Question: Hello Sir/Madam,
My mother who is 75 years old, has been diagnosed with these issues:
1. COPD - diagnosed since past 11 years
2. Cor Pulmonale (both left and right atrium grossly dilated, Aortic valve sclerotic, Mitral inflow suggestive elevated left ventricular end-diastolic pressure, moderate PAH+, atrial fibrillation with uncontrolled ventricular rate) - diagnosed since 1 year
3. Diabetes - Glucose random 285, diagnosed since 1 month
4. High Cholestral - diagnosed since 2 years
5. Intermittently Short term memory loss - started only 15 days ago, there is some brain shrinkage noticed in CT scan. Psychiatrist said it is too early to call it dementia and also she has issues with multiple organs and considering her age, psychiatric medication can not be added.

Currently see is on following medication:
1. Cap Pentocid DSR 40mg 1-0-0 before food
2. Tab Tadalafil 100mg 0-1-0
3. Tab Dilzem CD 120mg 0-1-0
4. Tab Warf 3mg 0-1-0
5. Tab Glycomet 0-0-1
6. Nebulizer Duolin (8am and 8pm) and Budecort 1mg (2pm) - earlier she used to take Budamate 200 Transcaps(1-0-1) and Tiova 18mg Rotacaps(0-1-0), but she is no longer capable to take these.

We have consulted best possible pulmonologist and cardiologist in XXXXXXX They said, there is not much that can be done. Now she is gone back to my native village in UP.

I am attaching following test reports
1. 2D Echo of Heart
2. ECG reports
3. Now, she is no longer able to blow in the PFT machine, so no report.
4. Her chest xray showed some fluid. We don't have report, had only film.

There was swelling in her legs also, Tab Dytor was given for a weak and stopped now.

Question - Assuming that there is not much that can be done to cure her ailments or increase longevity, we are very much worried with the pains she gets. Once in few days she gets severe pain in chest and head. It is too much for her to bear the pain and also we feel so much helpless to see that. Please suggest some medication/approach to reduce this pain in chest and head. It can be some SOS medication or regular medication. Do you think anything else can be done for her lungs or heart issues?
A humble request to please weigh both benefit and side effect of any medicine before prescribing. Please don't prescribe medicine only because I am asking for one, prescribe it only if absolutely needed.
I want to consult a very XXXXXXX cardiologist and/or Pulmonologist. Diabetes is not the main concern.

Thanks Dr XXXXXXX Few things are not very clear to me. Please clarify:
1. Is picnovit substitute for any existing medicine or in addition to current medicines?
2. How many mg and how many times, morning/evening picnovit is suggested for her?
3. Any known side effects of picnovit ?
4. 16-18 hours per day on oxygen? How is that possible?
a. Does that mean she has to be on oxygen during her entire sleep + most of the time while awake as well?
b. Will it not make her completely bedridden like an ICU patient?
c. She can't even take 15 mins of nebulizer (she removes few times and asks to stop complaining pain in nostrils). When she was admitted in hospital, she used to remove oxygen mask after some time. So how comfortable will it be for her to be on oxygen for 16-18 hours?
d. 4 times of nebulization and 16-18 hours of oxygen, will it not turn her lungs completely into dormant/passive mode and weaker?
e. What is the recommended doses of oxygen for her?
f. Will it not have any adverse effect for being on pure oxygen for such a long period compared to 20.9% oxygen normally?
5. When I checked online I see various options like Compressed oxygen cylinder, Liquid Oxygen Cylinder, Oxygen Concentrator. Choice is not very easy to make. She is not going to travel much and also we want to first try something for a month before spending big amount like 40K for concentrator. I need your help in deciding this.
6. Will it be like a mask on her face always? Can she talk/eat while on oxygen? Can you please share a picture of someone on oxygen therapy.
Thanks a lot,
XXXX

1. We couldn't find pincovit in city medical stores. He will get it in few days. I am assuming it is for long term benefit and it will not give any immediate quick relief. If it can give immediate relief, please let me know and we can try going to bigger city to get it.

2. We got nidek oxygen concentrator yesterday. My mother is not comfortable to take oxygen more than 0.25 LPM which is very low dose. If we increase more than this, she complains of mouth dryness and gasping for air sound from mouth. We gave oxygen from 4pm to 10.30pm at 0.25LPM and at 10.30pm she removed oxygen to go to restroom, after returning from restroom, she complained of severe dyspnoea (very fast breating), chest and head pain. we again started oxygen at 10.35pm and gave it whole night till 6am. We tried various oxygen level from 0.125 to 2 LPA, but nothing helped. We gave Abphylline, Omnacortil, nebulizer but nothing helped. Whole night was very difficult for her, none of us slept, she was asking death from God. There was a power cut in the morning 6am, so oxygen stopped. After 1 hour she started feeling better and from 8am without oxygen, she became alright, no breathlessness, no pain in head and chest. She had food, medicine everything.
This may be just a coincidence but we are thinking that she was worse with oxygen. We should note that she has become better in the morning after a worse night at few occasions before as well.
Questions:
a. Is dose as low as 0.25LPM helpful for her?
b. Due to power cut if we are able to give oxygen only for 10 hours, is that helpful?
c. We have currently stopped oxygen and will continue only when you say that the night time problem was not due to this.
d. We don't have an oximeter at village but whenever doctor measured her oxygen level using pulse oximeter, it came above 95%. even her artiory gas level was normal. Do we really need to buy pulse oximeter? I mean if we are administering oxygen at wrong level and we need to measure and adjust.
e. Some google search has given us these 2 links which talks about rare but harmful effect of oxygen therapy in COPD patients:
http://www.breathingbetterlivingwell.com/basics/oxygenqa.php - Please see point 6. Can too much oxygen hurt me?
https://en.wikipedia.org/wiki/Effect_of_oxygen_on_chronic_obstructive_pulmonary_disease - It talks about oxygen toxicity are due to high carbon dioxide content in the blood
How to rule out that this is not the case in my mother's case?
f. When she is in prolonged breathlessness and chest and head pain, it is very difficult situation, no medicine works that time. Can you please suggest any medicine which can help in that situation? It can even be any sedative, psychiatric medication. I read somewhere that in US patients use opioids, narcotic pain reliever etc. Please suggest some quick relief method that time. http://www.rtmagazine.com/2009/02/give-them-comfort-controlling-copd-symptoms-at-the-end-of-life/

Appreciate a quick reply. I will be consulting you further,

Please find attached
1. ABG report.
2. Other blood test reports. Sodium level slightly low, but it was later corrected with medication but was not tested again.

I am adding new questions and also asking unanswered question from past
1. Today whole day we didn't administer oxygen due to yesterday's bad experience. What should we do? Should we restart? Today whole day she didn't have breathlessness and pain without oxygen. Mostly nights become tough for her.
2. Tramadol can help in pain, but is there anything that can help in breathlessness?
3. If oxygen therapy is not able to solve breathlessness, does it mean that it is not due to lack of oxygen but due to anxiety or any other psychological cause?
4. If it is due to anxiety, do you suggest taking Petril MD 0.25mg?
5. We have only 10 hours of power, so is it Ok to give oxygen for 10 hours?
6. Once we get oximeter, can you please suggest how to decide on oxygen flow based on SPO2 level
7. How to rule out and avoid oxygen toxicity or any other harmful effect of oxygen

Thanks,
XXXX

Dear Dr XXXXXXX
I had attached ABG and Sodium reports. Not sure you saw that.

Instead of asking many questions and losing focus, please help with this only one question:

My mother remains OK for 1-2 days and then she starts feeling breathlessness and severe pain in head and chest. This extreme condition goes for 6-8 hours. It can happen in day or night anytime. It will be so severe that she and we all pray for her peaceful death during that 6-8 hours. Again she will be normal but we are scared about next such attack. She is not comfortable taking oxygen and we are yet to be sure about the extent tramadol is helping. We just got the medicine.
Now my question is - Suppose we take her to the best hospital in the country and admit and you are treating her there, what will you do for that 6-8 hours for in-patient? Is something possible in case of in-patient to ease her life for that 6-8 hours which is better than the home care that we are currently doing? She was already admitted in XXXXXXX in XXXXXXX Asia but then she didn't used to get this 6-8 hour attack thing and we didn't find in-patient care any better. This attack thing started recently.

How many more months will this go like this?
Thanks,
XXXX

Dear Sir,
Please find attached the CTPA report and suggest if this reveals any cause of her extreme breathlessness, pain in chest and head. During the attack period when it was measured in measured, following data was seen
SPO2- 93%
PCO2- 63%
Pulse rate- 190

Please suggest.