Bronchial Hyperresponsiveness to Methacholine in Patients with Impaired Left Ventricular Function

Abstract

To elucidate the pathogenesis of bronchospasm in congestive heart failure, we studied 23 patients with chronic impairment of left ventricular function due to coronary artery disease or dilated cardiomyopathy. In 21 of them we found marked bronchial hyperresponsiveness to methacholine. The mean dose (+/- SD) of methacholine that elicited a 20 percent decrease in the forced expiratory volume in one second (FEV1) was 421 +/- 298 micrograms, nearly the same as in patients with symptomatic asthma. In contrast, there was no bronchial response to methacholine in 9 of 10 patients who had coronary artery disease but normal left ventricular function. Administration of the bronchodilator albuterol led to a partial (43 percent) reversal of the methacholine-induced bronchial obstruction. In 12 patients, pretreatment with the alpha-adrenergic agonist methoxamine (10 mg by inhalation), a potent vasoconstrictor, fully prevented the methacholine-induced decrease in FEV1. The protective effect of methoxamine was blocked by the alpha-adrenergic antagonist phentolamine in all six patients who received this agent. We conclude that bronchial hyperresponsiveness to cholinergic agonists is frequent in patients with impaired left ventricular function and may contribute to the wheezy dyspnea commonly observed in such patients. The bronchoconstriction may be mediated at least in part by dilatation of the bronchial vessels.

Difficult asthma

“…Only a very small minority will develop the disease de novo after this age. In older individuals, increased bronchial responsiveness is an even less specific marker for asthma, as it is also found in chronic obstructive pulmonary disease (COPD), left ventricular dysfunction, and even in healthy elderly individuals (7). In a longitudinal survey study of respiratory disease, Burrows et al (8) showed that among asthmatic patients newly diagnosed over the age of 60, two-thirds had respiratory symptoms, and one-third had obstructive defects in lung function for a mean period of 8.5 years prior to the diagnosis.…”

Morbid Obesity: Obscuring the Diagnosis of Aortic Stenosis in a Patient with Cardiogenic Wheezing

“…Airway edema, bronchial hyper-responsiveness, and peribronchial cuffing are commonly associated with aortic stenosis and volume overload, 12,13 and will often manifest as wheezing on exam. Indeed, up to one-third of patients older than age 65 with congestive heart failure present with cardiac asthma.…”

Interactions between pulmonary hemodynamics and lung mechanics

“…Understanding the relationships between the pulmonary vasculature and bronchoalveolar networks has major importance in pathophysiological conditions encountered in various cardiopulmonary diseases, such as coronary ischaemia leading to left heart failure [3][4][5], congenital heart malfunctions [6,7] or valvular disfunction [5,8].…”

“…Some authors demonstrated the induction of bronchial hyperresponsiveness (BHR) to lung provocations [3][4][5]8] whereas others found no evidence of BHR in patients with chronic congestive heart failure [24,25]. In addition to this controversy, the underlying pathophysiological mechanisms leading to airway narrowing and occasionally BHR after pulmonary lung congestion have not been completely clarified.…”

“…A decrease in the airway cross-sectional area due to compression of the tracheobronchial tree by the dilated pulmonary vessels has been reported to be a major contributor to BHR [3,8], as have thickened bronchial walls [26] and peribronchial edema [27,28].…”