Breathlessness - unusual one for the chest doctors

[thepeoplespal]

After about 2 years of waiting My mum has been in for stents, only they didn't get them installed after the Doctors found nothing is blocked & deciding they could cause more harm than good. To say she is gutted is an understatement, given angiograms, CT scans done beforehand.

So with a Past Medical History of:
- Con-strictive Pericarditis (very unusual apparently, near death, 12 months in and out of hospital to get diagnosed, Dr only took risk of peeling pericardium when organs started shutting down as nothing showed up on the CT and MRI scans)
- Diagnosis of COPD probably related to smoking history, but none of the classic symptoms regarding sputum, doesn't have inhalers, doesn't get chest infections.
- fast walking 3 miles daily for quite a few years after the open heart surgery, always mega busy cooking & cleaning, with sudden onset breathlessness about 2 years ago getting worse.
- now out of breath walking 50 yards very slowly.
- mum feels it's the same feeling as the Con-strictive Pericarditis, but pericardiums aren't supposed to grow back & nothing on the CT scan, but it didn't show up before either.
- on max dose frusemide for leg oedema, which we thought was heart related.

Looks like she has now been given a referral to see a lung specialist, which given the oedema probably means pulmonary hypertension & severe COPD, can't think of anything else.

I've some medical knowledge after summarising about 5500 sets of Lloyd George notes (dangerous I Know), but it sounds to my mind a more unusual presentation of severe COPD given typical symptoms associated with it.

Is there anything that can be done to improve this breathlessness if it is severe COPD? are any of the inhalers going to improve this? or is oxygen going to be the only thing that is likely to help?

Can't see a lung transplant happening given her age.

"-" purposely added to reduce likelihood of this coming up in a search, but she's in quite a few medical journals

Edited by thepeoplespal on Friday 30th October 19:52

[joeg]

You mentioned the swelling in the legs, does the breathlessness get worse lying down? Could be start of heart failure. Also if copd related, yes inhalers will help. Also an air driven neb might be an option.

[thepeoplespal]

joeg said:

You mentioned the swelling in the legs, does the breathlessness get worse lying down? Could be start of heart failure. Also if copd related, yes inhalers will help. Also an air driven neb might be an option.

Strong possibility for both, given Past Medical history and having been on frusemide since her open heart surgery, but don't think it's worse lying down, legs more likely to swell when she doesn't have her feet up or if she has pushed things to much.

I don't think tramping the roads is ever going to be on the cards again by the looks of things.

[QuickQuack]

thepeoplespal said:

After about 2 years of waiting My mum has been in for stents, only they didn't get them installed after the Doctors found nothing is blocked & deciding they could cause more harm than good. To say she is gutted is an understatement, given angiograms, CT scans done beforehand.

So with a Past Medical History of:
- Con-strictive Pericarditis (very unusual apparently, near death, 12 months in and out of hospital to get diagnosed, Dr only took risk of peeling pericardium when organs started shutting down as nothing showed up on the CT and MRI scans)
- Diagnosis of COPD probably related to smoking history, but none of the classic symptoms regarding sputum, doesn't have inhalers, doesn't get chest infections.
- fast walking 3 miles daily for quite a few years after the open heart surgery, always mega busy cooking & cleaning, with sudden onset breathlessness about 2 years ago getting worse.
- now out of breath walking 50 yards very slowly.
- mum feels it's the same feeling as the Con-strictive Pericarditis, but pericardiums aren't supposed to grow back & nothing on the CT scan, but it didn't show up before either.
- on max dose frusemide for leg oedema, which we thought was heart related.

Looks like she has now been given a referral to see a lung specialist, which given the oedema probably means pulmonary hypertension & severe COPD, can't think of anything else.

I've some medical knowledge after summarising about 5500 sets of Lloyd George notes (dangerous I Know), but it sounds to my mind a more unusual presentation of severe COPD given typical symptoms associated with it.

Is there anything that can be done to improve this breathlessness if it is severe COPD? are any of the inhalers going to improve this? or is oxygen going to be the only thing that is likely to help?

Can't see a lung transplant happening given her age.

"-" purposely added to reduce likelihood of this coming up in a search, but she's in quite a few medical journals

Edited by thepeoplespal on Friday 30th October 19:52

Need a bit more information regarding your mother and her past medical history. A few things in there sound somewhat contradictory. How many angios had she had prior to the last one and are you sure they found nothing to be occluded or severely stenosed? It sounds more like the lesions were difficult to cross so the cardiologist made a call about not making things worse - dissecting or perforating a coronary artery is never a good thing, more so if the procedure is being performed in centre without surgical cover. If there were no lesions, there would be no mention of not making things worse. Therefore my guess would be that she does have significant lesions but they are not amenable to PCI. Do you know how many lesions there were and where they were?

What does her echo show? The important things are LV and RV function particularly ejection fraction, LV thickness, LVEDP (sometimes LVEDV is given instead, that'd be just as good), mitral and aortic valves, PA pressure and any regional wall motion abnormalities. Depending on those, might need further information.

What other cardiac investigations has she had (e.g. CMR, right heart cath, stress echo etc.) and what did they show?

She has obviously had a pericardectomy, but when was that done and did she have anything else at the same time, e.g. grafts or valves? She should've had an angio durig her work up for the surgery, do you remember what that showed? A pericardectomy doesn't mean that all the pericardium has been removed, this is simply due to technical and anatomical restrictions of what can be done. It isn't common to have a recurrance, but it can happen for a variety of reasons (due to scar tissue formation etc.) and redo surgery is very challenging.

How are her kidneys doing? It is possible to icrease the furosemide further to switch to a more potent loop diuretic, e.g. metalozone, or add another type of diuretic but this would need careful monitoring of her renal function and may not be possible if she already has an eleent of impairment.

Referral to a respiatory physician may be to optimise treatment options rather than PHT or severe COPD. Not every COPD patient responds to inhalers, they're only useful if there any evidence of reversibility, or if there's a need for steroids. It's not uncommon that there isn't much revesiblility with smoking related lung disease (COPD being just one of them). If her cardiac disease is not amenable to intervention (which includes surgery and PCI), optimising her COPD management is a good idea from a symtomatic point of view. Do you know any of the figures from a recent lung function test? Absolute values as well as % predicted would be helpful.

On the whole, this sounds like a combination of heart failure due to multiple aetiologies with background COPD in a very challenging clinical scenario. Good luck to your mother, I do hope she feels beer soon.