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Parikh R, Farber HW. Response to "Derivation and validation of a noninvasive prediction tool to identify pulmonary hypertension in patients with IPF: Evolution of the model FORD" by Nathan et al. J Heart Lung Transplant 2024; 43:691-692. [PMID: 38158103 DOI: 10.1016/j.healun.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- R Parikh
- Division of Pulmonary, Critical Care and Sleep Medicine, Hartford Hospital, Hartford, Connecticut.
| | - H W Farber
- Division of Pulmonary, Sleep and Critical Care Medicine, Tufts Medical Center, Boston, Massachusetts
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Arslan A, Smith J, Qureshi MR, Uysal A, Patel KK, Herazo-Maya JD, Bandyopadhyay D. Evolution of pulmonary hypertension in interstitial lung disease: a journey through past, present, and future. Front Med (Lausanne) 2024; 10:1306032. [PMID: 38298504 PMCID: PMC10827954 DOI: 10.3389/fmed.2023.1306032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/20/2023] [Indexed: 02/02/2024] Open
Abstract
Interstitial lung diseases (ILD) are a spectrum of disorders often complicated by pulmonary hypertension (PH) in its course. The pathophysiologic mechanism of WHO group 3 PH is different to other forms of PH. The advent of PH is a harbinger for adverse events like mortality and morbidity, implying that the PH component of disease expedites deteriorated clinical outcomes. In fact, WHO group 3 PH due to ILD has the worse prognosis among all groups of PH. Hence, early detection of PH by a comprehensive screening method is paramount. Given considerable overlap in clinical manifestations between ILD and PH, early detection of PH is often elusive. Despite, the treatment of PH due to ILD has been frustrating until recently. Clinical trials utilizing PAH-specific pulmonary vasodilators have been ongoing for years without desired results. Eventually, the INCREASE study (2018) demonstrated beneficial effect of inhaled Treprostinil to treat PH in ILD. In view of this pioneering development, a paradigm shift in clinical approach to this disease phenotype is happening. There is a renewed vigor to develop a well validated screening tool for early detection and management. Currently inhaled Treprostinil is the only FDA approved therapy to treat this phenotype, but emergence of a therapy has opened a plethora of research toward new drug developments. Regardless of all these recent developments, the overall outlook still remains grim in this condition. This review article dwells on the current state of knowledge of pre-capillary PH due to ILD, especially its diagnosis and management, the recent progresses, and future evolutions in this field.
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Affiliation(s)
| | | | | | | | | | | | - Debabrata Bandyopadhyay
- Division of Pulmonary, Critical Care and Sleep Medicine, University of South Florida, Tampa, FL, United States
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Gupta S, Mohta A, Thameem D. Vasoreactive pulmonary artery hypertension in non-fibrotic hypersensitive pneumonitis. BMJ Case Rep 2024; 17:e255921. [PMID: 38182168 PMCID: PMC10773307 DOI: 10.1136/bcr-2023-255921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
Group III pulmonary hypertension (PH) is common in patients with hypersensitivity pneumonitis (HSP). Group I PH and vasoreactivity in HSP have not been reported. We describe a case of an elderly veterinarian woman who presented with progressive shortness of breath and desaturation on exertion. The patient was diagnosed with non-fibrotic HSP after consistent findings on chest CT, transbronchial biopsy and a positive HSP serological panel. The patient relocated her birds, and prednisone was started. Due to persistent symptoms, she underwent a right heart catheterisation, which showed PH with vasoreactivity; subsequently, nifedipine was started. Over a 9-month follow-up, there was an improvement in symptoms and a complete resolution of PH and CT scan changes. Our case highlights the rare possibility of group I PH in HSP. It illustrates the importance of confirming the aetiology of PH and initiating treatment early to resolve symptoms.
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Affiliation(s)
- Sushan Gupta
- Carle Foundation Hospital, Urbana, Illinois, USA
| | - Avani Mohta
- Carle Foundation Hospital, Urbana, Illinois, USA
| | - Danish Thameem
- Pulmonary and Critical Care Medicine, Carle Foundation Hospital, Urbana, Illinois, USA
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Parikh R, Thomas A, Sharofi A, Moallem N, Fiscus G, Farber HW. Severe pulmonary hypertension-interstitial lung disease presenting as right ventricular failure: stabilisation with intravenous prostacyclin and maintenance with inhaled prostacyclin. ERJ Open Res 2024; 10:00659-2023. [PMID: 38288084 PMCID: PMC10823367 DOI: 10.1183/23120541.00659-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/05/2023] [Indexed: 01/31/2024] Open
Abstract
Background Pulmonary hypertension (PH) leads to increased morbidity and mortality in interstitial lung disease (ILD). While the INCREASE trial highlighted the use of inhaled prostacyclin in PH-ILD patients, such therapy may be inadequate when right ventricular failure (RVF) is also present. In this study, we report the use of intravenous prostacyclin in three PH-ILD patients to stabilise right ventricular (RV) function, with a subsequent transition to maintenance therapy with inhaled prostacyclin. Methods We evaluated three consecutive PH-ILD patients with RVF. RV afterload and pulmonary vascular resistance (PVR) were treated with intravenous prostacyclin during the induction phase of the therapy. Patients transitioned from intravenous prostacyclin to the maintenance phase of the treatment with inhaled prostacyclin once three transition criteria were met: cardiac index (CI) >2 L·min-1·m-2, PVR <7 Wood units (WU) and tricuspid annular plane systolic excursion (TAPSE) change >1 mm or TAPSE >1.6 cm. Results Pre-treatment parameters for the three patients were a mean PVR of 14.3 WU, a mean Fick CI of 1.8 L·min-1·m-2 and a mean TAPSE of 1.4 cm. The average intravenous prostacyclin dose at the time of transition to maintenance therapy was 20.7 ng·kg-1·m-2 of treprostinil. At 3-months follow-up, the mean PVR was 6.3 WU, Fick CI 2.2 L·min-1·m-2 and TAPSE 1.7 cm. Conclusion This case series of three PH-ILD patients with RVF introduces the concept of an initial intravenous prostacyclin induction phase, followed by a transition to maintenance therapy with inhaled prostacyclin. Further development of this treatment algorithm with a refinement of the transition criteria, potential testing in a clinical trial and a longer-term follow-up period is warranted to improve the outcomes of advanced PH-ILD patients with concomitant RVF.
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Affiliation(s)
- Raj Parikh
- Division of Pulmonary, Critical Care and Sleep, Hartford Hospital, Hartford, CT, USA
| | - Alysse Thomas
- A.T. Still University Osteopathic Medical School, Mesa, AZ, USA
| | | | - Niala Moallem
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Garrett Fiscus
- Division of Pulmonary, Critical Care and Sleep, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Harrison W. Farber
- Division of Pulmonary, Sleep and Critical Care Medicine, Tufts Medical Center, Boston, MA, USA
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Blanco I, Hernández-González F, García A, Torres-Castro R, Barberà JA. Management of Pulmonary Hypertension Associated with Chronic Lung Disease. Semin Respir Crit Care Med 2023; 44:826-839. [PMID: 37487524 DOI: 10.1055/s-0043-1770121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of chronic lung diseases, particularly in chronic obstructive pulmonary disease (COPD) and interstitial lung diseases (ILD) and especially in advanced disease. It is associated with greater mortality and worse clinical course. Given the high prevalence of some respiratory disorders and because lung parenchymal abnormalities might be present in other PH groups, the appropriate diagnosis of PH associated with respiratory disease represents a clinical challenge. Patients with chronic lung disease presenting symptoms that exceed those expected by the pulmonary disease should be further evaluated by echocardiography. Confirmatory right heart catheterization is indicated in candidates to surgical treatments, suspected severe PH potentially amenable with targeted therapy, and, in general, in those conditions where the result of the hemodynamic assessment will determine treatment options. The treatment of choice for these patients who are hypoxemic is long-term oxygen therapy and pulmonary rehabilitation to improve symptoms. Lung transplant is the only curative therapy and can be considered in appropriate cases. Conventional vasodilators or drugs approved for pulmonary arterial hypertension (PAH) are not recommended in patients with mild-to-moderate PH because they may impair gas exchange and their lack of efficacy shown in randomized controlled trials. Patients with severe PH (as defined by pulmonary vascular resistance >5 Wood units) should be referred to a center with expertise in PH and lung diseases and ideally included in randomized controlled trials. Targeted PAH therapy might be considered in this subset of patients, with careful monitoring of gas exchange. In patients with ILD, inhaled treprostinil has been shown to improve functional ability and to delay clinical worsening.
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Affiliation(s)
- Isabel Blanco
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Fernanda Hernández-González
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Agustín García
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Rodrigo Torres-Castro
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
| | - Joan A Barberà
- Department of Pulmonary Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic-University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Spain
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Haynes ZA, Chandel A, King CS. Pulmonary Hypertension in Interstitial Lung Disease: Updates in Disease, Diagnosis, and Therapeutics. Cells 2023; 12:2394. [PMID: 37830608 PMCID: PMC10572438 DOI: 10.3390/cells12192394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/15/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023] Open
Abstract
Pulmonary hypertension is a debilitating condition that frequently develops in the setting of interstitial lung disease, likely related to chronic alveolar hypoxemia and pulmonary vascular remodeling. This disease process is likely to be identified more frequently by providers given recent advancements in definitions and diagnostic modalities, and provides practitioners with emerging opportunities to improve patient outcomes and quality of life. Despite years of data suggesting against the efficacy of pulmonary vasodilator therapy in patients with pulmonary hypertension due to interstitial lung disease, new data have emerged identifying promising advancements in therapeutics. The authors present to you a comprehensive review of pulmonary hypertension in interstitial lung disease, reviewing our current understanding of pathophysiology, updates in diagnostic approaches, and highlights of recent clinical trials which provide an effective approach for medical management.
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Affiliation(s)
- Zachary A. Haynes
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Fairfax, VA 22031, USA;
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Olsson KM, Corte TJ, Kamp JC, Montani D, Nathan SD, Neubert L, Price LC, Kiely DG. Pulmonary hypertension associated with lung disease: new insights into pathomechanisms, diagnosis, and management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:820-835. [PMID: 37591300 DOI: 10.1016/s2213-2600(23)00259-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/19/2023]
Abstract
Patients with chronic lung diseases, particularly interstitial lung disease and chronic obstructive pulmonary disease, frequently develop pulmonary hypertension, which results in clinical deterioration, worsening of oxygen uptake, and an increased mortality risk. Pulmonary hypertension can develop and progress independently from the underlying lung disease. The pulmonary vasculopathy is distinct from that of other forms of pulmonary hypertension, with vascular ablation due to loss of small pulmonary vessels being a key feature. Long-term tobacco exposure might contribute to this type of pulmonary vascular remodelling. The distinct pathomechanisms together with the underlying lung disease might explain why treatment options for this condition remain scarce. Most drugs approved for pulmonary arterial hypertension have shown no or sometimes harmful effects in pulmonary hypertension associated with lung disease. An exception is inhaled treprostinil, which improves exercise capacity in patients with interstitial lung disease and pulmonary hypertension. There is a pressing need for safe, effective treatment options and for reliable, non-invasive diagnostic tools to detect and characterise pulmonary hypertension in patients with chronic lung disease.
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Affiliation(s)
- Karen M Olsson
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany.
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
| | - Jan C Kamp
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, INSERM Unité Mixte de Recherche 999, Université Paris-Saclay, Paris, France
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Lavinia Neubert
- Institute of Pathology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hanover (BREATH), German Center for Lung Research, Hannover, Germany
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; NIHR Biomedical Research Centre, Sheffield, UK
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Pereira CAC, Cordero S, Resende AC. Progressive fibrotic interstitial lung disease. J Bras Pneumol 2023; 49:e20230098. [PMID: 37610955 PMCID: PMC10578905 DOI: 10.36416/1806-3756/e20230098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/24/2023] [Indexed: 08/25/2023] Open
Abstract
Many interstitial lung diseases (ILDs) share mechanisms that result in a progressive fibrosing phenotype. In Brazil, the most common progressive fibrosing interstitial lung diseases (PF-ILDs) are chronic hypersensitivity pneumonitis, idiopathic pulmonary fibrosis, unclassified ILD, and connective tissue diseases. PF-ILD is seen in approximately 30% of patients with ILD. Because PF-ILD is characterized by disease progression after initiation of appropriate treatment, a diagnosis of the disease resulting in fibrosis is critical. Different criteria have been proposed to define progressive disease, including worsening respiratory symptoms, lung function decline, and radiological evidence of disease progression. Although the time elapsed between diagnosis and progression varies, progression can occur at any time after diagnosis. Several factors indicate an increased risk of progression and death. In the last few years, antifibrotic drugs used in patients with idiopathic pulmonary fibrosis have been tested in patients with PF-ILD. The effects of nintedanib and placebo have been compared in patients with PF-ILD, a mean difference of 107.0 mL/year being observed, favoring nintedanib. The U.S. Food and Drug Administration and the Brazilian Health Regulatory Agency have approved the use of nintedanib in such patients on the basis of this finding. Pirfenidone has been evaluated in patients with unclassified ILD and in patients with other ILDs, the results being similar to those for nintedanib. More studies are needed in order to identify markers of increased risk of progression in patients with ILD and determine the likelihood of response to treatment with standard or new drugs.
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Affiliation(s)
- Carlos A C Pereira
- . Programa de Assistência e Pesquisa em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | - Soraya Cordero
- . Programa de Pós-Graduação em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | - Ana Carolina Resende
- . Programa de Pós-Graduação em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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Parikh R, O'Sullivan DM, Farber HW. The PH-ILD Detection tool: External validation and use in patients with ILD. Pulm Circ 2023; 13:e12273. [PMID: 37564922 PMCID: PMC10410234 DOI: 10.1002/pul2.12273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/14/2023] [Accepted: 07/30/2023] [Indexed: 08/12/2023] Open
Abstract
Pulmonary hypertension (PH) results in increased morbidity and mortality in patients with interstitial lung disease (ILD). Early recognition of PH in this population is essential for planning diagnostic testing, initiating therapy, and evaluating for lung transplantation. The previously developed PH-ILD Detection tool has significant potential in the evaluation and treatment of ILD patients; the aim of this study was to validate the tool in an independent, multicenter cohort of patients. We conducted a retrospective review of prospectively collected data from 161 ILD patients. Patients were stratified into low- (n = 78, 48.4%), intermediate- (n = 54, 33.5%), and high-risk (n = 29, 18.0%) groups based on the score obtained with the tool. Intermediate- and high-risk patients underwent follow-up echocardiogram (TTE); 49.4% (n = 41) had an abnormal TTE suggestive of underlying PH. These patients underwent right heart catheterization; PH-ILD was diagnosed in 73.2% (n = 30) of these cases. The PH-ILD Detection tool has a sensitivity of 93.3%, specificity of 90.9%, and area-under-the-curve of 0.921 for diagnosing PH in ILD patients, validating the findings from the original study and establishing the tool as a fundamental resource for early recognition of PH in ILD patients.
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Affiliation(s)
- Raj Parikh
- Division of Pulmonary, Critical Care and Sleep, Hartford HospitalHartfordConnecticutUSA
| | - David M. O'Sullivan
- Department of Research AdministrationHartford HealthCareHartfordConnecticutUSA
| | - Harrison W. Farber
- Division of Pulmonary, Sleep and Critical Care Medicine, Tufts Medical CenterBostonMassachusettsUSA
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Trushenko NV, Suvorova OA, Nekludova GV, Levina IA, Chikina SY, Nikolenko AM, Tsareva NA, Volkov AV, Yaroshetskiy AI, Merzhoeva ZM, Nuralieva GS, Avdeev SN. Predictors of Pulmonary Hypertension and Right Ventricular Dysfunction in Patients with Hypersensitivity Pneumonitis. Life (Basel) 2023; 13:1348. [PMID: 37374130 PMCID: PMC10302253 DOI: 10.3390/life13061348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD) that occurs in susceptible individuals in response to various inhaled antigens. The fibrotic phenotype of HP is characterized by disease progression and can lead to pulmonary hypertension (PH). The aim of this study was to estimate the prevalence of PH and to identify predictors of PH in patients with chronic HP. METHODS We conducted an observational longitudinal study that included 85 patients with an established diagnosis of HP. Clinical examination, quality of life questionnaires, high-resolution computed tomography (HRCT) of the chest, arterial blood gases analyses, six-minute walking test (6-MWT), pulmonary function tests, and echocardiography were performed. RESULTS Patients were divided into groups with fibrotic (71.8%) and nonfibrotic phenotype (28.2%). PH was detected in 41 (48.2%) patients. Patients with PH had the predominant fibrotic phenotype of HP, were older, more symptomatic, and had a higher FVC/DLco ratio. The most significant predictors of PH were CT signs of fibrosis, finger clubbing, FVC/DLco, decreased distance, and SpO2 at the end of 6-MWT, as well as the presence of cardiovascular diseases. CONCLUSIONS PH is a common condition in patients with chronic HP, especially with the fibrotic phenotype. Early detection of the PH predictors is necessary for the timely diagnosis of this complication of HP.
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Affiliation(s)
- Natalia V. Trushenko
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Olga A. Suvorova
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Galina V. Nekludova
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Iuliia A. Levina
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Svetlana Y. Chikina
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Alexandra M. Nikolenko
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Natalia A. Tsareva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Alexandr V. Volkov
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Federal State Budgetary Scientific Institution, V. A. Nasonova Research Institute of Rheumatology, Kashirskoye Highway 34A, 115522 Moscow, Russia
| | - Andrey I. Yaroshetskiy
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
| | - Zamira M. Merzhoeva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Galiya S. Nuralieva
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
| | - Sergey N. Avdeev
- Pulmonology Department, Sechenov First Moscow State Medical University (Sechenov University), Healthcare Ministry of Russia, Trubetskaya St. 8, Build. 2, 119991 Moscow, Russia; (O.A.S.); (G.V.N.); (I.A.L.); (S.Y.C.); (A.M.N.); (N.A.T.); (A.V.V.); (A.I.Y.); (Z.M.M.); (G.S.N.); (S.N.A.)
- Pulmonology Scientific Research Institute, Federal Medical and Biological Agency of Russian Federation, Orekhovyy Boulevard 28, 115682 Moscow, Russia
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Thomas C, Chandel A, King CS, Aryal S, Brown AW, Khangoora V, Nyquist A, Singhal A, Fonseca OC, Shlobin O, Nathan SD. Prevalence of pulmonary hypertension in patients with COVID-19 related lung disease listed for lung transplantation: A UNOS registry analysis. Pulm Circ 2023; 13:e12228. [PMID: 37091120 PMCID: PMC10114532 DOI: 10.1002/pul2.12228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/11/2023] [Accepted: 04/09/2023] [Indexed: 04/25/2023] Open
Abstract
COVID-19 related lung disease (CRLD) has emerged as an indication for lung transplantation (LT) in highly select patients. The prevalence and prognostic implication of coexisting pulmonary hypertension (PH) in patients with CRLD listed for LT is not known. Adult patients in the United Network for Organ Sharing database listed for LT for COVID-19 related acute respiratory distress syndrome or fibrosis through March 2022 were identified. The prevalence and impact of precapillary PH on pre- and posttransplantation survival was determined. Time-to-event analysis was used to compare outcomes between those with and without precapillary PH. We identified 245 patients listed for LT for CRLD who had right heart catheterization data available at the time of registry listing. Median age of the cohort was 54 years (interquartile range [IQR]: 46, 60), 56 (22.9%) were female, and the median lung allocation score was 81.3 (IQR: 53.3, 89.4). The prevalence of precapillary PH at the time of transplant listing was 27.9%. There was no significant difference in pretransplant mortality in patients with and without precapillary PH (sHR: 0.5; 95% confidence interval [CI]: 0.1-1.7, p = 0.261). A total of 187 patients ultimately underwent LT; of those, 60 (31.0%) were identified as having precapillary PH during the waitlist period. Posttransplantation survival was similar between patients with and without pretransplant precapillary PH (hazard ratio: 0.96; 95% CI: 0.2-3.7, p = 0.953). We observed a high rate of concomitant precapillary PH in patients listed for LT for CRLD. Though common, coexisting precapillary PH was not associated with a significant difference in either pre- or post-transplantation outcomes.
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Affiliation(s)
- Christopher Thomas
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Christopher S. King
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Shambhu Aryal
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - A. Whitney Brown
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Vikramjit Khangoora
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Alan Nyquist
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Anju Singhal
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Onix Cantres Fonseca
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Oksana Shlobin
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Steven D. Nathan
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
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12
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Piccari L, Allwood B, Antoniou K, Chung JH, Hassoun PM, Nikkho SM, Saggar R, Shlobin OA, Vitulo P, Nathan SD, Wort SJ. Pathogenesis, clinical features, and phenotypes of pulmonary hypertension associated with interstitial lung disease: A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative - Group 3 Pulmonary Hypertension. Pulm Circ 2023; 13:e12213. [PMID: 37025209 PMCID: PMC10071306 DOI: 10.1002/pul2.12213] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
Pulmonary hypertension (PH) is a frequent complication of interstitial lung disease (ILD). Although PH has mostly been described in idiopathic pulmonary fibrosis, it can manifest in association with many other forms of ILD. Associated pathogenetic mechanisms are complex and incompletely understood but there is evidence of disruption of molecular and genetic pathways, with panvascular histopathologic changes, multiple pathophysiologic sequelae, and profound clinical ramifications. While there are some recognized clinical phenotypes such as combined pulmonary fibrosis and emphysema and some possible phenotypes such as connective tissue disease associated with ILD and PH, the identification of further phenotypes of PH in ILD has thus far proven elusive. This statement reviews the current evidence on the pathogenesis, recognized patterns, and useful diagnostic tools to detect phenotypes of PH in ILD. Distinct phenotypes warrant recognition if they are characterized through either a distinct presentation, clinical course, or treatment response. Furthermore, we propose a set of recommendations for future studies that might enable the recognition of new phenotypes.
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Affiliation(s)
- Lucilla Piccari
- Department of Pulmonary MedicineHospital del MarBarcelonaSpain
| | - Brian Allwood
- Department of Medicine, Division of PulmonologyStellenbosch University & Tygerberg HospitalCape TownSouth Africa
| | - Katerina Antoniou
- Department of Thoracic MedicineUniversity of Crete School of MedicineHeraklionCreteGreece
| | - Jonathan H. Chung
- Department of RadiologyThe University of Chicago MedicineChicagoIllinoisUSA
| | - Paul M. Hassoun
- Department of Medicine, Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Rajan Saggar
- Lung & Heart‐Lung Transplant and Pulmonary Hypertension ProgramsUniversity of California Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Health SystemFalls ChurchVirginiaUSA
| | - Patrizio Vitulo
- Department of Pulmonary MedicineIRCCS Mediterranean Institute for Transplantation and Advanced Specialized TherapiesPalermoSiciliaItaly
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Health SystemFalls ChurchVirginiaUSA
| | - Stephen John Wort
- National Pulmonary Hypertension Service at the Royal Brompton HospitalLondonUK
- National Heart and Lung Institute, Imperial CollegeLondonUK
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13
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Elnady MA, Elkorashy R, Nabil A, Ibrahim EK. Predictors of pulmonary hypertension in patients with hypersensitivity pneumonitis. BMC Pulm Med 2023; 23:61. [PMID: 36759788 PMCID: PMC9909854 DOI: 10.1186/s12890-023-02347-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 02/01/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Hypersensitivity pneumonitis (HP) is an immunologically induced inflammation of the lung parenchyma that occurs in susceptible individuals in response to a variety of antigens. Repeated exposures to the causative antigens lead to chronic HP. The condition could be complicated with pulmonary hypertension (PH). METHODOLOGY 60 patients with established diagnosis of HP were included, clinical examination, high resolution computed tomography (HRCT) of chest, arterial blood gases, six minute walking test (6MWT), desaturation index, spirometry, echocardiography were performed to all patients and right heart catheter was done for patients with high echo probability of PH. RESULTS The mean age of patients was 41.67 ± 13.4 years with female predominance 83.3% of patients had history of raising birds. 71.7% of cases suffered from resting hypoxia with oxygen saturation 89 ± 11% with desaturation index 9% ± 8%, Echo probability of PH ranged from low to high 71.67, 21.67 and 6.67% respectively, mean pulmonary artery systolic pressure was 63.65 (18.48) mmHg. PH was diagnosed in 17 (28.33%) patients. HP with PH patients were significantly more symptomatic with predominant fibrotic pattern in HRCT chest P < 0.001, 82% of them had hypoxia P < 0.001 with significant desaturation after 6MWT P = 0.001. Predictors of PH in study group were fibrotic pattern in HRCT chest and hypoxia OR = 62.22, P < 0.001; 49.2, P < 0.001 respectively. CONCLUSION PH was prevalent in 28.33% of patients with HP, predictors of development of PH were fibrotic pattern in HRCT chest and hypoxia. TRIAL REGISTRATION Retrospectively registered, registration number is NCT05458635, date of registration 07/12/2022.
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Affiliation(s)
| | - Reem Elkorashy
- grid.7776.10000 0004 0639 9286Faculty of Medicine, Cairo University, Almaadi, Cairo, Egypt
| | - Afnan Nabil
- grid.7776.10000 0004 0639 9286Faculty of Medicine, Cairo University, Almaadi, Cairo, Egypt
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14
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Hersi K, Elinoff JM. Pulmonary Hypertension Caused by Interstitial Lung Disease: A New iNK(T)ling into Disease Pathobiology. Am J Respir Crit Care Med 2022; 206:930-932. [PMID: 35772120 PMCID: PMC9801987 DOI: 10.1164/rccm.202206-1186ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Kadija Hersi
- Pulmonary Vascular Biology Section of the Critical Care Medicine DepartmentNational Institutes of Health Clinical CenterBethesda, Maryland,Division of Pulmonary and Critical Care MedicineUniversity of Maryland School of MedicineBaltimore, Maryland,National Heart, Lung and Blood InstituteNational Institutes of HealthBethesda, Maryland
| | - Jason M. Elinoff
- Pulmonary Vascular Biology Section of the Critical Care Medicine DepartmentNational Institutes of Health Clinical CenterBethesda, Maryland
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15
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Lee MH, Menezes TCF, Reisz JA, Ferreira EVM, Graham BB, Oliveira RKF. Exercise metabolomics in pulmonary arterial hypertension: Where pulmonary vascular metabolism meets exercise physiology. Front Physiol 2022; 13:963881. [PMID: 36171971 PMCID: PMC9510894 DOI: 10.3389/fphys.2022.963881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/23/2022] [Indexed: 01/29/2023] Open
Abstract
Pulmonary arterial hypertension is an incurable disease marked by dysregulated metabolism, both at the cellular level in the pulmonary vasculature, and at the whole-body level characterized by impaired exercise oxygen consumption. Though both altered pulmonary vascular metabolism and abnormal exercise physiology are key markers of disease severity and pulmonary arterial remodeling, their precise interactions are relatively unknown. Herein we review normal pulmonary vascular physiology and the current understanding of pulmonary vascular cell metabolism and cardiopulmonary response to exercise in Pulmonary arterial hypertension. We additionally introduce a newly developed international collaborative effort aimed at quantifying exercise-induced changes in pulmonary vascular metabolism, which will inform about underlying pathophysiology and clinical management. We support our investigative approach by presenting preliminary data and discuss potential future applications of our research platform.
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Affiliation(s)
- Michael H. Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Thaís C. F. Menezes
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Julie A. Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eloara V. M. Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Brian B. Graham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Rudolf K. F. Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil,*Correspondence: Rudolf K. F. Oliveira,
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16
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Nikkho SM, Richter MJ, Shen E, Abman SH, Antoniou K, Chung J, Fernandes P, Hassoun P, Lazarus HM, Olschewski H, Piccari L, Psotka M, Saggar R, Shlobin OA, Stockbridge N, Vitulo P, Vizza CD, John Wort S, Nathan SD. CLINICAL SIGNIFICANCE OF PULMONARY HYPERTENSION IN INTERSTITIAL LUNG DISEASE A Consensus Statement from The Pulmonary Vascular Research Institute's Innovative Drug Development Initiative ‐ Group 3 Pulmonary Hypertension. Pulm Circ 2022; 12:e12127. [PMID: 36016668 PMCID: PMC9395696 DOI: 10.1002/pul2.12127] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Pulmonary hypertension (PH) has been linked to worse outcomes in chronic lung diseases. The presence of PH in the setting of underlying Interstitial Lung Disease (ILD) is strongly associated with decreased exercise and functional capacity, an increased risk of hospitalizations and death. Examining the scope of this issue and its impact on patients is the first step in trying to define a roadmap to facilitate and encourage future research in this area. The aim of our working group is to strengthen the communities understanding of PH due to lung diseases and to improve the care and quality of life of affected patients. This introductory statement provides a broad overview and lays the foundation for further in‐depth papers on specific topics pertaining to PH‐ILD.
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Affiliation(s)
| | - Manuel J. Richter
- Department of Internal Medicine Pulmonary Hypertension Division Universities of Giessen and Marburg Lung Center (UGMLC) Germany
| | - Eric Shen
- United Therapeutics Corporation, Global Medical Affairs Silver Spring MD USA
| | - Steven H. Abman
- University of Colorado ‐ Anschutz Medical Campus School of Medicine and Children's Hospital Aurora CO USA
| | - Katerina Antoniou
- University of Crete School of Medicine, Department of Thoracic Medicine Heraklion Crete Greece
| | - Jonathan Chung
- Department of Radiology The University of Chicago Medicine Chicago IL USA
| | - Peter Fernandes
- Bellerophon Therapeutics Inc, Regulatory Safety and Quality Department Warren NJ USA
| | - Paul Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine Johns Hopkins University Baltimore MD
| | | | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine Medical University of Graz Graz Steiermark Austria
| | - Lucilla Piccari
- Department of Pulmonary Medicine Hospital del Mar, Pulmonary Hypertension Unit Barcelona Catalunya Spain
| | - Mitchell Psotka
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; 2. Division of Cardiology and Nephrology Food and Drug Administration Silver Spring MD
| | - Rajan Saggar
- University of California Los Angeles David Geffen School of Medicine Lung & Heart‐Lung Transplant and Pulmonary Hypertension Programs Los Angeles CA USA
| | - Oksana A. Shlobin
- Inova Health System, Advanced Lung Disease and Transplant Program Falls Church VA USA
| | - Norman Stockbridge
- US Food and Drug Administration Division of Cardiology and Nephrology Silver Spring MD USA
| | - Patrizio Vitulo
- IRCCS Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Department of Pulmonary Medicine Palermo Sicilia Italy
| | | | - S. John Wort
- National Pulmonary Hypertension Service at Royal Brompton Hospital London. UK. National Heart and Lung Institute, Imperial College London UK
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program Inova Heart and Vascular Institute Falls Church Virginia
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17
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Abstract
Pulmonary hypertension (PH) because of chronic lung disease is categorized as Group 3 PH in the most recent classification system. Prevalence of these diseases is increasing over time, creating a growing need for effective therapeutic options. Recent approval of the first pulmonary arterial hypertension therapy for the treatment of Group 3 PH related to interstitial lung disease represents an encouraging advancement. This review focuses on molecular mechanisms contributing to pulmonary vasculopathy in chronic hypoxia, the pathology and epidemiology of Group 3 PH, the right ventricular dysfunction observed in this population and clinical trial data that inform the use of pulmonary vasodilators in Group 3 PH.
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Affiliation(s)
- Navneet Singh
- Division of Pulmonary, Critical Care and Sleep Medicine (N.S., C.E.V.), Brown University, Providence, RI
| | - Peter Dorfmüller
- Department of Pathology, Universities of Giessen and Marburg Lung Center (UGMLC), Justus-Liebig University, Germany (P.D.).,German Center for Lung Research (DZL), Giessen, Germany (P.D.)
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA (O.A.S.)
| | - Corey E Ventetuolo
- Division of Pulmonary, Critical Care and Sleep Medicine (N.S., C.E.V.), Brown University, Providence, RI.,Department of Health Services, Policy and Practice (C.E.V.), Brown University, Providence, RI
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18
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Tyagi R, Kant S, Verma SK, Kushwaha RAS, Kumar S, Garg R, Verma AK, Srivastava A, Bajaj DK, Wakhlu A, Parihar A, Pradhan A, Jaiswal R. Spectrum of interstitial lung diseases and their association with pulmonary hypertension. Monaldi Arch Chest Dis 2021; 92. [PMID: 34873902 DOI: 10.4081/monaldi.2021.2027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/06/2021] [Indexed: 02/08/2023] Open
Abstract
Interstitial lung diseases (ILDs) are an intriguing group of pulmonary disorders, which still require the study of epidemiological, genetic, pathophysiological, clinical, and radiological parameters. Pulmonary hypertension (PH) is an underreported complication in interstitial lung diseases which is associated with worse outcome. In our study, we have reported the spectrum of ILDs and estimated the prevalence of pulmonary hypertension among these subjects at a tertiary care centre. A cross-sectional study was performed in which demographical, clinical, radiological, and histological data of subjects with ILD, attending the department of Respiratory Medicine in the University was collected from 1st September 2018 to 31st August 2019. Serological tests were done wherever indicated. Standard criteria along with multidisciplinary opinion were needed to arrive at the final diagnosis. All subjects were screened for pulmonary hypertension via 2-D echocardiography. Mean pulmonary artery pressure ≥20 mmHg was used to define PH. In the defined period, 239 subjects were enrolled (58% females, n=141; mean age 52.38±13.40 years). A tissue diagnosis was obtained in 34% cases. The most common ILD was hypersensitivity pneumonitis (32.2%), followed by autoimmune-ILD (31.4%), idiopathic pulmonary fibrosis (IPF) (15.9%) and sarcoidosis (12.6%), non-IPF idiopathic interstitial pneumonitis (2.1%) and rest 21 (5.9%) subjects were diagnosed as other types of ILD. Pulmonary hypertension was seen in 46.0% of subjects.
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Affiliation(s)
- Richa Tyagi
- Respiratory Medicine, King George's Medical University, Lucknow.
| | - Surya Kant
- Department of Respiratory Medicine, King George's Medical University, Lucknow.
| | - Sanjeev Kumar Verma
- Department of Respiratory Medicine, King George's Medical University, Lucknow.
| | | | - Santosh Kumar
- Department of Respiratory Medicine, King George's Medical University, Lucknow.
| | - Rajiv Garg
- Department of Respiratory Medicine, King George's Medical University, Lucknow.
| | - Ajay Kumar Verma
- Department of Respiratory Medicine, King George's Medical University, Lucknow.
| | - Anand Srivastava
- Department of Respiratory Medicine, King George's Medical University, Lucknow.
| | - Darshan Kumar Bajaj
- Department of Respiratory Medicine, King George's Medical University, Lucknow.
| | - Anupam Wakhlu
- Department of Clinical Immunology & Rheumatology, King George's Medical University, Lucknow.
| | - Anit Parihar
- Department of Radiodiagnosis, King George's Medical University, Lucknow.
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow.
| | - Riddhi Jaiswal
- Department of Pathology, King George's Medical University, Lucknow.
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19
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Tyagi R, Kant S, Pradhan A, Wakhlu A, Bajaj DK, Bajpai J. Estimates of Prevalence of Pulmonary Hypertension according to Different International Definitions. Can Respir J 2021; 2021:1385322. [PMID: 34876943 PMCID: PMC8645389 DOI: 10.1155/2021/1385322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/15/2021] [Indexed: 02/05/2023] Open
Abstract
Background Pulmonary hypertension is a dreaded disease associated with considerable morbidity and mortality. The pulmonary hypertension developing due to chronic respiratory disease is a unique subset with symptoms often getting masqueraded by the underlying respiratory condition. The importance of early detection of this complication has been realized worldwide, and recently, the definition of pulmonary hypertension was revised to set the cutoff of mean pulmonary artery pressure (mPAP) at 20 mmHg instead of 25 mmHg at rest. In our study, we have tried to estimate the difference this new definition brings to the prevalence of pulmonary hypertension among interstitial lung disease patients at our centre. Methods This was a cross-sectional study in which all the patients of ILDs (n = 239) attending the outdoor and indoor Department of Respiratory Medicine, King George's Medical University, India, for the duration of one year were subjected to transthoracic echocardiography along with measurement of serum pro-B-type natriuretic peptide (BNP) and troponin T values. The data were analyzed using the different definitions, and the prevalence was compared. Result Incidence of pulmonary hypertension among ILD patients at mPAP cutoff ≥ 25 was 28.9%, while that at value ≥20 mmHg, incidence of pulmonary hypertension increased to 46.0%. An increment of 15-20% in incidence of pulmonary hypertension was observed among different types of ILD when cutoff of mPAP was changed. Conclusion The new definition helps in a significant increase in the detection of pulmonary hypertension, which certainly helps in earlier detection and better management of patients.
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Affiliation(s)
- Richa Tyagi
- Department of Respiratory Medicine, King George's Medical University, Lucknow, UP, India
| | - Surya Kant
- Department of Respiratory Medicine, King George's Medical University, Lucknow, UP, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, UP, India
| | - Anupam Wakhlu
- Department of Rheumatology, King George's Medical University, Lucknow, UP, India
| | - Darshan Kumar Bajaj
- Department of Respiratory Medicine, King George's Medical University, Lucknow, UP, India
| | - Jyoti Bajpai
- Department of Respiratory Medicine, King George's Medical University, Lucknow, UP, India
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20
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Alberti ML, Rincon-Alvarez E, Buendia-Roldan I, Selman M. Hypersensitivity Pneumonitis: Diagnostic and Therapeutic Challenges. Front Med (Lausanne) 2021; 8:718299. [PMID: 34631740 PMCID: PMC8495410 DOI: 10.3389/fmed.2021.718299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is one of the most common interstitial lung diseases (ILD), that presents unique challenges for a confident diagnosis and limited therapeutic options. The disease is triggered by exposure to a wide variety of inciting antigens in susceptible individuals which results in T-cell hyperactivation and bronchioloalveolar inflammation. However, the genetic risk and the pathogenic mechanisms remain incompletely elucidated. Revised diagnostic criteria have recently been proposed, recommending to classify the disease in fibrotic and non-fibrotic HP which has strong therapeutic and outcome consequences. Confident diagnosis depends on the presence of clinical features of ILD, identification of the antigen(s), typical images on high-resolution computed tomography (HRCT), characteristic histopathological features, and lymphocytosis in the bronchoalveolar lavage. However, identifying the source of antigen is usually challenging, and HRCT and histopathology are often heterogeneous and not typical, supporting the notion that diagnosis should include a multidisciplinary assessment. Antigen removal and treating the inflammatory process is crucial in the progression of the disease since chronic persistent inflammation seems to be one of the mechanisms leading to lung fibrotic remodeling. Fibrotic HP has a few therapeutic options but evidence of efficacy is still scanty. Deciphering the molecular pathobiology of HP will contribute to open new therapeutic avenues and will provide vital insights in the search for novel diagnostic and prognostic biomarkers.
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Affiliation(s)
| | | | - Ivette Buendia-Roldan
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
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21
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Dybowska M, Barańska I, Franczuk M, Skoczylas A, Szturmowicz M. Echocardiographic signs of pulmonary hypertension in patients with newly recognized hypersensitivity pneumonitis, prevalence and clinical predictors. J Thorac Dis 2021; 13:3988-3997. [PMID: 34422329 PMCID: PMC8339783 DOI: 10.21037/jtd-21-130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/20/2021] [Indexed: 11/06/2022]
Abstract
Background Hypersensitivity pneumonitis (HP) is the third, according to frequency, interstitial lung disease, with the estimated incidence rate of 1–2/100,000. In HP patients, the extensive inflammatory lesions encompassing both small airways and lung parenchyma, as well as subsequent development of lung fibrosis, may result in respiratory insufficiency and secondary pulmonary hypertension (PH). The aim of the present retrospective study was to assess the prevalence of echocardiographic signs of PH and its’ clinical predictors, in newly recognized HP patients. Methods Consecutive HP patients, recognized in single pulmonary unit between 2005 and 2017, in whom echocardiography was performed at diagnosis, entered the present study. HP diagnosis was verified in every patient according to current diagnostic recommendations. The results of high resolution computed tomography of the chest (HRCT) were re-evaluated by two independent radiologists, blinded to clinical data. Echocardiographic signs of PH were defined as pulmonary artery systolic pressure (PASP) exceeding 36 mmHg. Regression analysis was applied to calculate PH risk, and receiver operator characteristic curves (ROC) were plotted to investigate diagnostic utility of various parameters in PH prediction. Results PASP exceeding 36 mmHg was noted in 26 out of 70 patients (37%)—with equal frequency among patients with fibrotic and non-fibrotic HP. Significant predictors of PH on echocardiography were: partial oxygen tension in arterialized capillary blood (PaO2) <69 mmHg, lung transfer capacity for carbon monoxide (TLCO) <42% of predicted, six minutes walking test (6MWT) distance <455 meters, and 6MWT desaturation rate >8%. In case of TLCO <42% of predicted, probability of PH on echocardiography was increased by five-fold, in case of 6MWT desaturation rate >8%—by four fold. Conclusions The best predictors of PASP >36 mmHg on echocardiography in HP patients at diagnosis were: TLCO <42% and 6MWT desaturation rate >8%. Neither the presence of lung fibrosis on HRCT, nor the duration of the disease or patients age, were helpful in PH prediction.
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Affiliation(s)
- Małgorzata Dybowska
- Ist Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Inga Barańska
- Department of Radiology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Monika Franczuk
- Department of Physiopathology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Agnieszka Skoczylas
- Department of Geriatrics, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Monika Szturmowicz
- Ist Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
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22
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Shioleno AM, Ruopp NF. Group 3 Pulmonary Hypertension: A Review of Diagnostics and Clinical Trials. Clin Chest Med 2021; 42:59-70. [PMID: 33541617 DOI: 10.1016/j.ccm.2020.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Group 3 pulmonary hypertension (PH) is a known sequelae of chronic lung disease. Diagnosis and classification can be challenging in the background of chronic lung disease and often requires expert interpretation of numerous diagnostic studies to ascertain the true nature of the PH. Stabilization of the underlying lung disease and adjunctive therapies such as oxygen remain the mainstays of therapy, as there are no Food and Drug Administration-approved therapies for group 3 PH. Referral to PH centers for individualized management and clinical trial enrollment is paramount.
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Affiliation(s)
- Andrea M Shioleno
- Division of Pulmonary and Critical Care Medicine, University of Miami, 1801 Northwest 9th Avenue, Miami, FL 33136, USA
| | - Nicole F Ruopp
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 800 Washington Street, #257 (Tupper 3), Boston, MA 02111, USA.
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Ruffenach G, Hong J, Vaillancourt M, Medzikovic L, Eghbali M. Pulmonary hypertension secondary to pulmonary fibrosis: clinical data, histopathology and molecular insights. Respir Res 2020; 21:303. [PMID: 33208169 PMCID: PMC7677848 DOI: 10.1186/s12931-020-01570-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension (PH) developing secondarily in pulmonary fibrosis (PF) patients (PF-PH) is a frequent co-morbidity. The high prevalence of PH in PF patients is very concerning since the presence of PH is a strong predictor of mortality in PF patients. Until recently, PH was thought to arise solely from fibrotic destruction of the lung parenchyma, leading to hypoxic vasoconstriction and loss of vascular bed density. Thus, potential cellular and molecular dysregulation of vascular remodeling as a driver of PF-PH has been under-investigated. The recent demonstrations that there is no correlation between the severity of the fibrosis and development of PH, along with the finding that significant vascular histological and molecular differences exist between patients with and without PH have shifted the etiological paradigm of PF-PH. This review aims to provide a comprehensive translational overview of PH in PF patients from clinical diagnosis and outcome to the latest understanding of the histology and molecular pathophysiology of PF-PH.
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Affiliation(s)
- Grégoire Ruffenach
- Division of Molecular Medicine, Department of Anesthesiology and Perioperiative Medicine, David Geffen School of Medicine, University of California, BH-550CHS, Los Angeles, CA, 90095-7115, USA
| | - Jason Hong
- Division of Molecular Medicine, Department of Anesthesiology and Perioperiative Medicine, David Geffen School of Medicine, University of California, BH-550CHS, Los Angeles, CA, 90095-7115, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Mylène Vaillancourt
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lejla Medzikovic
- Division of Molecular Medicine, Department of Anesthesiology and Perioperiative Medicine, David Geffen School of Medicine, University of California, BH-550CHS, Los Angeles, CA, 90095-7115, USA
| | - Mansoureh Eghbali
- Division of Molecular Medicine, Department of Anesthesiology and Perioperiative Medicine, David Geffen School of Medicine, University of California, BH-550CHS, Los Angeles, CA, 90095-7115, USA.
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King CS, Shlobin OA. The Trouble With Group 3 Pulmonary Hypertension in Interstitial Lung Disease: Dilemmas in Diagnosis and the Conundrum of Treatment. Chest 2020; 158:1651-1664. [PMID: 32387520 DOI: 10.1016/j.chest.2020.04.046] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 11/19/2022] Open
Abstract
Pulmonary hypertension (PH) due to interstitial lung disease (ILD; PH-ILD) can complicate a multitude of ILDs, including idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis, and nonspecific interstitial pneumonia. Development of PH-ILD is associated with increased need for supplemental oxygen, reduced mobility, and decreased survival. A high index of suspicion is required to make the diagnosis, given the substantial overlap in symptoms with those of ILD without PH. Severely reduced diffusing capacity or 6-min walk test distance, prominent exertional desaturation, and impaired heart rate recovery after exercise are all suggestive of the development of PH-ILD. Traditional transthoracic echocardiography is the most commonly used screening test for PH-ILD, but it lacks sensitivity and specificity. Newer echocardiographic tools involving 3-dimensional assessment of the right ventricle may have a role in both prognosis and the monitoring of patients with PH-ILD. Right-sided heart catheterization remains the gold standard for confirming a diagnosis of PH-ILD. Although there is little debate about the use of supplemental oxygen and diuretic therapy in the treatment of PH-ILD, treatment with pulmonary vasodilator therapy remains controversial. Although several studies have been terminated prematurely for harm, the recently completed INCREASE trial of inhaled treprostinil appears to validate the concept of treating PH-ILD with pulmonary vasodilators and, we hope, will serve as a foundation from which future studies can be developed.
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Affiliation(s)
- Christopher S King
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA
| | - Oksana A Shlobin
- Pulmonary Hypertension Program, Inova Fairfax Hospital, Falls Church, VA.
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Sobiecka M, Lewandowska K, Kober J, Franczuk M, Skoczylas A, Tomkowski W, Kuś J, Szturmowicz M. Can a New Scoring System Improve Prediction of Pulmonary Hypertension in Newly Recognised Interstitial Lung Diseases? Lung 2020; 198:547-554. [PMID: 32206858 PMCID: PMC7242254 DOI: 10.1007/s00408-020-00346-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/12/2020] [Indexed: 12/11/2022]
Abstract
Introduction Pulmonary hypertension (PH) is a well-recognised complication of interstitial lung diseases (ILD), which worsens prognosis and impairs exercise capacity. Echocardiography is the most widely used, non-invasive method for PH assessment. The aim of our study was to identify the factors predictive for echocardiographic signs of PH in newly recognised ILD patients. Methods Ninety-three consecutive patients (28F/65M) with different ILD were prospectively evaluated from January 2009 to March 2014. Pulmonary function testing, 6-min walk distance (6MWD), initial and sixth minute room air oxygen saturation, NT-proBNP and echocardiography were assessed in each patient. Echocardiographic PH probability was determined according to the 2009 ESC/ERS guidelines. Results In 41 patients (Group B) increased PH possibility has been diagnosed on echocardiography, in 52 patients (Group A)—low PH probability. Most pronounced differences (p ≤ 0.0005) between groups B and A concerned: age, 6MWD, room air oxygen saturation at 6 min, DLCO and TLC/DLCO index (57.6 vs 43.8 years; 478 vs 583 m; 89.1% vs 93.4%; 54.8% predicted vs 70.5% predicted and 1.86 vs 1.44; respectively). Univariate analysis showed four-fold increased probability of PH when TLC/DLCO exceeded 1.67. A scoring system incorporating age, TLC/DLCO index, 6MWD and room air oxygen saturation at 6 min provided high diagnostic utility, AUC 0.867 (95% CI 0.792–0.867). Conclusion ILD patients with TLC/DLCO index > 1.67 have a high likelihood of PH and should undergo further evaluation. The composite model of PH prediction, including age, 6-min walk test and TLC/DLCO was highly specific for recognition of PH on echocardiography.
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Affiliation(s)
- Małgorzata Sobiecka
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland.
| | - Katarzyna Lewandowska
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Jarosław Kober
- Department of Radiology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Monika Franczuk
- Department of Respiratory Physiopathology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Agnieszka Skoczylas
- Department of Geriatrics, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Witold Tomkowski
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Jan Kuś
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Monika Szturmowicz
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
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Pulmonary Vascular and Right Ventricular Burden During Exercise in Interstitial Lung Disease. Chest 2020; 158:350-358. [PMID: 32173491 DOI: 10.1016/j.chest.2020.02.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 12/25/2019] [Accepted: 02/03/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) adversely affects patient's exercise capacity in interstitial lung disease (ILD). The impact of pulmonary vascular and right ventricular (RV) dysfunction, however, has traditionally been believed to be mild and clinically relevant principally in advanced lung disease states. RESEARCH QUESTION The aim of this study was to evaluate the relative contributions of pulmonary mechanics, pulmonary vascular function, and RV function to the ILD exercise limit. STUDY DESIGN AND METHODS Forty-nine patients with ILD who underwent resting right heart catheterization followed by invasive exercise testing were evaluated. Patients with PH at rest (ILD + rPH) and with PH diagnosed exclusively during exercise (ILD + ePH) were contrasted with ILD patients without PH (ILD non-PH). RESULTS Peak oxygen consumption was reduced in ILD + rPH (61 ± 10% predicted) and ILD + ePH (67 ± 13% predicted) compared with ILD non-PH (81 ± 16% predicted; P < .001 and P = .016, respectively). Each ILD hemodynamic phenotype presented distinct patterns of dynamic changes of pulmonary vascular compliance relative to pulmonary vascular resistance from rest to peak exercise. Peak RV stroke work index was increased in ILD + ePH (24.7 ± 8.2 g/m2 per beat) and ILD + rPH (30.9 ± 6.1 g/m2 per beat) compared with ILD non-PH (18.3 ± 6.4 g/m2 per beat; P = .020 and P = .014). Ventilatory reserve was reduced in ILD + rPH compared with the other groups at the anaerobic threshold, but it was similar between ILD + ePH and ILD non-PH at the anaerobic threshold (0.32 ± 0.13 vs 0.30 ± 0.11; P = .921) and at peak exercise (0.70 ± 0.17 vs 0.73 ± 0.24; P = .872). INTERPRETATION ILD with resting and exercise PH is associated with increased exercise RV work, reduced pulmonary vascular reserve, and reduced peak oxygen consumption. The findings highlight the role of pulmonary vascular and RV burden to ILD exercise limit.
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Molgat-Seon Y, Schaeffer MR, Ryerson CJ, Guenette JA. Exercise Pathophysiology in Interstitial Lung Disease. Clin Chest Med 2020; 40:405-420. [PMID: 31078218 DOI: 10.1016/j.ccm.2019.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Interstitial lung disease (ILD) is a heterogeneous group of disorders that primarily affect the lung parenchyma. Patients with ILD have reduced lung volumes, impaired pulmonary gas exchange, and decreased cardiovascular function. These pathologic features of ILD become exacerbated during physical exertion, leading to exercise intolerance and abnormally high levels of exertional dyspnea. In this review, the authors summarize the primary pathophysiologic features of patients with ILD and their effect on the integrative response to exercise.
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Affiliation(s)
- Yannick Molgat-Seon
- Centre for Heart Lung Innovation, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, British Columbia V6T 1Y6, Canada; Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Michele R Schaeffer
- Centre for Heart Lung Innovation, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, British Columbia V6T 1Y6, Canada; Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Christopher J Ryerson
- Centre for Heart Lung Innovation, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, British Columbia V6T 1Y6, Canada; Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Gordon and Leslie Diamond Health Care Centre, 7th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada
| | - Jordan A Guenette
- Centre for Heart Lung Innovation, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, British Columbia V6T 1Y6, Canada; Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada; Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Gordon and Leslie Diamond Health Care Centre, 7th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada.
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension has been reported to complicate the course of a number of fibrotic lung diseases, including idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonitis and nonspecific interstitial pneumonitis. Most commonly, mild elevations in the mean pulmonary artery pressure are seen in patients with advanced pulmonary fibrosis. However, some patients may develop severe pulmonary hypertension, which appears out of proportion to the degree of their restrictive lung disease. RECENT FINDINGS The benefits of pulmonary vasodilator therapy have yet to be established in pulmonary hypertension complicating fibrotic lung disease. In fact, one recent clinical trial examining riociguat in patients with pulmonary hypertension complicating idiopathic interstitial pneumonias was terminated early for an increased risk of death or hospitalization. Multiple clinical trials on this topic are currently ongoing, including studies examining inhaled pulmonary vasodilator therapies. SUMMARY The development of pulmonary hypertension is associated with increased exertional oxygen requirements, worsened functional capacity and attenuated life expectancy. It is hoped that continued research will find an effective therapy for this condition, which will improve quality of life and extend life expectancy in patients with this condition.
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Affiliation(s)
- Christopher S King
- Inova Fairfax Advanced Lung Disease and Transplant Clinic, Falls Church, Virginia, USA
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Epidemiology of Hypersensitivity Pneumonitis among an Insured Population in the United States: A Claims-based Cohort Analysis. Ann Am Thorac Soc 2019; 15:460-469. [PMID: 29236517 DOI: 10.1513/annalsats.201704-288oc] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Hypersensitivity pneumonitis is a complex lung disease resulting from repeated inhalation of a variety of antigens. Limited data exist regarding its epidemiology. OBJECTIVES To describe the trends in the annual incidence and prevalence of hypersensitivity pneumonitis in the United States. METHODS We developed novel claims-based coding algorithms to identify hypersensitivity pneumonitis, chronic hypersensitivity pneumonitis, and fibrotic hypersensitivity pneumonitis cases using the 2004 to 2013 MarketScan Commercial and Medicare Supplemental healthcare claims databases. Algorithm validity and reliability were assessed with clinical data from National Jewish Health. We calculated yearly cumulative incidence and prevalence overall and by age. For the subgroup with vital status, Kaplan-Meier methods were used to analyze survival stratified by evidence of fibrosis. RESULTS We identified 7,498 cases that met our hypersensitivity pneumonitis definition over the 10-year study period, including 3,902 with chronic hypersensitivity pneumonitis and 1,852 with fibrotic hypersensitivity pneumonitis. On the basis of the clinical-radiological adjudication of the validation sample, 38 cases (95%) were confirmed as hypersensitivity pneumonitis. The mean age was 52 years, and 58% were women. The 1-year prevalence rates for hypersensitivity pneumonitis ranged from 1.67 to 2.71 per 100,000 persons, and 1-year cumulative incidence rates ranged from 1.28 to 1.94 per 100,000 persons. The prevalence increased with age, ranging from 0.95 per 100,000 among 0- to 9-year-olds to 11.2 per 100,000 among those aged 65 years and older. Between 56 and 68% of hypersensitivity pneumonitis cases in each year were classified as chronic hypersensitivity pneumonitis (prevalence, 0.91-1.70 per 100,000 persons; cumulative incidence, 0.63-1.08 per 100,000 persons). Fewer had fibrotic hypersensitivity pneumonitis (prevalence, 0.41-0.80 per 100,000 persons; cumulative incidence: 0.29-0.43 per 100,000 persons). Most cases (74%) were classified as unspecified hypersensitivity pneumonitis. Older age, male sex, and fibrosis were associated with higher mortality rates in unadjusted analyses. CONCLUSIONS Using U.S. administrative claims-based data, we developed an algorithm with a high sensitivity and specificity for hypersensitivity pneumonitis. Between 2004 and 2013, hypersensitivity pneumonitis was more common among women and those older than 65 years. Most cases were classified as chronic hypersensitivity pneumonitis. Approximately one-fourth met our criteria for fibrotic hypersensitivity pneumonitis, which was associated with a higher mortality rate.
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Soumagne T, Dalphin ML, Dalphin JC. [Hypersensitivity pneumonitis in children]. Rev Mal Respir 2019; 36:495-507. [PMID: 31010760 DOI: 10.1016/j.rmr.2018.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 06/14/2018] [Indexed: 12/13/2022]
Abstract
Hypersensitivity pneumonitis (HP) is an interstitial lung disease caused by an immune response to a variety of antigens to which patients have been previously sensitised. It can occur at any age. In children, it is a rare disease, probably under-diagnosed, with an estimated prevalence of 4 per million. The paediatric forms are not really different from those of adults but present some particularities. Avian exposure is by far the most frequent cause of HP, accounting for nearly two-thirds of cases. Although there is no current recommendation for the diagnosis of HP, it is commonly considered that the diagnosis can be made with confidence on the combination of (1) compatible respiratory symptoms, (2) exposure to a known offending antigen, (3) lymphocytic alveolitis, (4) decreased transfer factor for carbon monoxide or hypoxia on exertion and (5) compatible radiologic features. The treatment is based on antigen avoidance that must be complete and definitive. Corticosteroids can be necessary in severe forms. The prognosis of HP in children is better than in adults, with a full clinical and functional recovery in the majority of cases after complete antigenic withdrawal.
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Affiliation(s)
- T Soumagne
- Service de pneumologie, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France.
| | - M L Dalphin
- Service de pédiatrie, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France
| | - J C Dalphin
- Service de pneumologie, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France; UMR CNRS 6249, Chrono-environnement, université de Franche-Comté, 25000 Besançon, France.
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31
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Imaging of Pulmonary Hypertension: Pictorial Essay. Chest 2019; 156:211-227. [PMID: 30981724 DOI: 10.1016/j.chest.2019.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/01/2019] [Indexed: 11/20/2022] Open
Abstract
Pulmonary hypertension (PH) is an end result of a diverse array of complex clinical conditions that invoke hemodynamic and pathophysiological changes in the pulmonary vasculature. Many patients' symptoms begin with dyspnea on exertion for which screening tests such as chest roentgenograms and more definitive noninvasive tests such as CT scans are ordered initially. It is imperative that clinicians are cognizant of subtle clues on these imaging modalities that alert them to the possibility of PH. These clues may serve as a stepping stone towards more advanced noninvasive (echocardiogram) and invasive (right heart catheterization) testing. On the CT scan, the signs are classified into mediastinal and lung parenchymal abnormalities. In addition to suspecting the diagnosis of PH, this paper provides a pictorial essay to guide health care professionals in identifying the etiology of PH. This paper also provides concrete definitions, wherever possible, of what constitutes abnormalities in PH, such as dilated pulmonary arteries, pruning of vessels, and increased thickness of free wall of the right ventricle. The sensitivities and specificities of each sign are enumerated. The common radiographic and clinical features of many different etiologies of PH are tabulated for the convenience of the readers. Some newer imaging modalities such as dual-energy CT of the chest that hold promise for the future are also described.
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Nathan SD, Barbera JA, Gaine SP, Harari S, Martinez FJ, Olschewski H, Olsson KM, Peacock AJ, Pepke-Zaba J, Provencher S, Weissmann N, Seeger W. Pulmonary hypertension in chronic lung disease and hypoxia. Eur Respir J 2019; 53:13993003.01914-2018. [PMID: 30545980 PMCID: PMC6351338 DOI: 10.1183/13993003.01914-2018] [Citation(s) in RCA: 342] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 02/07/2023]
Abstract
Pulmonary hypertension (PH) frequently complicates the course of patients with various forms of chronic lung disease (CLD). CLD-associated PH (CLD-PH) is invariably associated with reduced functional ability, impaired quality of life, greater oxygen requirements and an increased risk of mortality. The aetiology of CLD-PH is complex and multifactorial, with differences in the pathogenic sequelae between the diverse forms of CLD. Haemodynamic evaluation of PH severity should be contextualised within the extent of the underlying lung disease, which is best gauged through a combination of physiological and imaging assessment. Who, when, if and how to screen for PH will be addressed in this article, as will the current state of knowledge with regard to the role of treatment with pulmonary vasoactive agents. Although such therapy cannot be endorsed given the current state of findings, future studies in this area are strongly encouraged. State of the art and research perspectives in pulmonary hypertension in chronic lung disease and hypoxiahttp://ow.ly/XcW730meWxy
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Affiliation(s)
| | - Joan A Barbera
- Dept of Pulmonary Medicine, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center on Respiratory Diseases, Madrid, Spain
| | - Sean P Gaine
- Respiratory Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | | | - Horst Olschewski
- Division of Pulmonology, Medizinische Universitat Graz, Graz, Austria
| | - Karen M Olsson
- Dept of Respiratory Medicine, Hannover Medical School and Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Regional Lung and Heart Centre, Glasgow, UK
| | | | - Steeve Provencher
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Quebec City, QC, Canada
| | - Norbert Weissmann
- University of Giessen and Marburg Lung Center (UGMLC), Justus-Liebig University Giessen and Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- University of Giessen and Marburg Lung Center (UGMLC), Justus-Liebig University Giessen and Member of the German Center for Lung Research (DZL), Giessen, Germany
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Dias OM, Baldi BG, Ferreira JG, Cardenas LZ, Pennati F, Salito C, Carvalho CRR, Aliverti A, Pereira de Albuquerque AL. Mechanisms of exercise limitation in patients with chronic hypersensitivity pneumonitis. ERJ Open Res 2018; 4:00043-2018. [PMID: 30151370 PMCID: PMC6104296 DOI: 10.1183/23120541.00043-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/05/2018] [Indexed: 01/02/2023] Open
Abstract
Small airway and interstitial pulmonary involvements are prominent in chronic hypersensitivity pneumonitis (cHP). However, their roles on exercise limitation and the relationship with functional lung tests have not been studied in detail. Our aim was to evaluate exercise performance and its determinants in cHP. We evaluated maximal cardiopulmonary exercise testing performance in 28 cHP patients (forced vital capacity 57±17% pred) and 18 healthy controls during cycling. Patients had reduced exercise performance with lower peak oxygen production (16.6 (12.3–19.98) mL·kg−1·min−1versus 25.1 (16.9–32.0), p=0.003), diminished breathing reserve (% maximal voluntary ventilation) (12 (6.4–34.8)% versus 41 (32.7–50.8)%, p<0.001) and hyperventilation (minute ventilation/carbon dioxide production slope 37±5 versus 31±4, p<0.001). All patients presented oxygen desaturation and augmented Borg dyspnoea scores (8 (5–10) versus 4 (1–7), p=0.004). The prevalence of dynamic hyperinflation was found in only 18% of patients. When comparing cHP patients with normal and low peak oxygen production (<84% pred, lower limit of normal), the latter exhibited a higher minute ventilation/carbon dioxide production slope (39±5.0 versus 34±3.6, p=0.004), lower tidal volume (0.84 (0.78–0.90) L versus 1.15 (0.97–1.67) L, p=0.002), and poorer physical functioning score on the Short form-36 health survey. Receiver operating characteristic curve analysis showed that reduced lung volumes (forced vital capacity %, total lung capacity % and diffusing capacity of the lung for carbon dioxide %) were high predictors of poor exercise capacity. Reduced exercise capacity was prevalent in patients because of ventilatory limitation and not due to dynamic hyperinflation. Reduced lung volumes were reliable predictors of lower performance during exercise. Besides significant small airway involvement, reduced exercise capacity is due to ventilatory limitation and not due to dynamic hyperinflation in chronic hypersensitivity pneumonitishttp://ow.ly/Ou9230kSBQz
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Affiliation(s)
- Olívia Meira Dias
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Bruno Guedes Baldi
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Jeferson George Ferreira
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Letícia Zumpano Cardenas
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Caterina Salito
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Carlos Roberto Ribeiro Carvalho
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - André Luis Pereira de Albuquerque
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
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Oliveira RKF, Ota-Arakaki JS, Gomes PS, Gimenez A, Messina CMS, Ramos RP, Ferreira EVM, Systrom DM, Pereira CAC. Pulmonary haemodynamics and mortality in chronic hypersensitivity pneumonitis. Eur Respir J 2018; 51:13993003.00430-2018. [PMID: 29622570 DOI: 10.1183/13993003.00430-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/25/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Rudolf K F Oliveira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Jaquelina S Ota-Arakaki
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Paula S Gomes
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Andrea Gimenez
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Carolina M S Messina
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Roberta P Ramos
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Eloara V M Ferreira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Carlos A C Pereira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
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Presence of Air Trapping and Mosaic Attenuation on Chest Computed Tomography Predicts Survival in Chronic Hypersensitivity Pneumonitis. Ann Am Thorac Soc 2018; 14:1533-1538. [PMID: 28513215 DOI: 10.1513/annalsats.201701-035oc] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
RATIONALE Significant heterogeneity of computed tomography (CT) presentation exists within chronic hypersensitivity pneumonitis (HP). There are limited data aimed at delineating the prognostic value of specific CT features, distribution, and patterns in chronic HP. OBJECTIVES To examine whether the presence of CT mosaic attenuation (MA) and air trapping (AT), and the distribution or patterns of fibrosis impact survival in subjects with chronic HP. METHODS We retrospectively identified 110 consecutively enrolled, well-characterized, biopsy-proven adult subjects with chronic HP between 1982 and 2015 from the National Jewish Health interstitial lung disease research database. The first available CT scan of diagnostic quality from each subject was formally evaluated for specific CT findings associated with chronic HP and for overall CT pattern. A Cox proportional hazards model was used to identify independent predictors in time-to-death analysis, and bootstrap analysis was performed for internal model validation. RESULTS Fibrotic HP (65%; 72/110) was most often peripheral in the axial plane and lower lung preponderant. The distribution of lung disease in those without fibrosis was most often axially and zonally diffuse. There was no association between survival and CT distribution or CT pattern in the whole cohort or within the fibrotic subset of subjects. After multivariate adjustment, AT/MA was independently associated with survival in the whole cohort (HR = 0.26; 95% confidence interval = 0.07-0.97). Results were similar after restricting the analyses to fibrotic HP cases. CONCLUSIONS Among subjects with chronic HP, the presence of CT AT/MA may identify subjects with better prognosis.
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Soumagne T, Dalphin JC. Current and emerging techniques for the diagnosis of hypersensitivity pneumonitis. Expert Rev Respir Med 2018; 12:493-507. [PMID: 29727203 DOI: 10.1080/17476348.2018.1473036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Hypersensitivity pneumonitis (HP) is the result of an immunologically induced inflammation of the lung parenchyma in response to inhalation exposure to a large variety of antigens in genetically susceptible individuals. HP shares clinical and radiological features with other acute and chronic interstitial lung diseases and is sometimes difficult to diagnose if exposure to an antigenic agent is not detected. Several classifications and diagnostic criteria have been proposed but are not currently recommended by guidelines from any scientific society. However, advances have been made over the past ten years in improving the diagnosis of HP. Areas covered: This article will provide a summary of the different classification and diagnostic criteria proposed in acute and chronic forms of HP. In addition, we review current diagnostic procedures including antigen detection, high resolution computed tomography, histopathology and provide an overview of emerging techniques. Expert commentary: Important changes are occurring in the field of HP and knowledge of the disease will likely progress enormously in the coming 5 to 10 years as many techniques continue to be developed, including genomic signature and diagnostic biomarkers.
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Affiliation(s)
- Thibaud Soumagne
- a Service de Pneumologie , CHU de Besançon , Besançon , France.,b UMR 6249 Chrono-environnement , Université de Franche-Comté , Besançon , France
| | - Jean Charles Dalphin
- a Service de Pneumologie , CHU de Besançon , Besançon , France.,b UMR 6249 Chrono-environnement , Université de Franche-Comté , Besançon , France
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37
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CT findings associated with survival in chronic hypersensitivity pneumonitis. Eur Radiol 2017; 27:5127-5135. [DOI: 10.1007/s00330-017-4936-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/01/2017] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
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Nathan SD, Behr J, Cottin V, Collard HR, Hoeper MM, Martinez FJ, Wells AU. Idiopathic interstitial pneumonia-associated pulmonary hypertension: A target for therapy? Respir Med 2016; 122 Suppl 1:S10-S13. [PMID: 27884593 DOI: 10.1016/j.rmed.2016.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/28/2016] [Accepted: 11/02/2016] [Indexed: 11/30/2022]
Abstract
Advances in the treatment of idiopathic interstitial pneumonia (IIP) represent an urgent, unmet medical need for patients with this category of diffuse parenchymal lung disease. IIPs involve varying combinations of fibrosis and inflammation of unknown cause and may be associated with pulmonary hypertension (PH). When it occurs, PH is associated with higher oxygen needs, greater functional impairment, and increased mortality. However, whether or when PH is a maladaptive versus adaptive phenomenon remains to be determined. Despite their differing prognoses, it does appear that the IIPs may follow a similar course once PH supervenes. Therefore, it may be worthwhile to explore studies of PH medications in IIP as a group rather than as individual entities. Such a broad approach eliminates the need to nuance specific diagnoses and thereby facilitates study recruitment and broadens the applicability of the results.
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Affiliation(s)
| | - Jürgen Behr
- Department of Internal Medicine V, University of Munich, Member of the German Center for Lung Research, Munich, Germany
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Regional Center for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard Lyon 1 University, Lyon, France
| | | | - Marius M Hoeper
- Hannover Medical School and Hannover and German Centre for Lung Research, Hannover, Germany
| | - Fernando J Martinez
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical School, New York, NY, USA
| | - Athol U Wells
- Royal Brompton & Harefield, NHS Foundation, London, England, United Kingdom
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39
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Pereira CA, Gimenez A, Kuranishi L, Storrer K. Chronic hypersensitivity pneumonitis. J Asthma Allergy 2016; 9:171-181. [PMID: 27703382 PMCID: PMC5036552 DOI: 10.2147/jaa.s81540] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Hypersensitivity pneumonitis (HSP) is a common interstitial lung disease resulting from inhalation of a large variety of antigens by susceptible individuals. The disease is best classified as acute and chronic. Chronic HSP can be fibrosing or not. Fibrotic HSP has a large differential diagnosis and has a worse prognosis. The most common etiologies for HSP are reviewed. Diagnostic criteria are proposed for both chronic forms based on exposure, lung auscultation, lung function tests, HRCT findings, bronchoalveolar lavage, and biopsies. Treatment options are limited, but lung transplantation results in greater survival in comparison to idiopathic pulmonary fibrosis. Randomized trials with new antifibrotic agents are necessary.
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Affiliation(s)
| | - Andréa Gimenez
- Pulmonology Postgraduate, Federal University of São Paulo, São Paulo, Brazil
| | - Lilian Kuranishi
- Pulmonology Postgraduate, Federal University of São Paulo, São Paulo, Brazil
| | - Karin Storrer
- Pulmonology Postgraduate, Federal University of São Paulo, São Paulo, Brazil
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40
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Barberà JA, Blanco I. Gaining insights into pulmonary hypertension in respiratory diseases. Eur Respir J 2016; 46:1247-50. [PMID: 26521275 DOI: 10.1183/13993003.01288-2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joan Albert Barberà
- Dept of Pulmonary Medicine, Hospital Clínic and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain Biomedical Research Networking Center in Respiratory Diseases, Madrid, Spain
| | - Isabel Blanco
- Dept of Pulmonary Medicine, Hospital Clínic and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain Biomedical Research Networking Center in Respiratory Diseases, Madrid, Spain
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41
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Shlobin OA, Brown AW, Nathan SD. Pulmonary Hypertension in Diffuse Parenchymal Lung Diseases. Chest 2016; 151:204-214. [PMID: 27554299 DOI: 10.1016/j.chest.2016.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/29/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022] Open
Abstract
Pulmonary hypertension (PH) can be triggered by any number of disease processes that result in increased pulmonary vascular resistance. Although historically associated with idiopathic pulmonary arterial hypertension (PAH), most patients with PH do not have the idiopathic subtype, but rather PH associated with another underlying diagnosis, such as left heart or lung disease. The World Health Organization (WHO) classification of PH helps conceptualize the different categories based on presumed etiology. WHO group 3 is PH associated with lung disease. This review focuses on PH in diffuse parenchymal lung diseases (DPLDs), such as the idiopathic interstitial pneumonias and other more rare forms of DPLD. Although there are clear associations of PH with DPLD, the exact pathophysiologic mechanisms and full clinical significance remain uncertain. Treatment of PH related to DPLD remains investigational, but an area of great interest given the negative prognostic implications and the growing number of available pulmonary vasoactive agents.
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Affiliation(s)
- Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, VA.
| | - A Whitney Brown
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, VA
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, VA
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Abstract
Pulmonary hypertension is a complication of sarcoidosis leading to dyspnea and associated with increased morbidity and mortality. Sarcoidosis-associated pulmonary hypertension (SAPH) can be due to several factors, including vascular involvement by the granulomatous inflammation, compression of the pulmonary arteries by adenopathy, fibrotic changes within the lung, and left ventricular diastolic dysfunction. Several case series have suggested that some patients with SAPH benefit from specific therapy for pulmonary hypertension. A randomized, placebo-controlled trial found 16 weeks' bosentan therapy to be associated with significant improvement in pulmonary artery pressure. Future studies may better define who would respond to treatment of pulmonary hypertension.
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Affiliation(s)
- Robert P Baughman
- Department of Medicine, University of Cincinnati, 1001 Holmes Eden Avenue, Cincinnati, OH 45220, USA.
| | - Peter J Engel
- Ohio Heart and Cardiovascular Center, Christ Hospital, Auburn Avenue, Cincinnati, OH 45219, USA
| | - Steven Nathan
- Advanced Lung Disease, INOVA Medical Care, 3300 Gallows Road, Falls Church, VA 22042, USA
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Vogiatzis I, Marvisi M, Coolen J, Gasparini S, Antoniou KM, Stallberg B, Bjerg A, Herth FJ, Clini E. Clinical highlights: messages from Munich. ERJ Open Res 2015; 1:00002-2015. [PMID: 27730129 PMCID: PMC5005128 DOI: 10.1183/23120541.00002-2015] [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: 03/20/2015] [Accepted: 04/29/2015] [Indexed: 11/05/2022] Open
Abstract
This article reviews a selection of presentations in the area of clinical problems that were presented at the 2014 European Respiratory Society International Congress in Munich, Germany. We review the most recent and relevant topics of interest in the area of clinical respiratory medicine, encompassing novel reports and studies that are of particular interest to healthcare professionals. Topics ranging from basic science to translation research are presented and discussed in the context of the most up-to-date literature. In particular, the reviewed topics deal with chronic obstructive pulmonary disease and asthma, idiopathic pulmonary fibrosis (pathogenesis and therapy), advances in functional chest imaging, interventional pulmonology, pulmonary rehabilitation, and chronic care.
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Affiliation(s)
- Ioannis Vogiatzis
- First Dept of Respiratory Medicine, Pulmonary Rehabilitation Unit, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
- First Dept of Critical Care Medicine, Pulmonary Rehabilitation Centre, National and Kapodistrian University of Athens, Athens, Greece
| | - Maurizio Marvisi
- Dept of Internal Medicine and Pneumunology, Clinica Figlie di S. Camillo, Cremona, Italy
| | - Johan Coolen
- Dept of Radiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Stefano Gasparini
- Dept of Biomedical Sciences and Public Health, Polytechnic University of the Marche Region, Ancona, Italy
- Pulmonary Diseases Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Katerina M. Antoniou
- Dept of Thoracic Medicine Department and Laboratory of Molecular and Cellular Pneumonology, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Bjorn Stallberg
- Dept of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Anders Bjerg
- University of Gothenburg, Krefting Research Centre, Gothenburg, Sweden
| | - Felix J.F. Herth
- Dept of Pulmonary and Critical Care Medicine, University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg, Heidelberg, Germany
| | - Enrico Clini
- Dept of Medical and Surgical Sciences, University of Modena-Reggio Emilia, Modena, Italy
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Maron BA. Hemodynamics should be the primary approach to diagnosing, following, and managing pulmonary arterial hypertension. Can J Cardiol 2014; 31:515-20. [PMID: 25742869 DOI: 10.1016/j.cjca.2014.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 08/28/2014] [Accepted: 09/04/2014] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a highly morbid cardiopulmonary disease characterized by plexogenic pulmonary arteriole remodelling. Importantly, PAH severity correlates inversely with cardiac output and directly with pulmonary vascular resistance and right atrial pressure, illustrating the importance of accurately measured hemodynamics to define the clinical profile of patients. Currently available noninvasive technology offers only hemodynamic estimates. In contrast, right heart catheterization is the principle diagnostic procedure in PAH and is required to: (1) definitively exclude alternative pulmonary vascular diseases; and (2) quantify hemodynamics at baseline, after vasoreactivity testing, or in response to therapy to prognosticate outcome and guide therapeutic escalation.
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Affiliation(s)
- Bradley A Maron
- Brigham and Women's Hospital and Harvard Medical School, Department of Medicine, Division of Cardiovascular Medicine, 75 Francis St, Boston, and the Department of Cardiology, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA.
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45
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[Pulmonary hypertension in chronic respiratory diseases]. Presse Med 2014; 43:945-56. [PMID: 25123317 DOI: 10.1016/j.lpm.2014.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 07/09/2014] [Indexed: 11/23/2022] Open
Abstract
Pulmonary hypertension is frequent in advanced chronic respiratory diseases, with an estimated prevalence at the time of pulmonary transplantation of 30-50 % in idiopathic pulmonary fibrosis, 30-50 % in chronic obstructive pulmonary disease, 50 % in combined pulmonary fibrosis and emphysema, 75 % in sarcoidosis, and more than 75 % of cases in pulmonary Langerhans cell histiocytosis. Histologic features include varying degrees of pulmonary arterial remodeling (prominent), vascular rarefaction (emphysema), fibrosis or specific involvement of the pulmonary arteries (idiopathic pulmonary fibrosis, sarcoidosis, lymphangioleiomyomatosis, pulmonary Langerhans cell histiocytosis), in situ thrombosis, and frequently associated involvement of the pulmonary veins (idiopathic pulmonary fibrosis, sarcoidosis). Pulmonary hypertension is usually detected using echocardiography with Doppler, however right heart catheterisation is required to confirm precapillary pulmonary hypertension defined by pulmonary artery pressure ≥ 25 mm Hg, with pulmonary artery wedge pressure ≤ 15 mm Hg. When present, it is associated with decreased exercise capacity and worse mortality. Pulmonary hypertension in chronic respiratory disease is almost invariably multifactorial; hypoxia is one of its main determinants, however supplemental oxygen therapy rarely reverses pulmonary hypertension. Management of pulmonary hypertension in chronic respiratory disease is mostly based on the optimal treatment of the underlying disease. Available data do not support the use of drug therapies specific for pulmonary hypertension in the setting of chronic respiratory diseases, however very few clinical studies have been conducted so far specifically in this context.
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