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Journal of Human Hypertension Apr 2023Renal artery stenosis manifests as poorly-controlled hypertension, impaired renal function or pulmonary oedema, therefore the success of treatment is dependent on... (Review)
Review
Renal artery stenosis manifests as poorly-controlled hypertension, impaired renal function or pulmonary oedema, therefore the success of treatment is dependent on indication. This study aims to determine the outcomes of patients undergoing renal artery stenting (RASt) based on therapeutic aim compared to criteria used in the largest randomised trial. Retrospective case-note review of patients undergoing RASt between 2008-2021 (n = 74). The cohort was stratified by indication for intervention (renal dysfunction, hypertension, pulmonary oedema) and criteria employed in the CORAL trial, with outcomes and adverse consequences reported. Intervention for hypertension achieved significant reduction in systolic blood pressure and antihypertensive agents at 1 year (median 43 mmHg, 1 drug), without detrimental impact on renal function. Intervention for renal dysfunction reduced serum creatinine by a median 124 μmol/L, sustained after 6 months. Intervention for pulmonary oedema was universally successful with significant reduction in SBP and serum creatinine sustained at 1 year. Patients who would have been excluded from the CORAL trial achieved greater reduction in serum creatinine than patients meeting the inclusion criteria, with equivalent blood pressure reduction. There were 2 procedure-related mortalities and 5 procedural complications requiring further intervention. 5 patients had reduction in renal function following intervention and 7 failed to achieve the intended therapeutic benefit. Renal artery stenting is effective in treating the indication for which it has been performed. Previous trials may have underestimated the clinical benefits by analysis of a heterogenous population undergoing a procedure rather than considering the indication, and excluding patients who would maximally benefit.
Topics: Humans; Renal Artery; Retrospective Studies; Creatinine; Pulmonary Edema; Treatment Outcome; Hypertension; Renal Artery Obstruction; Blood Pressure; Antihypertensive Agents; Stents
PubMed: 36526895
DOI: 10.1038/s41371-022-00785-8 -
Respiratory Physiology & Neurobiology Mar 2023Coronavirus disease-2019 (COVID-19) may severely affect respiratory function and evolve to life-threatening hypoxia. The clinical experience led to the implementation of... (Review)
Review
Coronavirus disease-2019 (COVID-19) may severely affect respiratory function and evolve to life-threatening hypoxia. The clinical experience led to the implementation of standardized protocols assuming similarity to severe acute respiratory syndrome (SARS-CoV-2). Understanding the histopathological and functional patterns is essential to better understand the pathophysiology of COVID-19 and then develop new therapeutic strategies. Epithelial and endothelial cell damage can result from the virus attack, thus leading to immune-mediated response. Pulmonary histopathological findings show the presence of Mallory bodies, alveolar coating cells with nuclear atypia, reactive pneumocytes, reparative fibrosis, intra-alveolar hemorrhage, moderate inflammatory infiltrates, micro-abscesses, microthrombus, hyaline membrane fragments, and emphysema-like lung areas. COVID-19 patients may present different respiratory stages from silent to critical hypoxemia, are associated with the degree of pulmonary parenchymal involvement, thus yielding alteration of ventilation and perfusion relationships. This review aims to: discuss the morphological (histopathological and radiological) and functional findings of COVID-19 compared to acute interstitial pneumonia, acute respiratory distress syndrome (ARDS), and high-altitude pulmonary edema (HAPE), four entities that share common clinical traits, but have peculiar pathophysiological features with potential implications to their clinical management.
Topics: Humans; COVID-19; SARS-CoV-2; Altitude; Pulmonary Edema; Pneumonia; Respiratory Distress Syndrome
PubMed: 36460252
DOI: 10.1016/j.resp.2022.104000 -
Journal of the American College of... Aug 2022Residual congestion detected using handheld ultrasound may be associated with increased risk of readmission and death after hospitalization for acute decompensated heart... (Observational Study)
Observational Study
BACKGROUND
Residual congestion detected using handheld ultrasound may be associated with increased risk of readmission and death after hospitalization for acute decompensated heart failure (ADHF). However, effective application necessitates routine use by nonexperts delivering clinical care.
OBJECTIVES
The objective of this study was to determine the ability of heart failure (HF) nurses to deliver a predischarge lung and inferior vena cava (IVC) assessment (LUICA) to predict 90-day outcomes.
METHODS
In this multisite, prospective, observational study, HF nurses scanned 240 patients with ADHF (median age: 77 years; 56% men) using a 9-zone LUICA protocol. Obtained images were reviewed by independent nurses who were blinded to clinical characteristics and outcomes. Based on a B-line cut-off of 10, patients were dichotomized as congested (n = 115) or not congested (n = 125).
RESULTS
Congested patients were more likely to have previous cardiac operations, long-standing HF (>6 months), and renal impairment. At 90 days, HF readmission or mortality occurred in 42 congested patients (37%) compared with 18 noncongested patients (14%). Pulmonary congestion increased at 30-day (OR: 3.86; 95% CI: 1.65-8.99; P < 0.01) and 90-day (OR: 3.42; 95% CI: 1.82-6.4; P < 0.01) HF readmission or mortality risk and 90-day mortality (OR: 5.18; 95% CI: 1.44-18.69; P < 0.01). Pulmonary congestion increased the 90-day odds of HF readmission and/or death by 3.3- to 4.2-fold (P < 0.01), independent of demographics, HF characteristics, comorbidities, and event risk score. Over 90 days, days alive out of hospital were fewer (78.3 ± 21.4 days vs 85.5 ± 12.4 days; P < 0.01) in congested patients.
CONCLUSIONS
LUICA can be a powerful tool for detection of predischarge residual congestion. HF nurses can obtain images and provide diagnostic reports that are predictive of ADHF outcomes.
Topics: Aged; Female; Heart Failure; Hospitalization; Humans; Hyperemia; Lung; Male; Prospective Studies; Pulmonary Edema; Vena Cava, Inferior
PubMed: 35902175
DOI: 10.1016/j.jacc.2022.04.064 -
Chest Aug 2022Swimming-induced pulmonary edema (SIPE) occasionally occurs during swimming in cold open water. Although optimal treatment for SIPE is unknown, non-invasive positive... (Observational Study)
Observational Study
BACKGROUND
Swimming-induced pulmonary edema (SIPE) occasionally occurs during swimming in cold open water. Although optimal treatment for SIPE is unknown, non-invasive positive pressure ventilation (NPPV) is an option for prehospital treatment.
RESEARCH QUESTION
Is NPPV a feasible and safe prehospital treatment for SIPE, and which outcome measures reflect recovery after treatment?
STUDY DESIGN AND METHODS
A prospective observational study was conducted at Vansbrosimningen, Sweden's largest open water swimming event, from 2017 through 2019. Swimmers with a diagnosis of SIPE and with peripheral oxygen saturation (Spo) of ≤ 95%, persistent respiratory symptoms, or both were eligible for the study. NPPV was administered on site as CPAP by facial mask or as positive expiratory pressure (PEP) by a PEP device. Discharge criteria were Spo of > 95% and clinical recovery. Four outcome measures were evaluated: Spo, crackles on pulmonary auscultation, pulmonary edema on lung ultrasound (LUS), and patient-reported respiratory symptoms.
RESULTS
Of 119 treated individuals, 94 received CPAP, 24 received treatment with a PEP device, and one required tracheal intubation. In total, 108 individuals (91%) were discharged after NPPV for a median of 10 to 20 min and 11 individuals (9%) required hospital transfer. NPPV resulted in increased Spo from a median of 91% to 97% (P < .0001) together with improvement of six patient-reported respiratory symptoms (median numerical rating scales, 1-7 to 0-1; P < .0001). No significant decrease in auscultation of crackles (93% vs 87%; P = .508) or pulmonary edema on LUS (100% vs 97%; P = .500) was seen during NPPV treatment.
INTERPRETATION
NPPV administered as CPAP or via a PEP device proved feasible and safe as prehospital treatment for SIPE with a vast majority of patients discharged on site. Spo and patient-reported respiratory symptoms reflected recovery after treatment, whereas pulmonary auscultation or LUS findings did not.
Topics: Emergency Medical Services; Humans; Pulmonary Edema; Respiratory Sounds; Swimming; Water
PubMed: 35288117
DOI: 10.1016/j.chest.2022.02.054 -
Chest Jul 2019Pulmonary edema may complicate the use of pulmonary arterial hypertension (PAH)-targeted therapies. We aimed to determine the proportion of patients who develop...
BACKGROUND
Pulmonary edema may complicate the use of pulmonary arterial hypertension (PAH)-targeted therapies. We aimed to determine the proportion of patients who develop pulmonary edema after initiation of parenteral prostacyclin therapy, to identify its risk factors, and to assess its implications for hospital length of stay and mortality.
METHODS
A retrospective cohort study of patients with PAH at the initiation of parenteral prostacyclin between 1997 and 2015 enrolled in the Cleveland Clinic PAH registry. Pulmonary edema was defined as at least one symptom or clinical sign and radiographic evidence of pulmonary edema. We determined patient characteristics predictive of pulmonary edema as well as the association between pulmonary edema and hospital length of stay (LOS) and 6-month mortality.
RESULTS
One hundred and fifty-five patients were included (median age, 51 years; female, 72%; white, 85%; idiopathic, 64%; and connective tissue disease [CTD], 23%). Pulmonary edema developed in 33 of 155 patients (21%). Independent predictors of pulmonary edema were high right atrial pressure (RAP), CTD etiology, and the presence of three or more risk factors for left heart disease (LHD). Pulmonary edema was associated with a 4.5-day increase in hospital LOS (95% CI, 1.4-7.5 days; P < .001) and a 4-fold increase in 6-month mortality (OR, 4.3; 95% CI, 1.28-14.36; P = .031).
CONCLUSIONS
Pulmonary edema occurred in 21% of patients with PAH initiated on parenteral prostacyclin. Three or more risk factors for LHD, CTD-PAH, and a high baseline RAP were independent predictors of pulmonary edema. Pulmonary edema was associated with a prolonged hospital LOS and increased 6-month mortality.
Topics: Antihypertensive Agents; Epoprostenol; Female; Humans; Infusions, Parenteral; Length of Stay; Male; Middle Aged; Pulmonary Arterial Hypertension; Pulmonary Edema; Retrospective Studies
PubMed: 30776364
DOI: 10.1016/j.chest.2019.02.005 -
JACC. Cardiovascular Imaging Apr 2022The authors hypothesized that quantitative computed tomography (QCT) imaging would reveal subclinical increases in lung congestion in patients with heart failure and...
OBJECTIVES
The authors hypothesized that quantitative computed tomography (QCT) imaging would reveal subclinical increases in lung congestion in patients with heart failure and preserved ejection fraction (HFpEF) and that this would be related to pulmonary vascular hemodynamic abnormalities.
BACKGROUND
Gross evidence of lung congestion on physical examination, laboratory tests, and radiography is typically absent among compensated ambulatory patients with HFpEF. However, pulmonary gas transfer abnormalities are commonly observed and associated with poor outcomes.
METHODS
Patients referred for invasive hemodynamic exercise testing who had undergone chest computed tomography imaging within 1 month were identified (N = 137). A novel artificial intelligence QCT algorithm was used to measure pulmonary fluid content.
RESULTS
Compared with control subjects with noncardiac dyspnea, patients with HFpEF displayed increased mean lung density (-758 HU [-793, -709 HU] vs -787 HU [-828, -747 HU]; P = 0.002) and a higher ratio of extravascular lung water to total lung volume (EVLWV/TLV) (1.25 [0.80, 1.76] vs 0.66 [0.01, 1.03]; P < 0.0001) by QCT imaging, indicating greater lung congestion. EVLWV/TLV was directly correlated with pulmonary vascular pressures at rest, with stronger correlations observed during exercise. Patients with increasing tertiles of EVLWV/TLV demonstrated higher mean pulmonary artery pressures at rest (34 ± 11 mm Hg vs 39 ± 14 mm Hg vs 45 ± 17 mm Hg; P = 0.0003) and during exercise (55 ± 17 mm Hg vs 59 ± 17 mm Hg vs 69 ± 22 mm Hg; P = 0.0003).
CONCLUSIONS
QCT imaging identifies subclinical lung congestion in HFpEF that is not clinically apparent but is related to abnormalities in pulmonary vascular hemodynamics. These data provide new insight into the long-term effects of altered hemodynamics on pulmonary structure and function in HFpEF.
Topics: Artificial Intelligence; Exercise Test; Heart Failure; Hemodynamics; Humans; Lung; Predictive Value of Tests; Pulmonary Edema; Stroke Volume
PubMed: 34801461
DOI: 10.1016/j.jcmg.2021.09.017 -
Journal of Applied Physiology... Jun 2022The spatial/temporal dynamics of blood flow in the human lung can be measured noninvasively with magnetic resonance imaging (MRI) using arterial spin labeling (ASL). We...
The spatial/temporal dynamics of blood flow in the human lung can be measured noninvasively with magnetic resonance imaging (MRI) using arterial spin labeling (ASL). We report a novel data analysis method using nonlinear prediction to identify dynamic interactions between blood flow units (image voxels), potentially providing a probe of underlying vascular control mechanisms. The approach first estimates the linear relationship (predictability) of one voxel time series with another using correlation analysis, and after removing the linear component, it estimates the nonlinear relationship with a numerical mutual information approach. Dimensionless global metrics for linear prediction () and nonlinear prediction () represent the average amplitude of fluctuations in one voxel estimated by another voxel, as a percentage of the global average voxel flow. A proof-of-principle test of this approach analyzed experimental data from a study of high-altitude pulmonary edema (HAPE), providing two groups exhibiting known differences in vascular reactivity. Subjects were mountaineers divided into HAPE-susceptible (S, = 4) and HAPE-resistant (R, = 5) groups based on prior history at high altitudes. Dynamic ASL measurements in the lung in normoxia (N, [Formula: see text] = 0.21) and hypoxia (H, [Formula: see text] = 0.13 ± 0.01) were compared. The nonlinear prediction metric decreased with hypoxia [7.4 ± 1.3 (N) vs. 6.3 ± 0.7 (H), = 0.03] and was significantly different between groups [7.4 ± 1.2 (R) vs. 6.2 ± 14.1 (S), = 0.03]. This proof-of-principle test demonstrates that this nonlinear analysis approach applied to ASL data is sensitive to physiological effects even in small subject cohorts, and it potentially can be used in a wide range of studies in health and disease in the lung and other organs. Pulmonary blood flow varies both spatially and temporally. We describe a novel technique to uncover nonlinear interactions in dynamic images of pulmonary blood flow measured using MRI, based on mutual information between the flow fluctuations in different imaging voxels. In a proof-of-principle study, we show that the proposed metric of nonlinear interactions was sufficiently sensitive to detect a difference between small cohorts of subjects susceptible to high-altitude pulmonary edema (HAPE) and subjects resistant to HAPE.
Topics: Altitude; Altitude Sickness; Disease Susceptibility; Humans; Hypertension, Pulmonary; Hypoxia; Lung; Pulmonary Edema; Spin Labels
PubMed: 35421317
DOI: 10.1152/japplphysiol.00715.2021 -
Frontiers in Immunology 2022Phosgene (COCl) gas is a chemical intermediate of high-volume production with numerous industrial applications worldwide. Due to its high toxicity, accidental exposure...
Phosgene (COCl) gas is a chemical intermediate of high-volume production with numerous industrial applications worldwide. Due to its high toxicity, accidental exposure to phosgene leads to various chemical injuries, primarily resulting in chemical-induced lung injury due to inhalation. Initially, the illness is mild and presents as coughing, chest tightness, and wheezing; however, within a few hours, symptoms progress to chronic respiratory depression, refractory pulmonary edema, dyspnea, and hypoxemia, which may contribute to acute respiratory distress syndrome or even death in severe cases. Despite rapid advances in medicine, effective treatments for phosgene-inhaled poisoning are lacking. Elucidating the pathophysiology and pathogenesis of acute inhalation toxicity caused by phosgene is necessary for the development of appropriate therapeutics. In this review, we discuss extant literature on relevant mechanisms and therapeutic strategies to highlight novel ideas for the treatment of phosgene-induced acute lung injury.
Topics: Acute Lung Injury; Humans; Lung; Phosgene; Pulmonary Edema; Respiratory Distress Syndrome
PubMed: 35983054
DOI: 10.3389/fimmu.2022.917395 -
European Review For Medical and... Aug 2023This meta-analysis was performed to evaluate the diagnostic efficacy of lung ultrasound (LUS) in cardiogenic pulmonary edema. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
This meta-analysis was performed to evaluate the diagnostic efficacy of lung ultrasound (LUS) in cardiogenic pulmonary edema.
MATERIALS AND METHODS
An electronic search of databases, including MEDLINE, Embase, PubMed, and Web of Science, was performed to collect clinical studies on ultrasound diagnosis of cardiogenic pulmonary edema from inception to 23 March 2023. The number of patients with true-positive, true-negative, false-positive, and false-negative cardiogenic pulmonary edema diagnosed by LUS was collected, and the R package was used to analyze the diagnostic efficacy of LUS.
RESULTS
Nine pieces of literature were finally included with 2,097 participants, including 1,047 patients with cardiogenic heart failure. Across the nine included papers, the pooled sensitivity of LUS in the included studies was 0.92 (95% CI: 0.84, 0.97) with a maximum sensitivity of 0.99 (95% CI: 0.96 to 1.00) and a minimum of 0.59 (95% CI: 0.50, 0.68). The pooled specificity of the included studies was 0.87 (95% CI: 0. 82, 0.91) with a maximum specificity of 0.93 (95% CI: 0.90-0.95) and a minimum of 0.80 (95% CI: 0.67, 0.89). The pooled AUC was 0.93 (95% CI: 0.84 to 0.97), suggesting a high diagnostic value of LUS in cardiogenic pulmonary edema.
CONCLUSIONS
Lung ultrasound offers a good diagnostic efficacy for cardiogenic pulmonary edema. Further standardization of the examination method is required to provide a reference for the clinical use of LUS.
Topics: Humans; Pulmonary Edema; Ultrasonography; Databases, Factual; Heart Failure; Lung
PubMed: 37606105
DOI: 10.26355/eurrev_202308_33267 -
Chest Oct 2020Despite the increasing popularity of open water swimming worldwide, swimming-induced pulmonary edema (SIPE) is a poorly recognized condition lacking established...
BACKGROUND
Despite the increasing popularity of open water swimming worldwide, swimming-induced pulmonary edema (SIPE) is a poorly recognized condition lacking established diagnostic criteria.
RESEARCH QUESTION
The aim of this study was to identify diagnostic criteria of SIPE during a large open water swimming event.
STUDY DESIGN AND METHODS
In this cross-sectional study, 17,904 individuals swam 1,000, 1,500, or 3,000 m in cold open water during Sweden's largest open water swimming event in 2018 and 2019. Of 166 swimmers seeking medical attention for acute respiratory symptoms, 160 were included in the study. Medical history, symptoms, and clinical findings were collected. On-site lung ultrasound (LUS) was performed to verify pulmonary edema.
RESULTS
Pulmonary edema was confirmed by LUS in 102 patients (64%); findings were unilateral in 11 (7%). Peripheral oxygen saturation was identified as a strong independent diagnostic test for pulmonary edema, with ≤ 95% as the suggested cut off based on receiver-operating characteristic curve analysis (area under the curve, 0.893; P < .0001). Crackles on lung auscultation, predominantly over the anterior chest, identified 88% of patients with edema. Peripheral oxygen saturation ≤ 95% or auscultation findings of crackles identified pulmonary edema with a sensitivity of 97% and a specificity of 86%. A specificity of 98% and a positive predictive value of 99% for LUS-verified pulmonary edema were reached if patients presented with both oxygen saturation ≤ 95% and auscultation of crackles.
INTERPRETATION
We suggest a clinical algorithm for diagnosis of SIPE for swimmers with acute respiratory symptoms during swimming in cold open water. Novel features of focally distributed edema in the anterior parts of the lungs, sometimes unilateral, add to this unique dataset of an underreported condition.
Topics: Adult; Cross-Sectional Studies; Female; Humans; Male; Middle Aged; Pulmonary Edema; Swimming; Ultrasonography
PubMed: 32360726
DOI: 10.1016/j.chest.2020.04.028