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Pulmonary function tests in systemic sclerosis-associated interstitial lung disease: new directions and future prospects. CURRENT OPINION IN PHYSIOLOGY 2021. [DOI: 10.1016/j.cophys.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Barisione G, Brusasco V. Lung diffusing capacity for nitric oxide and carbon monoxide following mild-to-severe COVID-19. Physiol Rep 2021; 9:e14748. [PMID: 33625799 PMCID: PMC7903940 DOI: 10.14814/phy2.14748] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 02/06/2023] Open
Abstract
A decreased lung diffusing capacity for carbon monoxide (DLCO ) has been reported in a variable proportion of subjects over the first 3 months of recovery from severe coronavirus disease 2019 (COVID-19). In this study, we investigated whether measurement of lung diffusing capacity for nitric oxide (DLNO ) offers additional insights on the presence and mechanisms of gas transport abnormalities. In 94 subjects, recovering from mild-to-severe COVID-19 pneumonia, we measured DLNO and DLCO between 10 and 266 days after each patient was tested negative for severe acute respiratory syndrome coronavirus 2. In 38 subjects, a chest computed tomography (CT) was available for semiquantitative analysis at six axial levels and automatic quantitative analysis of entire lungs. DLNO was abnormal in 57% of subjects, independent of time of lung function testing and severity of COVID-19, whereas standard DLCO was reduced in only 20% and mostly within the first 3 months. These differences were not associated with changes of simultaneous DLNO /DLCO ratio, while DLCO /VA and DLNO /VA were within normal range or slightly decreased. DLCO but not DLNO positively correlated with recovery time and DLCO was within the normal range in about 90% of cases after 3 months, while DLNO was reduced in more than half of subjects. Both DLNO and DLCO inversely correlated with persisting CT ground glass opacities and mean lung attenuation, but these were more frequently associated with DLNO than DLCO decrease. These data show that an impairment of DLNO exceeding standard DLCO may be present during the recovery from COVID-19, possibly due to loss of alveolar units with alveolar membrane damage, but relatively preserved capillary volume. Alterations of gas transport may be present even in subjects who had mild COVID-19 pneumonia and no or minimal persisting CT abnormalities. TRIAL REGISTRY: ClinicalTrials.gov PRS: No.: NCT04610554 Unique Protocol ID: SARS-CoV-2_DLNO 2020.
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Affiliation(s)
- Giovanni Barisione
- Struttura Semplice Fisiopatologia Respiratoria, Clinica Malattie Respiratorie e Allergologia, Dipartimento di Medicina Interna e Specialità Mediche, Università di Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Vito Brusasco
- Centro Polifunzionale di Scienze Motorie, Dipartimento di Medicina Sperimentale, Università di Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Occhipinti M, Bruni C, Camiciottoli G, Bartolucci M, Bellando-Randone S, Bassetto A, Cuomo G, Giuggioli D, Ciardi G, Fabbrizzi A, Tomassetti S, Lavorini F, Pistolesi M, Colagrande S, Matucci-Cerinic M. Quantitative analysis of pulmonary vasculature in systemic sclerosis at spirometry-gated chest CT. Ann Rheum Dis 2020; 79:1210-1217. [PMID: 32606043 DOI: 10.1136/annrheumdis-2020-217359] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/27/2020] [Accepted: 06/02/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To prospectively investigate whether differences in pulmonary vasculature exist in systemic sclerosis (SSc) and how they are distributed in patients with different pulmonary function. METHODS Seventy-four patients with SSc undergoing chest CT scan for interstitial lung disease (ILD) screening or follow-up were prospectively enrolled. A thorough clinical, laboratory and functional evaluation was performed the same day. Chest CT was spirometry gated at total lung capacity and images were analysed by two automated software programs to quantify emphysema, ILD patterns (ground-glass, reticular, honeycombing), and pulmonary vascular volume (PVV). Patients were divided in restricted (FVC% <80, DLco%<80), isolated DLco% reduction (iDLco- FVC%≥80, DLco%<80) and normals (FVC%≥80, DLco%≥80). Spearman ρ, Mann-Whitney tests and logistic regressions were used to assess for correlations, differences among groups and relationships between continuous variables. RESULTS Absolute and lung volume normalised PVV (PVV/LV) correlated inversely with functional parameters and positively with all ILD patterns (ρ=0.75 with ground glass, ρ=0.68 with reticular). PVV/LV was the only predictor of DLco at multivariate analysis (p=0.007). Meanwhile, the reticular pattern prevailed in peripheral regions and lower lung thirds, PVV/LV prevailed in central regions and middle lung thirds. iDLco group had a significantly higher PVV/LV (2.2%) than normal (1.6%), but lower than restricted ones (3.8%). CONCLUSIONS Chest CT in SSc detects a progressive increase in PVV/LV as DLco decreases. Redistribution of perfusion to less affected lung regions rather than angiogenesis nearby fibrotic lung may explain the results. Further studies to ascertain whether the increase in PVV/LV reflects a real increase in blood volume are needed.
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Affiliation(s)
- Mariaelena Occhipinti
- Dept Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Cosimo Bruni
- Biomedicine, Division of Rheumatology, University of Florence, Florence, Italy.,Dept Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianna Camiciottoli
- Dept Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy.,Dept CardioThoracoVascular, AOUC, Florence, Italy
| | | | - Silvia Bellando-Randone
- Biomedicine, Division of Rheumatology, University of Florence, Florence, Italy.,Dept Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Anna Bassetto
- Dept Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giovanna Cuomo
- Precision Medicine, Universita degli Studi della Campania Luigi Vanvitelli, Caserta, Italy
| | - Dilia Giuggioli
- Rheumatology Unit, Policlinico di Modena, Universita degli Studi di Modena e Reggio Emilia, Modena, Italy
| | | | | | - Sara Tomassetti
- Dept Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Dept CardioThoracoVascular, AOUC, Florence, Italy
| | - Federico Lavorini
- Dept Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Dept CardioThoracoVascular, AOUC, Florence, Italy
| | - Massimo Pistolesi
- Dept Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Stefano Colagrande
- Dept Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy.,Radiology Unit, University of Florence, Florence, Italy
| | - Marco Matucci-Cerinic
- Dept Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Dept Internal Medicine, University of Florence, Florence, Italy
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Barisione G, Garlaschi A, Occhipinti M, Baroffio M, Pistolesi M, Brusasco V. Value of lung diffusing capacity for nitric oxide in systemic sclerosis. Physiol Rep 2020; 7:e14149. [PMID: 31264386 PMCID: PMC6603284 DOI: 10.14814/phy2.14149] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/01/2019] [Indexed: 01/08/2023] Open
Abstract
A decreased lung diffusing capacity for carbon monoxide (DLCO ) in systemic sclerosis (SSc) is considered to reflect losses of alveolar membrane diffusive conductance for CO (DMCO ), due to interstitial lung disease, and/or pulmonary capillary blood volume (VC ), due to vasculopathy. However, standard DLCO does not allow separate DMCO from VC . Lung diffusing capacity for nitric oxide (DLNO ) is considered to be more sensitive to decrement of alveolar membrane diffusive conductance than DLCO . Standard DLCO and DLNO were compared in 96 SSc subjects with or without lung restriction. Data showed that DLNO was reduced in 22% of subjects with normal lung volumes and DLCO , whereas DLCO was normal in 30% of those with decreased DLNO . In 30 subjects with available computed tomography of the chest, both DLCO and DLNO were negatively correlated with the extent of pulmonary fibrosis. However, DLNO but not DLCO was always reduced in subjects with ≥ 5% fibrosis, and also decreased in some subjects with < 5% fibrosis. DMCO and VC partitioning and Doppler ultrasound-determined systolic pulmonary artery pressure could not explain individual differences in DLCO and DLNO . DLNO may be of clinical value in SSc because it is more sensitive to DMCO loss than standard DLCO , even in nonrestricted subjects without fibrosis, whereas DLCO partitioning into its subcomponents does not provide information on whether diffusion limitation is primarily due to vascular or interstitial lung disease in individual subjects. Moreover, decreased DLCO in the absence of lung restriction does not allow to suspect pulmonary arterial hypertension without fibrosis.
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Affiliation(s)
- Giovanni Barisione
- Unità Operativa Fisiopatologia Respiratoria, Dipartimento di Medicina Interna, Università di Genova, Genova, Italy
| | - Alessandro Garlaschi
- Dipartimento della Diagnostica per Immagini e Radioterapia, Ospedale Policlinico San Martino - IRCCS, Genova, Italy
| | - Mariaelena Occhipinti
- Dipartimento di Medicina Sperimentale e Clinica, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Michele Baroffio
- Unità Operativa Fisiopatologia Respiratoria, Dipartimento di Medicina Interna, Università di Genova, Genova, Italy
| | - Massimo Pistolesi
- Dipartimento di Medicina Sperimentale e Clinica, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Vito Brusasco
- Unità Operativa Fisiopatologia Respiratoria, Dipartimento di Medicina Interna, Università di Genova, Genova, Italy
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Richter MJ, Grimminger J, Krüger B, Ghofrani HA, Mooren FC, Gall H, Pilat C, Krüger K. Effects of exercise training on pulmonary hemodynamics, functional capacity and inflammation in pulmonary hypertension. Pulm Circ 2017; 7:20-37. [PMID: 28680563 PMCID: PMC5448538 DOI: 10.1086/690553] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/29/2016] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension (PH) is characterized by severe exercise limitation mainly attributed to the impairment of right ventricular function resulting from a concomitant elevation of pulmonary vascular resistance and pressure. The unquestioned cornerstone in the management of patients with pulmonary arterial hypertension (PAH) is specific vasoactive medical therapy to improve pulmonary hemodynamics and strengthen right ventricular function. Nevertheless, evidence for a beneficial effect of exercise training (ET) on pulmonary hemodynamics and functional capacity in patients with PH has been growing during the past decade. Beneficial effects of ET on regulating factors, inflammation, and metabolism have also been described. Small case-control studies and randomized clinical trials in larger populations of patients with PH demonstrated substantial improvements in functional capacity after ET. These findings were accompanied by several studies that suggested an effect of ET on inflammation, although a direct link between this effect and the therapeutic benefit of ET in PH has not yet been demonstrated. On this background, the aim of the present review is to describe current concepts regarding the effects of exercise on the pulmonary circulation and pathophysiological limitations, as well as the clinical and mechanistic effects of exercise in patients with PH.
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Affiliation(s)
- Manuel J. Richter
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Germany
| | - Jan Grimminger
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Germany
- Department of Internal Medicine, University Clinic Hamburg Eppendorf, University of Hamburg, Hamburg, Germany
| | - Britta Krüger
- Institute of Sport Science, Justus Liebig-University Giessen, Giessen, Germany
| | - Hossein A. Ghofrani
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Germany
- Department of Pneumology, Kerckhoff Heart and Thoracic Center, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - Frank C. Mooren
- Department of Sports Medicine, Justus Liebig-University Giessen, Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Germany
| | - Christian Pilat
- Department of Sports Medicine, Justus Liebig-University Giessen, Giessen, Germany
| | - Karsten Krüger
- Department of Sports Medicine, Justus Liebig-University Giessen, Giessen, Germany
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Godinas L, Amar D, Montani D, Lau EM, Jaïs X, Savale L, Jevnikar M, Sitbon O, Simonneau G, Humbert M, Laveneziana P, Garcia G. Lung capillary blood volume and membrane diffusion in precapillary pulmonary hypertension. J Heart Lung Transplant 2016; 35:647-56. [DOI: 10.1016/j.healun.2015.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/25/2015] [Accepted: 12/15/2015] [Indexed: 11/27/2022] Open
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Pulmonary Vascular Congestion: A Mechanism for Distal Lung Unit Dysfunction in Obesity. PLoS One 2016; 11:e0152769. [PMID: 27035663 PMCID: PMC4817979 DOI: 10.1371/journal.pone.0152769] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 03/18/2016] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Obesity is characterized by increased systemic and pulmonary blood volumes (pulmonary vascular congestion). Concomitant abnormal alveolar membrane diffusion suggests subclinical interstitial edema. In this setting, functional abnormalities should encompass the entire distal lung including the airways. OBJECTIVES We hypothesize that in obesity: 1) pulmonary vascular congestion will affect the distal lung unit with concordant alveolar membrane and distal airway abnormalities; and 2) the degree of pulmonary congestion and membrane dysfunction will relate to the cardiac response. METHODS 54 non-smoking obese subjects underwent spirometry, impulse oscillometry (IOS), diffusion capacity (DLCO) with partition into membrane diffusion (DM) and capillary blood volume (VC), and cardiac MRI (n = 24). Alveolar-capillary membrane efficiency was assessed by calculation of DM/VC. MEASUREMENTS AND MAIN RESULTS Mean age was 45±12 years; mean BMI was 44.8±7 kg/m2. Vital capacity was 88±13% predicted with reduction in functional residual capacity (58±12% predicted). Despite normal DLCO (98±18% predicted), VC was elevated (135±31% predicted) while DM averaged 94±22% predicted. DM/VC varied from 0.4 to 1.4 with high values reflecting recruitment of alveolar membrane and low values indicating alveolar membrane dysfunction. The most abnormal IOS (R5 and X5) occurred in subjects with lowest DM/VC (r2 = 0.31, p<0.001; r2 = 0.34, p<0.001). Cardiac output and index (cardiac output / body surface area) were directly related to DM/VC (r2 = 0.41, p<0.001; r2 = 0.19, p = 0.03). Subjects with lower DM/VC demonstrated a cardiac output that remained in the normal range despite presence of obesity. CONCLUSIONS Global dysfunction of the distal lung (alveolar membrane and distal airway) is associated with pulmonary vascular congestion and failure to achieve the high output state of obesity. Pulmonary vascular congestion and consequent fluid transudation and/or alterations in the structure of the alveolar capillary membrane may be considered often unrecognized causes of airway dysfunction in obesity.
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Fabius TM, Eijsvogel MM, van der Lee I, Brusse-Keizer M, de Jongh FH. The T L,NO /T L,CO ratio cannot be used to exclude pulmonary embolism. Clin Physiol Funct Imaging 2015; 37:400-404. [PMID: 26576757 DOI: 10.1111/cpf.12317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/09/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND The existing screening modalities for pulmonary embolism (PE), such as D-dimer and clinical prediction rules, have low positive predictive values. With its capability to indicate pulmonary vascular abnormalities, the ratio of the transfer factor of the lungs for nitric oxide and the transfer factor of the lungs for carbon monoxide (TL,NO /TL,CO ) might be an additional discriminating parameter. METHODS Carbon monoxide/Nitric oxide diffusion measurements were performed on unselected patients seen on the emergency department for which due to suspected PE a computed tomography pulmonary angiogram (CTPA) was ordered. RESULTS A total of 28 patients were included, PE was found in 12 on CTPA. Median TL,NO /TL,CO ratio was 4·09 (interquartile range (IQR) 3·83-4·40) in the no PE group versus 4·00 (IQR 3·78-4·32) in the PE group (P = 0·959). Median alveolar volume was 77·1% of predicted in the no PE group versus 71·0% of predicted in the PE group (P = 0·353). Median TL,CO was 75·8% of predicted in the no PE group versus 68·8% of predicted in the PE group (P = 0·120). Median TL,NO was 69·3% of predicted in the no PE group versus 60·5% of predicted in the PE group (P = 0·078). CONCLUSION The presented data indicate that the TL,NO /TL,CO ratio cannot be used to exclude PE.
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Affiliation(s)
- Timon M Fabius
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Michiel M Eijsvogel
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Ivo van der Lee
- Department of Pulmonology, Spaarne Hospital, Hoofddorp, The Netherlands
| | | | - Frans H de Jongh
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, The Netherlands
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Farha S, Laskowski D, George D, Park MM, Tang WHW, Dweik RA, Erzurum SC. Loss of alveolar membrane diffusing capacity and pulmonary capillary blood volume in pulmonary arterial hypertension. Respir Res 2013; 14:6. [PMID: 23339456 PMCID: PMC3560152 DOI: 10.1186/1465-9921-14-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/17/2013] [Indexed: 11/30/2022] Open
Abstract
Background Reduced gas transfer in patients with pulmonary arterial hypertension (PAH) is traditionally attributed to remodeling and progressive loss of pulmonary arterial vasculature that results in decreased capillary blood volume available for gas exchange. Methods We tested this hypothesis by determination of lung diffusing capacity (DL) and its components, the alveolar capillary membrane diffusing capacity (Dm) and lung capillary blood volume (Vc) in 28 individuals with PAH in comparison to 41 healthy individuals, and in 19 PAH patients over time. Using single breath simultaneous measure of diffusion of carbon monoxide (DLCO) and nitric oxide (DLNO), DL and Dm were respectively determined, and Vc calculated. Dm and Vc were evaluated over time in relation to standard clinical indicators of disease severity, including brain natriuretic peptide (BNP), 6-minute walk distance (6MWD) and right ventricular systolic pressure (RVSP) by echocardiography. Results Both DLCO and DLNO were reduced in PAH as compared to controls and the lower DL in PAH was due to loss of both Dm and Vc (all p < 0.01). While DLCO of PAH patients did not change over time, DLNO decreased by 24 ml/min/mmHg/year (p = 0.01). Consequently, Dm decreased and Vc tended to increase over time, which led to deterioration of the Dm/Vc ratio, a measure of alveolar-capillary membrane functional efficiency without changes in clinical markers. Conclusions The findings indicate that lower than normal gas transfer in PAH is due to loss of both Dm and Vc, but that deterioration of Dm/Vc over time is related to worsening membrane diffusion.
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Affiliation(s)
- Samar Farha
- Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Exercise intolerance in pulmonary arterial hypertension. Pulm Med 2012; 2012:359204. [PMID: 22737582 PMCID: PMC3377355 DOI: 10.1155/2012/359204] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 04/13/2012] [Accepted: 04/16/2012] [Indexed: 01/12/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is associated with symptoms of dyspnea and fatigue, which contribute to exercise limitation. The origins and significance of dyspnea and fatigue in PAH are not completely understood. This has created uncertainly among healthcare professionals regarding acceptable levels of these symptoms, on exertion, for patients with PAH. Dysfunction of the right ventricle (RV) contributes to functional limitation and mortality in PAH; however, the role of the RV in eliciting dyspnea and fatigue has not been thoroughly examined. This paper explores the contribution of the RV and systemic and peripheral abnormalities to exercise limitation and symptoms in PAH. Further, it explores the relationship between exercise abnormalities and symptoms, the utility of the cardiopulmonary exercise test in identifying RV dysfunction, and offers suggestions for further research.
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Wémeau-Stervinou L, Perez T, Murphy C, Polge AS, Wallaert B. Lung capillary blood volume and membrane diffusion in idiopathic interstitial pneumonia. Respir Med 2012; 106:564-70. [DOI: 10.1016/j.rmed.2011.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 11/26/2011] [Accepted: 12/13/2011] [Indexed: 12/01/2022]
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Piirilä P, Laiho M, Mustonen P, Graner M, Piilonen A, Raade M, Sarna S, Harjola VP, Sovijärvi A. Reduction in membrane component of diffusing capacity is associated with the extent of acute pulmonary embolism. Clin Physiol Funct Imaging 2011; 31:196-202. [PMID: 21143754 PMCID: PMC3121963 DOI: 10.1111/j.1475-097x.2010.01000.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 11/14/2010] [Indexed: 11/30/2022]
Abstract
Acute pulmonary embolism (PE) often decreases pulmonary diffusing capacity for carbon monoxide (DL,CO), but data on the mechanisms involved are inconsistent. We wanted to investigate whether reduction in diffusing capacity of alveolo-capillary membrane (DM) and pulmonary capillary blood volume (Vc) is associated with the extent of PE or the presence and severity of right ventricular dysfunction (RVD) induced by PE and how the possible changes are corrected after 7-month follow-up. Forty-seven patients with acute non-massive PE in spiral computed tomography (CT) were included. The extent of PE was assessed by scoring mass of embolism. DL,CO, Vc, DM and alveolar volume (VA) were measured by using a single breath method with carbon monoxide and oxygen both at the acute phase and 7 months later. RVD was evaluated with transthoracic echocardiography and electrocardiogram. Fifteen healthy subjects were included as controls. DL,CO, DL, CO/VA, DM, vital capacity (VC) and VA were significantly lower in the patients with acute PE than in healthy controls (P < 0.001). DM/Vc relation was significantly lower in patients with RVD than in healthy controls (P = 0.004). DM correlated inversely with central mass of embolism (r = -0.312; P = 0.047) whereas Vc did not. DM, DL,CO, VC and VA improved significantly within 7 months. In all patients (P = 0.001, P = 0.001) and persistent RVD (P = 0.020, P = 0.012), DM and DL,CO remained significantly lower than in healthy controls in the follow-up. DM was inversely related to central mass of embolism. Reduction in DM mainly explains the sustained decrease in DL,CO in PE after 7 months despite modern treatment of PE.
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Affiliation(s)
- Päivi Piirilä
- Department of Clinical Physiology, HUSLAB, Helsinki University Central Hospital, Finland.
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Zavorsky GS, Blood AB, Power GG, Longo LD, Artal R, Vlastos EJ. CO and NO pulmonary diffusing capacity during pregnancy: Safety and diagnostic potential. Respir Physiol Neurobiol 2010; 170:215-25. [PMID: 20149901 DOI: 10.1016/j.resp.2010.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Revised: 02/02/2010] [Accepted: 02/03/2010] [Indexed: 11/17/2022]
Abstract
This paper reviews the scientific evidence for the safety of carbon monoxide (CO) and nitric oxide (NO) inhalation to measure pulmonary diffusing capacity (DL(CO) and DL(NO)) in pregnant women and their fetuses. In eight earlier studies, 650 pregnant women had DL(CO) measurements performed at various times during pregnancy, with a minimum of two to four tests per session. Both pregnant subjects that were healthy and those with medical complications were tested. No study reported adverse maternal, fetal, or neonatal outcomes from the CO inhalation in association with measuring DL(CO). Eleven pregnant women, chiefly with pulmonary hypertension, and 1105 pre-term neonates, mostly with respiratory failure, were administered various dosages of NO (5-80ppm for 4 weeks continuously in pregnant women, and 1-20ppm for 15min to 3 weeks for the neonates). NO treatment was found to be an effective therapy for pregnant women with pulmonary hypertension. In neonates with respiratory failure and pulmonary hypertension, NO therapy improved oxygenation and survival and has been associated with only minor, transient adverse effects. In conclusion, maternal carboxyhemoglobin ([Hb(CO)]) levels can safely increase to 5% per testing session when the dose-exposure limit is 0.3% CO inhalation for <or=3min, and for NO, 80ppm for <or=3min. The risk of late fetal or neonatal death from increased Hb(CO) from diffusion testing is considerably less than the risk of death from all causes reported by the Centers for Disease Control, and is therefore considered "minimal risk".
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Affiliation(s)
- Gerald S Zavorsky
- Department of Obstetrics, Gynecology and Women's Health, School of Medicine, Saint Louis University, Saint Mary's Health Center, 6420 Clayton Road, Suite 290, Saint Louis, MO 63117, USA.
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Overbeek MJ, Groepenhoff H, Voskuyl AE, Smit EF, Peeters JWL, Vonk-Noordegraaf A, Spreeuwenberg MD, Dijkmans BC, Boonstra A. Membrane diffusion- and capillary blood volume measurements are not useful as screening tools for pulmonary arterial hypertension in systemic sclerosis: a case control study. Respir Res 2008; 9:68. [PMID: 18828919 PMCID: PMC2576177 DOI: 10.1186/1465-9921-9-68] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Accepted: 10/01/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is no optimal screening tool for the assessment of pulmonary arterial hypertension (PAH) in patients with systemic sclerosis (SSc). A decreasing transfer factor of the lung for CO (TLCO) is associated with the development of PAH in SSc. TLCO can be partitioned into the diffusion of the alveolar capillary membrane (Dm) and the capillary blood volume (Vc). The use of the partitioned diffusion to detect PAH in SSc is not well established yet. This study evaluates whether Dm and Vc could be candidates for further study of the use for screening for PAH in SSc. METHODS Eleven SSc patients with PAH (SScPAH+), 13 SSc patients without PAH (SScPAH-) and 10 healthy control subjects were included. Pulmonary function testing took place at diagnosis of PAH. TLCO was partitioned according to Roughton and Forster. As pulmonary fibrosis in SSc influences values of the (partitioned) TLCO, these were adjusted for fibrosis score as assessed on HRCT. RESULTS TLCO as percentage of predicted (%) was lower in SScPAH+ than in SScPAH- (41 +/- 7% vs. 63 +/- 12%, p < 0.0001, respectively). Dm% in SScPAH+ was decreased as compared with SScPAH- (22 +/- 6% vs. 39 +/- 12%, p < 0.0001, respectively), also after adjustment for total fibrosis score (before adjustment: B = 17.5, 95% CI 9.0-25.9, p = < 0.0001; after adjustment: B = 14.3, 95% CI 6.0-21.7, p = 0.008). No difference was found in Vc%. There were no correlations between pulmonary hemodynamic parameters and Dm% in the PAH groups. CONCLUSION SScPAH+ patients have lower Dm% than SScPAH- patients. There are no correlations between Dm% and hemodynamic parameters of PAH in SScPAH+. These findings do not support further study of the role of partitioning TLCO in the diagnostic work- up for PAH in SSc.
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Affiliation(s)
- Maria J Overbeek
- Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands.
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Abstract
The literature on pulmonary gas exchange at rest, during exercise, and with weight loss in the morbidly obese (body mass index or BMI > or = 40 kg m(-2)) is reviewed. Forty-one studies were found (768 subjects weighted mean = 40 years old, BMI = 48 kg m(-2)). The alveolar-to-arterial oxygen partial pressure difference (AaDO2) was large at rest in upright subjects at sea level (23, range 5-38 mmHg) while the arterial pressure of oxygen (PaO2) was low (81, range 50-95 mmHg). Arterial pressure of carbon dioxide (PaCO2) was normal. At peak exercise (162 W), gas exchange improves. Weight loss of 45 kg (BMI = -13 kg m(-2)) over 18 months is associated with an improvement in PaO2 (by 10 mmHg, range 1-23 mmHg), a reduction in AaDO2 (by 8 mmHg, range -3 to -16 mmHg), and PaCO2 (by -3 mmHg, range 3 to -14 mmHg) at rest. Every 5-6 kg reduction in weight increases PaO2 by 1 and reduces AaDO2 by 1 mmHg, respectively. Morbidly obese women have better gas exchange at rest compared with morbidly obese men which is likely due to lower waist-to-hip ratios in women than from differences in weight or BMI.
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Affiliation(s)
- G S Zavorsky
- Department of Obstetrics, Gynecology and Women's Health, School of Medicine, Saint Louis University, Saint Mary's Health Center, Saint Louis, Missouri 63117, USA.
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