Thorax: first published as 10.1136/thx.26.1.39 on 1 January 1971. Downloaded from Thorax (1971), 26, 39. Right heart pressures in bronchial asthma R. F. GUNSTONE St. George's Hospital, London S.W.1 Right heart pressures, electrocardiograms, blood gases, and peak expiratory flow rates were measured in nine patients admitted to hospital with severe bronchial asthma. Low or normal right heart pressures were found despite electrocardiographic changes in five patients consisting of right atrial P waves, abnormal right axis deviation, and in one patient T-wave changes in pre- cordial leads. These electrocardiographic changes reverted towards normal on recovery of the patient from the asthmatic attack. Electrocardiographic changes suggestive of right The procedure was carried out in the general ward heart embarrassment have been noted in acute with the patient in the sitting position supported at 60 bronchial asthma, particularly right atrial P waves to 90 degrees to the horizontal because orthopnoea (P and abnormal right axis deviation was always present. Immediately after catheterization pulmonale) the peak expiratory flow rate was measured with a (Harkavy and Romanoff, 1942; Miyamato, Wright peak flow meter (Wright and McKerrow, Bastaroli, and Hoffman, 1961; Ambiavagar, 1959) and blood (capillary or arterial) was taken for Jones and Roberts, 1967). These observations measurement of pH, Pco2, and standard bicarbonate raise the possibility that death in bronchial asthma by the Astrup method (Astrup, J0rgensen, Andersen, may be due to acute cor pulmonale although and Engel, 1960). The peak flow rate and electro- copyright. necropsy evidence is against this suggestion (Earle, cardiogram were repeated after recovery. One patient 1953; Houston, de Navasquez, and Trounce, (No. 5) was re-catheterized when she had recovered 1953). Cardiac catheter studies in asthmatics have from her asthma. with few exceptions been made during remission Cardiac catheterization was carried out with a miniature disposable cardiac catheter (Portland of symptoms. http://thorax.bmj.com/ a miniature cardiac cathe- Plastics Ltd.) inserted through a disposable Guest can- In the present study nula (Capon Heaton Ltd.). The cannula was intro- terization technique (Bradley, 1964) has been used duced percutaneously into a median antecubital vein to measure right heart pressures during acute under local anaesthesia. Right ventricular and/or pul- attacks of asthma in an attempt to determine the monary artery pressures were measured with an significance of the electrocardiographic changes. electromanometer and recorded together with a con- The results have been assessed in relation to the tinuous electrocardiogram on a direct-writing Elema blood gases and peak expiratory flow rates. All Schonander Minograf 34 Recorder (Siriex Ltd.). The the patients had asthma (as defined by the Ciba sternomanubrial junction was used as the zero refer- Guest Symposium, 1959), some had additional ence point. on September 30, 2021 by guest. Protected chronic bronchitis (as defined by the Medical RESULTS Research Council, 1965), and all had been ad- mitted to hospital because of the severity of Low or normal right heart pressures were recor- dyspnoea. ded in all patients. The pressures fell even further on inspiration by as much as 20 mmHg in the METHODS acute phase. These observations are illustrated in Figures IB, 2B, and 3. Figure 3 also shows the An attempt was made by clinical examination, chest prolonged expiration typical of bronchial asthma. radiographs, and electrocardiograms to exclude Detailed results are given in the Table which cardiopulmonary disease other than bronchial the nature of the asthma (with or without bronchitis). Patients received emphasizes reversible airways conventional treatment and the investigation was per- obstruction and describes the electrocardiograms. formed as soon as possible after admission and after Electrocardiographic abnormalities were present a full explanation and request for co-operation. No in five of the nine patients but were not asso- patient under 21 years of age or with important ciated with higher right heart pressures than in psychogenic factors was asked to participate. the other four. Right atrial P waves and right 39 Thorax: first published as 10.1136/thx.26.1.39 on 1 January 1971. Downloaded from 40 R. F. Gunstone +70 I I +60 +50 I I I I I +40 F I I I I I +30 I E. I I E I E Itt- +ZO I II I I I +10 1, : I I I: lll jl 1, 0 I ~~~~~~~~~~~~~~~~~~~Ia b ' I I; 3 4 5 5a 8 -10 supine expiration - - -- upright I - Inspiration -20 A B FIG. 1. Right ventricular pressures: A, Effect of posture copyright. (Donald et al. 1953) on (a) two normal subjects; (b) two patients with pulmonary hypertension. B, In four seated patients with acute bronchial asthma and one (5a) on recovery. --50 http://thorax.bmj.com/ - expiration +40 ---* inspiration +30 I. +20 I I' I I ~~~~II I I on September 30, 2021 by guest. Protected E +10 £ a. I abc c ~~~~~~~~~~~~aII i 0 b c c I I I I I -10 I - supine -20 - --- upright 1 2 5 5a 6 7 8 9 - -301 ~~~ABI FIG. 2. Pulmonary artery pressure: A, Effect ofposture on (a) two normal subjects (Donald et al. 1953); (b) one normal subject (Lagerlof et al. 1951); (c) two patients with pulmonary hypertension (Donald et al. 1953). B, in seven seated patients with acute bronchial asthma and one (5a) on recovery. Thorax: first published as 10.1136/thx.26.1.39 on 1 January 1971. Downloaded from Right heart pressures in bronchial asthma 41 lmV] III +10 E E -10- (a) IIN +25 copyright. E -25 http://thorax.bmj.com/ (b) 1mV] [II on September 30, 2021 by guest. Protected +20- 3: 0 E E 20- (C) FIG. 3. (a) Right ventricular pressure tracing and electrocardiogram-patient 3. (b) Pulmonary artery pressure tracing and electrocardiogram-patient 2. (c) Pulmonary artery pressure tracing and electrocardiogram-patient 9. Note the inspiratory fall of pressure lasting a much shorter time than the expiratory rise. Thorax: first published as 10.1136/thx.26.1.39 on 1 January 1971. Downloaded from 42 R. F. Gunstone 0 lz 0>~~~ 0 00 °4 c: 0 o 0 .0 0 CUC z 00 eq 0on ooe-0 ec S) W0 as00 0 0c0 CL CU; 0~ I_ IN V) I~ _ 1I i^ > CL P4 .~~- o fr.Y 00 0E 00o 0t o _ 0 lx.c o o o Se r>se - E copyright. 1- ___)0 __ ____ _j _0 Ooo2 m 0 c P.W.0& Cd http://thorax.bmj.com/ o0 Cv U 320 ..0.t Ub . m 0 e > _ PL ,It tm 'I O,m'tI cd _ W000 -t e0o -0 a " ,It qt m m lq r-: IU: eneCn %n I O on September 30, 2021 by guest. Protected _Yao. +O+± ++ I++ + 0. LCA l .2-C.II .E1 0 o ot b ___0c~< _ __t N_ ooo~L ooL ooooilL o o F wo n _-e'C f> -e_ or-ooo ~oe- u,oC)oo oo ooo x- PATIENT 3 ECG 1 ECG 2 Thorax: first published as 10.1136/thx.26.1.39 on 1 January 1971. Downloaded from -L I II 1 mV III (a) aVR I aVL VI V2 V3 /V4 Vs ~~Vb II aVF m copyright. PATIENT 4 ECG I I mV (b) http://thorax.bmj.com/ aVR I aVL Vi V1 \V2 V3 V4 V5. Vb on September 30, 2021 by guest. Protected II aVF III PATIENT4 ECG 2 l1 mVjl (c) FIG. 4. Legend on page 44. Thorax: first published as 10.1136/thx.26.1.39 on 1 January 1971. Downloaded from 44 R. F. Glnstone discussed later. Pressure measurements made from VI the sternomanubrial junction as the zero reference V2 point are about 4 mmHg lower than those using the mid right atrium. However, even if this figure II is added, the highest pressure recorded was only 31/8 mmHg. III V3 Most cardiac catheterizations are carried out on supine subjects, whereas in this study the asth- GVR matics could not lie flat. The effect of posture on right heart pressures has been studied by Donald, aVL Bishop, Cumming, and Wade (1953) and by V4 Lagerlof, Eliasch, Werko, and Berglund (1951) (Figs la and 2a): on sitting up from the supine VS aVF .~~~~ position the pulse pressure fell in all patients stu- PATIENT 7 Vb died, but in patients with pulmonary hypertension ECG the systolic and diastolic pressures both fell. It is an open question, therefore, whether the pressures in the present series would be higher had the patients been flat, as they were in the studies now I VI to be discussed. V2 Williams and Zohman (1960) and Irnell (1964) II noted moderate pulmonary hypertension on exer- cise in some but not all of the asthmatic patients and Helander, III they studied. Zimmerman (1951) V3 Lindell, Soderholm, and Westling (1962) noted a rise in pulmonary artery pressure in half of theircopyright. aVR patients in whom asthmatic attacks had been arti- ficially induced. These patients were studied in the -PI -I V4 aVL supine position; patients in whom bronchocon- striction is artificially induced may be distressed aVF AV--| V5 by the need to remain flat and this could con-http://thorax.bmj.com/ V6 tribute to the rise in pulmonary artery pressure. PATIENT 7 Harris and Heath (1962a) state that the pulmonary ECG 2 circulation, like the systemic circulation, is influ- enced by emotional factors. 1 mVJL All the 14 patients studied by Helander et al. showed systemic arterial desaturation, only two (d) having an oxygen saturation of more than 92°% asthmatic et al. FIG. 4. Selected electrocardiograms of patients. during the induced attack.