Pulmonary hypertension and COPD Investigations and treatment - - PowerPoint PPT Presentation

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Pulmonary hypertension and COPD Investigations and treatment - - PowerPoint PPT Presentation

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Pulmonary hypertension and COPD Investigations and treatment Rencontres Genevoises de Pneumologie 17 fvrier 2010 Ari Chaouat Service des Maladies Respiratoires et Ranimation Respiratoire CHU de Nancy ERS/ESC Guidelines Gali N. et al.

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Pulmonary hypertension and COPD

Investigations and treatment

Ari Chaouat Service des Maladies Respiratoires et Réanimation Respiratoire CHU de Nancy Rencontres Genevoises de Pneumologie 17 février 2010

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ERS/ESC Guidelines Galié N. et al. Eur Heart J 2009

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Pulmonary hypertension and COPD before LTOT

Levine et al. Ann Intern Med 1967 m Pap (mm Hg) 40 mm Hg

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Pulmonary haemodynamics during a period of disease stability

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Natural History of PH in COPD Rise of PAP during exacerbation

Weitzenblum E et al. Heart 2003; 89: 225

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Natural History of PH in COPD “Exercising” pulmonary hypertension

Weitzenblum E et al. Heart 2003; 89: 225

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m PAP (mm Hg) Number of patients

Severe pulmonary hypertension and COPD

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Severe pulmonary hypertension and COPD

Chaouat A, Bugnet AS, Kadaoui N et al. AJRCCM 2005; 172: 189

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Chaouat et al. Eur Respir J 2008; 32: 1371 PAP > 40 mm Hg PAP < 40 mm Hg MRC dyspnea scale, p < 0.05

Severe pulmonary hypertension and COPD

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Physiological consequences of PH in COPD

  • Worsening of blood gas exchanges
  • Right ventricular dysfunction

– Usually RV systolic function is normal at rest in patients with COPD

  • Peripheral edema

– RV failure – CO2 induces a decrease in renal blood flow

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Clinical consequences of PH in COPD

Sims M et al. Chest 2009; 136: 412 Oswald-Mammosser M et al. Chest 1995; 107: 1193

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Survival

Months m PAP ≥ 25 mm Hg m PAP < 25 mm Hg P < 0.001

  • Dyspnea on exertion
  • Exercise limitation
  • Survival
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Diagnosis strategy (1)

  • Dyspnea on exertion
  • Physical signs of PH
  • Prediction of mean PAP from pulmonary

function data

  • 6-min walk distance
  • B-type natriuretic peptide

Sims M et al. Chest 2009; 136: 412 Leuchte H et al. AJRCCM 2006; 173: 744

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  • Doppler echocardiography

– Estimation of systolic Pap with continuous Doppler well correlated with catheterization measurement (0.60-0.85)

  • 374 lung transplant

candidates, 68 % COPD

  • Prevalence of PH

(systolic Pap> 45 mm Hg) was 25 %

  • Inaccurate > 10 mm Hg

difference

Arcasoy S et al AJRCCM 2003; 167: 735

Diagnosis strategy (2)

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Diagnosis strategy (3)

Fisher M et al. ERJ 2007; 30: 914

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Doppler echocardiography

  • However

– The goals are to exclude an associated left heart disease and to raise suspicion of PH – These objectives can be achieved with the combination of

  • Estimation of RV systolic pressure
  • Measurement of pulmonary blood flow velocity
  • Right-side chamber size
  • Indices of right ventriclar dysfunction
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Chronic Lung Disease in stable state

Most commonly COPD History, Symptoms, Signs Chest radiograph Spirometry, ABG Unexplained severity of CRF

  • r signs of PH
  • r signs of chronic heart failure

Doppler echocardiography

Technically adequate study Technically inadequate study

Evidence

  • f CHF

Severe increased systolic PAP depending of the airflow limitation

Static lung volumes, DLCO HRCT, V/Q scan Sleep study Exercise testing

RHC

ACE inhibitor and other treatments of CHF if needed Treatments of an

  • verlap of 2 lung

diseases e.g. COPD and sleep apnea syndrome

Elevated PWP Out of proportion PH

Treatment of an associated DHF Send to a PAH referral centre No No PH or proportionate PH Yes

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Treatment: LTOT

  • LTOT, MRC and NOT trials

– LTOT improve survival in COPD patients with severe chronic hypoxemia – LTOT stabilises, or at least attenuates, and sometimes reverses, the progression of PH

  • In one study mean PAP increases before the
  • nset of LTOT and decreases after the initiation
  • f LTOT

NOT trial group Ann Intern Med 1980; 93: 391 MRC working party Lancet 1981; 1: 681 Weitzenblum E et al ARRD 1985; 131: 493

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Treatment: inhaled nitric oxide

Vonbank K et al Thorax 2003; 58: 289 No change in arterial blood gases Concerns about long-term safety and cumbersome device

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Treatment: Endothelin Receptor Antagonist

Stolz D et al ERJ 2008; 32: 619

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Treatment: Endothelin Receptor Antagonist

Stolz D et al ERJ 2008; 32: 619

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Treatment: Endothelin Receptor Antagonist

Stolz D et al ERJ 2008; 32: 619

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Treatment: PDE-5 inhibitors

Blanco I et al AJRCCM 2010; 181: 270

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Treatment: PDE-5 inhibitors

Blanco I et al AJRCCM 2010; 181: 270

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Chaouat Naeije, Weitzenblum et al. Eur Respir J 2008; 32: 1371

Treatments

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Conclusions

  • Diagnosis strategy

– Determine the impact of the pulmonary vascular impairment in COPD patients on clinical end points – Search for an associated condition

  • Treatment

– Treat the underlying disease (s) – Correct severe hypoxemia – Pulmonary vasodilators are deleterious – Lung transplantation

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