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Torres-Castro R, Hinojosa W, Martínez-Meñaca A, Sala Llinas E, Jiménez Arjona J, Rueda Soriano J, Aurtenetxe A, Barberà JA, Escribano-Subías P, Blanco I. Epidemiology of supplemental oxygen in patients with pulmonary hypertension. Respirology 2024. [PMID: 39210654 DOI: 10.1111/resp.14821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND OBJECTIVE Patients with pulmonary hypertension (PH) may present with hypoxaemia at rest or during daily activities. There is no epidemiological data on the prescription of long-term oxygen therapy (LTOT) in patients with PH. The study sought to analyse the prevalence and incidence of LTOT prescription among patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) in Spain and to determine predictors for this prescription. METHODS A retrospective analysis was performed from the Spanish Registry of Pulmonary Arterial Hypertension (REHAP). Collected data included demographics and anthropometric measurements, functional class (FC), arterial blood gases, pulmonary function tests, haemodynamic measurements, six-minute walking distance (6MWD) and LTOT prescription. In addition, we assessed the prevalence and incidence of LTOT prescription by PH group and subtype and potential predictors for LTOT initiation in the first 5 years after diagnosis. RESULTS We analysed 4533 patients (69.9% PAH and 30.1% CTEPH), mostly female (64.5%), with a mean age of 53.0 ± 18.3 years. The prevalence of LTOT was 19.3% for all patients. The incidence of LTOT prescriptions decreased from 5.6% to 1.6% between 2010 and 2019, respectively. Predictors for LTOT prescription, excluding those that represent the indication for oxygen therapy were: FC (HR: 1.813), 6MWD (HR: 1.002), mean pulmonary arterial pressure (mPAP) (HR: 1.014), cardiac index (CI) (HR: 1.253), pulmonary vascular resistance (PVR) (HR: 1.023) and diffusing capacity of carbon monoxide (DLCO) (HR: 1.294). CONCLUSION The prevalence of LTOT in PAH and CTEPH patients is close to 20%. FC, 6MWD, mPAP, CI, PVR and DLCO were predictors for LTOT prescription.
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Affiliation(s)
- Rodrigo Torres-Castro
- Department of Pulmonary Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), University of Barcelona, Barcelona, Spain
- Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Williams Hinojosa
- Pulmonary Hypertension Unit, Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Amaya Martínez-Meñaca
- Department of Pneumology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
- Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
- ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Spain
| | - Ernest Sala Llinas
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Department of Pneumology, Hospital Universitario Son Espases, Balearic Islands, Spain
- Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | - Joaquín Rueda Soriano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Agueda Aurtenetxe
- Depatrment of Pneumology, Hospital Universitario Basurto, Bilbao, Spain
| | - Joan Albert Barberà
- Department of Pulmonary Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), University of Barcelona, Barcelona, Spain
- ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Pilar Escribano-Subías
- Pulmonary Hypertension Unit, Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Instituto de investigación del Hospital 12 de Octubre ( i+12), Madrid, Spain
| | - Isabel Blanco
- Department of Pulmonary Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Fundació de Recerca Clínic Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (FRCB-IDIBAPS), University of Barcelona, Barcelona, Spain
- ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Fu Z, Tao X, Xie W, Yang P, Gao Q, Wang J, Zhai Z. Different response of the oxygen pathway in patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy versus balloon pulmonary angioplasty. Front Cardiovasc Med 2022; 9:990207. [PMID: 36237910 PMCID: PMC9551285 DOI: 10.3389/fcvm.2022.990207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundOxygen pathway limitation exists in chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA) are two effective interventions for CTEPH, but their effects and comparison of these two interventions on the oxygen pathway are not well demonstrated.MethodsCTEPH patients with available pulmonary function test, hemodynamics, and blood gas analysis before and after the interventions were included for comparison of oxygen pathway in terms of lung ventilation, lung gas exchange, oxygen delivery, and oxygen extraction between these two interventions.ResultsThe change in the percentage of the predicted forced expiratory volume in the 1 s (−3.4 ± 12.7 vs. 3.8 ± 8.7%, P = 0.006) and forced vital capacity (−5.5 ± 13.0 vs. 4.2 ± 9.9%, P = 0.001) among the PEA group (n = 24) and BPA group (n = 46) were significantly different. Patients in the PEA group had a significant increase in their arterial oxygen saturation (from 92.5 ± 3.6 to 94.6 ± 2.4%, P = 0.022), while those in the BPA group had no change, which could be explained by a significant improvement in ventilation/perfusion (−0.48 ± 0.53 vs. −0.17 ± 0.41, P = 0.016). Compared with patients post-BPA, patients post-PEA were characterized by higher oxygen delivery (756.3 ± 229.1 vs. 628.8 ± 188.5 ml/min, P = 0.016) and higher oxygen extraction (203.3 ± 64.8 vs. 151.2 ± 31.9 ml/min, P = 0.001).ConclusionPartial amelioration of the oxygen pathway limitations could be achieved in CTEPH patients treated with PEA and BPA. CTEPH patients post-PEA had better performance in lung gas exchange, oxygen delivery, and extraction, while those post-BPA had better lung ventilation. Cardiopulmonary rehabilitation may assist in improving the impairment of the oxygen pathway.
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Affiliation(s)
- Zhihui Fu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Xincao Tao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wanmu Xie
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Peiran Yang
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- State Key Laboratory of Medical Molecular Biology, Department of Physiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Qian Gao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Jinzhi Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
- *Correspondence: Zhenguo Zhai,
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Howden EJ, Ruiz-Carmona S, La Gerche A, Delcroix M, Claessen G. Response by Howden et al to Letter Regarding Article, "Oxygen Pathway Limitations in Patients With Chronic Thromboembolic Pulmonary Hypertension". Circulation 2021; 144:e330-e331. [PMID: 34807765 DOI: 10.1161/circulationaha.121.056806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Erin J Howden
- Baker Heart and Diabetes Institute, Melbourne, Australia (E.J.H., S.R.-H., A.L.G.)
| | - Sergio Ruiz-Carmona
- Baker Heart and Diabetes Institute, Melbourne, Australia (E.J.H., S.R.-H., A.L.G.)
| | - André La Gerche
- Baker Heart and Diabetes Institute, Melbourne, Australia (E.J.H., S.R.-H., A.L.G.)
| | - Marion Delcroix
- KU Leuven, Belgium (M.D., G.C.).,University Hospitals Leuven, Belgium (M.D., G.C.)
| | - Guido Claessen
- KU Leuven, Belgium (M.D., G.C.).,University Hospitals Leuven, Belgium (M.D., G.C.)
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Tromeur C, Jaïs X, Mercier O, Couturaud F, Montani D, Savale L, Jevnikar M, Weatherald J, Sitbon O, Parent F, Fabre D, Mussot S, Dartevelle P, Humbert M, Simonneau G, Fadel E. Factors predicting outcome after pulmonary endarterectomy. PLoS One 2018; 13:e0198198. [PMID: 29927944 PMCID: PMC6013172 DOI: 10.1371/journal.pone.0198198] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/15/2018] [Indexed: 11/18/2022] Open
Abstract
Objective Few studies have reported predictive factors of outcome after pulmonary endarterectomy (PEA) in chronic thromboembolic pulmonary hypertension. The purpose of this study was to determine factors influencing mortality and predictors of hemodynamic improvement after PEA. Methods A total of 383 consecutive patients who underwent PEA between January 2005 and December 2009 were retrospectively reviewed. Among them, 150 were fully reevaluated 7.5±1 months after PEA by NYHA class, 6–minute walk distance (6MWD), percentage of predicted carbon monoxide transfer factor (TLCO) and right heart catheterisation. Results Mortality rates at 1 month, 1 year and 3 years were 2.8%, 6.9% and 7.5%, respectively. Preoperative pulmonary vascular resistance (PVR) independently predicted 1-month, 1- and 3-year mortality and age predicted mortality at 1 year and 3 years. Significant improvement in NYHA class and 6MWD were observed and PVR decreased from 773±353 to 307±221 dyn.sec.cm-5 (p<0.001). In 96 patients (64%), PVR decreased by at least 50% and/or was reduced to lower than 250 dyn.sec.cm-5. Preoperative cardiac output (CO) and TLCO predicted hemodynamic improvement. Conclusion PEA is associated with an excellent long-term survival and a marked improvement in clinical status and hemodynamics. Some preoperative factors including PVR, CO and TLCO can predict postoperative outcomes.
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Affiliation(s)
- Cécile Tromeur
- European Brittany University, Brest, France
- Department of Internal Medicine and Chest Diseases, University Hospital Centre La Cavale Blanche, Brest, France
- Groupe d’Etude de la Thrombose de Bretagne Occidentale (GETBO), EA 3878, CIC INSERM 1412, Brest, France
- * E-mail:
| | - Xavier Jaïs
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olaf Mercier
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Francis Couturaud
- European Brittany University, Brest, France
- Department of Internal Medicine and Chest Diseases, University Hospital Centre La Cavale Blanche, Brest, France
- Groupe d’Etude de la Thrombose de Bretagne Occidentale (GETBO), EA 3878, CIC INSERM 1412, Brest, France
| | - David Montani
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Laurent Savale
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Mitja Jevnikar
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Jason Weatherald
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
| | - Olivier Sitbon
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Florence Parent
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Dominique Fabre
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Sacha Mussot
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Philippe Dartevelle
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Gérald Simonneau
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Elie Fadel
- Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
- Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Jujo T, Tanabe N, Sakao S, Ishibashi-Ueda H, Ishida K, Naito A, Kato F, Takeuchi T, Sekine A, Nishimura R, Sugiura T, Shigeta A, Masuda M, Tatsumi K. Severe Pulmonary Arteriopathy Is Associated with Persistent Hypoxemia after Pulmonary Endarterectomy in Chronic Thromboembolic Pulmonary Hypertension. PLoS One 2016; 11:e0161827. [PMID: 27571267 PMCID: PMC5003341 DOI: 10.1371/journal.pone.0161827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 08/14/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by occlusion of pulmonary arteries by organized chronic thrombi. Persistent hypoxemia and residual pulmonary hypertension (PH) following successful pulmonary endarterectomy (PEA) are clinically important problems; however, the underlying mechanisms remain unclear. We have previously reported that residual PH is closely related to severe pulmonary vascular remodeling and hypothesize that this arteriopathy might also be involved in impaired gas exchange. The purpose of this study was to evaluate the association between hypoxemia and pulmonary arteriopathy after PEA. METHODS AND RESULTS Between December 2011 and November 2014, 23 CTEPH patients underwent PEA and lung biopsy. The extent of pulmonary arteriopathy was quantified pathologically in lung biopsy specimens. We then analyzed the relationship between the severity of pulmonary arteriopathy and gas exchange after PEA. We observed that the severity of pulmonary arteriopathy was negatively correlated with postoperative and follow-up PaO2 (postoperative PaO2: r = -0.73, p = 0.0004; follow-up PaO2: r = -0.66, p = 0.001), but not with preoperative PaO2 (r = -0.373, p = 0.08). Multivariate analysis revealed that the obstruction ratio and patient age were determinants of PaO2 one month after PEA (R2 = 0.651, p = 0.00009). Furthermore, the obstruction ratio and improvement of pulmonary vascular resistance were determinants of PaO2 at follow-up (R2 = 0.545, p = 0.0002). Severe pulmonary arteriopathy might increase the alveolar-arterial oxygen difference and impair diffusion capacity, resulting in hypoxemia following PEA. CONCLUSION The severity of pulmonary arteriopathy was closely associated with postoperative and follow-up hypoxemia.
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Affiliation(s)
- Takayuki Jujo
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
- * E-mail:
| | - Nobuhiro Tanabe
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Seiichiro Sakao
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Hatsue Ishibashi-Ueda
- Department of Pathology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-Dai, Suita City, Osaka, 565–8565, Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Akira Naito
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Fumiaki Kato
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Takao Takeuchi
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Ayumi Sekine
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Rintaro Nishimura
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Toshihiko Sugiura
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Ayako Shigeta
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
| | - Masahisa Masuda
- Department of Cardiovascular Surgery, Chiba Medical Center, National Hospital Organization, 4-1-2, Tsubakimori, Chuo-ku, Chiba City, 260–8606, Japan
| | - Koichiro Tatsumi
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba City, 260–8670, Japan
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Poullis M. Central and peripheral pulmonary vascular resistance: Implications for who should undergo pulmonary thromboendarterectomy. Med Hypotheses 2015; 85:113-6. [PMID: 25997984 DOI: 10.1016/j.mehy.2015.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 01/23/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
Pulmonary thromboendarterectomy remains a technically challenging procedure with variable outcomes with regard to improvement in pulmonary function. Reducing the resistance to flow between the pulmonary valve and the pulmonary capillary bed is the key aim of surgery. The resistance to flow is due to the combination of resistance due to the central clot and distal capillary resistance. We hypothesise that the use of fluid mechanics in combination with modern radiology and electronic circuit theory can potentially predict who should or should not undergo a thromboendarterectomy. Electronic circuit theory of two resistors in series was utilised to demonstrate the concept of a model of a central clot and the peripheral pulmonary capillary bed. A simplified 2D model of the lungs utilising finite element analysis and Poiseuille's law was constructed for proof of principle. Modelling predicts that cardiac output and anatomical obstruction interplay and can have profound effects on the outcomes after thromboendarterectomy. Identical pulmonary artery pressures, due to differing cardiac outputs and identical anatomical obstructions due to thrombus can have very different physiological outcomes with regard to changes in pulmonary artery pressure. Modelling the pulmonary vasculature to determine central and peripheral pulmonary vascular resistance may help in predicting who should undergo pulmonary thromboendarterectomy. Mathematical modelling can potentially predict which patients have haemodynamically significant clots in their pulmonary arteries that thromboendarterectomy may potentially help in the setting of pulmonary capillary disease.
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Affiliation(s)
- Mike Poullis
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, England, United Kingdom.
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Banks DA, Pretorius GVD, Kerr KM, Manecke GR. Pulmonary Endarterectomy. Semin Cardiothorac Vasc Anesth 2014; 18:319-30. [DOI: 10.1177/1089253214536621] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from recurrent or incomplete resolution of pulmonary embolism. CTEPH is much more common than generally appreciated. Although pulmonary embolism (PE) affects a large number of Americans, chronic pulmonary hypertension (PH) remains underdiagnosed. It is imperative that all patients with PH be screened for the presence of CTEPH since this form of PH is potentially curable with pulmonary thromboendarterectomy (PTE) surgery. The success of this procedure depends greatly on the collaboration of a multidisciplinary team approach that includes pulmonary medicine, cardiothoracic surgery, and cardiac anesthesiology. This review, based on the experience of more than 3000 pulmonary endarterectomy surgeries, is divided into 2 parts. Part I focuses on the clinical history and pathophysiology, diagnostic workup, and intraoperative echocardiography. Part II focuses on the surgical approach, anesthetic management, postoperative care, and complications.
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Affiliation(s)
| | | | - Kim M. Kerr
- University of California, San Diego, La Jolla, CA, USA
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.
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Affiliation(s)
- Peter S Marshall
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, 15 York Street, LCI 101, New Haven, CT 06510, USA.
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10
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Farha S, Laskowski D, George D, Park MM, Tang WHW, Dweik RA, Erzurum SC. Loss of alveolar membrane diffusing capacity and pulmonary capillary blood volume in pulmonary arterial hypertension. Respir Res 2013; 14:6. [PMID: 23339456 PMCID: PMC3560152 DOI: 10.1186/1465-9921-14-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/17/2013] [Indexed: 11/30/2022] Open
Abstract
Background Reduced gas transfer in patients with pulmonary arterial hypertension (PAH) is traditionally attributed to remodeling and progressive loss of pulmonary arterial vasculature that results in decreased capillary blood volume available for gas exchange. Methods We tested this hypothesis by determination of lung diffusing capacity (DL) and its components, the alveolar capillary membrane diffusing capacity (Dm) and lung capillary blood volume (Vc) in 28 individuals with PAH in comparison to 41 healthy individuals, and in 19 PAH patients over time. Using single breath simultaneous measure of diffusion of carbon monoxide (DLCO) and nitric oxide (DLNO), DL and Dm were respectively determined, and Vc calculated. Dm and Vc were evaluated over time in relation to standard clinical indicators of disease severity, including brain natriuretic peptide (BNP), 6-minute walk distance (6MWD) and right ventricular systolic pressure (RVSP) by echocardiography. Results Both DLCO and DLNO were reduced in PAH as compared to controls and the lower DL in PAH was due to loss of both Dm and Vc (all p < 0.01). While DLCO of PAH patients did not change over time, DLNO decreased by 24 ml/min/mmHg/year (p = 0.01). Consequently, Dm decreased and Vc tended to increase over time, which led to deterioration of the Dm/Vc ratio, a measure of alveolar-capillary membrane functional efficiency without changes in clinical markers. Conclusions The findings indicate that lower than normal gas transfer in PAH is due to loss of both Dm and Vc, but that deterioration of Dm/Vc over time is related to worsening membrane diffusion.
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Affiliation(s)
- Samar Farha
- Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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11
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Abstract
The development and clinical application of lung function tests have a long history, and the various components of lung function tests provide very important tools for the clinical evaluation of respiratory health and disease. Spirometry, measurement of the diffusion factor, bronchial provocation tests and forced oscillation techniques have found diverse clinical applications in the diagnosis and monitoring of respiratory diseases, such as chronic obstructive pulmonary disease, interstitial lung diseases and asthma. However, there are some practical issues to be resolved, including the establishment of reference values for individual test parameters and the roles of these tests in preoperative risk assessment and pulmonary rehabilitation. Novel measurements, including negative expiratory pressure, the fraction of exhaled nitric oxide and analysis of exhaled breath condensate, may provide new insights into physiological abnormalities or airway inflammation in respiratory diseases, but their clinical applications need to be further evaluated. The clinical application of lung function tests continues to face challenges, which may be overcome by further improvement of conventional techniques for lung function testing and further specification of new testing techniques.
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Affiliation(s)
- Bin-Miao Liang
- Department of Respiratory Medicine, West China Hospital of Sichuan University, Sichuan, China
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12
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Fedullo P, Kerr KM, Kim NH, Auger WR. Chronic Thromboembolic Pulmonary Hypertension. Am J Respir Crit Care Med 2011; 183:1605-13. [DOI: 10.1164/rccm.201011-1854ci] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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13
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Piirilä P, Laiho M, Mustonen P, Graner M, Piilonen A, Raade M, Sarna S, Harjola VP, Sovijärvi A. Reduction in membrane component of diffusing capacity is associated with the extent of acute pulmonary embolism. Clin Physiol Funct Imaging 2011; 31:196-202. [PMID: 21143754 PMCID: PMC3121963 DOI: 10.1111/j.1475-097x.2010.01000.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 11/14/2010] [Indexed: 11/30/2022]
Abstract
Acute pulmonary embolism (PE) often decreases pulmonary diffusing capacity for carbon monoxide (DL,CO), but data on the mechanisms involved are inconsistent. We wanted to investigate whether reduction in diffusing capacity of alveolo-capillary membrane (DM) and pulmonary capillary blood volume (Vc) is associated with the extent of PE or the presence and severity of right ventricular dysfunction (RVD) induced by PE and how the possible changes are corrected after 7-month follow-up. Forty-seven patients with acute non-massive PE in spiral computed tomography (CT) were included. The extent of PE was assessed by scoring mass of embolism. DL,CO, Vc, DM and alveolar volume (VA) were measured by using a single breath method with carbon monoxide and oxygen both at the acute phase and 7 months later. RVD was evaluated with transthoracic echocardiography and electrocardiogram. Fifteen healthy subjects were included as controls. DL,CO, DL, CO/VA, DM, vital capacity (VC) and VA were significantly lower in the patients with acute PE than in healthy controls (P < 0.001). DM/Vc relation was significantly lower in patients with RVD than in healthy controls (P = 0.004). DM correlated inversely with central mass of embolism (r = -0.312; P = 0.047) whereas Vc did not. DM, DL,CO, VC and VA improved significantly within 7 months. In all patients (P = 0.001, P = 0.001) and persistent RVD (P = 0.020, P = 0.012), DM and DL,CO remained significantly lower than in healthy controls in the follow-up. DM was inversely related to central mass of embolism. Reduction in DM mainly explains the sustained decrease in DL,CO in PE after 7 months despite modern treatment of PE.
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Affiliation(s)
- Päivi Piirilä
- Department of Clinical Physiology, HUSLAB, Helsinki University Central Hospital, Finland.
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14
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Overbeek MJ, Groepenhoff H, Voskuyl AE, Smit EF, Peeters JWL, Vonk-Noordegraaf A, Spreeuwenberg MD, Dijkmans BC, Boonstra A. Membrane diffusion- and capillary blood volume measurements are not useful as screening tools for pulmonary arterial hypertension in systemic sclerosis: a case control study. Respir Res 2008; 9:68. [PMID: 18828919 PMCID: PMC2576177 DOI: 10.1186/1465-9921-9-68] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Accepted: 10/01/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is no optimal screening tool for the assessment of pulmonary arterial hypertension (PAH) in patients with systemic sclerosis (SSc). A decreasing transfer factor of the lung for CO (TLCO) is associated with the development of PAH in SSc. TLCO can be partitioned into the diffusion of the alveolar capillary membrane (Dm) and the capillary blood volume (Vc). The use of the partitioned diffusion to detect PAH in SSc is not well established yet. This study evaluates whether Dm and Vc could be candidates for further study of the use for screening for PAH in SSc. METHODS Eleven SSc patients with PAH (SScPAH+), 13 SSc patients without PAH (SScPAH-) and 10 healthy control subjects were included. Pulmonary function testing took place at diagnosis of PAH. TLCO was partitioned according to Roughton and Forster. As pulmonary fibrosis in SSc influences values of the (partitioned) TLCO, these were adjusted for fibrosis score as assessed on HRCT. RESULTS TLCO as percentage of predicted (%) was lower in SScPAH+ than in SScPAH- (41 +/- 7% vs. 63 +/- 12%, p < 0.0001, respectively). Dm% in SScPAH+ was decreased as compared with SScPAH- (22 +/- 6% vs. 39 +/- 12%, p < 0.0001, respectively), also after adjustment for total fibrosis score (before adjustment: B = 17.5, 95% CI 9.0-25.9, p = < 0.0001; after adjustment: B = 14.3, 95% CI 6.0-21.7, p = 0.008). No difference was found in Vc%. There were no correlations between pulmonary hemodynamic parameters and Dm% in the PAH groups. CONCLUSION SScPAH+ patients have lower Dm% than SScPAH- patients. There are no correlations between Dm% and hemodynamic parameters of PAH in SScPAH+. These findings do not support further study of the role of partitioning TLCO in the diagnostic work- up for PAH in SSc.
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Affiliation(s)
- Maria J Overbeek
- Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands.
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15
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Orfanos SE, Hirsch AM, Giovinazzo M, Armaganidis A, Catravas JD, Langleben D. Pulmonary capillary endothelial metabolic function in chronic thromboembolic pulmonary hypertension. J Thromb Haemost 2008; 6:1275-80. [PMID: 18532994 DOI: 10.1111/j.1538-7836.2008.03046.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) causes physical plugging of large pulmonary arteries as well as a distal micro-vasculopathy. Pulmonary endothelium is an active metabolic tissue in normal humans. The effects of CTEPH on pulmonary endothelial metabolism are unknown. OBJECTIVES We studied pulmonary capillary endothelium-bound angiotensin converting enzyme (ACE) activity as an index of endothelial metabolism in patients with CTEPH. PATIENTS/METHODS We measured single-pass transpulmonary per cent metabolism (%M) and hydrolysis of an ACE synthetic substrate and calculated functional capillary surface area (FCSA), normalized to body surface area (BSA), in 13 patients with CTEPH and 23 controls. RESULTS Mean %M for CTEPH (71.6 +/- 4.0% SE) was similar to controls (74.7 +/- 2.7%). Substrate hydrolysis (v) was similar for CTEPH (1.47 +/- 0.22) and controls (1.51 +/- 0.11). However, FCSA/BSA was reduced (P < 0.01) for CTEPH (1530 +/- 218 mL min(-1)*m(-2)) as compared with controls (2948 +/- 245). CONCLUSIONS The metabolically functional pulmonary capillary bed is reduced in CTEPH. However, because %M and hydrolysis are preserved, this points to a reduction in functional capillary surface area rather than reduced ACE activity on the pulmonary capillary endothelial cell. The reduction in functional capillary surface area may just be a result of decreased capillary recruitment because of upstream vascular plugging by chronic organized thrombus.
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Affiliation(s)
- S E Orfanos
- Second Department of Critical Care, University of Athens Medical School and Pulmonary Hypertension Clinic, Attikon Hospital, Athens-Haidari, Greece
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16
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17
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Abstract
Chronic thromboembolic pulmonary hypertension is a condition that is recognised in an increased percentage of patients. Pulmonary endarterectomy is recognised as being the only curative option for a subgroup of those patients, but anaesthesiologists and intensivists face many challenges in how they manage these patients perioperatively. Ultimately, it is the combination of skills in a multidisciplinary team that leads to a successful procedure and dramatically improves patient's quality of life and life expectancy.
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18
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Oppenheimer BW, Berger KI, Hadjiangelis NP, Norman RG, Rapoport DM, Goldring RM. Membrane diffusion in diseases of the pulmonary vasculature. Respir Med 2006; 100:1247-53. [PMID: 16376536 DOI: 10.1016/j.rmed.2005.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 10/07/2005] [Accepted: 10/16/2005] [Indexed: 11/23/2022]
Abstract
INTRODUCTION We examined pulmonary diffusing capacity (D(LCO)) and its partition in pulmonary vascular diseases without evident parenchymal disease to assess the pattern and proportionality of change in membrane diffusion (D(m)) and capillary blood volume (V(c)). Disproportionate reduction in D(m) relative to V(c) (low D(m)/V(c)) in these diseases has been attributed to associated alveolar membrane/parenchymal disease, thus providing a potentially important diagnostic tool. METHODS Diseases included: idiopathic pulmonary arterial hypertension (n=6), chronic thromboembolic disease (n=5), and intravenous drug use (n=14), providing a spectrum of pulmonary vascular diseases. V(c) and D(m) were determined as described by Roughton and Forster. RESULTS All diseases showed a reduced V(c) (59+/-10, 69+/-14, 71+/-21 % predicted, respectively) and D(m) (76+/-22, 53+/-19, 63+/-16 % predicted, respectively) with no differences between groups (p>0.05). Disproportionate reduction of D(m) (D(m)/V(c) % predicted <1) was seen in all diseases (range 0.36-1.89). A mathematical analysis is presented to illustrate that changes in vascular geometry may additionally influence the proportionality of changes in D(m) and V(c). The mathematical analysis suggests that when reduction in patency of some vessels co-exits with compensatory dilatation of the remaining vasculature, a disproportionate reduction in D(m) relative to V(c) may result. CONCLUSIONS The balance between vascular curtailment and compensatory dilatation may contribute to the variability of the D(m)/V(c) relationship seen in pulmonary vascular disease. Disproportionate reduction in D(m) relative to V(c) may result from this imbalance and need not imply subclinical alveolar membrane and/or parenchymal disease.
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Affiliation(s)
- Beno W Oppenheimer
- Division of Pulmonary and Critical Care Medicine, Bellevue Hospital Chest Service, Department of Medicine, New York University School of Medicine, 462 First Ave 7W54, New York, NY 10016, USA.
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19
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van der Lee I, Zanen P, Grutters JC, Snijder RJ, van den Bosch JMM. Diffusing Capacity for Nitric Oxide and Carbon Monoxide in Patients With Diffuse Parenchymal Lung Disease and Pulmonary Arterial Hypertension. Chest 2006; 129:378-383. [PMID: 16478855 DOI: 10.1378/chest.129.2.378] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The passage of carbon monoxide (CO) through the alveolocapillary membrane and into the plasma and intraerythrocytic compartments determines the diffusing capacity of the lung for CO (DLCO) as defined by the Roughton and Forster equation. On the other hand, the single-breath diffusing capacity of the lung for nitric oxide (DLNO) is thought to represent the true membrane diffusing capacity because of its very high affinity for hemoglobin (Hb) and its independence from pulmonary capillary blood volume. Therefore, the DLNO/DLCO ratio can be used to differentiate between thickened alveolocapillary membranes (both DLNO and DLCO are decreased, and the DLNO/DLCO ratio is normal) and decreased perfusion of ventilated alveoli (the DLNO less decreased than the DLCO; therefore, the DLNO/DLCO ratio is high) in patients with pulmonary disease. STUDY DESIGN We measured the combined values of DLCO and DLNO in 41 patients with diffuse parenchymal lung disease (DPLD), 26 patients with pulmonary arterial hypertension (PAH), and 71 healthy subjects. RESULTS The DLCO (corrected to the standard Hb value) was lowered in the DPLD group (64% of predicted) and in the PAH group (64% of predicted), and was normal in the control group (105% of predicted). The DLNO/DLCO ratio in patients with PAH (4.98) was significantly higher than that in patients with DPLD (4.56) and in healthy subjects (4.36). CONCLUSION The DLNO/DLCO ratio is significantly higher in patients with PAH than in healthy subjects, although this ratio cannot be applied as a screening test to discriminate between patients with DPLD and PAH as the overlap between these groups is too large.
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Affiliation(s)
- Ivo van der Lee
- Heart Lung Centre Utrecht, Department of Pulmonary Diseases, St. Antonius Hospital, Nieuwegein, Netherlands.
| | - Pieter Zanen
- Heart Lung Centre Utrecht, Department of Pulmonary Diseases, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Jan C Grutters
- Heart Lung Centre Utrecht, Department of Pulmonary Diseases, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Repke J Snijder
- Heart Lung Centre Utrecht, Department of Pulmonary Diseases, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Jules M M van den Bosch
- Heart Lung Centre Utrecht, Department of Pulmonary Diseases, St. Antonius Hospital, Nieuwegein, Netherlands
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20
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Escribano PM, Sánchez MAG, de Atauri MJD, Frade JP, García IM. [Lung function testing in patients with pulmonary arterial hypertension]. Arch Bronconeumol 2005; 41:380-4. [PMID: 16029731 DOI: 10.1016/s1579-2129(06)60245-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The main objective was to describe the results of lung function testing in a series of 120 patients with pulmonary arterial hypertension, and the secondary objective was to compare these findings with hemodynamic variables. PATIENTS AND METHODS This was a descriptive study of lung function in 120 patients with stable pulmonary arterial hypertension (Evian/Venice groups 1 and 4) studied until January 2002 in the Pulmonary Hypertension and Lung Transplant Working Group attached to the Cardiology Department of the Hospital Universtario 12 de Octubre in Madrid, Spain. Data were collected retrospectively for the first 47 patients (1981 to 1995) and prospectively thereafter for the remaining 73 patients. The diagnosis was idiopathic arterial hypertension or hypertension associated with collagenosis, chronic pulmonary embolism, cardiac shunt, or toxic oil syndrome (30 cases). RESULTS In the group as a whole, forced vital capacity, forced expiratory volume in 1 second, and total lung capacity were normal; mean (SD) values revealed low carbon dioxide diffusing capacity (67.6% [23.2%]), and moderate hypoxemia (65.8 [15.4] mm Hg). No significant associations were observed between lung function and hemodynamic parameters. Mean age in the toxic oil syndrome group was lower (33.7 [11.4] years), and these patients had higher mean scores on the New York Heart Association scale (3.3 [0.5]) and for pulmonary vascular resistance (20.3 [8.1] kPa.L(-1).s). CONCLUSIONS Lung function was studied in a series of 120 patients with pulmonary arterial hypertension (Evian/ Venice groups 1 and 4), 30 of whom had toxic oil syndrome. No significant associations were found between lung function and hemodynamic parameters.
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Affiliation(s)
- P Martín Escribano
- Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain.
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21
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Martín Escribano P, Gómez Sánchez M, Díaz de Atauri M, Palomera Frade J, Martín García I. Exploración funcional pulmonar en pacientes con hipertensión arterial pulmonar. Arch Bronconeumol 2005. [DOI: 10.1157/13076968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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Zagorski J, Debelak J, Gellar M, Watts JA, Kline JA. Chemokines Accumulate in the Lungs of Rats with Severe Pulmonary Embolism Induced by Polystyrene Microspheres. THE JOURNAL OF IMMUNOLOGY 2003; 171:5529-36. [PMID: 14607960 DOI: 10.4049/jimmunol.171.10.5529] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pulmonary thromboembolism (PEm) is a serious and life threatening disease and the most common cause of acute pulmonary vascular occlusion. Even following successful treatment of PEm, many patients experience long-term disability due to diminished heart and lung function. Considerable damage to the lungs presumably occurs due to reperfusion injury following anti-occlusive treatments for PEm and the resulting chronic inflammatory state in the lung vasculature. We have used a rat model of irreversible PEm to ask whether pulmonary vascular occlusion in the absence of reperfusion is itself sufficient to induce an inflammatory response in lungs. By adjusting the severity of the vascular occlusion, we were able to generate hypertensive and nonhypertensive PEm, and then examine lung tissue for expression of CXC and C-C chemokine genes and bronchoalveolar lavage (BAL) fluid for the presence of chemokine proteins. Hypertensive and nonhypertensive PEm resulted in increased expression of both CXC and C-C chemokines genes in lung tissues. Hypertensive PEm was also associated with a 50-100-fold increase in protein content in lung BAL fluid, which included the CXC chemokines cytokine-induced neutrophil chemoattractant and macrophage-inflammatory protein 2. The presence of chemokines in BALs was reflected by a potent neutrophil chemotactic activity in in vitro chemotaxis assays. Abs to cytokine-induced neutrophil chemoattractant blocked the in vitro neutrophil chemotactic activity of BAL by 44%. Our results indicate that the ischemia and hypertension associated with PEm are sufficient to induce expression of proinflammatory mediators such as chemokines, and establish a proinflammatory environment in the ischemic lung even before reperfusion.
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MESH Headings
- Animals
- Bronchoalveolar Lavage Fluid/chemistry
- Bronchoalveolar Lavage Fluid/cytology
- Bronchoalveolar Lavage Fluid/immunology
- Cell Line
- Chemokine CXCL2
- Chemokines, CXC/biosynthesis
- Chemokines, CXC/genetics
- Chemokines, CXC/metabolism
- Chemokines, CXC/physiology
- Chemotaxis, Leukocyte
- Endothelium, Vascular/cytology
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/immunology
- Endothelium, Vascular/pathology
- Eosinophils/pathology
- Infusions, Intravenous
- Intercellular Signaling Peptides and Proteins/biosynthesis
- Intercellular Signaling Peptides and Proteins/genetics
- Intercellular Signaling Peptides and Proteins/physiology
- Leukocyte Count
- Lung/drug effects
- Lung/immunology
- Lung/metabolism
- Lung/pathology
- Male
- Microspheres
- Monokines/biosynthesis
- Monokines/genetics
- Monokines/physiology
- Neutrophils/immunology
- Neutrophils/pathology
- Pilot Projects
- Pleural Effusion/immunology
- Pleural Effusion/metabolism
- Pleural Effusion/pathology
- Polystyrenes
- Proteins/analysis
- Pulmonary Embolism/chemically induced
- Pulmonary Embolism/immunology
- Pulmonary Embolism/metabolism
- Pulmonary Embolism/pathology
- Rats
- Rats, Sprague-Dawley
- Severity of Illness Index
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Affiliation(s)
- John Zagorski
- Department of Emergency Medicine, James G. Cannon Research Center, Carolinas Medical Center, Charlotte, NC 28203, USA.
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23
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Zoia MC, D'Armini AM, Beccaria M, Corsico A, Fulgoni P, Klersy C, Piovella F, Viganò M, Cerveri I. Mid term effects of pulmonary thromboendarterectomy on clinical and cardiopulmonary function status. Thorax 2002; 57:608-12. [PMID: 12096204 PMCID: PMC1746368 DOI: 10.1136/thorax.57.7.608] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) can be successfully treated surgically by pulmonary thromboendarterectomy (PTE) but there are few data on mid-term cardiopulmonary function, particularly on exertion, and clinical benefits following pulmonary PTE. METHODS A 2 year follow up study was undertaken of clinical status, haemodynamic and lung function indices, gas exchange, and exercise tolerance in 38 patients of mean (SD) age 50 (15) years who had undergone PTE. RESULTS In-hospital mortality was about 10%. Before PTE all the patients were severely impaired (NYHA classes III-IV). There was no time difference in the improvement in the parameters: nearly all the improvement in cardiac output, gas exchange, and clinical status was achieved in the first 3 months as a result of the relief of pulmonary obstruction. At 3 months the percentage of patients with normal cardiac output and PaO(2) and of those with reduced clinical impairment increased to 97%, 59%, and 87%, respectively, without any further change. Only mean pulmonary artery pressure (mPAP), carbon monoxide transfer factor (TLCO), and exercise tolerance improved gradually during the second year, probably due to the recovery of the damaged small vessels. TLCO was overestimated before PTE but afterwards the trend was similar to that of mPAP. CONCLUSIONS At mid term only a few patients did not have a satisfactory recovery because of lack of operative success, hypertension relapse, or the effect of preoperative hypertension on vessels in non-obstructed segments. Most of the patients, even the more compromised ones, had excellent long lasting results.
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Affiliation(s)
- M C Zoia
- Clinic of Respiratory Diseases, IRCCS San Matteo Hospital, University of Pavia, Italy
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24
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Waxman AB. Pulmonary function test abnormalities in pulmonary vascular disease and chronic heart failure. Clin Chest Med 2001; 22:751-8. [PMID: 11787662 DOI: 10.1016/s0272-5231(05)70063-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Diagnostic criteria based on pulmonary function testing for pulmonary vascular disease and CHF are imprecise. Although these tests constitute a necessary part of the work-up of a patient with dyspnea, additional studies are required to obtain a final diagnosis in the setting of cardiopulmonary vascular disease. In contrast, specific pulmonary function tests may offer an objective means of assessing severity of dysfunction resulting from pulmonary hypertension or CHE Serial measurements of pulmonary function offer insight into general and specific patterns of cardiopulmonary vascular disease and are useful in evaluating response to treatment.
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Affiliation(s)
- A B Waxman
- Division of Pulmonary and Critical Care, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
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25
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Abstract
Measurement of DL(CO) remains a clinically useful way to assess transfer of gases across the lung. It is important, however, to be vigilant in controlling the sources of variation and to be aware of those that remain when interpreting the measured values.
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Affiliation(s)
- R O Crapo
- University of Utah School of Medicine, Pulmonary Division, LDS Hospital, Salt Lake City, USA.
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26
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Affiliation(s)
- P F Fedullo
- Department of Medicine, University of California, San Diego, Medical Center, La Jolla 92037-1300, USA
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27
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Fedullo PF, Auger WR, Channick RN, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. Clin Chest Med 2001; 22:561-81. [PMID: 11590849 DOI: 10.1016/s0272-5231(05)70292-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Remarkable advances have occurred over the past 2 decades in the diagnostic approach, surgical management, and postoperative care of patients afflicted with chronic thromboembolic pulmonary hypertension. Despite these advances, a great deal needs to be achieved if the morbidity and mortality of the disease process are to be reduced further. First, the preliminary insights that have been achieved into the natural history of the disease must be defined further. The level of pulmonary hypertension encountered in most patients with chronic thromboembolic pulmonary hypertension at the time of initial clinical recognition cannot be reached on an acute basis. Gradual hemodynamic progression, therefore, must occur over time. The basis for this progression, why it occurs in certain patients and not others, following an acute thromboembolic event and why it seems to occur over months in certain patients and over decades in others, remain entirely speculative. It is possible that the overall extent of central pulmonary vascular obstruction represents the primary pathophysiologic determinant of disease progression. Given the lack of correlation between the degree of central thromboembolic obstruction and hemodynamic impairment in certain patients, however, it is also possible that other factors, such as the circulating vasoconstrictors, the development of a hypertensive pulmonary arteriopathy, an individual genetic predisposition to pulmonary hypertension, or the compensatory adaptations of the right ventricle, contribute to the extent and rate of disease progression. By identifying and sequentially evaluating patients with persistent pulmonary vascular obstruction or pulmonary hypertension following an acute thromboembolic event, valuable insights into the natural history of thromboembolic pulmonary hypertension and other variants of pulmonary hypertension might be achieved. It is also important to recognize that the development of chronic thromboembolic pulmonary hypertension represents a failure in the long-term management or follow-up surveillance of those with documented acute thromboembolic disease. Recent insights into the recurrent nature of acute thromboembolic disease and its potential for only partial resolution in a number of afflicted individuals suggest that a repeat perfusion scan and, if abnormal, an echocardiogram be performed at the time of anticipated discontinuation of anticoagulation in patients with documented pulmonary embolic disease. Although the cost-effectiveness of this approach has been questioned in the past, recent data suggest that doing so would help identify that subset of patients with unresolved embolism, provide additional information regarding the optimal duration of anticoagulation, and provide a new baseline study for patients in whom anticoagulation is discontinued and who subsequently present with suspected embolic recurrence. Improved diagnostic techniques are also necessary if the mortal risk of thromboendarterectomy is to be reduced. Even in the setting of a broad experiential base, prognostic uncertainty exists in approximately 10% of patients before operative intervention. Because many of these patients will benefit from the procedure, and because many are ineligible for transplantation for reason of age or other restriction, it has been the authors' practice to offer surgery to these patients, although at an assumed higher risk. To not do so would be to deny a potentially lifesaving procedure to many who would benefit and who might be left without an effective therapeutic alternative. The ability to better define the group of patients who will not benefit from surgery, however, would spare those patients the morbid and mortal risks of the procedure and provide a basis for the investigation of other therapeutic alternatives such as pulmonary vasodilating agents. Finally, this patient population offers a unique opportunity to enhance understanding of the pathophysiologic mechanisms involved in acute lung injury. The population involved is uniform, the predisposing event is consistent, the time of onset is predictable, and, compared with other populations at risk for acute lung injury, the presence of confounding variables is negligible. It also provides a unique opportunity to evaluate pharmacologic interventions designed to prevent or diminish the occurrence of acute lung injury and postoperative management strategies designed to minimize its impact.
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Affiliation(s)
- P F Fedullo
- Division of Pulmonary and Critical Care, University of California, San Diego Medical Center, San Diego, California, USA.
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Abstract
Until recently, many physicians considered pulmonary hypertension a rare and esoteric condition that is difficult to diagnose and nearly impossible to treat. However, pulmonary hypertension can complicate a variety of relatively common diseases and, with the development of new and effective therapies, there is a need for greater awareness of this condition. Pulmonary hypertension should be considered when patients present with unexplained shortness of breath, chest pain, or syncope. The usual delay of 1 to 2 years between onset of symptoms and diagnosis underscores the importance of considering pulmonary hypertension in the differential diagnosis of patients who present with atypical cardiorespiratory symptoms.
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Affiliation(s)
- G L Yung
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego School of Medicine, La Jolla, CA, USA
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Imanaka H, Miyano H, Takeuchi M, Kumon K, Ando M. Effects of nitric oxide inhalation after pulmonary thromboendarterectomy for chronic pulmonary thromboembolism. Chest 2000; 118:39-46. [PMID: 10893357 DOI: 10.1378/chest.118.1.39] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To examine the hypothesis that nitric oxide (NO) inhalation improves hemodynamics and gas exchange in patients with chronic pulmonary thromboembolism after pulmonary thromboendarterectomy. DESIGN Prospective crossover clinical study. SETTING : Surgical ICU in a national education and research hospital. PATIENTS : Seven patients (mean age +/- SD, 54 +/- 11 years) who underwent elective pulmonary thromboendarterectomy for chronic pulmonary thromboembolism. INTERVENTIONS Patients breathed 20 parts per million of NO gas for 30 min at 12-h intervals until extubation of the trachea. MEASUREMENTS AND RESULTS Hemodynamics and arterial blood gas levels were analyzed before, during, and after NO inhalation. Waveform of pulmonary artery pressure (PAP) was evaluated using fractional pulse pressure (PPf): (systolic PAP - diastolic PAP)/mean PAP. After surgery, pulmonary vascular resistance decreased, PPf decreased, and cardiac index increased significantly. At the first trial, NO inhalation resulted in a slight improvement in arterial oxygen tension (from 173 +/- 33 to 196 +/- 44 mm Hg; p < 0.05), while hemodynamics did not change significantly. Twelve hours later, NO inhalation decreased pulmonary vascular resistance index (from 312 +/- 98 to 277 +/- 93 dyne.s. cm(-5)/m(2); p < 0.01), while the change in oxygenation was not significant. CONCLUSIONS Immediately after pulmonary thromboendarterectomy for chronic pulmonary thromboembolism, NO inhalation improved oxygenation; at 12 h after surgery, NO inhalation resulted in decreased pulmonary vascular resistance, although both changes were small.
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Affiliation(s)
- H Imanaka
- Surgical Intensive Care Unit, National Cardiovascular Center, Osaka, Japan.
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