Chest
Volume 96, Issue 2, August 1989, Pages 230-235
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Bronchial Hyperresponsiveness to Inhaled Methacholine in Subjects with Chronic Left Heart Failure at a Time of Exacerbation and After Increasing Diuretic Therapy

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Cough and wheezing are common findings in left heart failure. However, it is still questionable whether nonallergic bronchial hyperresponsiveness, the hallmark of asthma, is also associated with this condition. In 12 subjects with acute decompensation of chronic postischemic LV failure, we assessed the PC20 methacholine during an episode of acute LV failure and after five to 15 days of intensive diuretic therapy. Weight, arterial blood gases, plethysmographic lung volumes, and expiratory flows were also measured on both visits. Extravascular lung water was estimated indirectly with a radiologic score. During acute decompensation, six subjects had significant airway obstruction and eight had a PC20 ≤ 16 mg/ml (significant bronchial hyperresponsiveness). After diuretic therapy, subjects improved significantly, losing an average of 2.2 kg, but they still had chronic LV failure and evidence of an obstructive breathing defect. Although mean PC20 was unchanged, three subjects had significantly improved PC20 after treatment. We conclude that: (1) left ventricular failure is often associated with mild bronchial hyperresponsiveness, although it is not excluded that smoking and the resulting possibility of bronchial obstruction can also play some role; and (2) acute treatment does not generally alter bronchial responsiveness to methacholine, suggesting that chronic LV failure can cause chronic changes to the airways. (Chest 1989; 96:230–35)

Section snippets

Subjects

Twelve adult subjects with chronic (two to six years' duration except in two patients for whom it had been <six months) LV failure were assessed by a cardiologist for exacerbation of dyspnea either in the emergency room (n = 5) or during visits to the outpatient heart failure clinic (n = 7). Eleven were classified as having grade 4 (“inability to carry on any physical activity without discomfort”); one was classified as grade 3 (“comfortable at rest; less than ordinary physical activities cause

RESULTS

Baseline anthropometric and clinical results at the beginning of the study are shown in Table 1. Every subject was either a smoker or an ex-smoker. Two subjects had symptoms of chronic bronchitis. Mean ± SD pack-years reported by the subjects was 43.2 ± 20.3. Two subjects had a history of atopy, but none had a previous history of asthma. As well as reporting dyspnea, all except subject 6 had symptoms frequently encountered in asthma, ie, cough, wheezing, respiratory symptoms after exercise

DISCUSSION

Three stages of pulmonary edema have been described. The initial step is characterized by an increase in pulmonary blood volume without a change in extravascular pulmonary water. Peripheral but not total airway resistance is then increased.4 The second stage of pulmonary edema is characterized by interstitial edema which accumulates around vessels and bronchi.3 An increase in total airway resistance is then found at the level of either the small4,5,8 or large airways,22,23 although some authors6

ACKNOWLEDGMENTS

Christophe Pison was sponsored as a fellow by the Echanges France-Québec through the Fonds de la Recherche en Santé du Québec. This study was partially funded by the Canadian Lung Association. We thank Katherine Tallman for reviewing the manuscript.

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    Manuscript received October 13; accepted December 12.

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