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Blanco I, Hernández-González F, García A, Torres-Castro R, Barberà JA. Management of Pulmonary Hypertension Associated with Chronic Lung Disease. Semin Respir Crit Care Med 2023; 44:826-839. [PMID: 37487524 DOI: 10.1055/s-0043-1770121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of chronic lung diseases, particularly in chronic obstructive pulmonary disease (COPD) and interstitial lung diseases (ILD) and especially in advanced disease. It is associated with greater mortality and worse clinical course. Given the high prevalence of some respiratory disorders and because lung parenchymal abnormalities might be present in other PH groups, the appropriate diagnosis of PH associated with respiratory disease represents a clinical challenge. Patients with chronic lung disease presenting symptoms that exceed those expected by the pulmonary disease should be further evaluated by echocardiography. Confirmatory right heart catheterization is indicated in candidates to surgical treatments, suspected severe PH potentially amenable with targeted therapy, and, in general, in those conditions where the result of the hemodynamic assessment will determine treatment options. The treatment of choice for these patients who are hypoxemic is long-term oxygen therapy and pulmonary rehabilitation to improve symptoms. Lung transplant is the only curative therapy and can be considered in appropriate cases. Conventional vasodilators or drugs approved for pulmonary arterial hypertension (PAH) are not recommended in patients with mild-to-moderate PH because they may impair gas exchange and their lack of efficacy shown in randomized controlled trials. Patients with severe PH (as defined by pulmonary vascular resistance >5 Wood units) should be referred to a center with expertise in PH and lung diseases and ideally included in randomized controlled trials. Targeted PAH therapy might be considered in this subset of patients, with careful monitoring of gas exchange. In patients with ILD, inhaled treprostinil has been shown to improve functional ability and to delay clinical worsening.
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Affiliation(s)
- Isabel Blanco
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Fernanda Hernández-González
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Agustín García
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Rodrigo Torres-Castro
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Joan A Barberà
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
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Daher A, Klose H. [Pathophysiology, diagnosis, prognosis and treatment of pulmonary hypertension associated with chronic lung disease]. Dtsch Med Wochenschr 2023; 148:1507-1513. [PMID: 37949079 DOI: 10.1055/a-2012-0856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
The pathophysiology of pulmonary hypertension associated with chronic lung disease (PH-CLD) is complex, multifactorial, and not consistent among pulmonary diseases. However, pulmonary vasculopathy triggered by various factors, such as chronic alveolar hypoxia or cigarette smoking, seems to play a central role in the pathogenesis of PH-CLD. While the initial workup of PH-CLD is usually complicated by an overlap of symptoms of PH and the underlying lung disease, PH-CLD should be considered when there is a discrepancy between symptoms (especially exertional dyspnea) and pulmonary function tests. Clinical suspicion of PH-CLD can be strengthened by noninvasive diagnostic tools such as transthoracic echocardiography (TTE) or N-terminal pro-B-type natriuretic peptide (NT-pro-BNP). However, a right heart catheterization should only be performed in specialized centers to establish the diagnosis if therapeutic consequences for the patient were expected.The basic treatment of PH-CLD is optimal management of the underlying lung disease. Among the existing interventional and registry-based studies, only a small number of data suggests favorable outcomes when treating PH-CLD patients with PAH-specific medications. Some publications even suggest negative effects. Nevertheless, recent data on inhaled vasoactive therapy in PH-CLD showed positive results for inhaled Treprostinil, although long-term data for this therapeutic approach are still lacking. Treatment of PH-CLD patients with PAH-specific drugs should only be performed in specialized centers and preferably in the context of clinical trials.
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Halank M, Zeder KE, Sommer N, Ulrich S, Held M, Köhler T, Foris V, Heberling M, Neurohr C, Ronczka J, Holt S, Skowasch D, Kneidinger N, Behr J. [Pulmonary hypertension associated with lung disease]. Pneumologie 2023; 77:916-925. [PMID: 37963481 DOI: 10.1055/a-2145-4756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Lung diseases and hypoventilation syndromes are often associated with pulmonary hypertension (PH). In most cases, PH is not severe. This is defined hemodynamically by a mean pulmonary arterial pressure (PAPm) > 20 mmHg, a pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg and a pulmonary vascular resistance of ≤ 5 Wood units (WU). Both the non-severe (PVR ≤ 5 WU) and much more the severe PH (PVR > 5 WU) have an unfavorable prognosis.If PH is suspected, it is recommended to primarily check whether risk factors for pulmonary arterial hypertension (PAH, group 1 PH) or chronic thromboembolic pulmonary hypertension (CTEPH, group 4 PH) are present. If risk factors are present or there is a suspicion of severe PH in lung patients, it is recommended that the patient should be presented to a PH outpatient clinic promptly.For patients with severe PH associated with lung diseases, personalized, individual therapy is recommended - if possible within the framework of therapy studies. Currently, a therapy attempt with PH specific drugs should only be considered in COPD patients if the associated PH is severe and a "pulmonary vascular" phenotype (severe precapillary PH, but typically only mild to moderate airway obstruction, no or mild hypercapnia and DLCO < 45 % of predicted value) is present. In patients with severe PH associated with interstitial lung disease phosphodiesterase-5-inhibitors may be considered in individual cases. Inhaled treprostinil may be considered also in non-severe PH in this patient population.
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Affiliation(s)
- Michael Halank
- Universitätsklinikum Carl Gustav Carus an der TU Dresden, Med. Klinik I, Bereich Pneumologie, Dresden, Deutschland
| | - Katarina E Zeder
- Klinische Abteilung für Pulmonologie, Med. Universität Graz, Österreich
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Natascha Sommer
- Justus-Liebig-Universitätsklinikum Gießen, Medizinische Klinik II, Pneumologie
- Excellence Cluster Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC)
| | | | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin
| | - Thomas Köhler
- Universitätsklinikum Freiburg, Department Innere Medizin, Klinik für Pneumologie, Freiburg, Deutschland
| | - Vasile Foris
- Klinische Abteilung für Pulmonologie, Med. Universität Graz, Österreich
- Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Melanie Heberling
- Universitätsklinikum Carl Gustav Carus an der TU Dresden, Med. Klinik I, Bereich Pneumologie, Dresden, Deutschland
| | - Claus Neurohr
- RBK Lungenzentrum Stuttgart am Robert-Bosch-Krankenhaus, Abteilung Pneumologie und Beatmungsmedizin, Stuttgart, Deutschland
| | - Julia Ronczka
- Universitätsklinikum Carl Gustav Carus an der TU Dresden, Med. Klinik I, Bereich Pneumologie, Dresden, Deutschland
| | | | - Dirk Skowasch
- Universitätsklinikum Bonn, Med. Klinik und Poliklinik II, Sektion Pneumologie, Bonn, Deutschland
| | - Nikolaus Kneidinger
- Medizinische Klinik und Poliklinik V, LMU Klinikum, LMU München, Comprehensive Pneumology Center, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), München, Deutschland
| | - Jürgen Behr
- Medizinische Klinik und Poliklinik V, LMU Klinikum, LMU München, Comprehensive Pneumology Center, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), München, Deutschland
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Olsson KM, Corte TJ, Kamp JC, Montani D, Nathan SD, Neubert L, Price LC, Kiely DG. Pulmonary hypertension associated with lung disease: new insights into pathomechanisms, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:820-835. [PMID: 37591300 DOI: 10.1016/s2213-2600(23)00259-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/19/2023]
Abstract
Patients with chronic lung diseases, particularly interstitial lung disease and chronic obstructive pulmonary disease, frequently develop pulmonary hypertension, which results in clinical deterioration, worsening of oxygen uptake, and an increased mortality risk. Pulmonary hypertension can develop and progress independently from the underlying lung disease. The pulmonary vasculopathy is distinct from that of other forms of pulmonary hypertension, with vascular ablation due to loss of small pulmonary vessels being a key feature. Long-term tobacco exposure might contribute to this type of pulmonary vascular remodelling. The distinct pathomechanisms together with the underlying lung disease might explain why treatment options for this condition remain scarce. Most drugs approved for pulmonary arterial hypertension have shown no or sometimes harmful effects in pulmonary hypertension associated with lung disease. An exception is inhaled treprostinil, which improves exercise capacity in patients with interstitial lung disease and pulmonary hypertension. There is a pressing need for safe, effective treatment options and for reliable, non-invasive diagnostic tools to detect and characterise pulmonary hypertension in patients with chronic lung disease.
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Affiliation(s)
- Karen M Olsson
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany.
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Jan C Kamp
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, INSERM Unité Mixte de Recherche 999, Université Paris-Saclay, Paris, France
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Lavinia Neubert
- Institute of Pathology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; NIHR Biomedical Research Centre, Sheffield, UK
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 554] [Impact Index Per Article: 554.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1259] [Impact Index Per Article: 629.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Li S, Chen LN, Zhong L. A 7-year-old boy with recurrent cyanosis and tachypnea: A case report. World J Clin Cases 2022; 10:6974-6980. [PMID: 36051109 PMCID: PMC9297426 DOI: 10.12998/wjcc.v10.i20.6974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/10/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Brain tumors are the most common solid tumors in children and comprise 25% of all malignancies in children. Common presentations include headache, nausea and vomiting, gait abnormality, papilledema, and epileptic seizure; however, some symptoms can be very insidious, with atypical and misleading manifestations.
CASE SUMMARY Here, we report a 7-year-old boy who presented with recurrent cyanosis and tachypnea after exercise for 2 years. His body mass index was 26.43 kg/m2. Hepatosplenomegaly, blood gas analysis, biochemical parameters, chest computed tomography scan, and echocardiograph suggested type II respiratory failure, pulmonary heart disease, and mild liver injury. Non-invasive breathing support, antibiotics, and anti-heart failure therapy were given. The patient’s pulse oxygen saturation increased to over 95% when he was awake but dropped to 50%-60%, accompanied by cyanosis, during sleep while receiving high-flow nasal cannula oxygen. Sleep-related breathing disorder was suspected. In the intensive care unit, however, polysomnography was unavailable. Brain magnetic resonance imaging revealed a space-occupying (cerebellum and brainstem) lesion, which was later confirmed to be pleomorphic xanthoastrocytoma by surgery and histopathology by tissue biopsy.
CONCLUSION When treating patients with cyanosis and tachypnea, a broad differential diagnosis should be considered, including brain tumor.
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Affiliation(s)
- Shu Li
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital of Sichuan University, Chengdu 610066, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital of Sichuan University, Chengdu 610066, Sichuan Province, China
- NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu 610066, Sichuan Province, China
| | - Li-Na Chen
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital of Sichuan University, Chengdu 610066, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital of Sichuan University, Chengdu 610066, Sichuan Province, China
- NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu 610066, Sichuan Province, China
| | - Lin Zhong
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital of Sichuan University, Chengdu 610066, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital of Sichuan University, Chengdu 610066, Sichuan Province, China
- NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu 610066, Sichuan Province, China
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Murta MS, Duarte RLM, Waetge D, Gozal D, Cardoso AP, Mello FCQ. Sleep-Disordered Breathing in Adults with Precapillary Pulmonary Hypertension: Prevalence and Predictors of Nocturnal Hypoxemia. Lung 2022; 200:523-530. [PMID: 35717489 DOI: 10.1007/s00408-022-00547-w] [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: 04/16/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the frequency of sleep-disordered breathing (SDB) and predictors of the presence of nocturnal desaturation in adults with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. METHODS Outpatients with a hemodynamic diagnosis of precapillary pulmonary hypertension who underwent portable polysomnography were evaluated. Diagnosis and severity of SDB were assessed using three well-established respiratory disturbance index (RDI) thresholds: 5.0/h, 15.0/h, and 30.0/h, while nocturnal hypoxemia was defined by the average oxygen saturation (SpO2) < 90%. Multiple linear regression analysis evaluated the potential relationships among explanatory variables with the dependent variable (average SpO2 values), with comparisons based on the standardized regression coefficient (β). The R-squared (R2; coefficient of determination) was used to evaluate the goodness-of-fit measure for the linear regression model. RESULTS Thirty-six adults were evaluated (69.4% females). The majority of the participants (75.0%) had SDB (26 with obstructive sleep apnea [OSA] and one with central sleep apnea [CSA]); while 50% of them had nocturnal hypoxemia. In the linear regression model (R2 = 0.391), the mean pulmonary artery pressure [mPAP] (β - 0.668; p = 0.030) emerged as the only independent parameter of the average SpO2. CONCLUSION Our study found that the majority of the participants had some type of SDB with a marked predominance of OSA over CSA, while half of them had nocturnal desaturation. Neither clinical and hemodynamic parameters nor the RDI was a predictor of nocturnal desaturation, except for mPAP measured during a right heart catheterization, which emerged as the only independent and significant predictor of average SpO2.
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Affiliation(s)
- Marcia S Murta
- Instituto de Doenças Do Tórax (IDT), Universidade Federal Do Rio de Janeiro (UFRJ), Rua Professor Rodolpho Paulo Rocco, 255 - 1° andar - sala 01D 58/60, Rio de Janeiro, RJ, CEP, 21941-913, Brazil
| | - Ricardo L M Duarte
- Instituto de Doenças Do Tórax (IDT), Universidade Federal Do Rio de Janeiro (UFRJ), Rua Professor Rodolpho Paulo Rocco, 255 - 1° andar - sala 01D 58/60, Rio de Janeiro, RJ, CEP, 21941-913, Brazil.
| | - Daniel Waetge
- Instituto de Doenças Do Tórax (IDT), Universidade Federal Do Rio de Janeiro (UFRJ), Rua Professor Rodolpho Paulo Rocco, 255 - 1° andar - sala 01D 58/60, Rio de Janeiro, RJ, CEP, 21941-913, Brazil
| | - David Gozal
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO, USA
| | - Alexandre P Cardoso
- Instituto de Doenças Do Tórax (IDT), Universidade Federal Do Rio de Janeiro (UFRJ), Rua Professor Rodolpho Paulo Rocco, 255 - 1° andar - sala 01D 58/60, Rio de Janeiro, RJ, CEP, 21941-913, Brazil
| | - Fernanda C Q Mello
- Instituto de Doenças Do Tórax (IDT), Universidade Federal Do Rio de Janeiro (UFRJ), Rua Professor Rodolpho Paulo Rocco, 255 - 1° andar - sala 01D 58/60, Rio de Janeiro, RJ, CEP, 21941-913, Brazil
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9
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Affiliation(s)
- Paul M Hassoun
- From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
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10
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Spiesshoefer J, Herkenrath S, Harre K, Kahles F, Florian A, Yilmaz A, Mohr M, Naughton M, Randerath W, Emdin M, Passino C, Regmi B, Dreher M, Boentert M, Giannoni A. Sleep-Disordered Breathing and Nocturnal Hypoxemia in Precapillary Pulmonary Hypertension: Prevalence, Pathophysiological Determinants, and Clinical Consequences. Respiration 2021; 100:865-876. [PMID: 33910200 DOI: 10.1159/000515602] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/22/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The clinical relevance and interrelation of sleep-disordered breathing and nocturnal hypoxemia in patients with precapillary pulmonary hypertension (PH) is not fully understood. METHODS Seventy-one patients with PH (age 63 ± 15 years, 41% male) and 35 matched controls were enrolled. Patients with PH underwent clinical examination with assessment of sleep quality, daytime sleepiness, 6-minute walk distance (6MWD), overnight cardiorespiratory polygraphy, lung function, hypercapnic ventilatory response (HCVR; by rebreathing technique), amino-terminal pro-brain natriuretic peptide (NT-proBNP) levels, and cardiac MRI (n = 34). RESULTS Prevalence of obstructive sleep apnea (OSA) was 68% in patients with PH (34% mild, apnea-hypopnea index [AHI] ≥5 to <15/h; 34% moderate to severe, AHI ≥15/h) versus 5% in controls (p < 0.01). Only 1 patient with PH showed predominant central sleep apnea (CSA). Nocturnal hypoxemia (mean oxygen saturation [SpO2] <90%) was present in 48% of patients with PH, independent of the presence of OSA. There were no significant differences in mean nocturnal SpO2, self-reported sleep quality, 6MWD, HCVR, and lung and cardiac function between patients with moderate to severe OSA and those with mild or no OSA (all p > 0.05). Right ventricular (RV) end-diastolic (r = -0.39; p = 0.03) and end-systolic (r = -0.36; p = 0.04) volumes were inversely correlated with mean nocturnal SpO2 but not with measures of OSA severity or daytime clinical variables. CONCLUSION OSA, but not CSA, is highly prevalent in patients with PH, and OSA severity is not associated with nighttime SpO2, clinical and functional status. Nocturnal hypoxemia is a frequent finding and (in contrast to OSA) relates to structural RV remodeling in PH.
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Affiliation(s)
- Jens Spiesshoefer
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany.,Department of Neurology with Institute for Translational Neurology, University Hospital Muenster, Münster, Germany.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Simon Herkenrath
- Bethanien Hospital Solingen, Solingen, Germany.,Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Katharina Harre
- Department of Neurology with Institute for Translational Neurology, University Hospital Muenster, Münster, Germany
| | - Florian Kahles
- Department of Cardiology, Vascular Medicine and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Anca Florian
- Department of Cardiology I, University Hospital Muenster, Münster, Germany
| | - Ali Yilmaz
- Department of Cardiology I, University Hospital Muenster, Münster, Germany
| | - Michael Mohr
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Münster, Germany
| | - Matthew Naughton
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Winfried Randerath
- Bethanien Hospital Solingen, Solingen, Germany.,Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy
| | - Binaya Regmi
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Matthias Boentert
- Department of Neurology with Institute for Translational Neurology, University Hospital Muenster, Münster, Germany.,Department of Medicine, UKM Marienhospital Steinfurt, Steinfurt, Germany
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy
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11
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Tan L, Latshang TD, Aeschbacher SS, Huber F, Flueck D, Lichtblau M, Ulrich S, Hasler ED, Scheiwiller PM, Ulrich S, Bloch KE, Furian M. Effect of Nocturnal Oxygen Therapy on Nocturnal Hypoxemia and Sleep Apnea Among Patients With Chronic Obstructive Pulmonary Disease Traveling to 2048 Meters: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e207940. [PMID: 32568400 PMCID: PMC7309443 DOI: 10.1001/jamanetworkopen.2020.7940] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE There are no established measures to prevent nocturnal breathing disturbances and other altitude-related adverse health effects (ARAHEs) among lowlanders with chronic obstructive pulmonary disease (COPD) traveling to high altitude. OBJECTIVE To evaluate whether nocturnal oxygen therapy (NOT) prevents nocturnal hypoxemia and breathing disturbances during the first night of a stay at 2048 m and reduces the incidence of ARAHEs. DESIGN, SETTING, AND PARTICIPANTS This randomized, placebo-controlled crossover trial was performed from January to October 2014 with 32 patients with COPD living below 800 m with forced expiratory volume in the first second of expiration (FEV1) between 30% and 80% predicted, pulse oximetry of at least 92%, not requiring oxygen therapy, and without history of sleep apnea. Evaluations were performed at the University Hospital Zurich (490 m, baseline) and during 2 stays of 2 days and nights each in a Swiss Alpine hotel at 2048 m while NOT or placebo treatment was administered in a randomized order. Between altitude sojourns, patients spent at least 2 weeks below 800 m. Data analysis was performed from January 1, 2015, to December 31, 2018. INTERVENTION During nights at 2048 m, NOT or placebo (room air) was administered at 3 L/min by nasal cannula. MAIN OUTCOMES AND MEASURES Coprimary outcomes were differences between NOT and placebo intervention in altitude-induced change in mean nocturnal oxygen saturation (SpO2) as measured by pulse oximetry and apnea-hypopnea index (AHI) measured by polysomnography during night 1 at 2048 m and analyzed according to the intention-to-treat principle. Further outcomes were the incidence of predefined ARAHE, other variables from polysomnography results and respiratory sleep studies in the 2 nights at 2048 m, clinical findings, and symptoms. RESULTS Of the 32 patients included, 17 (53%) were women, with a mean (SD) age of 65.6 (5.6) years and a mean (SD) FEV1 of 53.1% (13.2%) predicted. At 490 m, mean (SD) SpO2 was 92% (2%) and mean (SD) AHI was 21.6/h (22.2/h). At 2048 m with placebo, mean (SD) SpO2 was 86% (3%) and mean (SD) AHI was 34.9/h (20.7/h) (P < .001 for both comparisons). Compared with placebo, NOT increased SpO2 by a mean of 9 percentage points (95% CI, 8-11 percentage points; P < .001), decreased AHI by 19.7/h (95% CI, 11.4/h-27.9/h; P < .001), and improved subjective sleep quality measured on a visual analog scale by 9 percentage points (95% CI, 0-17 percentage points; P = .04). During visits to 2048 m or within 24 hours after descent, 8 patients (26%) using placebo and 1 (4%) using NOT experienced ARAHEs (P < .001). CONCLUSIONS AND RELEVANCE Lowlanders with COPD experienced hypoxemia, sleep apnea, and impaired well-being when staying at 2048 m. Because NOT significantly mitigated these undesirable effects, patients with moderate to severe COPD may benefit from preventive NOT during high altitude travel. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02150590.
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Affiliation(s)
- Lu Tan
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Tsogyal D. Latshang
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Sayaka S. Aeschbacher
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Fabienne Huber
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Deborah Flueck
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Stefanie Ulrich
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Elisabeth D. Hasler
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp M. Scheiwiller
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Konrad E. Bloch
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Michael Furian
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
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12
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Lajoie AC, Sériès F, Bernard S, Bernard E, Santaolalla CJE, Abad Fernández A, Maltais F, Lacasse Y. Reliability of Home Nocturnal Oximetry in the Diagnosis of Overlap Syndrome in COPD. Respiration 2020; 99:132-139. [PMID: 31995805 DOI: 10.1159/000505299] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 12/08/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) and sleep apnea are common conditions and often coexist. The proper diagnosis of sleep apnea may affect the management and outcome of patients with COPD. OBJECTIVE To determine the accuracy of home nocturnal oximetry to distinguish between nocturnal oxygen desaturation related to COPD alone or to sleep apnea in patients with moderate-to-severe COPD who have significant nocturnal hypoxemia with cyclical changes in saturation. METHODS This study involved a comparison of home nocturnal oximetry and laboratory-based polysomnography (PSG) in patients with moderate-to-severe COPD considered for inclusion in a trial of nocturnal oxygen therapy. All of the patients had significant nocturnal oxygen desaturation (defined as ≥30% of the recording time with a transcutaneous arterial oxygen saturation <90%) with cyclical changes in saturation suggestive of sleep apnea. RESULTS PSG was obtained in 90 patients; 45 patients (mean age = 68 years, SD = 8; 71% men; mean forced expiratory volume in 1 s [FEV1] = 50.6% predicted value, SD = 18.6%; data from 41 patients) fulfilled the criteria for sleep apnea (mean apnea-hypopnea index = 32.6 events/h, SD = 19.9) and 45 patients (mean age = 69 years, SD = 8; 87% men; mean FEV1 predicted value 44.6%, SD = 15%) did not (mean apnea-hypopnea index = 5.5 events/h, SD = 3.8). None of the patients' characteristics (including demographic, anthropometric, and physiologic measures) predicted the diagnosis of sleep apnea according to PSG results. CONCLUSION The diagnosis of sleep apnea in patients with moderate to severe COPD cannot rely on nocturnal oximetry alone, even when typical cyclical changes in saturation are seen on oximetry tracing. When suspecting an overlap syndrome, a full-night, in-laboratory PSG should be obtained.
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Affiliation(s)
- Annie-Christine Lajoie
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Frédéric Sériès
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Sarah Bernard
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Emmanuelle Bernard
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | | | | | - François Maltais
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Yves Lacasse
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada,
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13
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Naito A, Sakao S, Terada J, Iwasawa S, Jujo Sanada T, Suda R, Kasai H, Sekine A, Nishimura R, Sugiura T, Shigeta A, Tanabe N, Tatsumi K. Nocturnal Hypoxemia and High Circulating TNF-α Levels in Chronic Thromboembolic Pulmonary Hypertension. Intern Med 2020; 59:1819-1826. [PMID: 32741891 PMCID: PMC7475001 DOI: 10.2169/internalmedicine.4458-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension caused by persistent thromboemboli of the pulmonary arteries, and one of its etiological factors may be inflammation. Sleep disordered breathing (SDB) is reportedly an important complication of pulmonary hypertension. However, the association between SDB and inflammation in CTEPH has been undefined. This prospective observational study analyzed the association between the severity of SDB, pulmonary hemodynamic parameters and the systemic inflammation level in patients with CTEPH. Methods CTEPH patients admitted for a right heart catheter (RHC) examination were consecutively enrolled from November 2017 to June 2019 at the pulmonary hypertension center in Chiba University Hospital. Patients with idiopathic pulmonary arterial hypertension (IPAH) were also enrolled as a control group. All patients underwent a sleep study using a WatchPAT 200 during admission. Results The CTEPH patients showed worse nocturnal hypoxemia, oxygen desaturation index (ODI), and apnea-hypopnea index than the IPAH patients. Among these factors, only the nocturnal mean percutaneous oxygen saturation (SpO2) was negatively correlated with the pulmonary hemodynamic parameters. The circulating tumor necrosis factor-alpha (TNF-α) level was also high in the CTEPH group, and a multivariate analysis showed that the nocturnal mean SpO2 was the most important predictive factor for a high TNF-α level. Conclusion We showed that CTEPH patients had high serum TNF-α levels and that the nocturnal mean SpO2 was a predictive factor for serum TNF-α levels. Further investigations focused on nocturnal hypoxemia and the TNF-α level may provide novel insight into the etiology and new therapeutic strategies for CTEPH.
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Affiliation(s)
- Akira Naito
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Shunichiro Iwasawa
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | | | - Rika Suda
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Hajime Kasai
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Ayumi Sekine
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Rintaro Nishimura
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Toshihiko Sugiura
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Ayako Shigeta
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
- Pulmonary Hypertension Center, Chibaken Saiseikai Narashino Hospital, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
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14
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Pulmonary Hypertension and Left Ventricular Diastolic Dysfunction in Patients with Obesity Hypoventilation Syndrome. CURRENT SLEEP MEDICINE REPORTS 2019. [DOI: 10.1007/s40675-019-00161-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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15
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Nokes BT, Raza HA, Cartin-Ceba R, Lyng PJ, Krahn LE, Wesselius L, Jokerst CE, Umar SB, Griffing WL, Neville MR, Malhotra A, Parish JM. Individuals With Scleroderma May Have Increased Risk of Sleep-Disordered Breathing. J Clin Sleep Med 2019; 15:1665-1669. [PMID: 31739857 PMCID: PMC6853384 DOI: 10.5664/jcsm.8036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVES Scleroderma is associated with abnormal skin thickening, interstitial lung disease, pulmonary hypertension, and abnormalities of the upper airway. These changes can cause cardiopulmonary complications, potentially including sleep-disordered breathing. The objective of this study is to examine the risk of sleep-disordered breathing in patients with scleroderma. METHODS We retrospectively identified patients with documented scleroderma. We abstracted data from their electronic health records, including findings from antibody tests, serial pulmonary function tests, transthoracic echocardiography, high-resolution computed tomography, and overnight forehead oximetry. RESULTS We identified 171 patients with scleroderma. Mean age at the time of initial consult was 56.5 years (range, 18-96 years), and 150 (86.7%) were women. Scleroderma was categorized as limited disease for 108 (62.4%), diffuse disease for 59 (34.1%), and mixed connective tissue disease for 6 (3.5%). Fifty-four patients (31.2%) had abnormal overnight forehead oximetry results, defined as an oxygen desaturation index greater than 5 or a baseline mean arterial oxygen saturation level less than 90%. CONCLUSIONS Cardiopulmonary complications are common in patients with scleroderma, one of which may be sleep-disordered breathing. In our cohort, approximately one-third of individuals with scleroderma had evidence of sleep-disordered breathing. Moreover, the rate of sleep-disordered breathing in our population of scleroderma patients was twice the rate of pulmonary hypertension and was approximately the same as the rate of interstitial lung disease. Future prospective studies are needed to further assess the role of sleep-disordered breathing in scleroderma clinical outcomes.
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Affiliation(s)
- Brandon T. Nokes
- Department of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, California
| | - Hassan A. Raza
- Division of Pulmonary Medicine, Mayo Clinic Hospital, Phoenix, Arizona
| | | | - Phillip J. Lyng
- Division of Pulmonary Medicine, Mayo Clinic Hospital, Phoenix, Arizona
| | - Lois E. Krahn
- Division of Pulmonary Medicine, Mayo Clinic Hospital, Phoenix, Arizona
- Division of Adult Psychiatry, Mayo Clinic Hospital, Phoenix, Arizona
| | - Lewis Wesselius
- Division of Pulmonary Medicine, Mayo Clinic, Scottsdale, Arizona
| | | | - Sarah B. Umar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | | | | | - Atul Malhotra
- Department of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, California
| | - James M. Parish
- Division of Pulmonary Medicine, Mayo Clinic Hospital, Phoenix, Arizona
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16
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Spiesshoefer J, Linz D, Skobel E, Arzt M, Stadler S, Schoebel C, Fietze I, Penzel T, Sinha AM, Fox H, Oldenburg O. Sleep – the yet underappreciated player in cardiovascular diseases: A clinical review from the German Cardiac Society Working Group on Sleep Disordered Breathing. Eur J Prev Cardiol 2019; 28:189-200. [PMID: 33611525 DOI: 10.1177/2047487319879526] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 09/10/2019] [Indexed: 11/16/2022]
Abstract
Abstract
Patients with a wide variety of cardiovascular diseases, including arterial and pulmonary hypertension, arrhythmia, coronary artery disease and heart failure, are more likely to report impaired sleep with reduced sleep duration and quality, and also, sometimes, sleep interruptions because of paroxysmal nocturnal dyspnoea or arrhythmias. Overall, objective short sleep and bad sleep quality (non-restorative sleep) and subjective long sleep duration are clearly associated with major cardiovascular diseases and fatal cardiovascular outcomes. Sleep apnoea, either obstructive or central in origin, represents the most prevalent, but only one, of many sleep-related disorders in cardiovascular patients. However, observations suggest a bidirectional relationship between sleep and cardiovascular diseases that may go beyond what can be explained based on concomitant sleep-related disorders as confounding factors. This makes sleep itself a modifiable treatment target. Therefore, this article reviews the available literature on the association of sleep with cardiovascular diseases, and discusses potential pathophysiological mechanisms. In addition, important limitations of the current assessment, quantification and interpretation of sleep in patients with cardiovascular disease, along with a discussion of suitable study designs to address future research questions and clinical implications are highlighted. There are only a few randomised controlled interventional outcome trials in this field, and some of the largest studies have failed to demonstrate improved survival with treatment (with worse outcomes in some cases). In contrast, some recent pilot studies have shown a benefit of treatment in selected patients with underlying cardiovascular diseases.
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Affiliation(s)
- Jens Spiesshoefer
- Institute of Life Sciences, Scuola Superiore Sant Anna, Pisa, Italy
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Dominik Linz
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Erik Skobel
- Medical Care Unit Pneumology, Sleep Medicine, Allergology and Cardiology, Luisenhospital Aachen, Aachen, Germany
| | - Michael Arzt
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Stefan Stadler
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Christoph Schoebel
- Interdisciplinary Sleep Medicine Center, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ingo Fietze
- Interdisciplinary Sleep Medicine Center, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Penzel
- Interdisciplinary Sleep Medicine Center, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Henrik Fox
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Olaf Oldenburg
- Ludgerus-Kliniken Münster, Clemenshospital, Department of Cardiology, Münster, Germany
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17
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Furian M, Lichtblau M, Aeschbacher SS, Estebesova B, Emilov B, Sheraliev U, Marazhapov NH, Mademilov M, Osmonov B, Bisang M, Ulrich S, Latshang TD, Ulrich S, Sooronbaev TM, Bloch KE. Effect of Dexamethasone on Nocturnal Oxygenation in Lowlanders With Chronic Obstructive Pulmonary Disease Traveling to 3100 Meters: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e190067. [PMID: 30794302 PMCID: PMC6484579 DOI: 10.1001/jamanetworkopen.2019.0067] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE During mountain travel, patients with chronic obstructive pulmonary disease (COPD) are at risk of experiencing severe hypoxemia, in particular, during sleep. OBJECTIVE To evaluate whether preventive dexamethasone treatment improves nocturnal oxygenation in lowlanders with COPD at 3100 m. DESIGN, SETTING, AND PARTICIPANTS A randomized, placebo-controlled, double-blind, parallel trial was performed from May 1 to August 31, 2015, in 118 patients with COPD (forced expiratory volume in the first second of expiration [FEV1] >50% predicted, pulse oximetry at 760 m ≥92%) who were living at altitudes below 800 m. The study was conducted at a university hospital (760 m) and high-altitude clinic (3100 m) in Tuja-Ashu, Kyrgyz Republic. Patients underwent baseline evaluation at 760 m, were taken by bus to the clinic at 3100 m, and remained at the clinic for 2 days and nights. Participants were randomized 1:1 to receive either dexamethasone, 4 mg, orally twice daily or placebo starting 24 hours before ascent and while staying at 3100 m. Data analysis was performed from September 1, 2015, to December 31, 2016. INTERVENTIONS Dexamethasone, 4 mg, orally twice daily (dexamethasone total daily dose, 8 mg) or placebo starting 24 hours before ascent and while staying at 3100 m. MAIN OUTCOMES AND MEASURES Difference in altitude-induced change in nocturnal mean oxygen saturation measured by pulse oximetry (Spo2) during night 1 at 3100 m between patients receiving dexamethasone and those receiving placebo was the primary outcome and was analyzed according to the intention-to-treat principle. Other outcomes were apnea/hypopnea index (AHI) (mean number of apneas/hypopneas per hour of time in bed), subjective sleep quality measured by a visual analog scale (range, 0 [extremely bad] to 100 [excellent]), and clinical evaluations. RESULTS Among the 118 patients included, 18 (15.3%) were women; the median (interquartile range [IQR]) age was 58 (52-63) years; and FEV1 was 91% predicted (IQR, 73%-103%). In 58 patients receiving placebo, median nocturnal Spo2 at 760 m was 92% (IQR, 91%-93%) and AHI was 20.5 events/h (IQR, 12.3-48.1); during night 1 at 3100 m, Spo2 was 84% (IQR, 83%-85%) and AHI was 39.4 events/h (IQR, 19.3-66.2) (P < .001 both comparisons vs 760 m). In 60 patients receiving dexamethasone, Spo2 at 760 m was 92% (IQR, 91%-93%) and AHI was 25.9 events/h (IQR, 16.3-37.1); during night 1 at 3100 m, Spo2 was 86% (IQR, 84%-88%) (P < .001 vs 760 m) and AHI was 24.7 events/h (IQR, 13.2-33.7) (P = .99 vs 760 m). Altitude-induced decreases in Spo2 during night 1 were mitigated by dexamethasone vs placebo by a mean of 3% (95% CI, 2%-3%), and increases in AHI were reduced by 18.7 events/h (95% CI, 12.0-25.3). Similar effects were observed during night 2. Subjective sleep quality was improved with dexamethasone during night 2 by 12% (95% CI, 0%-23%). Sixteen (27.6%) patients using dexamethasone had asymptomatic hyperglycemia. CONCLUSIONS AND RELEVANCE In lowlanders in Central Asia with COPD traveling to a high altitude, preventive dexamethasone treatment improved nocturnal oxygen saturation, sleep apnea, and subjective sleep quality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02450994.
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Affiliation(s)
- Michael Furian
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | | | - Bermet Estebesova
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Berik Emilov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Ulan Sheraliev
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Nuriddin H. Marazhapov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Maamed Mademilov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Batyr Osmonov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Maya Bisang
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Stefanie Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Tsogyal D. Latshang
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Talant M. Sooronbaev
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Konrad E. Bloch
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
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La Rovere MT, Fanfulla F, Taurino AE, Bruschi C, Maestri R, Robbi E, Maestroni R, Pronzato C, Pin M, D'Armini AM, Pinna GD. Chronic thromboembolic pulmonary hypertension: Reversal of pulmonary hypertension but not sleep disordered breathing following pulmonary endarterectomy. Int J Cardiol 2018; 264:147-152. [DOI: 10.1016/j.ijcard.2018.02.112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/23/2018] [Accepted: 02/26/2018] [Indexed: 10/16/2022]
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Latshang TD, Furian M, Aeschbacher SS, Ulrich S, Osmonov B, Mirrakhimov EM, Isakova J, Aldashev AA, Sooronbaev TM, Bloch KE. Association between sleep apnoea and pulmonary hypertension in Kyrgyz highlanders. Eur Respir J 2017; 49:13993003.01530-2016. [PMID: 28007792 DOI: 10.1183/13993003.01530-2016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 10/21/2016] [Indexed: 02/03/2023]
Abstract
This case-control study evaluates a possible association between high altitude pulmonary hypertension (HAPH) and sleep apnoea in people living at high altitude.Ninety highlanders living at altitudes >2500 m without excessive erythrocytosis and with normal spirometry were studied at 3250 m (Aksay, Kyrgyzstan); 34 healthy lowlanders living below 800 m were studied at 760 m (Bishkek, Kyrgyzstan). Echocardiography, polysomnography and other outcomes were assessed. Thirty-six highlanders with elevated mean pulmonary artery pressure (mPAP) >30 mmHg (31-42 mmHg by echocardiography) were designated as HAPH+. Their data were compared to that of 54 healthy highlanders (HH, mPAP 13-28 mmHg) and 34 healthy lowlanders (LL, mPAP 8-24 mmHg).The HAPH+ group (median age 52 years (interquartile range 47-59) had a higher apnoea-hypopnoea index (AHI) of 33.8 events·h-1 (26.9-54.6) and spent a greater percentage of the night-time with an oxygen saturation <90% (T<90; 78% (61-89)) than the HH group (median age 39 years (32-48), AHI 9.0 events·h-1 (3.6-16), T<90 33% (10-69)) and the LL group (median age 40 years (30-47), AHI 4.3 events·h-1 (1.4-12.6), T<90 0% (0-0)); p<0.007 for AHI and T<90, respectively, in HAPH+ versus others. In highlanders, multivariable regression analysis confirmed an independent association between mPAP and both AHI and T<90, when controlled for age, gender and body mass index.Pulmonary hypertension in highlanders is associated with sleep apnoea and hypoxaemia even when adjusted for age, gender and body mass index, suggesting pathophysiologic interactions between pulmonary haemodynamics and sleep apnoea.
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Affiliation(s)
- Tsogyal D Latshang
- Clinic of Pneumology and Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael Furian
- Clinic of Pneumology and Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland
| | - Sayaka S Aeschbacher
- Clinic of Pneumology and Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Clinic of Pneumology and Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland
| | - Batyr Osmonov
- Dept of Respiratory, Critical Care and Sleep Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Erkin M Mirrakhimov
- Dept of Respiratory, Critical Care and Sleep Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic.,Kyrgyz State Medical Academy, Bishkek, Kyrgyz Republic
| | - Jainagul Isakova
- Research Institute for Molecular Biology and Medicine, Bishkek, Kyrgyz Republic
| | - Almaz A Aldashev
- Research Institute for Molecular Biology and Medicine, Bishkek, Kyrgyz Republic
| | - Talant M Sooronbaev
- Dept of Respiratory, Critical Care and Sleep Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Konrad E Bloch
- Clinic of Pneumology and Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland
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