for that but I really don't think that's the problem here. I've spent a good deal of time with you on this so I'd ask that we close the page with a rating of my service to you and please get back to me when you've got more information on his case
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