Outcome measurement in pulmonary rehabilitation.

The measurement of outcomes of therapy is becoming ever more important as part of the overall management of an individual patient. This is particularly true when considering pulmonary rehabilitation for a patient with chronic lung disease. Health, clinical, and behavioral domains should be assessed when evaluating the effectiveness of pulmonary rehabilitation. This assessment of outcomes can be easily made using currently available tools.

The effects of exercise testing on the prescription of oxygen therapy.

This study reviews the effects of using oxygen saturation measurements during exercise and the effects of the method of exercise testing on the prescription of oxygen therapy. Using cutaneous oximetry (designated A and B models) and co-oximetry, 25 of 41 patients (model A), 30 of 39 patients (model B), and 28 of 42 patients (co-oximetry) had an oxygen saturation measurement greater than 85 percent at maximal incremental exercise despite an arterial oxygen tension less than 55 mm Hg. Also, in a group of patients who underwent incremental followed by constant work rate testing, 9 of 28 exhibited a fall in arterial oxygen tension to 55 mm Hg or below only during the constant work rate testing. Oxygen saturation measurements cannot reliably be used as a substitute for arterial oxygen tension measurements for the prescription of oxygen therapy. The type of exercise study performed may influence the outcome of such oxygen prescription.

Tracheal perforation. A complication associated with transtracheal oxygen therapy.

A 73-year-old woman with a transtracheal oxygen catheter in place developed sudden onset of respiratory distress and subcutaneous emphysema. Bronchoscopy revealed the presence of three posterior tracheal wall perforations and a blind pouch arising from one of the perforations. Subsequent bronchoscopies revealed complete healing of the perforations. We believe that these perforations occurred during placement of the transtracheal catheter.

Pressure support ventilation with a simplified ventilatory support system administered with a nasal mask in patients with respiratory failure.

Thirty-one consecutive patients with respiratory failure in whom treatment with intubation and mechanical ventilation was being strongly considered received alternative ventilatory support by means of a BiPAP ventilatory support system and nasal mask. Laboratory measurements and physical findings were documented before and 1 h after initiation of support. This support improved patient comfort, slowed respiratory rate, and improved oxygenation. Support lasted from 2 h to six days. Seventy-six percent (22/29) of patients recovered from this episode of respiratory failure, avoiding alternative mechanical ventilatory support. There were no complications associated with aspiration, gastric distention, or acute separation from support.

Chylothorax complicating right upper lobectomy.

Chylothorax after pleuropulmonary surgery is unusual. We have described the case of a patient in whom this complication followed a right upper lobectomy. Early recognition is important to avoid potential morbidity and mortality.

False-positive transcarinal needle aspirate in the evaluation of bronchogenic carcinoma.

Advances in the staging of regional mediastinal lymph node metastases from lung carcinoma include transcarinal needle aspiration. However, since most clinicians feel that documented tumor involvement of subcarinal nodes is a strong contraindication to aggressive surgical resection, a falsely positive carinal aspirate could deny a patient potentially curative resectional surgery. Herein, we present a case of a falsely positive transcarinal needle aspirate in which resectional surgery was carried out with a subsequent 34-month disease-free state.

Endobronchial metastases due to colorectal carcinoma.

Metastatic disease from colorectal carcinoma to the tracheobronchial tree has previously been reported in only 15 cases. Various modalities of treatment have been attempted but have met with limited success. We describe an additional nine cases, as documented by fiberoptic bronchoscopy, treated by Nd-Yag laser therapy debulking. Improvement in bronchial patency was evidenced visually in each case, and relief of symptoms occurred in eight cases. Survival periods of up to 21 months occurred. This type of metastatic disease may be more common than previously reported and combination therapy to include Nd-Yag laser debulking offers a safe and effective alternative in the palliative management of pulmonary symptoms and increased survival in select patients.

The use of cutaneous oximetry in the prescription of long-term oxygen therapy.

Using current Medicare guidelines for the prescription of long-term oxygen therapy, we studied the impact on decision-making of substituting cutaneous oxyhemoglobin saturation measurements (SaO2) for direct arterial oxygen tension measurements (PaO2). Fifty-five patients with chronic lung disease and resting hypoxemia were studied. More than 80 percent of patients with a resting PaO2 of 7.33 kPa (55 mm Hg) or less had a cutaneous oximetry SaO2 greater than 85 percent. These patients would not have met the guidelines for long-term oxygen therapy if the cutaneous oximetry measurements were used instead of direct PaO2 measurements. Substituting a threshold criterion of 88 percent instead of 85 percent resulted in fewer patients being denied oxygen therapy but also included patients with PaO2 values greater than 7.33 kPa (55 mm Hg). We conclude that cutaneous oximetry cannot be substituted equivalently for PaO2 measurements in prescribing long-term oxygen therapy.

The treatment of endobronchial stenosis using balloon catheter dilatation.

Acquired bronchial stenosis has been associated with sleeve resection, tuberculosis, sarcoidosis, and prolonged intubation. Various modalities of therapy for the relief of such stenoses include surgery, cryotherapy, and laser photoresection. Several recent reports have described the use of angioplasty balloon catheters for dilatation of stenotic areas. In two patients with endobronchial stenosis, we found that balloon dilatation, using either angioplasty or valvuloplasty catheters, in combination with laser photoresection can be safely and effectively performed with alleviation of pulmonary symptoms.

Impotence and diabetes.

The link between impotence and diabetes has been suspected since the 1700s, but it has been only within the last few decades that it has been scientifically investigated and confirmed. Of the 5 million diabetic men in the United States, 30% to 60% suffer from impotence, a complication of their disease that many of them fear more than any other, including blindness. Diabetes is the leading physiologic cause of impotence, and it occurs in both insulin-dependent and non-insulin dependent patients. In most cases, there is no relationship between the control, the duration, or the severity of diabetes and the occurrence of impotence. Treatment methods range from adjustments in nutrition to penile implants.

Pulmonary artery obstruction due to malignant fibrous histiocytoma.

Obstruction of the pulmonary artery can be due to a variety of conditions, including chronic thromboembolic disease, neoplasia, and fibrosing mediastinitis. Differentiation can be difficult. We report a case of malignant fibrous histiocytoma causing intravascular obstruction and include a review of the literature.

Right ventricular inflow and outflow obstruction due to adrenal cell carcinoma.

A 48-year-old man with surgically removed adrenal cell carcinoma presented with shortness of breath and fatigue. Physical examination revealed neck vein distention and a new systolic murmur. Echocardiography showed a right ventricular mass causing inflow and outflow tract obstruction. These findings were confirmed at surgery.