Ask Mark

image057-1Bruce B. from California tells Mark he was told that blowing up balloons was dangerous for those with emphysema but good for asthmatics. Those with emphysema risk bursting bullae blowing against too much pressure or even straining too hard holding their breath. Is this true?

Mark answers, A bullae is an air­filled sac that sits along the lining of the lung in some people with emphysema. If this should rupture, the air escapes into the chest cavity causing a pneumothorax (air between the lung and chest cavity) which can result in a collapsed lung.

I cringe every time I learn yet another person has been taught that bal­ loons are dangerous for those with emphysema. It’s utter nonsense that is not based in any evidence or an understanding of physics. It is an old notion that has somehow carried over through the years going back to the 1970s when we had a breathing exercise called ‘blow bottles’. It was a system that used two bottles filled with water that we dropped a blue colored pill into to turn the water blue so the user could see it better than without color. The bottles were interconnected with tubing such that when you blew into the tube connected to the bottle with water in it, the air pressure you generated in the bottle pushed the water through another tube and on into the empty bottle. You would then blow into the other bottle and send the water back into the bottle you had just emptied into it. You went back and forth from one bottle to the other.

Doing this caused you to generate ‘sustained’ airway pressures that could exceed 100 cm of water pressure. Instead of expanding the airways, as it was intended, the practice often collapsed smaller airways and increased pressure in the airways beyond those that did collapse. This could poten­ tially foster bursting of blebs or bullae in those with bullous emphysema. In other people, even without lung disease, it caused lung collapse, the very problem we were trying to prevent.

Blow bottles were taken off the market in the mid to late 1970s but along the way, some misguided people postulated that blowing up balloons could generate the same dynamics and potential for injury. The problem is blowing up balloons simply does not generate anywhere near similar pressures or dynamics unless one tries to blow really hard and fast when inflating a balloon.

The fact of the matter is that coughing generates many times the pressure of blowing up a balloon – even a fresh one out of the package. So, coughing is by nature more likely to cause a bleb to burst. Another fact to consider is that the percentage of people with emphysema who have bullous lung disease is less than 10 percent. So, to apply an unsupported caution to the entire population is misdirected.

I used balloon inflation exercises in my pulmonary rehab program for the entire time I managed it. That covers a few thousand people over more than 20 years. I had many with bullous lung dis­ ease who used the exercise. Not once did anyone ever blow a bleb while blowing up those balloons. I did have a few people who indeed blew blebs while coughing very hard during a coughing jag.image060-3

EFFORTS readers recently asked about pulmo- nary function testing and why you are asked to keep repeating the test!

Mark tells us, It can take five or six repetitions to achieve the required three results that must be in a close percentage of each other. Among other measurements, we determine your Forced Vital Capacity (FVC) which is the maximum amount of air you can exhale after a maximal inhalation and your Forced Expiratory Volume in one second (FEV­1) which is the amount of air you can forcibly exhale in one second.

This testing tells us about the mechanics of your lungs ability to ‘move air’. Under the GOLD Global Initiative for Chronic Obstructive Lung

Disease ( guidelines and Amer­ ican Thoracic Society standards, we classify folks into a stage of their disease (I, II, III, IV) based on the results of pulmonary function tests. Consid­ erations for treatment choices are loosely tied to what stage a person is in. Also (more loosely), mortality expectations are extrapolated from those stages.

Doing the test might be uncomfortable but it should not be painful. Drinking water during the testing maneuvers may help reduce the ‘burning’ people feel with the maximum exhalations.image062-3

What is important for clinicians like me is to know what the FVC and FEV­1 are. Those two values require the absolute maximum effort you can generate to provide reliable results to interpret. Less than maximum effort can make a person look ‘sicker’ than they actually are.

Many people undergo the tests on a yearly basis, the need for that kind of frequency in those with ‘stable’ COPD is questionable. I would suggest that one should undergo spirometry testing at least every five years. After age 70, it is reasonable to do it every two years or every year, especially if statistically and clinically significant changes are observed. After 80 though, unless the person’s condition is not ‘stable’, I don’t see great value in arbitrary testing. As a physician friend always says, “They pretty much tell us what we already know without needing the numbers.”