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Ewert R, Stubbe B, Heine A, Desole S, Habedank D, Knaack C, Hortien F, Opitz CF. [Invasive Cardiopulmonary Exercise Testing: A Review]. Pneumologie 2021; 76:98-111. [PMID: 34844269 DOI: 10.1055/a-1651-7450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Right heart catheterization (RHC) is the internationally standardized reference method for measuring pulmonary hemodynamics under resting conditions. In recent years, increasing efforts have been made to establish the reliable assessment of exercise hemodynamics as well, in order to obtain additional diagnostic and prognostic data. Furthermore, cardiopulmonary exercise testing (CPET), as the most comprehensive non-invasive exercise test, is increasingly performed in combination with RHC providing detailed pathophysiological insights into the exercise response, so-called invasive cardiopulmonary exercise testing (iCPET).In this review, the accumulated experience with iCPET is presented and methodological details are discussed. This complex examination is especially helpful in differentiating the underlying causes of unexplained dyspnea. In particular, early forms of cardiac or pulmonary vascular dysfunction can be detected by integrated analysis of hemodynamic as well as ventilatory and gas exchange data. It is expected that with increasing validation of iCPET parameters, a more reliable differentiation of normal from pathological stress reactions will be possible.
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Affiliation(s)
- Ralf Ewert
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Beate Stubbe
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Alexander Heine
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Susanna Desole
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Dirk Habedank
- DRK Kliniken Berlin Köpenick, Medizinische Klinik Kardiologie, Berlin
| | - Christine Knaack
- Universitätsmedizin Greifswald, Klinik für Innere Medizin C, Greifswald
| | - Franziska Hortien
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Christian F Opitz
- DRK Kliniken Berlin Westend, Klinik für Innere Medizin, Schwerpunkt Kardiologie, Berlin
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Ewert R, Heine A, Bollmann T, Müller-Heinrich A, Gläser S, Opitz CF. Right Heart Catheterization During Exercise in Patients with COPD-An Overview of Clinical Results and Methodological Aspects. COPD 2019; 15:588-599. [PMID: 30894079 DOI: 10.1080/15412555.2018.1545832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
While right heart catheterization (RHC) at rest is the gold standard to assess pulmonary hemodynamics in patients with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension (PH), the invasive measurement of exercise hemodynamics is less well established in this group. Since exercise hemodynamics are increasingly recognized as important clinical information in patients with PH, our goal was to review the literature in this field to provide a basis for clinical use, further studies, and future recommendations. We identified 69 studies (published since 1968) reporting RHC data in 2819 patients with COPD, of whom 2561 underwent exercise testing. Few studies simultaneously measured gas exchange during exercise. Overall, these studies showed large variations in the patient populations and research questions studied and the methods and definitions employed. Despite these limitations, the data consistently demonstrated the presence of precapillary PH at rest in up to 38% of patients with COPD. With exercise, a relevant proportion of patients developed an abnormal hemodynamic response, depending on the definition used. Furthermore, some studies assessed right ventricular function during exercise and showed a blunted increase in right ventricular ejection fraction. Drug effects and the impact of interventional procedures were also studied. Again, due to large variations in the patients studied and the methods used, firm conclusions are difficult to derive. Despite the limitations of this dataset, several recommendations with respect to technical aspects (body position, exercise protocol, and data acquisition) can be inferred for this challenging patient population and may be helpful for further studies or recommendations.
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Affiliation(s)
- Ralf Ewert
- a Department of Internal Medicine B , University Hospital Greifswald , Greifswald, Germany
| | - Alexander Heine
- a Department of Internal Medicine B , University Hospital Greifswald , Greifswald, Germany
| | - Tom Bollmann
- a Department of Internal Medicine B , University Hospital Greifswald , Greifswald, Germany
| | | | - Sven Gläser
- b Vivantes Klinik Berlin-Spandau, Klinik für Pneumologie , Berlin , Germany
| | - Christian F Opitz
- c DRK-Kliniken Berlin-Westend, Klinik für Kardiologie , Berlin , Germany
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Acute exacerbations and respiratory failure in chronic obstructive pulmonary disease. Ann Am Thorac Soc 2008; 5:530-5. [PMID: 18453367 DOI: 10.1513/pats.200707-088et] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) describe the phenomenon of sudden worsening in airway function and respiratory symptoms in patients with COPD. These exacerbations can range from self-limited diseases to episodes of florid respiratory failure requiring mechanical ventilation. The average patient with COPD experiences two such episodes annually, and they account for significant consumption of health care resources. Although bacterial infections are the most common causes of AECOPD, viral infections and environmental stresses are also implicated. AECOPD episodes can be triggered or complicated by other comorbidities, such as heart disease, other lung diseases (e.g., pulmonary emboli, aspiration, pneumothorax), or systemic processes. Pharmacologic management includes bronchodilators, corticosteroids, and antibiotics in most patients. Oxygen, physical therapy, mucolytics, and airway clearance devices may be useful in selected patients. In hypercapneic respiratory failure, noninvasive positive pressure ventilation may allow time for other therapies to work and thus avoid endotracheal intubation. If the patient requires invasive mechanical ventilation, the focus should be on avoiding ventilator-induced lung injury and minimizing intrinsic positive end-expiratory pressure. These may require limiting ventilation and "permissive hypercapnia." Although mild episodes of AECOPD are generally reversible, more severe forms of respiratory failure are associated with a substantial mortality and a prolonged period of disability in survivors.
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Lee JE, Min BR, Park JS, Park HP, Jun MJ, Won KS, Choi WI. Right Ventricle Ejection Fraction Contributes Severity of Dyspnea in Chronic Obstructive Pulmonary Disease (COPD). Tuberc Respir Dis (Seoul) 2006. [DOI: 10.4046/trd.2006.60.6.631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jung Eun Lee
- Department of Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Bo Ram Min
- Department of Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Seok Park
- Department of Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hun Pyo Park
- Department of Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Mi Jung Jun
- Department of Preventive Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung Sook Won
- Department of Nuclear Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Won Il Choi
- Department of Medicine, Keimyung University School of Medicine, Daegu, Korea
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Abstract
Current research is providing new understanding in the pathophysiology of emphysema, and this knowledge will be translated in finding better modalities of therapy for patients currently affected by COPD. The single best effort that can alter the course of COPD is promoting policies to remove smoking as an available option to young people, before they become addicted and thus prey of tobacco-producing companies. Landmark studies like NETT and the GOLD initiative are providing tool classify emphysema in the context of physiological criteria and possible therapeutic alternatives.
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Affiliation(s)
- Cesar A Keller
- Mayo Clinic, 4205 Belfort Road, Suite 1100, Jacksonville, FL 32216, USA.
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Rusche WP, Ince A, Alvarez F, Keller C, Daud U, Moore TL. Cardiopulmonary Exercise Testing With Pulmonary Artery Catheterization Detects Early Pulmonary Vasculature Changes in Patients With Connective Tissue Diseases. J Clin Rheumatol 2002; 8:247-50; discussion 250. [PMID: 17041378 DOI: 10.1097/00124743-200210000-00002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pulmonary hypertension is a well-recognized complication of connective tissue diseases (CTD), with clinical symptoms typically limited to those with relatively advanced disease. The objective of this study was to identify patients with early pulmonary vasculature changes using cardiopulmonary exercise testing with pulmonary artery catheterization. Four patients with CTD and normal Doppler echocardiogram results identified as high risk for pulmonary hypertension on the basis of disease process underwent cardiopulmonary exercise testing with pulmonary artery catheterization. All patients had normal mean pulmonary artery pressures at rest (<25 mmHg), but exhibited an abnormal rise in mean pulmonary artery pressure with exercise. Cardiopulmonary exercise testing should be considered in patients at high risk for pulmonary hypertension to identify those individuals who may benefit from early therapeutic intervention.
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Affiliation(s)
- William P Rusche
- Division of Rheumatology, Department of Internal Medicine, Saint Louis University Health Sciences Center, St. Louis, Missouri 63104, USA
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Abstract
Lung transplantation is able to provide dramatic gains in pulmonary function to patients with advanced pulmonary emphysema. At the present time, however, transplantation is available to a strictly defined pool of candidates, and outcomes are limited by numerous respiratory and nonrespiratory postoperative complications. Further progress is needed in expanding the supply of donor lungs, minimizing perioperative complications, and optimizing postoperative immunologic management.
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Affiliation(s)
- L L Schulman
- Department of Medicine, Lung Transplant Service, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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Schulman LL, Leibowitz DW, Anandarangam T, DiTullio MR, McGregor CC, Smith CR, Homma S. Variability of right ventricular functional recovery after lung transplantation. Transplantation 1996; 62:622-5. [PMID: 8830826 DOI: 10.1097/00007890-199609150-00014] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to assess by echocardiography the effects of lung transplantation on recovery of right ventricular (RV) function in patients with preoperative RV dysfunction. METHODS Fourteen (20%) of 71 lung transplant recipients were identified by echocardiography as manifesting abnormal RV function before lung transplantation. These 14 patients were selected for follow-up echocardiographic study 8 months after transplantation. RESULTS RV function improved significantly in the study group. Mean RV end-diastolic area decreased from 26.8 +/- 7.9 cm2 to 20.1 +/- 4.7 cm2 (P < 0.01); mean RV end-systolic area decreased from 21.5 +/- 6.8 cm2 to 13.1 +/- 4.2 (P < 0.01); and mean RV fractional area change (FAC) increased from 20.4 +/- 3.3% to 35.8 +/- 8.9% (P < 0.001). A subgroup of four patients, however, exhibited no change in RV function. Patients who achieved improvement in RV function tended to be younger, had shorter duration of disease before transplantation, and had higher pulmonary arterial (PA) pressures before transplantation (PA systolic, 89 +/- 28 mmHg vs. 38 +/- 11 mmHg, P < 0.001; PA diastolic, 42 +/- 11 mmHg vs. 19 +/- 3 mmHg, P < 0.002). Each of the eight patients with primary pulmonary hypertension exhibited improvement in RV function (mean delta FAC +20.6 +/- 5.9%), while two of three patients with emphysema and both patients with idiopathic pulmonary fibrosis failed to achieve improvement in RV function (mean delta FAC +2.3 +/- 1.2%). CONCLUSIONS Improvement of RV function assessed by echocardiography occurs after lung transplantation, even in patients with severe preoperative RV dysfunction. However, the degree of improvement is variable and may depend on the degree of RV after-load reduction and the presence or absence of intrinsic myocardial disease. RV ejection parameters do not distinguish between these two possibilities.
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Affiliation(s)
- L L Schulman
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York 10032, USA
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