Tidal volume expandability affected by flow, dynamic hyperinflation, and quasi-fixed inspiratory time in patients with COPD and healthy individuals.

Exertional dyspnea (ED) and impaired exercise performance (EP) are mainly caused by dynamic hyperinflation (DH) in chronic obstructive pulmonary disease (COPD) patients by constraining tidal volume expansion at peak exercise (VTpeak). As VTpeak is the product of inspiratory time (TIpeak) and flow (VT/TIpeak), it was hypothesized that VTpeak and VTpeak/total lung capacity (VTpeak/TLC) may be affected by TIpeak and VT/TIpeak. Hence, the study investigated the (1) effect of TIpeak and VT/TIpeak on VTpeak expansion, (2) factors associated with TIpeak, expiratory time (TEpeak), VT/TIpeak, and VTpeak/TLC, and (3) relationships between VT/TIpeak and VTpeak/TLC with ED and EP in COPD patients and controls. The study enrolled 126 male stable COPD patients and 33 sex-matched controls. At peak exercise, TIpeak was similar in all subjects (COPD versus controls, mean ± SD: 0.78 ± 0.17 s versus 0.81 ± 0.20 s, p = NS), whereas the COPD group had lower VT/TIpeak (1.71 ± 0.49 L/s versus 2.58 ± 0.69 L/s, p < .0001) and thus the COPD group had smaller VTpeak (1.31 ± 0.34 L versus 2.01 ± 0.45 L,p < .0001) and VTpeak/TLC (0.22 ± 0.06 vs 0.33 ± 0.05, p < .0001). TIpeak, TEpeak, and VT/TIpeak were mainly affected by exercise effort, whereas VTpeak/TLC was not. TEpeak, VT/TIpeak, and VTpeak/TLC were inversely changed by impaired lung function. TIpeak was not affected by lung function. Dynamic hyperinflation did not occur in the controls, however, VTpeak/TLC was strongly inversely related to DH (r = -0.79) and moderately to strongly related to lung function, ED, and EP in the COPD group. There was a slightly stronger correlation between VTpeak/TLC with ED and EP than VT/TIpeak in the COPD group (|r| = 0.55-0.56 vs 0.38-0.43). In summary, TIpeak was similar in both groups and the key to understanding how flow affects lung expansion. However, the DH volume effect was more important than the flow effect on ED and EP in the COPD group.

Effects of exertional dyspnea on early mobilization of patients with acute decompensated heart failure.

[Purpose] In this study, we investigated the association between exertional dyspnea and length of the mobilization program in patients with acute decompensated heart failure. [Participants and Methods] We recruited all consecutive patients with heart failure who were hemodynamically stabilized after administration of intravenous medication and were able to walk >10 m before admission. Exertional dyspnea was evaluated using the visual analog scale in all patients after the 10-m walk during each session of the mobilization program. Multiple regression analysis was used to determine the factors associated with length of the mobilization program. [Results] Our study included 52 patients. Multiple regression analysis showed that the length of the mobilization program was significantly associated with the visual analog scale on day 3 and the length before the start of the mobilization program; however, the length of the mobilization program showed no significant association with age and blood urea nitrogen levels. The standardized coefficients for the visual analog scale scores on day 3 and the length before the start of the mobilization program were 0.49 and 0.33, respectively. [Conclusion] Exertional dyspnea is a good predictor of the length of the mobilization program. Our findings highlight the importance of evaluation of exertional dyspnea.

[ESC guidelines 2019 on chronic coronary syndrome (CCS, previously "stable coronary artery disease") : What is new? What is particularly important?] / ESC-Leitlinie 2019 zum chronischen Koronarsyndrom (CCS, vormals "stabile KHK") : Was ist neu? Was ist besonders wichtig?

After an unusually long period of time of 6 years, in August 2019 the updated version of the European Society of Cardiology (ESC) guidelines from 2013 on the management of stable coronary artery disease was published. The course of "stable" coronary artery disease is only assumed to be stable and pathologically is often progressive but initially goes unnoticed. In order to raise awareness for the progressive character of "stable" coronary artery disease, the term chronic coronary syndrome (CCS) was introduced. In this overview the various phenotypes of CCS are divided into three groups. 1) Suspected obstructive coronary artery disease: the emphasis here is on functional, noninvasive imaging diagnostics of ischemia and cardiac computed tomography (CT). These diagnostic options have become even more important in the light of the decreasing prevalence of coronary artery disease. 2) Known obstructive coronary artery disease: here there are many new practice-relevant recommendations, particularly in the field of pharmaceutical treatment with antithrombotic drugs. 3) Microvascular disease: in symptomatic patients the exclusion of epicardial coronary stenoses using invasive coronary angiography should not signify the end of the diagnostic procedure. Functional tests in the catheter laboratory should be initiated in order not to overlook a microvascular cause of the complaints and do an injustice to the patient.

Diastolic Stress Testing Along the Heart Failure Continuum.

PURPOSE OF REVIEW: This review summarizes recent developments highlighting the clinical utility of diastolic stress testing along the heart failure continuum. RECENT FINDINGS: Invasive hemodynamic assessment of cardiac filling pressures during physiological stress is the gold-standard technique for unmasking diastolic dysfunction. Non-invasive surrogate techniques, such as Doppler ultrasound, have shown excellent agreement with invasive approaches and are now recommended by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. While cycle exercise is often advocated, recent evidence supports the use of isometric handgrip as a viable alternative stressor. Diastolic stress testing is a powerful tool to enhance detection of diastolic dysfunction, is able to differentiate between cardiac and non-cardiac pathology, and should be incorporated into routine clinical assessment.

Relief of exertional dyspnea and spinal pains by increasing the thoracic kyphosis in straight back syndrome (thoracic hypo-kyphosis) using CBP® methods: a case report with long-term follow-up.

[Purpose] To present the clinically significant improvement of straight back syndrome (SBS) in a patient with spinal pain and exertional dyspnea. [Subject and Methods] A 19 year old presented with excessive thoracic hypokyphosis and other postural deviations. A multimodal CBP® mirror image® protocol of corrective exercises, traction procedures and spine/posture adjusting were given over an initial 12-week course of intensive treatment followed by a 2.75 year follow-up with minimal supportive treatment. [Results] The patient had significant postural improvements in all postural measures and specifically a 14° increase in the thoracic kyphosis that was maintained at long-term follow-up. The postural improvements were consistent with relief of exertional dyspnea and pain, as well as increases in both antero-posterior thoracic diameter and the ratio of antero-posterior to transthoracic diameter, measurements critical to the wellbeing of patients with SBS. [Conclusion] Long-term follow-up confirmed stable improvement in physiologic thoracic kyphosis in this patient. Nonsurgical correction in thoracic hypokyphosis/SBS can be achieved by mirror image traction procedures configured to flex the thoracic spine into hyperkyphosis as well as corrective exercise and manipulation as a part of CBP technique protocols.

Atrial Myxoma in a Patient With Chronic Obstructive Pulmonary Disease (COPD): Unmasking Overlapping Symptomatology.

Atrial myxoma, though the most common primary cardiac tumor, often presents with nonspecific symptoms that can obscure its diagnosis. This case report details an unusual presentation of dyspnea on exertion (DOE) in a patient initially considered to have chronic obstructive pulmonary disease (COPD), a common pulmonary etiology of DOE. The diagnostic journey underscores the critical importance of considering atrial myxoma in patients with DOE, especially when symptoms are not fully explained by apparent pulmonary conditions. Our findings highlight the necessity of a comprehensive diagnostic approach, including the early use of resting transthoracic echocardiogram, to unveil less common causes like atrial myxoma. This case reinforces the pivotal role of considering alternative diagnoses in complex presentations of DOE, thereby guiding more accurate and tailored patient management.

Unilateral Diaphragmatic Paralysis: A Case Report of an Often Overlooked Diagnosis.

Unilateral diaphragmatic paralysis, resulting from nerve or muscle injuries, is an uncommon phenomenon often missed due to its asymptomatic nature. This condition can lead to decreased pulmonary function, particularly in patients with underlying comorbidities or cardiopulmonary issues. Identification and understanding of the underlying cause of the paralysis are essential for effective management and improved patient outcomes. Here, we present a case of a 49-year-old male who presented with left flank pain and complained of dyspnea on exertion. Further workup and a sniff test confirmed the diagnosis of left hemidiaphragm paralysis.

Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study.

BACKGROUND: Exertional dyspnea is a frequently encountered complaint in clinical practice. However, the prevalence of pulmonary embolism (PE) among patients with dyspnea on exertion has not been reported. OBJECTIVE: The objective of this study was to assess the prevalence of objectively confirmed PE among consecutive patients visiting an emergency department because of recent onset of exertional dyspnea. METHODS: Patients aged ≤75 years with recent (<1 month) marked exertional dyspnea had a systematic workup for PE, irrespective of concomitant signs or symptoms of venous thromboembolism and alternative explanations for dyspnea. PE was excluded on the basis of a low pretest clinical probability and normal age-adjusted D-dimer. All other patients had computed tomography pulmonary angiography. An interim analysis after inclusion of 400 patients would stop recruitment if the 95% confidence interval (CI) of the PE prevalence had a lower limit exceeding 20%. RESULTS: The study was prematurely terminated after the inclusion of 417 patients. In 134 patients (32.1%), PE was excluded based on low clinical probability and normal D-dimer. PE was found in 134 (47.3%) of the remaining 283 patients, for an overall prevalence of 32.1% (95% CI, 27.8-36.8). PE was present in 40 of 204 (19.6%) patients without other findings suspicious for PE and in 94 of 213 patients (44.1%) with such findings. PE involved a main pulmonary artery in 37% and multiple lobes in 87% of the patients. CONCLUSION: The angiographic demonstration of PE is common in patients presenting with recent onset of marked exertional dyspnea, including 20% without other findings suggesting pulmonary embolism.

Relationship between depression severity and respiratory symptoms in US adults: A national cross-sectional study.

OBJECTIVE: The relationship between depression severity and cough, wheeze and exertional dyspnoea is unclear. The aim of this study was to explore this relationship. METHODS: We used weighted logistic regression analysis and fitted curves to explore the relationship between depression severity and respiratory symptoms. In addition, we examined the relationship between depression and COPD and asthma. Stratified analyses were used to analyse specific populations. RESULTS: We weighted 10,142 subjects to reflect the entire US population. Using the population without depression as a reference, the risk of cough and asthma in the severely depressed population was 3.32 times (OR 3.324, 95% CI 1.567-7.050) and 2.84 times (OR 2.842, 95% CI 1.521-5.311) higher than that in the population without depressive symptoms, and the risk of asthma and COPD was 2.4 times and 2.6 times (OR 2.410, 95% CI 1.371-4.236; OR 2.566, 95% CI 1.236-4.921). In subgroup analyses, the correlation between depression scores and prevalence of cough and wheeze was corrected for gender level. In addition, smoking status and marital status were interaction factors between depression score and prevalence of cough. The prevalence of exertional dyspnoea by depression score was influenced by CVD. CONCLUSIONS: Depression severity was associated with respiratory symptoms, asthma, and COPD. Gender corrected the correlation between depression and cough and asthma, and depressive state was an independent risk factor for asthma and COPD. This finding provides new ideas for the management of respiratory symptoms and diseases.

The Clinical Utility of Continuous Laryngoscopy During Exercise: A Report of Two Cases.

Exertional dyspnea is a common and disabling symptom in otherwise healthy children and adolescents, as well as in children with baseline airway abnormalities. It impairs the quality of life and may be associated with fatigue and underperformance in sports. Exertional dyspnea can be caused by a wide variety of structural and psychogenic causes. Exercise-induced laryngeal obstruction (EILO) is a relatively prevalent entity in young people that usually presents with exertional stridor, coughing, and dyspnea caused by transient closure of the larynx. In more complex cases where conventional tests such as pulmonary function tests (PFTs), chest imaging, ECG, and echocardiography are unrevealing, continuous laryngoscopy during exercise (CLE) tests may provide diagnostic utility. In addition to the baseline abnormalities visualized by conventional laryngoscopy, CLE can assess dynamic laryngeal responses during exercise. This article describes the clinical characteristics of two pediatric patients with various degrees of laryngeal dysfunction at baseline and the utility of CLE testing in tailoring management strategies.

Functional Capacity in Patients Who Recovered from Mild COVID-19 with Exertional Dyspnea.

BACKGROUND: Post mild COVID-19 dyspnea is poorly understood. We assessed physiologic limitations in these patients. METHODS: Patients with post mild COVID-19 dyspnea (group A) were compared (pulmonary function tests, 6-min walk test (6MWT), echocardiography and cardiopulmonary exercise test (CPET)) to post moderate/severe COVID-19 (group B) and to CPET and spirometry of patients with unexplained dyspnea (group C). RESULTS: The study included 36 patients (13 in A, 9 in B and 14 in C). Diffusion capacity was lower in group B compared to group A (64 ± 8 vs. 85 ± 9% predicted, p = 0.014). 6MWT was normal and similar in both patient groups. Oxygen uptake was higher in group A compared to groups B and C (108 ± 14 vs. 92 ± 13 and 91 ± 23% predicted, p = 0.013, 0.03, respectively). O2 pulse was normal in all three groups but significantly higher in the mild group compared to the control group. Breathing reserve was low/borderline in 2/13 patients in the mild group, 2/9 in the moderate/severe group and 3/14 in the control group (NS). CONCLUSIONS: Patients with post mild COVID-19 dyspnea had normal CPET, similar to patients with unexplained dyspnea. Other mechanisms should be investigated and the added value of CPET to patients with post mild COVID-19 dyspnea is questionable.

Baseline Spirometry as a Predictor of Positive Methacholine Challenge Testing for Exertional Dyspnea.

BACKGROUND: There are several tests recommended by the American Thoracic Society (ATS) to evaluate for airway hyper-responsiveness (AHR), one of which is methacholine challenge testing (MCT). Few studies have examined the correlation of baseline spirometry to predict AHR in MCT, especially in the younger, relatively healthy military population under clinical evaluation for symptoms of exertional dyspnea. The study aim was to retrospectively correlate baseline spirometry values with MCT responsiveness. METHODS: This study is a retrospective review of all MCT performed at Brooke Army Medical Center/Wilford Hall Medical Center over a 12-y period; all completed studies were obtained from electronic databases. The following parameters were analyzed from the studies: baseline FEV1, FVC, FEV1/FVC, mid-expiratory flow (FEV25-75%), FEV25-75%/FVC. Studies were categorized based on baseline obstruction, restriction, FEF25-75% lower limit of normal, and response to bronchodilator testing (if completed); these values were compared based on methacholine reactivity and severity. RESULTS: Methacholine challenge studies (n = 1,933) were reviewed and categorized into reactive (n = 577) and nonreactive (n = 1,356) as determined by ATS guidelines. The mean baseline FEV1 (% predicted) with MCT reactivity was 88.0 ± 13.0% versus no MCT reactivity was 92.7 ± 13.0% (P < .001). The mean baseline FVC (% predicted) was 93.1 ± 13.7% versus 95.3 ± 13.5% (P < .001). The mean baseline FEV25-75% (% predicted) was 80.0 ± 22.1% versus 89.0 ± 23.4% (P < .001). Based on partition analysis, methacholine reactivity was most prevalent with baseline obstruction, n = 115 (43%), and in the absence of obstruction, when the FEF25-75% (% predicted) was below 0.70, n = 111 (40%). The negative predictive value with normal spirometry was 73%. CONCLUSIONS: The analysis of baseline spirometry prior to MCT proved useful in the evaluation of exertional dyspnea in a military population. The presence of airways obstruction (FEV1/FVC < lower limit of the normal range) followed by a reduction in FEV25-75% < 70% predicted showed a positive correlation with underlying AHR. In patients with exertional dyspnea and normal baseline spirometry, the use of the FEF25-75% may be a useful surrogate measurement to predict reactivity during MCT and consideration for additional testing or treatment.

Case report: Pulmonary arterial hypertension in ENG-related hereditary hemorrhagic telangiectasia.

A young adult woman presented with exertional dyspnea and she had had recurrent epistaxis for more than 10 years. On physical examination, cyanosis was noted on the lips, and telangiectasias were seen on the oral mucosa and fingertips. Routine investigations revealed iron deficiency anemia and slightly elevated bilirubin. The result of right heart catheterization was indicative of pulmonary arterial hypertension (PAH). Pulmonary angiography showed arteriovenous malformations of the left upper pulmonary artery, and anterior cerebral artery malformation was seen in cranial computed tomographic angiogram. Genetic testing revealed that she and her three daughters carried heterozygous variant of ENG c.1195-1196del p.Arg399GlyfsTer2, which is characterized by pulmonary and cerebral arteriovenous malformations. In addition, our patient had pulmonary hypertension (PH) that is commonly associated with ACVRL1 mutations, revealing her phenotype was not consistent with isolated ENG genetic mutations. Here, we report a case with hereditary hemorrhagic telangiectasia (HHT) combined with PAH, which is associated with interesting differential diagnosis and etiological analysis. We have discussed the relationship between PH and HHT and the characteristics of PAH in HHT patients.

Atrial Septal Aneurysm: An Incidental Finding or a Clinically Significant Anomaly?

Atrial septal aneurysm (ASA) is a condition involving the bulging of the interatrial septum into one or both of the atrial chambers. We present the case of an ASA found on transesophageal echocardiogram in a patient who presented with exertional dyspnea. This case report aims to highlight the growing clinical association of ASA with arterial embolism through various mechanisms and emphasize the unknown aspects of clinical management for such patients. While there are currently no clear recommendations on whether to start anticoagulation after an ASA is diagnosed, many suggest a careful patient-centered approach for such decisions due to the reported increased risk of thromboembolic events. Further studies regarding the significance of ASA and cardioembolic events are needed.

Brugada Syndrome Misdiagnosed As Acute Myocardial Infarction: A Case Report.

Brugada syndrome (BrS) is an autosomal-dominant condition mainly caused by defects in sodium channels causing ST-segment elevation in electrocardiograms (ECGs) in the V1 and V2 precordial leads, with ventricular tachyarrhythmias due to premature ventricular contractions, which increases the risk of sudden cardiac death. BrS usually presents in adulthood, with an average age of presentation of 41 years. In this article, we describe a case of BrS diagnosed in a 36-year-old male having sudden cardiac arrest with no comorbidities such as hypertension, diabetes mellitus, smoking, or any valvular disease history. We then explain the ECG-based diagnosis, signs and symptoms, presentation at the emergency department, and treatment options.

Partial anomalous pulmonary venous return with secundum atrial septal defect: A case report.

Partial anomalous pulmonary venous return (PAPVR) is a congenital heart anomaly in which some of the pulmonary veins return to the right atrium or one of its supplying veins instead of normally connecting with the left atrium. Oftentimes it is concurrent with a secundum atrial septal defect. PAPVR is typically asymptomatic, however symptoms of pulmonary hypertension can arise at higher degrees of left-to-right shunting. An 80-year-old male presented with exertional dyspnea and was found to have a secundum atrial septal defect on echocardiogram. A subsequent contrast enhanced computed tomography of the chest revealed a concomitant PAPVR.

Prognostic Value of the MAGGIC Score, H2FPEF Score, and HFA-PEFF Algorithm in Patients with Exertional Dyspnea and the Incremental Value of Exercise Echocardiography.

BACKGROUND: The strategies for improving outcomes in heart failure with preserved ejection fraction (HFpEF) are insufficiently defined, which affects optimal patient management. The aim of the study was to compare the prognostic value of the previously validated Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score with 2 approaches primarily dedicated to diagnosing HFpEF: the H2FPEF score (heavy, 2 or more hypertensive drugs, atrial fibrillation, pulmonary hypertension [pulmonary artery systolic pressure >35 mm Hg], elder age >60, elevated filling pressures [E/e' > 9]) and the HFA-PEFF algorithm (Heart Failure Association diagnostic algorithm-pretest assessment; echocardiography and natriuretic peptide score; functional testing; final etiology) in patients with exertional dyspnea categorized as HFpEF. METHODS: Clinical and biochemical variables and echocardiographic resting and exercise data from 201 enrollees were retrospectively analyzed. Participants were followed for 48 (24-60) months for HF hospitalization and cardiovascular death. RESULTS: Seventy-four patients (36.8%) met the study outcome. In sequential Cox analysis, the addition of MAGGIC risk score, H2FPEF score, and HFA-PEFF step 2 (including only resting echocardiographic evaluation) and step 3 (including also exercise diastolic data) algorithms to the base model comprising brain natriuretic peptide and peak oxygen uptake improved the predictive power for the study endpoint. Harrell's c statistic showed a greater predictive ability for the HFA-PEFF step 3 algorithm than for each of the other scores (c index 0.715 vs 0.637, 0.644, and 0.638 for MAGGIC, H2FPEF, and HFA-PEFF step 2, respectively; all P < .05). No significant differences were found for other between-score comparisons. CONCLUSION: In patients with exertional dyspnea and a possible HFpEF, the H2FPEF score and HFA-PEFF algorithm limited to resting echocardiography provide prognostic value comparable to the MAGGIC risk score. Extending the HFA-PEFF algorithm with exercise diastolic data is associated with a significant improvement in risk stratification.

A Case of Chronic Aspiration Bronchiolitis.

Chronic aspiration bronchiolitis or diffuse aspiration bronchiolitis is a rare disease characterized by chronic inflammation of the bronchioles due to recurrent aspiration of foreign material. To date, there are limited data on chronic aspiration bronchiolitis because it is often present subclinically or remains undiscovered until autopsy. Additionally, time to diagnosis is often prolonged and includes invasive workup prior to definitive diagnosis. Here, we present a case of lung disease attributed to chronic aspiration after a thorough workup resulted in histopathology consistent with a primary diagnosis of aspiration bronchiolitis. Radiographic and pathologic specimens also demonstrated features of usual interstitial pneumonia adding to the complexity of pathology that can be seen with aspiration diseases.

One minute sit-to-stand test as a potential triage marker in COVID-19 patients: A pilot observational study.

Background: The crisis of critical care resource allocation during the novel coronavirus infectious disease 2019 (COVID-19) pandemic has underscored the importance of triage. COVID-19 is associated with increased hypoxemia and desaturation on exertion. We hypothesized that desaturation after 1-min sit-to-stand test (1MSTS), a validated field exercise test can serve as a potential marker for triage of COVID 19 patients. Methods: Subjects with proven COVID 19 without hypoxemia on ambient air at presentation underwent the 1MSTS. The demographic details, clinical profile, pre and post-test vitals and pulse oximetric saturation was recorded and they were followed up for outcome throughout the hospital stay and after discharge. Results: 55 mild cases of COVID-19 and 6 cases of recovering severe COVID-19 were included. The mild cohort had a median age of 35 years (IQR, 27-41.5) and a median hospital stay of 16 days (IQR 14,20). The severe cohort had a median age of 47.5 years (IQR, 42.3,54.3) and median intensive care and hospital stays of respectively 9 (IQR, 7.5,9) and 23.5 (IQR, 21.5,27) days. The two cohorts showed median desaturations of 0% (IQR, 0.5-1) and 5.5% (IQR, 4.3-6) respectively. No subjects in the mild cohort needed oxygen therapy or escalation of care to intensive care. Conclusions: Significant desaturation after 1-MSTSin severe COVID 19 patients demonstrates the potential role of 1-MSTS both in triage for planning care and as a discharge criteria from intensive care unit. However, larger prospective studies are warranted for its evaluation and establishment of relevant cut-offs.

Yellow Nail Syndrome Successfully Treated with Oral Terbinafine and Topical Minoxidil.

Yellow nail syndrome (YNS) is a rare disease of unknown etiology that is characterized by varying degrees of pulmonary manifestations, lymphedema, and yellow discoloration of the nails. Herein, we report the efficacy of oral terbinafine and topical minoxidil in treating the associated nail abnormalities of YNS in a 66-year-old woman. The patient presented with yellow, brittle, slow-growing nails, which had developed progressively over the past 8 months; left ankle edema; a chronic, purulent, productive cough; and exertional dyspnea. Based on these symptoms, she was diagnosed with YNS. She failed to respond to treatment with fluconazole and vitamin E; however, she was successfully treated with oral terbinafine and topical minoxidil. The treatment was well tolerated, and we speculate that its mode of action includes promoting lymphatic formation and barrier enhancement, thereby improving the distal lymphedema, in addition to distal vasodilation that accelerates the nail growth. To our knowledge, this is the first report of successful treatment of YNS using these agents.