Biomedical subjects
Publications and source records attributed to M S Stulbarg.
This article reviews the differential diagnosis of obstructive lung disease, including lesions that may mimic chronic obstructive pulmonary disease, as well as the tools on which the clinician relies for making a proper diagnosis. The clinician's view of the radiologist's role is briefly discussed, but the details of specific radiologic techniques are discussed elsewhere in this issue.
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This study investigated whether people with chronic obstructive pulmonary disease (COPD) can differentiate distress and anxiety associated with dyspnea from the intensity of dyspnea and the perceived effort of breathing. Fifty-two subjects with COPD rated their perception of the individual components of dyspnea on a 200 mm visual analog scale at rest, after a 6-min walk (6MD), and every 2 min during an incremental treadmill test (ET). Subjects differentiated among the four dyspnea components at the end of the 6MD (p < .0001) and during ET (at rest, p < 0.001; at 75% VO2 max, p < 0.0001; and at end exercise, p < 0.0001). Intensity was significantly related to perceived effort of breathing (p < .0001), as distress was to anxiety (p < .0001), suggesting that each pair measures similar components. Subjects were able to differentiate their affective response to dyspnea from the intensity of the symptom. Measurement of a patient's affective response to dyspnea may improve the selection of specific treatments and validity of outcomes.
STUDY OBJECTIVE: To describe the clinical, radiographic, and autopsy features of AIDS-related non-Hodgkin's Iymphoma (NHL) with pulmonary involvement. DESIGN: Retrospective series of patients with HIV infection and NHL with pathologically documented lung or pleural involvement. SETTING: A university and a county hospital in San Francisco. PATIENTS: Thirty-eight patients with HIV infection and NHL involving the lungs or pleura. RESULTS: Most patients had respiratory symptoms (87%) and signs (84%). The majority of patients had advanced HIV infection, with a mean CD4 count of 67 (+/- 65). The most common laboratory abnormalities were elevated lactate dehydrogenase value (89%), elevated erythrocyte sedimentation rate (94%), hematologic abnormalities (95%), and widened alveolar-arterial gradient (89%). Thoracic CT revealed pulmonary nodules (50%), lobar infiltrates (27%), and lung mass (19%) as the most common parenchymal abnormalities. Pleural effusion (68%) and thoracic lymphadenopathy (54%) were unexpectedly common. Autopsy confirmed the high prevalence of pulmonary nodules (30%), airspace disease (35%), and lung mass (25%). Pleural effusions (65%) and thoracic lymphadenopathy (60%) were also common at autopsy. The respiratory system was the most common extranodal site (71%) in patients with AIDS-related NHL undergoing autopsy. Of the bronchoscopic procedures performed, transbronchial biopsy had the highest diagnostic yield (58%) for lymphoma. BAL and bronchial brushing were never diagnostic. Pleural fluid cytologic study and open lung biopsy specimens also had high diagnostic yields (75% each). CONCLUSIONS: The lung is a common extranodal site in AIDS-related NHL. NHL with pulmonary involvement occurs primarily in patients with advanced HIV infection. Most patients have nodules, infiltrates, or masses by thoracic imaging and autopsy. Thoracic lymphadenopathy is much more common than previously believed. Transbronchial biopsy, pleural fluid cytologic study, and open lung biopsy are the most useful diagnostic procedures.
STUDY OBJECTIVE: To determine whether exercise training with coaching is more effective than exercise training alone in reducing dyspnea and the anxiety and distress associated with it and improving exercise performance, self-efficacy for walking, and dyspnea with activities of daily living. DESIGN: Randomized clinical trial of 51 dyspnea-limited patients with COPD assigned to monitored (n = 27) or coached (n = 24) exercise groups. SETTING: Outpatient area of university teaching hospital. INTERVENTION: Both groups completed 12 supervised treadmill training sessions (phase 1) over 4 weeks followed by 8 weeks of home walking (phase 2). The CE group also received coaching during training. MEASUREMENTS: Perceived work of breathing, dyspnea intensity, distress associated with dyspnea, and anxiety associated with dyspnea were rated on a visual analog scale during incremental treadmill testing and after 6-min walks before and after phase 1. Dyspnea with activities of daily living, self-efficacy for walking, state anxiety, and 6-min walks were measured before and after both phases. RESULTS: Dyspnea and the associated distress and anxiety improved significantly for both groups relative to work performed and in relation to ventilation (p < 0.05). There were no significant differences between groups in any outcomes. The phase 1 improvement in laboratory dyspnea was accompanied by improvements in dyspnea with activities of daily living (p < 0.01) and self-efficacy for home walking (p < 0.01) that were sustained during the home phase. CONCLUSIONS: Coaching with exercise training was no more effective than exercise training alone in improving exercise performance, dyspnea, and the anxiety and distress associated with it, dyspnea with activities, and self-efficacy for walking.
Velocity-encoded cine magnetic resonance (MR) imaging provides two-dimensional velocity maps of a cross-sectional area of a vessel. Pulmonary flow and flow patterns in the main pulmonary artery were analyzed with velocity-encoded cine MR imaging and Doppler echocardiography in 10 patients with pulmonary hypertension (PH), one patient with a dilated main pulmonary artery, and 10 healthy subjects, and these findings were compared. Peak systolic velocity measured with velocity-encoded cine MR imaging was similar to that measured with Doppler echocardiography in healthy subjects and in patients with PH. Velocity-encoded cine MR imaging demonstrated substantial differences in velocity across the vascular lumen in PH. The flow pattern in healthy subjects was different than that in patients with PH; the latter had lower peak systolic velocity and greater retrograde flow after middle to late systole. The retrograde flow observed in patients with PH reflected hemodynamic events, since it was inversely proportional to pulmonary flow volume and directly proportional to pulmonary resistance and cross-sectional area of the vessel. Velocity-encoded cine MR imaging demonstrates an inhomogeneous flow profile in PH and may serve as a noninvasive method to estimate pulmonary vascular resistance.
Oxygen (O2) has been reported to improve exercise tolerance in some patients with chronic obstructive pulmonary disease (COPD) despite only mild resting hypoxemia (PaO2 greater than 60 mm Hg). To confirm these prior studies and evaluate potential mechanisms of benefit, we measured dyspnea scores by numeric rating scale during cycle ergometry endurance testing and correlated the severity of dyspnea with right ventricular systolic pressure (RVSP) measured by Doppler echocardiography during a separate supine incremental exercise test. Both sets of exercise were performed according to a randomized double-blind crossover protocol in which patients breathed compressed air or 40% O2. We studied 12 patients with severe COPD (FEV1 0.89 +/- 0.09 L [mean +/- SEM], FEV1/FVC 37 +/- 2%, DLCO 9.8 +/- 1.5 ml/min/mm Hg[47% of predicted], PaO2 71 +/- 2.6 mm Hg). With endurance testing on compressed air, PaO2 did not change significantly in the group as whole (postexercise PaO2 63 +/- 5.1 mm Hg, p = NS), but did fall to less than 55 mm Hg in four patients from this group. Duration of exercise increased on 40% O2 from 10.3 +/- 1.6 to 14.2 +/- 1.5 min (p = 0.005), and the rise in dyspnea scores was delayed. Oxygen delayed the rise in RVSP with incremental exercise in all patients and lowered the mean RVSP at maximum exercise from 71 +/- 8 to 64 +/- 7 mm Hg (p less than 0.03). Improvement in duration of exercise correlated with decrease in dyspnea (r2 = 0.66, p = 0.001) but not with decreases in heart rate, minute ventilation, or RVSP.(ABSTRACT TRUNCATED AT 250 WORDS)
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Pulmonary infiltrates, cough, dyspnea, and fever developed in a 62-year-old woman with chronic degenerative arthritis who had been receiving sulindac therapy for six months. Her pulmonary signs and symptoms resolved upon withholding the drug. Inadvertent rechallenge resulted in rapid recurrence of respiratory symptoms and pulmonary infiltrates. This constellation of clinical findings provides strong evidence of isolated pulmonary reactions as a complication of sulindac therapy.
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In an effort to better understand the cardiac contribution to exercise limitation in chronic lung disease, 21 patients with advanced chronic pulmonary parenchymal disease and 10 normal control subjects were evaluated for changes in right ventricular (RV) pressure, volume and function during incremental, symptom-limited supine bicycle exercise. Patients underwent sequential exercise tests with Doppler echocardiography and ultrafast cine computed tomography (CT). RV systolic pressure during exercise was determined by saline-enhanced Doppler of tricuspid regurgitation. RV ejection fraction, end-diastolic volume, stroke volume and cardiac index were obtained by CT at rest and peak exercise. Sixteen of the 21 study patients also exercised on high-flow oxygen. In the control subjects RV systolic pressure increased from 21 +/- 6 mm Hg (mean +/- standard deviation) at rest to 32 +/- 8 mm Hg at peak exercise, whereas in patients with lung disease, RV systolic pressure increased from 42 +/- 17 to 81 +/- 26 mm Hg (both p less than 0.01). Compared with the control subjects, the patients with lung disease had significantly lower mean values for RV ejection fraction at rest (47 +/- 7 vs 55 +/- 7%) and at peak exercise (47 +/- 9 vs 57 +/- 3%, respectively, both p less than 0.05). The patients who demonstrated oxyhemoglobin desaturation during exercise showed the most abnormal cardiac responses, with marked increases in mean RV systolic pressure, decreases in mean RV ejection fraction and blunted increases in cardiac index and RV stroke volume. Although acute oxygen supplementation was associated with a slight decrease in RV systolic pressure at peak exercise and a longer duration of exercise, there was no significant improvement in RV function. Doppler echocardiography and CT provide complementary and potentially useful information about right-sided heart pressures and RV ejection fraction during exercise in patients with advanced chronic lung disease. Oxyhemoglobin desaturation during exercise is a marker for the most abnormal pulmonary vascular reserve, as indicated by RV contractile dysfunction and limited ability to increase cardiac index.
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For many patients with advanced chronic airflow limitation (COPD) the treatment of dyspnea remains inadequate despite medications, rehabilitation programs, and supplemental oxygen. Bilateral carotid body resection (BCBR) is a controversial operation which has been reported anecdotally to relieve dyspnea in such patients, but its risks and long-term effects are not known. We studied pulmonary function and the ventilatory response to exercise of three severely dyspneic COPD patients who had chosen independently and without our knowledge to undergo this operation. All three patients reported improvement in dyspnea following BCBR despite the absence of improvement in their severe airflow limitation (mean FEV1 = 0.71 L before and 0.67 L after BCBR). The three patients died 6, 18 and 36 months after the removal of their carotid bodies, still convinced of the efficacy of their surgery. Their reported relief of dyspnea was associated with substantial decreases in minute ventilation and deterioration in arterial blood gases. Arterial blood gases worsened both at rest (PO2 fell from 57 to 45 mm Hg; PCO2 rose from 45 to 57 mm Hg) and during identical steady state exercise (at peak exercise, PO2 fell from 46 to 37 mm Hg and PCO2 rose from 50 to 61 mm Hg) postoperatively. Total minute ventilation decreased postoperatively both at rest (-3.4 L/min, -25 percent) and with exercise (-9.4 L/min, -39 percent) primarily because of decreases in respiratory rate (from 21 to 16 breaths/min at rest and from 25 to 18 breaths/min with exercise), and this was associated with decreases in both oxygen uptake (-26 percent) and carbon dioxide production (-22 percent) for the same external exercise workload. Whether the reported improvement in dyspnea was due to decrease in ventilation resulting from decrease in respiratory drive, a surgical placebo effect or some other unestablished effect of removal of the carotid bodies deserves further study.
Despite the known association of pleural effusion with constrictive pericarditis, the presentation of constrictive pericarditis as pleural effusion of unknown origin has, to our knowledge, never been described. After evaluating such a case, we retrospectively analyzed all cases of established constrictive pericarditis seen in this institution in the last six years. The clinical and laboratory features of this cohort of 30 patients are similar to those of other reported series. Pleural effusion was present in 18 (60%) of 30 cases. In six (12%) of the 18 cases, pleural effusion was a major component of the clinical presentation, and in three (10%) of these six cases, the persistence of pleural effusion of unknown origin was the indication for referral to this institution. Analysis of pleural fluid in four cases revealed three exudates and one transudate. We believe this is the first report of unexplained pleural effusion as the presenting manifestation of constrictive pericarditis, and this diagnosis should be added to the list of causes of unexplained pleural effusion.
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Percutaneous drainage of an infected bulla was performed under fluoroscopy in a patient who was receiving positive pressure ventilation. The procedure was without complications, and the patient was later weaned from mechanical ventilation.
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