Pulmonary Hemodynamics in Patients With Chronic Obstructive Pulmonary Disease Before and During an Episode of Peripheral Edema

doi:10.1378/chest.105.5.1377

Chest

Volume 105, Issue 5, May 1994, Pages 1377-1382

https://doi.org/10.1378/chest.105.5.1377 Get rights and content

We have investigated pulmonary hemodynamics in 16 patients with COPD with respiratory insufficiency, exhibiting marked peripheral edema. All the patients had previously undergone, within the last 6 months (T1), a right heart catheterization, in a stable state of their disease, when they were free of edema. Patients were subdivided into two groups according to the level of right ventricular end-diastolic pressure (RVEDP) during the episode of edema (T2): patients with a markedly elevated RVEDP (>12 mm Hg) indicating the presence of right ventricular failure (RVF)=group 1, n=9; patients with a normal or slightly elevated RVEDP (<12 mm Hg)=group 2 (no RVF), n=7. In group 1 pulmonary artery mean pressure (PAP) increased very significantly from T1 (27±5) to T2 (40±6 mm Hg, p<0.001) as did RVEDP, from 7.5±3.9 to 13.4±1.2 mm Hg (p<0.001). These hemodynamic changes paralleled a marked worsening of arterial blood gases, PaO₂ falling from 63±4 to 49±7 mm Hg (p<0.01) and PaCO₂ increasing from 4±7 to 59±14 mm Hg (p<0.01). On the other hand, in group 2, PAP was stable during the episode of edema (from 20±6 to 2±5 mm Hg), as was RVEDP (from 5.5±2.4 to 5.1±1.5 mm Hg), and changes in arterial blood gases from T1 to T2 were small and nonsignificant. It is concluded that RVF is effectively present in at least some patients with COPD with peripheral edema and is associated with a significant increase of PAP from baseline, probably accounted for by hypoxic vasoconstriction. Thus, pressure overload may contribute to the development of RVF. In other patients there are no hemodynamic signs of RVF, PAP is stable, and the origin of edema is not well understood.

Section snippets

Methods

We have investigated 16 patients with COPD. All had a history of chronic bronchitis defined on usual grounds,⁸ and a spirographic pattern of airway obstruction defined by an FEV₁/VC ratio <60 percent. Pulmonary volumes, measured in a stable state of the disease, are shown in Table 1; it can be seen that bronchial obstruction was generally severe since the average values of FEV₁ and FEV₁/VC were respectively 1,000 ml and 40 percent. Hypoxemia was mild to moderate in most of the patients (Table 2

Results

According to the hemodynamic results at T2, that is during the episode of edema, the patients were subdivided into two groups: those with markedly elevated (>12 mm Hg) right ventricular end-diastolic pressure (RVEDP) (group 1) and those with normal or near normal RVEDP (<12 mm Hg) (group 2). A marked increase of the filling pressures of the right heart (right atrial pressure, RVEDP) is generally considered as reflecting right ventricular failure. Patients exhibiting both peripheral edema and an

Discussion

Our results show that among patients with COPD with marked peripheral (ankle) edema, it was possible to distinguish two groups: a group of patients exhibiting a worsening of pulmonary hemodynamics, compared with baseline value, and hemodynamic signs of right heart failure (elevated RVEDP); and a group of patients whose hemodynamic data were stable, compared with those obtained when the patients were free of edema; RVEDP was normal in these patients. In the first group, the worsening of

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Cited by (71)

Prevalence of pulmonary hypertension in COPD patients living at high altitude
2022, Pulmonology
Citation Excerpt :
However, these variables did not completely explain the changes of sPAP, suggesting that other variables, not evaluated herein, could play an important role in increased PAP in COPD patients. Some conditions previously related to increased PAP, such as weight49 and heart function,54 were reasonably controlled by excluding patients with BMI ≥ 30 Kg/m2 or significant heart dysfunction. We did not evaluate biomarkers of systemic inflammation such as C-reactive protein (CRP) and tumoral necrosis factor alpha (TNF-α) that have previously been associated with PH in patients with COPD.55
Pulmonary hypertension (PH) is associated with poor prognosis for patients with chronic obstructive pulmonary disease (COPD). Most of the knowledge about PH in COPD has been generated at sea level, with limited information associated with high altitude (HA).
To assess the prevalence and severity of PH in COPD patients living in a HA city (2,640 m).
Cross-sectional study in COPD patients with forced expiratory volume in the first second / forced vital capacity ratio (FEV₁/FVC) post-bronchodilator <0,7. Transthoracic echocardiography (TTE), spirometry, carbon monoxide diffusing capacity, and arterial blood gasses tests were performed. Patients were classified according to the severity of airflow limitation. PH was defined by TTE as an estimated systolic pulmonary artery pressure (sPAP) > 36 mmHg or indirect PH signs; severe PH as sPAP > 60 mmHg; and disproportionate PH as an sPAP > 60 mmHg with non-severe airflow limitation (FEV₁ > 50% predicted).
We included 176 COPD patients. The overall estimated prevalence of PH was 56.3% and the likelihood of having PH increased according to airflow-limitation severity: mild (31.6%), moderate (54.9%), severe (59.6%) and very severe (77.8%) (p = 0.038). The PH was severe in 7.3% and disproportionate in 3.4% of patients.
The estimated prevalence of PH in patients with COPD at HA is high, particularly in patients with mild to moderate airflow limitation, and greater than that described for COPD patients at low altitude. These results suggest a higher risk of developing PH for COPD patients living at HA compared to COPD patients with similar airflow limitation living at low altitude.
Group 3 PH: Clinical Features and Treatment
2021, Encyclopedia of Respiratory Medicine, Second Edition
Group 3 pulmonary hypertension (PH) is a broad category of PH caused by chronic lung diseases (CLD) including chronic obstructive pulmonary disease (COPD), diffuse parenchymal lung diseases (DPLD), sleep disordered breathing, chronic exposure to high altitudes and developmental abnormalities. It is the second most common type after group 2 PH which is secondary to left heart disease or pulmonary venous hypertension. Clinical features of group 3 PH are often difficult to discern from the signs and symptoms of the primary lung disease and most of the time, symptoms out of proportion to the severity of lung disease prompts evaluation for group 3 PH. In most patients with group 3 PH, the mean pulmonary artery pressure (mPAP) is usually mildly elevated. However, it is invariably associated with reduced functional ability, impaired quality of life, greater oxygen requirements and an increased risk of mortality. Transthoracic echocardiography is the best screening test to evaluate for underlying PH. Right heart catheterization (RHC) is the gold standard test for confirmation and is performed when significant PH is suspected and the patient’s management will likely be influenced by the RHC results. Treatment of group 3 PH can be divided into four major categories- primary, adjunctive, PH-specific and treatment of refractory disease. Treatment of the primary lung disease is the most important aspect but supportive therapy including supplemental oxygen and pulmonary rehabilitation are also very essential. The role of pulmonary vasodilators in group 3 PH is still unclear and large, randomized controlled trials are in dire need.
McConnell's Sign Is Not Specific for Pulmonary Embolism: Case Report and Review of the Literature
2015, Journal of Emergency Medicine
Citation Excerpt :
RV dysfunction may be seen in severe COPD, although outright RV failure is far less common (16). However, a subset of COPD patients can manifest acute RV failure, with characteristic peripheral edema and increased pulmonary mean artery pressures, during acute exacerbations of COPD (17). Given the mixed data on the specificity of McConnell's sign, it is important to clarify the role of FOCUS in the diagnosis and management of PE.
McConnell's sign (right ventricular [RV] free wall hypokinesis with apical sparing on echocardiography) is often described as very specific for the diagnosis of pulmonary embolism (PE). We present the case of a patient who, despite manifesting a classic McConnell's sign, was not found to have a PE.
A 58-year-old woman presented to the emergency department with a cough, dyspnea, and leg swelling. A bedside focused cardiac ultrasound revealed hypokinesis of the RV free wall, with apical sparing, in the apical four-chamber view. A computed tomography angiogram for PE was negative. Ultrasounds of both lower extremities were negative for deep venous thrombosis, and a D-dimer was only marginally elevated. The patient was ultimately diagnosed with pulmonary hypertension due to chronic obstructive pulmonary disease and systemic lupus erythematosus.
Emergency physicians should be aware that McConnell's sign is not completely specific for acute right heart strain from PE.
CT scan-measured pulmonary artery to aorta ratio and echocardiography for detecting pulmonary hypertension in severe COPD
2014, Chest
Citation Excerpt :
Measurement of the PA:A ratio is reproducible, requires minimal training, and performs better than echocardiography for the identification of PH in patients with severe COPD.11,16,26,27 Estimates of the prevalence of PH in COPD vary widely from as low as 10% to as high as 85% depending on the severity of the underlying lung disease and the diagnostic criteria as well as approach used.11,28‐30 Accurate estimates have also been problematic, because RHC is not routinely used in patients with COPD, particularly in those with moderate disease.11
COPD is associated with significant morbidity primarily driven by acute exacerbations. Relative pulmonary artery (PA) enlargement, defined as a PA to ascending aorta (A) diameter ratio greater than one (PA:A > 1) identifies patients at increased risk for exacerbations. However, little is known about the correlation between PA:A, echocardiography, and invasive hemodynamics in COPD.
A retrospective observational study of patients with severe COPD being evaluated for lung transplantation at a single center between 2007 and 2011 was conducted. Clinical characteristics, CT scans, echocardiograms, and right-sided heart catheterizations were reviewed. The PA diameter at the bifurcation and A diameter from the same CT image were measured. Linear and logistic regression were used to examine the relationships between PA:A ratio by CT scan and PA systolic pressure (PASP) by echocardiogram with invasive hemodynamics. Receiver operating characteristic analysis assessed the usefulness of the PA:A ratio and PASP in predicting resting pulmonary hypertension (PH) (mean pulmonary artery pressure [mPAP] > 25 mm Hg).
Sixty patients with a mean predicted FEV₁ of 27% ± 12% were evaluated. CT scan-measured PA:A correlated linearly with mPAP after adjustment for multiple covariates (r = 0.30, P = .03), a finding not observed with PASP. In a multivariate logistic model, mPAP was independently associated with PA:A > 1 (OR, 1.44; 95% CI, 1.02-2.04; P = .04). PA:A > 1 was 73% sensitive and 84% specific for identifying patients with resting PH (area under the curve, 0.83; 95% CI, 0.72-0.93; P < .001), whereas PASP was not useful.
A PA:A ratio > 1 on CT scan outperforms echocardiography for diagnosing resting PH in patients with severe COPD.
Hypoxaemia in patients with pulmonary arterial hypertension during simulated air travel
2013, Respiratory Medicine
Recent air travel recommendations suggest patients with precapillary pulmonary hypertension (PCPH) in New York Heart Association (NYHA) functional class 3 and 4 should have in-flight oxygen without the need for pre-flight testing. However it remains unclear as to how best to determine patients fitness to fly.
This study (i) investigates the effect of hypoxic challenge testing (HCT) on the arterial oxygen levels in a cohort of 36 patients with PCPH and (ii) compares the relative frequency with which FC and HCT predict the requirement for in-flight oxygen.
The degree of arterial hypoxaemia induced by HCT (fall in partial pressure of oxygen in arterial blood (PaO₂) 2.36 kPa, 95% CI 2.06–2.66 kPa) was similar to the drop observed in other published studies of chronic respiratory diseases.
Following current air travel recommendations based on FC, 25 patients of the cohort would require in-flight oxygen whilst 10 subjects failed the HCT. Fourteen subjects had flown post-diagnosis. Of these, nine subjects should have had in-flight oxygen based on FC but were asymptomatic without. Also one who passed the HCT had developed symptoms during the flight whilst three who failed the HCT were asymptomatic flying without in-flight oxygen.
Hypoxaemia induced by simulated air travel in patients with PCPH is similar to that seen in published studies of patients with other chronic respiratory diseases. HCT failed to predict correctly who had developed symptoms during an aircraft flight in a significant minority of the study subjects. Similarly guidelines based on functional class result in a major increase in the proportion of patients being advised to use oxygen, many of whom had been asymptomatic on previous flights without it. More work is required to improve prediction of need for in-flight oxygen in patients with PCPH.
Right Ventricular Dysfunction in Chronic Lung Disease
2012, Cardiology Clinics

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Chest

Clinical InvestigationsCOPDPulmonary Hemodynamics in Patients With Chronic Obstructive Pulmonary Disease Before and During an Episode of Peripheral Edema

Section snippets

Methods

Results

Discussion

Lancet

Chest

Chest

Chest

Chest

Am J Med

Edema in cor pulmonale

Clin Sci

Cardiac output and regional blood flow

Etudes hémodynamiques des décompensations respiratoires aigues des bronchopneumopathies chroniques

Bull Physiopathol Respir

Long-term course of pulmonary arterial pressure in chronic observative pulmonary disease

Am Rev Respir Dis

The effects of controlled oxygen therapy on ventricular function in patients with stable and decompensated cor pulmonale

Am Rev Respir Dis

Clinical Investigations
COPD
Pulmonary Hemodynamics in Patients With Chronic Obstructive Pulmonary Disease Before and During an Episode of Peripheral Edema