Expiratory flow limitation as a determinant of orthopnea in acute left heart failure

Duguet, Alexandre; Tantucci, Claudio; Lozinguez, Olivier; Isnard, Richard; Thomas, Daniel; Zelter, Marc; Derenne, Jean‐Philippe; Milic–Emili, J.; Similowski, Thomas

doi:10.1016/s0735-1097(99)00627-0

Cited by 66 publications

(47 citation statements)

References 37 publications

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“…Lung mechanics at rest are within the predicted normal range, except for a mild reduction in VC, FEV1 and in end-expiratory airflow, as described previously [19]. During lung function and exercise testing, the supine position was avoided, since this position induced an increase in airflow resistance, an aggravated expiratory flow limitation and a decrease in lung compliance in patients with left ventricular failure [20][21][22]. In IPAH patients, the effects of assuming a supine position have not been investigated so far.…”

Section: Patients' Characteristicsmentioning

confidence: 58%

Respiratory muscle dysfunction in idiopathic pulmonary arterial hypertension

Meyer¹

2005

Eur Respir J

163

144

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Idiopathic pulmonary arterial hypertension (IPAH) is a pulmonary vasculopathy of unknown aetiology. Dyspnoea, peripheral airway obstruction and inefficient ventilation are common in IPAH. Data on respiratory muscle function are lacking.This prospective single-centre study included 26 female and 11 male patients with IPAH in World Health Organization functional classes II-IV. Mean¡SD pulmonary artery pressure was 48.6¡16.9 in females and 53.1¡22.9 mmHg in males; cardiac output was 3.7¡1.3 and 4.2¡1.7 L?min -1 .Maximal inspiratory pressure (PI,max) was lower in the female patients than in 20 controls (5.3¡2.0 versus 8.2¡2.0 kPa). In the male patients, PI,max was lower than in 25 controls (6.8¡2.2 versus 10.5¡3.7 kPa). Maximal expiratory pressure (PE,max) was lower in the female patients than in controls (6.2¡2.6 versus 9.5¡2.1 kPa), and in male patients as compared to controls (7.1¡1.6 versus 10.3¡3.9 kPa). There was no correlation between PI,max or PE,max and parameters of pulmonary haemodynamics or exercise testing. The ratio of mouth occlusion pressure within the first 0.1 s of inspiration and PI,max was higher in IPAH than in controls (females 0.067¡0.066 versus 0.021¡0.008; males 0.047¡0.061 versus 0.023¡0.016).In conclusion, this study provides the first evidence of inspiratory and expiratory muscle weakness in idiopathic pulmonary arterial hypertension. The pathomechanisms and the prognostic significance should be further investigated.KEYWORDS: Exercise test, pulmonary hypertension, respiratory function test, respiratory muscles I diopathic pulmonary arterial hypertension (IPAH) is defined as a pulmonary vasculopathy of unknown aetiology, predominantly affecting females [1]. Minute ventilation (V9E) is increased at rest and during exercise [2]. The ventilatory response to exercise in IPAH patients, i.e. the ratio of V9E to carbon dioxide production (V9CO 2 ) during exercise (V9E/V9CO 2 slope), is also increased and is a predictor of poor prognosis [2,3]. The increased V9E/V9CO 2 slope indicates inefficient ventilation in IPAH, which can partly be attributed to pulmonary-perfusion abnormalities [2]. It has been shown by the current authors' group and others that, in congestive left ventricular failure, inefficient ventilation is associated with reduced inspiratory muscle strength [4][5][6]. Moreover, inspiratory muscle function has recently been identified as a prognostic predictor in congestive left ventricular failure [7]. Risk stratification of patients with congestive left ventricular failure is improved by using the combination of maximal inspiratory pressure (PI,max) and peak oxygen consumption (V9O 2 ) [7].Inspiratory and expiratory muscle strength have not been studied in IPAH. Therefore, this prospective study investigated respiratory muscle function and the mouth occlusion pressures in 37 patients with IPAH. PI,max and maximal expiratory pressure (PE,max) were prospectively assessed in IPAH patients with varying degrees of disease and exercise limitation. Moreover, invasive (right heart c...

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Section: Patients' Characteristicsmentioning

confidence: 58%

Respiratory muscle dysfunction in idiopathic pulmonary arterial hypertension

Meyer¹

2005

Eur Respir J

163

144

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“…The effect of posture on lung function is also important. Studies have shown increased flow limitation in patients with both acute 21, 22 and chronic, stable HF 23 when placed in the supine position. This is likely to be caused by fluid shift from the lower limbs into the lung and upper airway resulting in increased airway resistance.…”

Section: Effects Of Hf On Respiratory Function Testingmentioning

confidence: 99%

Heart Failure and the Lung

Kee

Naughton

2010

Circ J

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Heart failure (HF) is a highly prevalent disease that leads to significant morbidity and mortality. There is increasing evidence that the symptoms of HF are exacerbated by its deleterious effects on lung function. HF appears to cause airway obstruction acutely and leads to impaired gas diffusing capacity and pulmonary hypertension in the longer term. It is postulated that this is the result of recurrent episodes of elevated pulmonary capillary pressure leading to pulmonary oedema and pulmonary capillary stress fracture, which produces lung fibrosis. It is likely that impaired lung function impairs the functional status of HF patients and makes them more prone to central sleep apnoea. (Circ J 2010; 74: 2507 - 2516

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“…In conclusion, the NEP technique has been used clinically in studies with the following: 1) COPD (during mechanical ventilation and exercise, correlation with dyspnoea, orthopnoea, and other lung function indexes, before and after bronchodilatation, various postures) [22-25, 27, 33, 42, 43, 49, 50]; 2) asthma (stable asthma, during MCh bronchocostriction, and during exercise) [28,[44][45][46]; 3) cystic fibrosis [52,53] and bronchiectasis [54]; 4) restrictive lung disease [33,37]; 5) obesity [32,55,56]; 6) mechanically ventilated with acute respiratory failure and ARDS [7,8,23,[30][31][32]; 7) left heart failure [57]; 8) after single lung transplantation [29,58]; 9) euthyroid goitre [59]; and 10) assessment of bronchial hyperreactivity [60]. It appears that the use of the NEP technique during tidal flow-volume analysis studies has led to the realisation of the important role of EFL in exertional dyspnoea and ventilatory impairment for a surprisingly wide range of clinical circumstances [61].…”

Section: Clinical Applicationsmentioning

confidence: 99%

Flow limitation and dynamic hyperinflation: key concepts in modern respiratory physiology

Calverley¹

2005

Eur Respir J

224

168

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Fashions in ideas, like clothes, come and go. From approximately 1950From approximately -1980, physiological research was seen as the key discipline in understanding lung disease and was at the cutting edge of pulmonary science. Subsequently, its importance has been down played amid a widely accepted but unfounded assumption that we now have a perfect working understanding of the physiological behaviour of the respiratory system in health and disease. Although it seems improbable that completely new disciplines within respiratory physiology will emerge with fundamentally different ways of describing the mechanical or gas exchanging function of the lung, advances in computing and new observations in disease have highlighted previously unsuspected physiological abnormalities that have changed the way we view lung disease and the interface between disordered lung mechanics, symptomatology and disability. This is especially true for the two related physiological concepts of expiratory flow limitation and dynamic hyperinflation, which are now being taken from the physiological laboratory to the bedside with dramatic effect. Each arises from well-established theoretical and practical observations first made 40 yrs ago and now adapted to a range of settings, particularly in the field of obstructive lung disease. This review focuses on how these conditions are defined and assessed and what evidence there is that they might be important in lung disease.

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Expiratory flow limitation as a determinant of orthopnea in acute left heart failure

Abstract: Expiratory FL appears to be common in patients with acute LHF, particularly so when orthopnea is present. Its postural aggravation could contribute to LHF-related orthopnea.

Cited by 66 publications

References 37 publications

Respiratory muscle dysfunction in idiopathic pulmonary arterial hypertension

Respiratory muscle dysfunction in idiopathic pulmonary arterial hypertension

Heart Failure and the Lung

Flow limitation and dynamic hyperinflation: key concepts in modern respiratory physiology

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