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Alerhand S, Adrian RJ. What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension? Am J Emerg Med 2023; 72:72-84. [PMID: 37499553 DOI: 10.1016/j.ajem.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions. OBJECTIVE This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation. DISCUSSION The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic). CONCLUSIONS Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Robert James Adrian
- Department of Emergency Medicine, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Netzer NC, Strohl KP, Högel J, Gatterer H, Schilz R. Right ventricle dimensions and function in response to acute hypoxia in healthy human subjects. Acta Physiol (Oxf) 2017; 219:478-485. [PMID: 27332955 DOI: 10.1111/apha.12740] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/01/2016] [Accepted: 06/20/2016] [Indexed: 02/06/2023]
Abstract
AIM Acute hypoxia produces acute vasoconstriction in the pulmonary circulation with consequences on right ventricular (RV) structure and function. Previous investigations in healthy humans have been restricted to measurements after altitude acclimatization or were interrupted by normoxia. We hypothesized that immediate changes in RV dimensions in healthy subjects in response to normobaric hypoxia differ without the aforementioned constraints. METHODS Transthoracic echocardiography was performed in 35 young, healthy subjects exposed to 11% oxygen, as well as six controls under sham hypoxia (20.6% oxygen, single blind) first at normoxia and after 30, 60, 100, 150 min of hypoxia or normoxia respectively. A subgroup of 15 subjects continued with 3-min cycling exercise in hypoxia with subsequent evaluation followed by an assessment 1 min at rest while breathing 4 L min-1 oxygen. RESULTS During hypoxia, there was a significant linear increase of all RV dimensions (RVD1 + 29 mm, RVD2 + 42 mm, RVD3 + 41 mm, RVOT + 13 mm, RVEDA + 18 mm, P < 0.01) in the exposure group vs. the control group. In response to hypoxia, right ventricular systolic pressure (RVSP) showed a modest increase in hypoxia at rest (+7.3 mmHg, P < 0.01) and increased further with physical effort (+11.8 mmHg, P < 0.01). After 1 min of oxygen at rest, it fell by 50% of the maximum increase. CONCLUSION Acute changes in RV morphology occur quickly after exposure to normobaric hypoxia. The changes were out of proportion to a relatively low-estimated increase in pulmonary pressure, indicating direct effects on RV structure. The results in healthy subjects are basis for future clinically oriented interventional studies in normobaric hypoxia.
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Affiliation(s)
- N. C. Netzer
- Department of Sport Science; Hermann Buhl Institute for Hypoxia and Sleep Medicine Research; University Innsbruck; Bad Aibling Germany
- Division of Sports- and Rehabilitative Medicine; Department of Medicine; University Hospitals Ulm; Ulm Germany
- Pulmonary and Critical Care Division; Department of Medicine; University Hospitals; Case Western Reserve University; Cleveland OH USA
| | - K. P. Strohl
- Pulmonary and Critical Care Division; Department of Medicine; University Hospitals; Case Western Reserve University; Cleveland OH USA
| | - J. Högel
- Department of Human Genetics; University Hospitals Ulm; Ulm Germany
| | - H. Gatterer
- Department of Sport Science; University Innsbruck; Innsbruck Austria
| | - R. Schilz
- Pulmonary and Critical Care Division; Department of Medicine; University Hospitals; Case Western Reserve University; Cleveland OH USA
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Bright-Thomas RJ, Ray SG, Webb AK. Pulmonary artery pressure in cystic fibrosis adults: Characteristics, clinical correlates and long-term follow-up. J Cyst Fibros 2012; 11:532-8. [DOI: 10.1016/j.jcf.2012.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/06/2012] [Accepted: 04/30/2012] [Indexed: 10/28/2022]
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Zeinaloo AA, Aghamohammadi A, Shabanian R, Salavati A, Abdollahzade S, Rezaei N, Alizadeh H, Zanjani KS, Kiani A. Echocardiographic abnormalities and their correlation with bronchiectasis score in primary antibody deficiencies. J Cardiovasc Med (Hagerstown) 2010; 11:244-9. [PMID: 19918187 DOI: 10.2459/jcm.0b013e3283347df3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Primary antibody deficiencies are characterized by defective antibody production and recurrent infections. Patients usually present with recurrent respiratory tract infections with consequent chronic pulmonary damage and bronchiectasis, which could potentially influence cardiac function. Our aim was to assess noninvasively the cardiac complications due to pulmonary disease in patients with primary antibody deficiency. METHODS A cross-sectional series of patients with primary antibody deficiency syndromes from our referral immunology center were recruited. Individuals undergoing high-resolution computed tomography (HRCT) and transthoracic echocardiography were reviewed. RESULTS Thirty primary immunodeficient patients aged 5-55 years of age (21 males and 9 females) were enrolled in this study. Half of the patients (50%) were found to have bronchiectasis in HRCT imaging. In echocardiographic examination, 20 patients (67%) had at least one abnormality; among which pulmonary hypertension was the most common (33%). Patients with bronchiectasis had higher pulmonary artery pressures and HRCT bronchiectasis score was strongly correlated with pulmonary artery pressure (regression R = 0.59, P value = 0.001). CONCLUSION Echocardiographic evaluation of right ventricular function and noninvasive estimation of pulmonary artery pressure could have an important diagnostic role in the follow-up and therapeutic management of patients with primary immune deficiency.
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Affiliation(s)
- Ali Akbar Zeinaloo
- Growth and Development Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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5
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Funk GC, Lang I, Schenk P, Valipour A, Hartl S, Burghuber OC. Left ventricular diastolic dysfunction in patients with COPD in the presence and absence of elevated pulmonary arterial pressure. Chest 2008; 133:1354-1359. [PMID: 18339780 DOI: 10.1378/chest.07-2685] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Increased right ventricular afterload leads to left ventricular diastolic dysfunction due to ventricular interdependence. Increased right ventricular afterload is frequently present in patients with COPD. The purpose of this study was to determine whether left ventricular diastolic dysfunction could be detected in COPD patients with normal or elevated pulmonary artery pressure (PAP). METHODS Twenty-two patients with COPD and 22 matched control subjects underwent pulsed Doppler echocardiography. Left ventricular systolic dysfunction and other causes of left ventricular diastolic dysfunction (eg, coronary artery disease) were excluded in all patients and control subjects. PAP was measured invasively in 13 patients with COPD. RESULTS The maximal atrial filling velocity was increased and the early filling velocity was decreased in patients with COPD compared to control subjects. The early flow velocity peak/late flow velocity peak (E/A) ratio was markedly decreased in patients with COPD compared to control subjects (0.79 +/- 0.035 vs 1.38 +/- 0.069, respectively; p < 0.0001), indicating the presence of left ventricular diastolic dysfunction. The atrial contribution to total left diastolic filling was increased in patients with COPD. This was also observed in COPD patients with normal PAP, as ascertained using a right heart catheter. The atrial contribution to total left diastolic filling was further increased in COPD patients with PAP. PAP correlated with the E/A ratio (r = -0.85; p < 0.0001). CONCLUSIONS Left ventricular diastolic dysfunction is present in COPD patients with normal PAP and increases with right ventricular afterload.
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Affiliation(s)
- Georg-Christian Funk
- Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital, Vienna, Austria
| | - Irene Lang
- Department of Internal Medicine 2, Intensive Care Unit 13H1, University of Vienna, Vienna, Austria
| | - Peter Schenk
- Division of Cardiology, and the Department of Internal Medicine 3, Intensive Care Unit 13H1, University of Vienna, Vienna, Austria
| | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital, Vienna, Austria
| | - Sylvia Hartl
- Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital, Vienna, Austria
| | - Otto Chris Burghuber
- Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital, Vienna, Austria.
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Chaouat A, Canuet M, Gomez E, Chabot F, Weitzenblum E. Hypertension pulmonaire des affections respiratoires chroniques. Rev Mal Respir 2007; 24:509-21. [PMID: 17468707 DOI: 10.1016/s0761-8425(07)91573-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary hypertension of chronic respiratory disease is defined as elevation of the mean resting pulmonary artery pressure to over 20 mm Hg. It is the commonest cause of pre-capillary pulmonary hypertension on account of the high prevalence of chronic obstructive pulmonary disease. It is primarily due to alveolar hypoxia that leads to remodelling of the distal pulmonary vasculature and consequently to an increase in pulmonary resistance. It is not as severe as idiopathic pulmonary hypertension. The mean pulmonary artery pressure is usually moderately increased (20-35 mm Hg) when patients are seen during a stable period of the disease. There are, however, more severe cases of pulmonary hypertension called, in some cases, disproportionate but these are uncommon. Increased right ventricular afterload can lead to the development of right ventricular failure that is a definite prognostic factor. The clinical symptoms of pulmonary hypertension are at a secondary level compared with those of the causal disease. Non-invasive diagnosis depends on Doppler echocardiography. Currently the most effective treatment is long term oxygen therapy (16-18 hr/24 hr). This improves or, at least stabilises, the pulmonary hypertension.
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Affiliation(s)
- A Chaouat
- Service des Maladies Respiratoires et Réanimation Respiratoire, Hôpital de Brabois, CHU de Nancy, France.
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Chaouat A, Kraemer JP, Canuet M, Kadaoui N, Ducoloné A, Kessler R, Weitzenblum E. [Pulmonary hypertension associated with disorders of the respiratory system]. Presse Med 2005; 34:1465-74. [PMID: 16301978 DOI: 10.1016/s0755-4982(05)84208-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Pulmonary hypertension associated with disorders of the respiratory system is defined by a pulmonary artery mean pressure above 20 mmHg at rest in stable disease. The most frequent form of precapillary pulmonary hypertension is associated with chronic obstructive pulmonary disease, because of its high prevalence. Pulmonary vascular remodeling occurs in the small pulmonary arteries and is due mainly to chronic alveolar hypoxia. Pulmonary hypertension associated with disorders of the respiratory system is usually mild to moderate, with resting pulmonary artery mean pressure ranging between 20 and 35 mm Hg. It may increase markedly during sleep, exercise or exacerbation of respiratory failure, however. Abrupt postload elevation can lead to right heart failure, an indisputable indicator of prognosis. Because the symptoms of pulmonary hypertension are minimal relative to those of the chronic hypoxic lung disease, noninvasive diagnosis is difficult, particularly in patients with chronic obstructive pulmonary disease. Oxygen therapy (at least 16 h/day) is currently the best treatment for this type of pulmonary arterial hypertension.
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Affiliation(s)
- A Chaouat
- Service de pneumologie, Hôpitaux universitaires de Strasbourg.
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Weill D, Weill H. Diagnosis and Initial Management of Nonmalignant Diseases Related to Asbestos. Am J Respir Crit Care Med 2005; 171:527-8; author reply 528-30. [PMID: 15722420 DOI: 10.1164/ajrccm.171.5.951] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hodgev V, Kostianev S, Marinov B. University of Cincinnati Dyspnea Questionnaire for Evaluation of Dyspnoea during physical and speech activities in patients with chronic obstructive pulmonary disease: a validation analysis. Clin Physiol Funct Imaging 2003; 23:269-74. [PMID: 12950324 DOI: 10.1046/j.1475-097x.2003.00506.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
University of Cincinnati Dyspnea Questionnaire (UCDQ) was developed to measure the impact of dyspnoea during (1) physical activity (Phys), (2) speech activity (Speech) and (3) simultaneous speech and physical activity (Comb). The aim of this study was to evaluate the validity of UCDQ in COPD patients, comparing it to a large set of dyspnoeic indices and functional parameters. Fifty COPD patients (age 58.7 +/- 9.1 years, FEV1%pred = 39.3 +/- 17.0%, Baseline Dyspnoea Index (BDI) = 4.9 +/- 2.5, Six Minute Walk Distance (6MWD) = 373 +/- 128 m, Symptoms score = 9.4 +/- 2.5; mean +/- SD) participated in the study. We found the following mean scores for the three sections of the questionnaire: Phys = 3.5 +/- 0.9; Speech = 2.4 +/- 1.1; Comb = 4.2 +/- 1.0, meaning that patients report the most breathlessness during the combination of speaking and physical activity and the least breathlessness during speech activities. All three section of UCDQ had significant strong correlation with dyspnoea indices (BDI, Borg, MRC, OCD), 6MWD and symptoms score, which proves its concurrent and construct validity. Differentiation of patients by speech section (=3<) discriminated them significantly with respect to all dyspnoeic indices, symptoms score and 6MWD. All three dimensions of UCDQ had high test-retest reliability - ICC between 0.76 and 0.93. Factor analysis yielded three interpretable factors, as all dyspnoeic indices, three sections of UCDQ, symptoms score and 6MWD were loaded on the first factor. In conclusion, UCDQ provides valid and reliable information about the effect of dyspnoea on speech and daily activities.
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Affiliation(s)
- V Hodgev
- Pulmonology Clinic and Pathophysiology Department, Medical University, Plovdiv, Bulgaria.
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Schenk P, Fuhrmann V, Madl C, Funk G, Lehr S, Kandel O, Müller C. Hepatopulmonary syndrome: prevalence and predictive value of various cut offs for arterial oxygenation and their clinical consequences. Gut 2002; 51:853-9. [PMID: 12427789 PMCID: PMC1773478 DOI: 10.1136/gut.51.6.853] [Citation(s) in RCA: 200] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, arterial deoxygenation, and pulmonary vascular dilatation. The reported prevalence of HPS in cirrhotic patients varies between 4% and 19%, and various threshold values defining arterial deoxygenation have been used and recommended previously. However, it is not known how the prevalence of HPS differs using different cut off values for arterial deoxygenation. METHODS We studied 127 patients for the presence of HPS using transthoracic contrast echocardiography for detection of pulmonary vasodilation, pulmonary function tests, and blood gas analysis. RESULTS Ninety eight patients were included in the study, of whom 33 (34%) had a positive contrast echocardiography. Using an increased alveolar-arterial difference for the partial pressure of oxygen (AaDO(2)) as an indication of hypoxaemia, the prevalence of HPS was considerably higher (>15 mm Hg, 32%; >20 mm Hg, 31%; and >age related threshold, 28%) than using reduced partial pressure of arterial oxygen (PaO(2)) as a threshold (<80 mm Hg, 19%; <70 mm Hg, 15%; and <age related threshold, 15%). For AaDO(2) as the cut off, the positive predictive value for a diagnosis of HPS was low (34%, 37%, and 53%, respectively). In contrast, PaO(2) as a cut off had considerably higher positive predictive values (44%, 93%, and 94%, respectively). Introducing PaO(2) <65 mm Hg as the cut off, the positive predictive value increased to 100%. Dyspnoea was more often present in patients with "clinically significant" HPS (57%) compared with "subclinical HPS" (8%), and patients without HPS (6%). The Child-Pugh score correlated significantly with the severity of HPS. Two of five liver transplanted patients with "subclinical HPS" had embolic brain infarcts, possibly induced by venous emboli passing through dilated intrapulmonary vessels. CONCLUSIONS Defining arterial hypoxaemia in HPS by different, previously used, cut off values for arterial oxygenation leads to a wide variation in the prevalence of HPS in the same sample of cirrhotic patients.
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Affiliation(s)
- P Schenk
- Department of Internal Medicine IV, Intensive Care Unit, University of Vienna, Allgemeines Krankenhaus, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Kunichika N, Miyahara N, Harada M, Tanimoto M. Respiratory variation in superior vena cava flow in patients with chronic obstructive pulmonary disease: estimation of pulmonary hypertension using Doppler flow index. J Am Soc Echocardiogr 2002; 15:1165-9. [PMID: 12411900 DOI: 10.1067/mje.2002.122355] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) are difficult to assess by conventional transthoracic echocardiography (TTE) because of emphysematous lungs or mediastinal deviation. We hypothesized that superior vena cava (SVC) flow is related to pulmonary circulation and may be useful for the detection of pulmonary hypertension (PH) in patients with COPD that cannot been assessed by direct evaluation using the tricuspid regurgitant Doppler velocity. SVC Doppler flow velocities were examined in 46 patients with COPD and the pressure gradient between the right ventricular and right atrial pressure (RV-RADeltaP) was calculated by tricuspid regurgitant Doppler velocities. The patients were divided into 2 groups: 11 patients with PH (RV-RADeltaP > 25 mm Hg) were compared with 35 without PH. There was no significant difference in the maximal SVC peak systolic forward flow velocity during inspiration (INS) between these 2 groups. However, the minimal SVC peak systolic forward flow velocity during expiration (EXP) in the group with PH was significantly higher than that in the group without PH (37.4 +/- 20.0 cm/s vs 26.4 +/- 8.5 cm/s, P =.01). Linear regression analysis revealed a significant correlation between RV-RADeltaP and the EXP/INS ratio (r = 0.61, P <.001). In COPD patients with PH, the increased expiratory SVC systolic flow supplemented the preload for the impaired right ventricular filling flow caused by PH, thereby maintaining the transtricuspid driving pressure. Our observation suggests that respiratory variation in SVC systolic forward flow may be a sensitive Doppler flow index for evaluating severity of PH in patients with COPD that cannot been assessed by conventional TTE.
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MESH Headings
- Aged
- Aged, 80 and over
- Blood Flow Velocity/physiology
- Echocardiography, Doppler
- Female
- Forced Expiratory Volume/physiology
- Humans
- Hypertension, Pulmonary/complications
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/physiopathology
- Lung/blood supply
- Lung/diagnostic imaging
- Lung/physiopathology
- Male
- Middle Aged
- Pulmonary Circulation/physiology
- Pulmonary Disease, Chronic Obstructive/complications
- Pulmonary Disease, Chronic Obstructive/diagnosis
- Pulmonary Disease, Chronic Obstructive/physiopathology
- ROC Curve
- Respiration
- Respiratory Function Tests
- Sensitivity and Specificity
- Systole/physiology
- Vena Cava, Superior/diagnostic imaging
- Vena Cava, Superior/physiopathology
- Vital Capacity/physiology
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Affiliation(s)
- Naomi Kunichika
- Department of Internal Medicine, National Sanyo Hospital, Yamaguchi, Japan.
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Schenk P, Mittermayer C, Ratheiser K. Inhaled nitric oxide in a patient with severe pulmonary embolism. Ann Emerg Med 1999. [DOI: 10.1016/s0196-0644(99)80011-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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