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Correspondence |

Phentolamine for Neurogenic Pulmonary EdemaPhentolamine for Neurogenic Pulmonary Edema: Bench to Bedside Progress FREE TO VIEW

Vijay Krishnamoorthy, MD, FCCP; Guy Weinberg, MD
Author and Funding Information

From the Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington (Dr Krishnamoorthy); and the University of Illinois at Chicago (Dr Weinberg).

Correspondence to: Vijay Krishnamoorthy, MD, FCCP, Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA 98104; e-mail: vkrish@u.washington.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(3):809. doi:10.1378/chest.12-0855
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To the Editor:

We read with interest the article by Davison et al1 in CHEST (March 2012). The authors reported rapid resolution of refractory ARDS/neurogenic pulmonary edema after IV phentolamine was administered as a last resort. We believe that, although merely a singlet, when seen within the larger context of the literature on the pulmonary effects of catechol excess, the authors’ description points to a novel treatment modality for this poorly understood disease.

The association of pulmonary edema with catecholamine excess was recognized more than a century ago by investigators who found that high-dose epinephrine reliably induced cardiopulmonary failure in various animal models of shock.2,3 Berk et al4 showed detrimental effects on pulmonary gas exchange after infusion of epinephrine in anesthetized dogs. We reported the acute deterioration of arterial oxygen tension and pulmonary gas exchange in rats within a minute of bolus epinephrine administration. Interestingly, this effect was attenuated or completely prevented by pretreatment with phentolamine.5 Although the mechanism continues to remain speculative, preliminary studies in our isolated murine lung model suggest that catecholamine-induced pulmonary edema and secondary hypoxemia result from the combination of increases in pulmonary capillary pressure and shear injury secondary to elevated cardiac output. The use of α blockade may help correct one factor of this pathophysiologic equation and, thereby, improve gas exchange. This putative explanation of our experimental observations should also apply to the clinical success of phentolamine in repairing severe neurogenic pulmonary edema.

The authors are to be commended for their excellent clinical care and particularly for their “thinking outside the box.” We add this case to the growing body of data confirming a potent, pathologic effect of catecholamine excess on pulmonary circulation. Both laboratory and clinical experience now suggest a potential clinical benefit to giving α-blockers in such situations. Clinical trials are the next step.

Davison DL, Chawla LS, Selassie L, Tevar R, Junker C, Seneff MG. Neurogenic pulmonary edema: successful treatment with IV phentolamine. Chest. 2012;141(3):793-795. [PubMed] [CrossRef]
 
Bainbridge FA, Trevan JW. Memorandum upon surgical shock and some allied conditions. BMJ. 1917;1(2934):381-383. [PubMed] [CrossRef]
 
Freeman NE, Freedman H, Miller CC. The production of shock by the prolonged continuous injection of adrenalin in unanesthetized dogs. Am J Physiol. 1940;131(3):545-553.
 
Berk JL, Hagen JF, Koo R, et al. Pulmonary insufficiency caused by epinephrine. Ann Surg. 1973;178(4):423-435. [PubMed] [CrossRef]
 
Hiller D, Krishnamoorthy V, Vogel S, Minshall R, Weinberg G. Oxygenation decrement after high-dose epinephrine. Paper presented at: Society of Critical Care Medicine Annual Meeting; January 17, 2011; San Diego, CA.
 

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References

Davison DL, Chawla LS, Selassie L, Tevar R, Junker C, Seneff MG. Neurogenic pulmonary edema: successful treatment with IV phentolamine. Chest. 2012;141(3):793-795. [PubMed] [CrossRef]
 
Bainbridge FA, Trevan JW. Memorandum upon surgical shock and some allied conditions. BMJ. 1917;1(2934):381-383. [PubMed] [CrossRef]
 
Freeman NE, Freedman H, Miller CC. The production of shock by the prolonged continuous injection of adrenalin in unanesthetized dogs. Am J Physiol. 1940;131(3):545-553.
 
Berk JL, Hagen JF, Koo R, et al. Pulmonary insufficiency caused by epinephrine. Ann Surg. 1973;178(4):423-435. [PubMed] [CrossRef]
 
Hiller D, Krishnamoorthy V, Vogel S, Minshall R, Weinberg G. Oxygenation decrement after high-dose epinephrine. Paper presented at: Society of Critical Care Medicine Annual Meeting; January 17, 2011; San Diego, CA.
 
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