Letter to the Editor
Respiratory failure in pulmonary hypertension patients
Insuficiência respiratória na hipertensão pulmonar
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array:22 [ "pii" => "S2174204920303251" "issn" => "21742049" "doi" => "10.1016/j.repce.2020.01.014" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "1594" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Rev Port Cardiol. 2020;39:551-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemAnterior" => array:18 [ "pii" => "S2174204920303238" "issn" => "21742049" "doi" => "10.1016/j.repce.2019.12.009" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "1592" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2020;39:547-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in Cardiology</span>" "titulo" => "Iatrogenic dissection of the ascending aorta after transcatheter aortic valve implantation treated conservatively" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "547" "paginaFinal" => "549" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Dissecção da aorta ascendente iatrogénica após implantação de TAVI tratada de forma conservadora" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 475 "Ancho" => 1300 "Tamanyo" => 96174 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intracardiac echocardiography images: (A) intimal flap dividing the aorta into a true lumen, in which the tip of the pigtail catheter can be seen (arrow), and a false lumen (*); (B) color Doppler with virtually no systolic antegrade flow in the false lumen.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro G. Magalhães, Pieter R. Stella, Michiel Voskuil, Adriaan O. Kraaijeveld" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Pedro G." "apellidos" => "Magalhães" ] 1 => array:2 [ "nombre" => "Pieter R." "apellidos" => "Stella" ] 2 => array:2 [ "nombre" => "Michiel" "apellidos" => "Voskuil" ] 3 => array:2 [ "nombre" => "Adriaan O." "apellidos" => "Kraaijeveld" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920303238?idApp=UINPBA00004E" "url" => "/21742049/0000003900000009/v1_202012210618/S2174204920303238/v1_202012210618/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Respiratory failure in pulmonary hypertension patients" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "551" "paginaFinal" => "552" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Miguel Filipe Guia, Fernanda Paula, Paula Pinto, Filipe Froes" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Miguel Filipe" "apellidos" => "Guia" "email" => array:1 [ 0 => "miguelguia7@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernanda" "apellidos" => "Paula" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Paula" "apellidos" => "Pinto" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Filipe" "apellidos" => "Froes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pulmonology Department, Hospital Professor Doutor Fernando da Fonseca, Amadora, Lisbon, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Tórax do Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "ISAMB, Faculdade de Medicina de Lisboa, Lisbon, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Insuficiência respiratória na hipertensão pulmonar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Management of respiratory failure (RF) in pulmonary hypertension (PH) is a complex subject, since positive pressure ventilation (PPV) can reduce right ventricular (RV) output.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> During PPV there is an increase in intrathoracic pressure, increasing right atrial pressure.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> This leads to lower venous return and consequently to decreased RV preload and output.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Furthermore, pulmonary vascular resistance (PVR), the main determinant of RV afterload, is directly affected by changes in lung volume, since when the lung is hyper-inflated, alveolar distension occurs, leading to compression of the alveolar vessels.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> On the other hand, low lung volumes result in terminal airway collapse and hypoxic vasoconstriction, and parenchymal vessels also become more tortuous and predisposed to collapse.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> All the above factors tend to reduce left ventricular output, leading to systemic hypotension.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Protective ventilation may reduce the negative effects of significant changes in lung volume.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Epoprostenol is a potent vasodilator that is used in more severe cases of PH. One of its main side effects is systemic hypotension, which can be enhanced by PPV, as previously described.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Santos et al. recently showed that parenteral prostanoids are underused in group 1 PH, in only 20% of PH patients at the time of death in their study.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> As RF is an important concern in advanced PH, we conducted a retrospective analysis of RF treatment and its impact in advanced PH patients who began epoprostenol as salvage therapy in the intensive care unit of Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal, over a two-year period.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ten patients were included, mean age 65 years, 50% female.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Six patients had group 1 PH (four idiopathic PH, one congenital heart disease and one associated with schistosomiasis), and four had group 4 PH. All presented mean pulmonary artery pressure over 35 mmHg on right heart catheterization (mean 51 mmHg). Mean estimated pulmonary artery systolic pressure on the last echocardiographic assessment was 97 mmHg.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most of these patients were in New York Heart Association functional class IV, with worsening RF, and most (60%) were on long-term oxygen therapy.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Previous medication included ambrisentan (four patients), bosentan (three), macitentan (two), sildenafil (five) and riociguat (four). Epoprostenol was initiated as salvage therapy and dosages were titrated to ≥11 ng/kg/min in six patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Initially, partial RF was present in eight patients and the other two rapidly developed general RF. Three of the partial RF patients required high-flow oxygen therapy (HFOT) with flow 50 l/min and fraction of inspired oxygen 100%. The two patients with general RF began non-invasive ventilation (NIV) and were titrated to inspiratory positive airway pressure (IPAP) 30 cmH<span class="elsevierStyleInf">2</span>O and expiratory positive airway pressure (EPAP) 10 cmH<span class="elsevierStyleInf">2</span>O in one, and IPAP 24 cmH<span class="elsevierStyleInf">2</span>O and EPAP 12 cmH<span class="elsevierStyleInf">2</span>O in the other (this patient alternated NIV with HFOT).</p><p id="par0050" class="elsevierStylePara elsevierViewall">There were four deaths, three due to hemodynamic collapse and one due to nosocomial infection. All of these four patients had group 1 PH. It was not possible to titrate epoprostenol dosage to 11 ng/kg/min in three of the patients who died. The two patients who were on NIV died, as did two of the patients on HFOT due to progression of partial RF.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This study illustrates the limitations of RF treatment in patients with PH on epoprostenol therapy, particularly those on NIV (due its deleterious hemodynamic effects on already hypotensive patients). In fact, all patients on NIV died, probably due to underlying disease, severity of RF and worsening of RV failure due to increased positive airway pressure. Of the three patients who were only on HFOT, only one survived, but HFOT may be an interesting option in PH patients, especially at the beginning of RF development. More studies are needed to validate the possible usefulness of HFOT in PH and to establish an appropriate NIV management approach, in particular the use of protective ventilation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authorship</span><p id="par0060" class="elsevierStylePara elsevierViewall">Fernanda Paula, Paula Pinto and Filipe Froes participated in the clinical management of the patients. Miguel Filipe Guia analyzed patients’ clinical data, particularly on classification of pulmonary hypertension, oxygen and ventilator strategies, and their outcomes. Miguel Filipe Guia also performed a short review of respiratory failure management in pulmonary hypertension and interpreted the results based on that review. Fernanda Paula, Paula Pinto and Filipe Froes participated in the revision of the present work.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The present letter has four authors since all four made essential contributions to it.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authorship" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular effects of mechanical ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. 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Cruz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2018.02.009" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2018" "volumen" => "37" "paginaInicial" => "749" "paginaFinal" => "757" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30144959" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003900000009/v1_202012210618/S2174204920303251/v1_202012210618/en/main.assets" "Apartado" => array:4 [ "identificador" => "21592" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003900000009/v1_202012210618/S2174204920303251/v1_202012210618/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920303251?idApp=UINPBA00004E" ]
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