Allergy and Airway |

Out of Proportion Pulmonary Hypertension Secondary to Chronic Obstructive Pulmonary Disease Reversed With ICS LABA Treatment FREE TO VIEW

Reinalyn Cartago, MD; Lenora Fernandez, MD
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University of the Philippines - Philippine General Hospital, Metro Manila, Philippines

Chest. 2013;144(4_MeetingAbstracts):39A. doi:10.1378/chest.1700364
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SESSION TITLE: Airway Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary hypertension (PH) in COPD shows mild to moderate elevation in pulmonary artery pressure (PAP). However, a small subgroup of may present with “out of proportion” PH. We report a case of severe PH secondary to COPD, with PAP returning to near normal values after Inhaled Corticosteroid/Long Acting B-agonist (ICS/LABA) treatment.

CASE PRESENTATION: RO is a 36yo male miner/fisherman originally from Surigao - consulted our clinic due to hemoptysis. There was history of pulmonary tuberculosis; he was a previous 60 pack year smoker. Symptoms of exertional dyspnea, pleuritic chest pain and palpitations started 15 months prior to consult. During this time there was also note of icteric sclerae. Expectoration of pink frothy sputum was noted about thirteen months prior to consult. Initial 2D Echocardiography (2DE) revealed ejection fraction (EF) of 84; PAP 42mmHg; dilated right ventricle (RV), right atrium (RA), main pulmonary artery, severe PH; TEE confirmed PH, no congenital heart defect noted. Patient had stable vital signs, BMI 22.96kg/m2; room air SaO2 90%; unremarkable pulmonary and cardiac findings; no edema, cyanosis nor clubbing. Spirometry revealed moderate obstructive ventilatory defect (FEV1 59% predicted), no significant bronchodilator response; baseline 6-minute walk test (6MWT) 395 m. Rectal imprint negative for schistosoma eggs. At this point, COPD as the possible etiology of PH was confirmed. Three months post-treatment with ICS/LABA, there was noted improved symptoms; repeat 6MWT increased to 498.5 m; repeat 2DE after 6 months - EF 86; PAP of 21.62mmHg.

DISCUSSION: A small subgroup of COPD patients (<5%) have “out-of-proportion” PH - defined by PAP >35 - 40 mmHg and mild to moderate airflow limitation. Doppler echocardiography is best to screen PH; with right heart catheterization (RHC) as the gold standard. However, there are no evidence-based studies demonstrating clinical value of RHC among COPD patients. Recent studies hypothesize that systemic inflammation may play a role in the pathophysiology of PH in COPD. LTOT remains the cornerstone of treatment; optimal ICS/LABA treatment cannot be overemphasized given the potential role of inflammation.

CONCLUSIONS: Our patient presented with “out - of - proportion” PH, treated with ICS/LABA. Optimal LTOT improves and stabilizes PH; no reports reverting PAP to near normal values were retrieved as of this writing. Our case has demonstrated that PAP may return to near normal values with optimal ICS/LABA treatment.

Reference #1: Weitzenblum, E., FCCP and Chaouat, A., MD , “Severe Pulmonary Hypertensio in COPD: Is It a Distinct Disease”. CHEST 2005; 127; 1480 - 1482.

Reference #2: Minai, O., et al., “Pulmonary Hypertension in COPD: Epidemiology, Significance, and Management: Pulmonary Vascular Disease: The Global Perspective”. CHEST 2010; 137; 39S - 51S.

Reference #3: Preston, I., “Pulmonary Hypertension in Chronic Obstructive Pulmonary Disease: Diagnosis and Management”. Advances in Pulmonary Hypertension 2009; 8: 3.

DISCLOSURE: The following authors have nothing to disclose: Reinalyn Cartago, Lenora Fernandez

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