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Orthopnea and Inspiratory Effort in Chronic Heart Failure Patients

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Orthopnea and Inspiratory Effort in Chronic Heart Failure Patients CORE Metadata, citation and similar papers at core.ac.uk Provided by ElsevierVol. - Publisher97 (2003) Connector 647^653 Orthopnea and inspiratory e¡ort in chronic heart failure patients w z S. NAVA*,M.TERESA LAROVERE ,F.FANFULLA ,P.NAVALESI*,M.DELMASTRO* w AND A. MORTARA w *Respiratory Intensive Care Unit, Fondazione S.Maugeri, Istituto Scienti¢co di Pavia, Italy Cardiology Department, Fondazione S.Maugeri Istituto Scienti¢co di Montescano, Italy, zRespiratoryDepartmentFondazioneS.Maugeri Istituto Scienti¢co di Montescano, Italy Abstract Study objective: Orthopnea is a typical feature of patients with chronic heart failure (CHF), the factors con- tributing to it are not completely understood.We investigated changes in dyspnea and other respiratory variables, in- duced by altering posture (from sitting to supine) in 11 CHF patients (NYHA classes II^IV) and 10 control subjects. Methods and Results: We measured dyspnea (Borg scale), the diaphragm pressure time product per minute (PTPdi/m, index of metabolic consumption), and mechanical properties ofthe lung (lung compliance (C,L) and resistances (R,L).CHF patients also underwent a trial of non-invasive mechanicalventilation (NIMV) inthe supine positionin order to ascertain whether unloading theinspiratorymuscles could somehowrelieve dyspnea.While sitting the PTPdi/minwas significantly higher in CHF patients than in controls (181754 cm H2O Â s/min vs.96732; Po0.05). Assuming a supine position caused no major changes in controls, whereas CHF patients showed a significant worsening in dyspnea, a rise in PTPdi/ min (243797 po0.01) and R,L (4.7 71.2 cm H2O/L Â ssittingvs.7.972.5 supine; Po0.01) and a decrease in C,L (0.0870.02 L/cm H2Osittingvs. 0.07+0.01supine; Po0.05). Applying NIMV to supine CHF patients significantly reduced the PTPdi/min to 81742 (Po0.001).Changes in dyspnea, produced by varying position or applying NIMV, were signifi- cantly correlated with PTPdi/min (r=0.80, Po0.005 and r=0.58, Po0.01, respectively). Conclusions: CHF patients had a higher PTPdi/min than controls when sitting, and assuming a supine position induced severe dyspnea, a large rise in R,L,andareductioninC,L so that PTPdi/min increased further.Orthopnea was strongly correlated with the increased diaphragmatic effort. r 2003 Elsevier Science Ltd. Allrightsreserved. doi:10.1053/rmed.2003.1495, available online at http://www.sciencedirect.com Keywords CHF; dyspnea; diaphragm; inspiratory muscle; non-invasive ventilation. INTRODUCTION return might also reduce lung compliance by increasing pulmonary hydrostatic pressure and causing interstitial Orthopnea is a common feature in patients with chronic edema (3^5). Both increased air£ow resistance and de- heart failure (CHF). Surprisingly, however, little is known creased lung compliance may lead to greater energy ex- about the mechanisms underlying this symptom. A re- penditure by the diaphragm and other respiratory cent study has shown that air£ow resistance, as assessed muscles, an event which has been shown to be linked to by the oscillation technique, increases signi¢cantly in the genesis of dyspnea (6). Indeed, regardless of the spe- CHF patients, but not in normal subjects, when they as- ci¢c cause, a sudden increase in respiratory impedance sume a supine position (1). In another study, performed provoked by lying down should produce, together with on patients with acute heart failure, Duguet et al.(2)de- an abrupt rise in inspiratory e¡ort, the onset of orthop- monstrated a relationship between expiratory £ow lim- nea (2). In order to evaluate this hypothesis we measured itation and orthopnea, exaggerated by changing posture lung mechanics, inspiratory muscle e¡ort, and sensation from sitting to supine.Whether or not this mechanism is of dyspnea in the sitting and supine position in 11stable also responsible for orthopnea in stable CHF is not CHF patients and compared these results with those ob- known. Indeed, in CHF patients, increased blood venous tained in a control group of normal subjects. Further- more, we applied inspiratory pressure support plus Recieved10 June 2002, accepted on revised form11November 2002 continuous positive airway pressure to the supine CHF Correspondence should be addressed to: Stefano Nava, MD, patients to verify whether unloading the inspiratory Respiratory Intensive Care Unit, Fondazione S.Maugeri, Istituto Scienti¢co di Pavia,Via Ferrata 8, 27100 Pavia, Italy. muscles was somehow associated with a relief of dys- Fax: 0382 592 075; E-mail: [email protected] pnea. 648 RESPIRATORY MEDICINE MATERIAL AND METHODS sured using the balloon-catheter technique (7). Pressure at the airway opening (Paw) was measured via a side Subjects port. Eleven in-patients with stable CHF with no history of Respiratory mechanics were assessed using Mead and neurological or chronic respiratory disease were re- Wittenberger’s technique (8). Inspiratory pulmonary re- cruited.Two patients were in New York Heart Associa- sistance (R,L)andelastance(E,L) were calculated by ¢tting tion functional class II, seven in class III and two in class IV. the equation of motion of a single-compartment model All of them were receiving diuretics and ACE-inhibitor using multilinear regression. drugs,whichwerecontinuedonthedayofthestudy. Dynamic PEEPi (PEEPi,dyn) was measured according They were in a phase of clinical stability and were ad- to Appendini et al.(9).The pressure time integrals of the mitted to the hospital for a medical control and even- diaphragm and the other inspiratory muscles were calcu- tually for a short period of rehabilitation. Patients with lated per breath (PTPdi/b and PTPes/b, respectively) and X-ray evidence of pulmonary edema or congestion were per minute (PTPdi/min and PTPes/min) (10). excluded from the study.Data from a control group of10 Relative changes in lung volumes were recorded by matched subjects were used for comparison. Spiro- means of inductive plethysmography. A rib cage band metric and hemodynamic data on patients and controls was placed at the level of the axilla and an abdominal are shown inTable1.Written consent was obtained from one was positioned just above the umbilicus. Calibration all subjects, and the protocol was approved by the Fon- was performed with the isovolume maneuver (11). dazione Maugeri Ethics Committee. Subjective ratings of dyspnea were made during the various trials using Borg’s scale. Arterial blood gases (BG) were measured in samples ta- Measurements ken from the radial artery (ABL 550 Radiometer,Copen- hagen, Denmark). Static and dynamic lung volumes were assessed The above-mentioned variables, excluding arterial bybody plethysmography (MasterLab-Jaeger,Hochberg, blood gases and body plethysmography, were recorded Germany). in the CHF patients and control subjects both in sitting Flow was measured with a pneumotachograph and supine positions after15min of spontaneous breath- (Screenmate Box 0586, Jaeger GmbH, Hochberg, Ger- ing, unless there was the onset of severe (Borg scale46) many), connected to a rigid mouthpiece. dyspnea, so that the measurements were recorded once Airway pressure was measured through tubing in- reached that dyspnea value. At the end of this part of the serted in the mouthpiece and connected to a di¡erential study, the CHF patients were administered non-invasive pressure transducer (Honeywell7300 cm H2O, Free- mechanical ventilation (NIMV) through a nose mask for port, IL, U.S.A.). VT was obtained by integration of the 20 min while they were in a supine position. The follow- £ow signal.The inspiratory (TI), expiratory (TE)andtotal ing pressures were used: 10cm H2O of inspiratory aid breathing cycle (TTOT ) duration, respiratory frequency and 5 cm H2O of expiratory-positive airway pressure. (RR), and duty cycle (TI/TTOT ) were calculated as average ECG, SaO2 and end-tidal CO2 (ETCO2)weremonitored values of10 consecutive breaths, after 5 min of breathing. continuously. Baseline frompeakchangesin esophageal (Pes), gastric All signals were collected using a personal computer (Pga), and transdiaphragmatic (Pdi) pressures were mea- equipped with an A/D board, and stored at a sampling rate of100 Hz.The mean value of each physiological vari- able during the 5 min of recording was used for analyses. Results are presented as mean+standard deviation (SD). TABLE 1. Patients’characteristicsinthe two groups Di¡erences between physiological parameters recorded Variables CHF patients Control subjects in sitting and supine positions were analysed by paired Student’s t-test, both for CHF patients and normal sub- Age (year) 57.078.4 51.6711.5 jects. Di¡erences between patients and controls were 7 7 BMI 22.1 3.5 24.9 6.4 analysed using unpaired Student’s t-test. Pearson’s coe⁄- 7 7 FEV1(% pred) 84.1 16.8 98.6 2.5 cient was calculated to assess correlation between vari- FVC (% pred) 89.7716.6 99.472.9 ables. A P value 0.05 was chosen as the threshold of FEV1/FVC 76.679.17 9. 5 73.8 o TLC (% pred) 92.5712.3 101.575.2 statistical signi¢cance. FRC (% pred) 89.277.0 9 7.7 77. 3 LVEF (%) 22.679.4 N A Wedge pressure (mm Hg) 21.376.6 NA RESULTS BMI, body mass index; LVEF,left ventricular ejection fraction. The participants completed the protocols without di⁄culty except one patient who was able to tolerate ORTHOPNEA AND INSPIRATORY EFFORT 649 the supine position for only 2 min. Data from that crease. NIMV, applied only to the CHF patients, particular trial were, therefore, discarded from analysis. signi¢cantly reduced the energy expenditure of the dia- phragm and the other inspiratory muscles. Figure1
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