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Fiorentù G, Bernardinello N, Giulianelli G, Cocconcelli E, Balestro E, Spagnolo P. Pulmonary Hypertension Associated with Interstitial Lung Disease (PH-ILD): Back to the Future. Adv Ther 2025; 42:1627-1641. [PMID: 39969780 PMCID: PMC11929637 DOI: 10.1007/s12325-025-03129-3] [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: 11/21/2024] [Accepted: 01/27/2025] [Indexed: 02/20/2025]
Abstract
Pulmonary hypertension (PH) is a progressive syndrome characterized by increased pulmonary artery pressure. PH often complicates chronic lung diseases, thus contributing to a substantial disease burden and poor prognosis. The WHO Group 3 Pulmonary Hypertension has many subcategories, including sleep-hypoventilation PH, high altitude-PH, chronic obstructive pulmonary disease (COPD)-PH, and interstitial lung disease (PH-ILD), the latter carrying the worst prognosis. ILD is a heterogeneous group of disorders characterized by cough and shortness of breath and, in progressive forms, irreversible loss of function and respiratory failure. The development of PH in patients with ILD worsens exercise capacity and exertional dyspnea and impairs quality of life. Thus, suspicion and early detection of PH following thorough cardiologic evaluation (i.e., echocardiography, pro-BNP, and right heart catheterization) is paramount for appropriate patient management. For PH secondary to chronic respiratory diseases, current guidelines recommend optimizing the treatment of the underlying respiratory condition and offering long-term oxygen therapy. In recent years, several clinical trials have failed to identify drugs beneficial for group 3 PH. Conversely, the INCREASE trial of inhaled treprostinil has recently provided hope for treating PH-ILD. In this review, we summarize and critically discuss the present and future of the pharmacological management of PH-ILD.
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Affiliation(s)
- Giordano Fiorentù
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
| | - Nicol Bernardinello
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy.
| | - Giacomo Giulianelli
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
| | - Elisabetta Cocconcelli
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
| | - Elisabetta Balestro
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
| | - Paolo Spagnolo
- Departement of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padua, Italy
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Patsoura A, Baldini G, Puggioni D, Delle Vergini M, Castaniere I, Andrisani D, Gozzi F, Samarelli AV, Raineri G, Michelacci S, Ruini C, Carzoli A, Cuculo A, Marchioni A, Beghè B, Clini E, Cerri S, Tonelli R. The Link Between Sleep-Related Breathing Disorders and Idiopathic Pulmonary Fibrosis: Pathophysiological Mechanisms and Treatment Options-A Review. J Clin Med 2025; 14:2205. [PMID: 40217656 PMCID: PMC11989984 DOI: 10.3390/jcm14072205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2025] [Revised: 03/05/2025] [Accepted: 03/15/2025] [Indexed: 04/14/2025] Open
Abstract
In recent years, several studies have examined the impact of sleep-disordered breathing (SBD) on the quality of life and prognosis of patients with idiopathic pulmonary fibrosis (IPF). Among these disorders, obstructive sleep apnea (OSA) and nocturnal hypoxemia (NH) are the most prevalent and extensively studied, whereas central sleep apnea (CSA) has only been documented in recent research. The mechanisms underlying the relationship between IPF and SBDs are complex and remain an area of active investigation. Despite growing recognition of SBDs in IPF, no standardized guidelines exist for their management and treatment, particularly in a population characterized by distinct structural pulmonary abnormalities. This review outlines the pathophysiological connections between sleep-breathing disorders (SBDs) and idiopathic pulmonary fibrosis (IPF), as well as current therapeutic options. A comprehensive literature search using PubMed identified relevant studies, confirming the efficacy of CPAP in treating severe OSA and CSA. While high-flow oxygen therapy has not been validated in this patient cohort, it may offer a potential solution for select patients, particularly the elderly and those with low compliance. Conventional oxygen therapy, however, is limited to cases of isolated nocturnal hypoxemia or mild central sleep apnea.
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Affiliation(s)
- Athina Patsoura
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Giulia Baldini
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Daniele Puggioni
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Matteo Delle Vergini
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Ivana Castaniere
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
| | - Dario Andrisani
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
- Center for Rare Lung Diseases, University Hospital of Modena, 41125 Modena, Italy
| | - Filippo Gozzi
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
- Center for Rare Lung Diseases, University Hospital of Modena, 41125 Modena, Italy
| | - Anna Valeria Samarelli
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
| | - Giulia Raineri
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
| | - Sofia Michelacci
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Cristina Ruini
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Andrea Carzoli
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Aurelia Cuculo
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Alessandro Marchioni
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
| | - Bianca Beghè
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
| | - Enrico Clini
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
- Center for Rare Lung Diseases, University Hospital of Modena, 41125 Modena, Italy
| | - Stefania Cerri
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
- Center for Rare Lung Diseases, University Hospital of Modena, 41125 Modena, Italy
| | - Roberto Tonelli
- Respiratory Disease Unit, Department of Medical and Surgical Sciences of Motherhood and Child, University Hospital of Modena, 41125 Modena, Italy; (A.P.); (G.B.); (D.P.); (M.D.V.); (I.C.); (D.A.); (F.G.); (S.M.); (C.R.); (A.C.); (A.C.); (A.M.); (B.B.); (S.C.); (R.T.)
- Experimental Pneumology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.V.S.); (G.R.)
- Center for Rare Lung Diseases, University Hospital of Modena, 41125 Modena, Italy
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Lawrence A, Myall KJ, Mukherjee B, Marino P. Converging Pathways: A Review of Pulmonary Hypertension in Interstitial Lung Disease. Life (Basel) 2024; 14:1203. [PMID: 39337985 PMCID: PMC11433497 DOI: 10.3390/life14091203] [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: 08/10/2024] [Revised: 09/10/2024] [Accepted: 09/11/2024] [Indexed: 09/30/2024] Open
Abstract
Pulmonary hypertension (PH) in interstitial lung disease (ILD) is relatively common, affecting up to 50% of patients with idiopathic pulmonary fibrosis (IPF). It occurs more frequently in advanced fibrotic ILD, although it may also complicate milder disease and carries significant clinical implications in terms of morbidity and mortality. Key pathological processes driving ILD-PH include hypoxic pulmonary vasoconstriction and pulmonary vascular remodelling. While current understanding of the complex cell signalling pathways and molecular mechanisms underlying ILD-PH remains incomplete, there is evidence for an interplay between the disease pathogenesis of fibrotic ILD and PH, with interest in the role of the pulmonary endothelium in driving pulmonary fibrogenesis more recently. This review examines key clinical trials in ILD-PH therapeutics, including recent research showing promise for the treatment of both ILD-PH and the underlying pulmonary fibrotic process, further supporting the hypothesis of interrelated pathogenesis. Other important management considerations are discussed, including the value of accurate phenotyping in ILD-PH and the success of the "pulmonary vascular" phenotype. This article highlights the close and interconnected nature of fibrotic ILD and PH disease pathogenesis, a perspective likely to improve our understanding and therapeutic approach to this complex condition in the future.
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Affiliation(s)
| | - Katherine Jane Myall
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
- King's College Hospital, London SE5 9RS, UK
| | - Bhashkar Mukherjee
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London SW3 6NP, UK
| | - Philip Marino
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
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