• BETA BLOCKERS
  • In addition to the emails that come into the PERF office asking for advice and information there are handwritten letters and occasional telephone calls. What is printed in the newsletter is a composite of our answers to the most common problems we have heard in the past few months. Every response, whether published or not, is edited for accuracy and appropriateness by our medical team. We always try to caution you, answers can only be very general. Only your physician has access to all of your records and has also done the thorough physical examination needed to truly evaluate and advise you about the complex problems you often present us with.
  • There are exceptions to everything, however. This month we are focusing on only one patient and his trials and tribulations. We are writing this article, and releasing some of his medical information, at his specific request. He has a mission! He doesn't want anyone else to suffer as he did. He is sure, as are we, that he is not the only one who has had a similar unfortunate experience. Hugh is committed to warning all pulmonary patients, and all of their healthcare team, to be aware this very serious, preventable problem.
  • Hugh first contacted us by phone. He came across as being intelligent, well educated, knowledgeable about his disease and factual in his presentation of his problem. In fact, he was remarkably calm as he presented his case history as carefully as a physician making Rounds with interns.
  • Until about late June of last year, he had no problems. He was extremely active riding his mountain bike about 5 miles, 6 days a week, up and down hills with only normal shortness of breath. He had seen his family practice physician in June and had medication prescribed which lowered his pulse from 96 to 69. In the weeks that followed he started noticing shortness of breath. By September he was suffering from extreme shortness of breath with exercise and returned to his family practice physician.
  • Hugh outlined all the steps taken to diagnose his problem and they were impressive.
  • 9-2-05 a CT scan showing diffuse emphysema
  • 9-5-05 a pulmonary function test (PFT) showing an FEV1 (forced expiratory volume of air in one second) 30% of predicted. His FVC (forced vital capacity of the lung) was only 52% of predicted. It felt to Hugh as if he had lost 50% of his breathing capacity in the last 90 days.
  • His family practice physician, and the pulmonologist now also seeing him, attributed this to 50 years of smoking 2 packs a day. Hugh agreed this was a reasonable assumption but couldn't understand why he had such a rapid decline in pulmonary function. Nevertheless, he quit smoking yet continued to feel worse.
  • 11/18/05 a treadmill test was halted when he had a panic attack.
  • 11-30-05 an angiogram, showed that he had “the heart of a 35 year old and no blockages.” His problem was not cardiac in origin, according to the cardiologist to whom he had been referred.
  • Hugh started a pulmonary rehabilitation program, which helped by giving him lots of tips in managing his increasing inability to handle activities of daily living, BUT his exercise capacity continued to decline, rather than improving with rehab. Taking a shower caused him to break into a sweat and required 10 minutes in bed on oxygen to recuperate. Though he was on oxygen with exercise, he was still desaturating, with marked shortness of breath, biking only 15 minutes with 2 rest stops. This was a man who had been riding mountain bikes 1-½ hours without stopping 3 months earlier. Nothing he tried, none of the medications and inhalers he was prescribed, were helping. His pulmonologist told him there was nothing else she could do. Hugh was understandably depressed.
  • Hugh called the PERF office over the New Year's holiday to see if he could arrange an appointment with Dr. Petty, or get a recommendation for where he might get lung surgery. He felt he had exhausted all other options and was desperate. He said he kept insisting to his physicians that something other than smoking or the normal course of COPD must have been causing his problem. A 50% decline in lung function in such a short time did not sound logical to him.
  • Here was a man who had the best of care including referrals to a cardiologist, a pulmonologist, extensive testing (which ruled out cancer of the lung among other things), and finally, referral to a pulmonary rehabilitation program. His list of pulmonary medications was all that could be expected. He doggedly continued to try to exercise, which became more difficult all the time. His care seemed excellent yet his history was far from typical. There certainly was nothing that could be done over the phone except to suggest a consult with another pulmonologist.
  • Dr. Petty couldn't see him as a private patient but strongly agreed that Hugh should see one of the fine pulmonologists in this area. Since Hugh was local we were able to highly recommend someone known as an excellent diagnostician. This physician was affiliated with Cedars-Sinai Medical Center so he could also evaluate Hugh as a candidate for surgery if that became his only other option.
  • Hugh called back a few weeks later. Before seeing the new pulmonologist he had another pulmonary function test. The bad news was that it showed his FEV1 was now down to 28% of predicted. The good news was less than five minutes into his appointment the new pulmonologist had discovered his problem! Hugh's difficulties, unknown to him, had started back in June when he had been placed on a cardiac medication called Nadolol to lower his pulse rate. Nadolol is a beta blocker. Beta blockers are usually contra-indicated in pulmonary patients since they can often (though not always) cause bronchoconstriction, or spasm of the airways resulting in shortness of breath! In spite of the best of care, Hugh had fallen through all the cracks. His primary physician, the pharmacist filling the prescription, the cardiologist, his pulmonologist, the pulmonary rehab team and even the pharmacist working the rehab team had all missed the significance of his shortness of breath and bronchospasm after being put on the Nadolol.
  • So what happened to Hugh? He stopped taking the Nadolol immediately. By April his FEV1 was up to 45% of predicted. His FVC was back to a more normal 82%. His peak flow went from a daily average low of 150 to a 320 to 460. He is again riding his mountain bike 1 ½ hours six days a week, using oxygen only on the last uphill leg. Oh, yes, and he can take showers again without any problem! In June he is going on a 3-week tour of Scotland and England. He feels great! His advice to all of you?
  • No matter how excellent your medical care seems to be, you must take some responsibility for your own well being!
  • Read all those inserts you get with your prescriptions!
  • If you ever get one that says it is a beta blocker, or contraindicated for those with emphysema or COPD, don't take it without first discussing this very thoroughly with your physician! We might add that this applies even to medications like beta blocker eye drops, which have gotten more than one of our patients into the type of problem that Hugh experienced.
  • However, each of you is unique and different. Not everyone reacts as negatively as Hugh did. It may be that in your case a trial with a beta blocker may be indicated because of a cardiac problem. But it is very important to be aware of the possibility of developing the symptoms of shortness of breath and notifying your physician about this common side effect immediately.
  • Dr. Casaburi, in reviewing this newsletter, wanted to chime in with a little more information. Some beta-blockers are "cardioselective": they tend to influence the heart but not the lungs. These cardioselective drugs have been shown to be relatively safe in patients with lung disease. Unfortunately, Nadolol is not cardioselective and seems to be a poor choice for a patient with COPD.
  • Hugh suffered, and survived a terrible 6 months. We know all of you appreciate his willingness to share this experience with you. If he can spare even one of you from going through a similar experience he feels his mission is accomplished. Thanks, Hugh for allowing us to tell your story!