Ask Mark …


Mark Mangus, RRT EFFORTS Board

Ruby from EFFORTS asks, I am on Symbicort® and Spiriva®, is there a substitute for Spiriva that works as well, but isn’t as drying? My mouth gets so dry with Spiriva!

Mark explains, Anticholinergics are a class of drugs that block the action of the neurotransmitter acetylcholine in the brain, allowing the airways to relax and open. The anticholinergic medications are drying to your mouth. There is no way around that with any of them.

image049-8What I always recommend is to carry lemon drops or peppermint hard candies to counter the dry mouth problem. If you are not on fluid restrictions, a sip of water at intervals is also another way to combat the problem. There is also Biotene® spray and gum, Salese lozenges and products from ACT®, Epic and Xylimelts that are available at your local drugstores. Cayenne pepper is mentioned to get your saliva juices running! Aloe vera juice, lemon, ginger, grapeseed oil, fennel seeds and the herb, cardamom, are also suggested to counteract dry mouth.


Kathleen from Georgia recently began taking Breo® Ellipita®, a once a day maintenance inhaler that combines a corticosteroid to reduce swelling and a long-acting bronchodilator to open airways. She enjoyed not having to take Qvar® and Serevent each twice daily. After using it for a few weeks, she began to feel that she was not breathing as well.

image051-3Mark advises, Some folks will not do as well with once-a-day dosing of their long-acting bronchodilators. The medication seems to work well for a period of time and then not so much. You may need to return to what you were taking previously, if it worked better overall and over the long run. Each person will react differently – please be sure to discuss this with your physician!


Joy from EFFORTS recently had a six-minute walk test (6MW) and was frustrated when the person performing the test would not give her more than 2LPM of oxygen during the test.

image053-5Mark tells us, Depending upon the purpose of the walk test, you should either be on your usual oxygen flow rate that you use during exertion or no oxygen at all. A true 6MW test should not be interrupted to put on oxygen. You are the one who should always determine when you need to stop and recover.

If the test is to assess if your oxygen saturation levels decrease or desaturate when you are active, you would do it breathing room air. It would be expected that if you desaturate you’d be very uncomfortable. You should complete the full six minutes including any rest time you deter- mine necessary. Heart rate and oxygen saturation should be recorded at intervals. Blood pressure should be measured before and immediately after you complete the test.

When testing to assess the difference between your room air baseline and your performance wearing adequate oxygen support, you should start out wearing the oxygen and increase the flow rate as needed during the test – again with you making the changes to whatever flow is needed to maintain 88 percent to 90 percent saturation or higher. You can also set it to “4” or whatever you find necessary by your own oximetry settings at home for the entire walk test.

When the walk test is intended to serve as a titration guide, time doesn’t matter as much as saturation and breathing symptoms. You should start out at a lower flow rate, as 2LPM, and increase from there to find the highest flow required to maintain acceptable oxygen saturations. We call it titrate to saturate!

The person conducting the test should not try to pace you or otherwise control your speed. They should never arbitrarily stop you if they are monitoring your saturation and don’t like to see it drop. They should count all activity during the six minutes – including rest. They should not stop the timer during rest and resume timing when the person resumes walking.


image055-7Jo asks Mark if it is ok to mix DuoNeb and Mucomyst in the nebulizer together for an aerosol treatment.

Mark assures Jo, Yes, you may mix Mucomyst and DuoNeb. You may also take them separately but be sure to take the DuoNeb first which contains the bronchodilator to open up your airways and then the Mucomyst which breaks up your secretions.