Biomedical subjects
M S Stulbarg
Publications and source records attributed to M S Stulbarg.
Bronchoalveolar lavage as the exclusive diagnostic modality for Pneumocystis carinii pneumonia. A prospective study among patients with acquired immunodeficiency syndrome.
Pneumocystis carinii pneumonia (PCP) is the most common life-threatening opportunistic infection among patients with the acquired immunodeficiency syndrome (AIDS). Because retrospective studies suggested that bronchoalveolar lavage (BAL) compared favorably to lung biopsy in the diagnosis of PCP, we prospectively evaluated the utility of BAL in 40 consecutive patients with AIDS or risk of AIDS who presented with respiratory complaints. The BAL revealed P carinii in 36 of 42 episodes of pneumonia (86 percent) among 40 patients. Clinical follow-up of the six patients whose BAL was negative for PCP suggested only one possible false negative BAL for PCP. Therefore, BAL detected PCP in 36 of 37 patients for a sensitivity of 97 percent. BAL detected cytomegalovirus in 15 of 38 patients, as well as Mycobacterium avium-intracellulare and Cryptococcus (each in one patient). By virtue of accuracy and lack of morbidity demonstrated in our study, BAL should supplant lung biopsy techniques in the evaluation of AIDS patients with pulmonary symptoms.
Helium-oxygen gas therapy. Use and availability for the emergency treatment of inoperable airway obstruction.
Inoperable obstruction of the upper airway due to extrinsic malignancy may present as respiratory failure. We treated such a patient for 48 hours with 80 percent: 20 percent helium-oxygen delivered by a nonrebreathing mask while chemotherapy and radiation therapy reduced the tumor size. The need for intubation, mechanical ventilation, and high risk surgical intervention was avoided through the use of this gas therapy. We then surveyed San Francisco Bay area hospitals and found that fewer than one half could provide this potentially lifesaving gas therapy in an emergency situation. Physiologic basis of helium-oxygen gas therapy is reviewed and recommendations made for its use and availability.
Pneumocystis carinii pneumonia radiographically simulating tuberculosis.
Eight immunocompromised patients presented with upper lobe infiltrates that radiographically simulated tuberculosis. Bilateral lobar consolidation was present in 5, and apical or posterior segmental consolidation was present in 3. Pneumocystis carinii was diagnosed in 7 patients from material obtained at bronchoscopy after sputum stained for mycobacteria had been negative. In the eighth patient, sputum submitted for cytologic evaluation demonstrated P. carinii. The 7 patients surviving this episode of pneumonia responded clinically and radiographically to specific therapy directed against P. carinii. Predominant upper lobe involvement has not been previously emphasized as a pattern of P. carinii pneumonia but should be considered in immunocompromised patients.
Bronchoalveolar lavage and transbronchial biopsy for the diagnosis of pulmonary infections in the acquired immunodeficiency syndrome.
The efficacy of bronchoalveolar lavage and transbronchial biopsy in diagnosing lung infection was determined in 276 fiberoptic bronchoscopic examinations done on 171 patients with known or suspected acquired immunodeficiency syndrome. Of 173 pathogens (Pneumocystis carinii, cytomegalovirus, Mycobacterium avium-intracellulare, Cryptococcus neoformans, M. tuberculosis, Coccidioides immitis, and Histoplasma capsulatum) identified during the initial evaluation or in the subsequent month, the initial bronchoscopic examination detected 166 (96%). Bronchoalveolar lavage and transbronchial biopsy had sensitivities of 86% and 87%, respectively. When bronchoscopy included both bronchoalveolar lavage and transbronchial biopsy, the yield for all pathogens was 98% and the sensitivity for P. carinii infections was 100%. Follow-up for at least 3 weeks after examination failed to detect any additional false-negative results. Fiberoptic bronchoscopy is extremely accurate for the detection of pathogens in patients with the acquired immunodeficiency syndrome, especially when bronchoalveolar lavage and transbronchial biopsy are combined. In patients at high risk of complications from transbronchial biopsy, bronchoalveolar lavage is sufficiently accurate to be used alone.
Outpatient treatment of chronic obstructive pulmonary disease--a practitioner's guide.
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Pulmonary embolus: detection and follow-up using magnetic resonance.
Magnetic resonance imaging (MRI) of an angiographically confirmed pulmonary embolus was performed. The thrombus appeared as an intense intraluminal signal within the left descending pulmonary artery; this signal was absent on repeat examination after clot lysis. Because MR will not image flowing blood, it provides a potential method of non-invasive identification of stationary emboli within the pulmonary vascular tree.
Computed tomography of diffuse tracheal stenosis in Wegener granulomatosis.
A patient with Wegener granulomatosis presented with diffuse tracheal narrowing and was evaluated using CT and cine-CT. The CT findings included severe laryngeal and tracheal airway narrowing, due to abnormal soft tissue within the laryngeal cartilages and tracheal rings, and enlarged abnormally calcified tracheal cartilages. Computed tomography precisely confirmed the site, level, and submucosal extent of tracheal narrowing, not obtainable on physical or bronchoscopic examination, and assisted in choosing a site for tracheostomy. Wegener granulomatosis should be considered in patients with diffuse tracheal narrowing even when the typical histology is not present.
Dyspnea and the affective response during exercise training in obstructive pulmonary disease.
BACKGROUND: Dyspnea (SOB), dyspnea-related anxiety (DA), and exercise performance have been shown to improve after exercise training in patients with Chronic Obstructive Pulmonary Disease (COPD). However, there are no published descriptions of the changes in dyspnea intensity or dyspnea-related anxiety during or across the exercise training sessions. OBJECTIVES: To describe and compare the differences in the patterns of change in SOB, DA, and exercise performance during 12 exercise training sessions with and without nurse coaching. METHODS: Forty-five dyspnea-limited patients with COPD were randomly assigned to nurse-monitored (ME) or nurse-coached exercise (CE). SOB and DA were rated on a 200 mm VAS every 2 minutes during each of 12 treadmill training sessions. RESULTS: Warm-up, peak, cool-down, mean SOB, and peak SOB/stage remained constant over the exercise sessions, with increasing exercise performance for both groups over the 12 sessions (p < .001). There was a significant difference in the pattern of mean SOB over time between the ME and CE group (p < . 05). Mean, peak DA, and peak DA/stage showed a rapid decrease within the first 4 sessions (p < . 05) with no significant differences between the groups. Warm-up and cool-down DA remained constant. There were large intra- and inter-subject variations in the rating of dyspnea and dyspnea-related anxiety within and across sessions. CONCLUSIONS: As theoretically proposed, both groups significantly decreased their DA over the training sessions. This decrease was early in the sessions and was not accompanied by a decrease in the SOB. In contrast, subjects maintained a nearly constant mean and peak SOB with increasing exercise performance, suggesting that people may have a dyspnea threshold above which they are unable to tolerate greater dyspnea. Description of the changes in dyspnea and the affective response during training need to be expanded, while studying the type and timing of strategies to enhance the improvement in dyspnea and dyspnea-related anxiety.
Accuracy of recall of dyspnea after exercise training sessions.
BACKGROUND: Although clinicians often rely on patients' retrospective reporting of dyspnea, it is not known if dyspnea scores recalled after exercise are equivalent to dyspnea scores during exercise. The objective of this study was to determine whether patients could accurately recall after exercise the maximum ratings of the intensity of dyspnea and the anxiety associated with it that they experienced during exercise. METHODS: Forty-nine patients with chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1 second 0.92 +/- 0.23 L) participating in a randomized clinical trial of the impact of coached versus monitored exercise training on dyspnea rated dyspnea intensity (shortness of breath [SOB]) and dyspnea-related anxiety (DA) on a visual analog scale every 2 minutes during treadmill exercise. After each of 12 training sessions each subject was asked to rate the worst level of the two sensations that they recalled having experienced during exercise. RESULTS: For the groups as a whole, actual maximum scores for SOB and DA during exercise were highly correlated with recalled maximum values after exercise (r > or = 0.85, P < 0.0001) and the average differences were small (0-10.9 mm on a 200-mm scale). However, individual variation was substantial, limiting predictability for individual ratings. CONCLUSIONS: After exercise, patients with COPD as a group can accurately recall the worst SOB and DA that they experienced during exercise. This finding supports the further study and use of retrospective symptom ratings as a method for dyspnea assessment during exercise training in pulmonary rehabilitation.
Desensitization and guided mastery: treatment approaches for the management of dyspnea.
Dyspnea is a frequent and distressing symptom for people with cardiopulmonary disease. Activity tolerance with presumably less dyspnea has been shown to increase after patients have been exposed to higher than usual dyspnea in a safe, monitored environment. Authors have suggested this decrease in dyspnea with activity may be due to a process of "desensitization" to the anxiety associated with the shortness of breath. The use of desensitization for other symptoms and phobias has evolved over time from an exposure-anxiety approach to a coping-mastery paradigm, labeled by some as guided mastery. This article reviews selected research studies that have used desensitization and guided mastery to treat other symptoms and phobias. Components of these two approaches are described and clinical strategies incorporating the two techniques with pulmonary patients during exercise-induced dyspnea are presented. A conceptual model that relates the two treatment approaches to the perception of the symptom and health outcomes is proposed.