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History of pneumonectomy due to TB. On home BIPAP therapy. Is there evidence of CHF or Pulmonary hypertension?

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Practicing since : 1997
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Im looking for some advice from a cardiac specialist. I know that I should seek advice from my treating physician but I am just after some guidance. Here is my history.

I am a 72 year old male with history of right pneumonectomy due to TB back in 1960. As a result of this procedure I have been under treatment for COPD since then. I have lived a full life and managed very well with my condition. I have no other medical conditions.
A few years ago I had an acute exacerbation of my condition and was found to be in type II respiratory failure. I have been a chronic CO2 retainer since. Regardless of this, I have managed well on nebulised bronchodialators and nebulised steroids.
Last year I had another acute exacerbation and was admitted into hospital where I was put under the care of a new Respiratory Consultant. This consultant put me on home BIPAP therapy designed to manage my CO2 retention. I use this non invasive ventilator 8-9 hours per day (so usually over night). Once again, whilst on the BIPAP therapy, I have previously been managing well and still active.

Last month I began to progressively become more and more breathless on exertion. At rest I was fine with my sats in high 90’s. But on slight exertion I would desaturate to the 80’s and become dyspnoeic. I do not feel faint and have not suffered syncope. At its worst I got peripheral eodema – swelling in my ankles and feet with pitting. My hands also became swollen. This resolved after a few days. Currently I have no peripheral eodema. I am fantastic at rest and have even clocked my resting sats at 99%. But on exertion I become very very breathless. Even when walking across the room. I also feel pressure around my chest sometimes. This isn’t acute pain or radiating pain or crushing pain associated with MI or angina. This is just a dull, long lasting feeling of weight on my chest. It is worse when I lie down. In fact I am unable to lie down.

I spoke to my respiratory consultant about this and he ordered an echo. I had my echo last week. I am very interested to see if there is evidence of CHF or Pulmonary hypertension. I am yet to hear from my consultant but he implied that the next step would be to put me on ambulatory oxygen. He said the respiratory nurses will deal with that and that I was to see him in 6 months for a review appointment.

Now here is where I would like my guidance.
I am a bit worried that my doctors will put me on ambulatory oxygen to relieve the symptoms without trying to resolve the underlying condition. I am also worried that wont get to talk to a doctor about the results of my echo. If my echo shows evidence of CHF or Pulmonary hypertension, should I be requesting that pharmacological intervention (ACE inhibitors, digoxin, diuretics, ect) be carried out to relieve the strain and load on my heart which may relieve the breathlessness? Or should I just accept the fact that I have to carry round oxygen wherever I go? Is oxyen a first line treatment? Should I be speaking to a cardiologist or is a respiratory specialist adequate to manage my condition?
I just want some information at hand for when I have this discussion with the department.
What I have also noticed is that previously, my usual resting HR was between 95-105. Tachy for normal people but it seemed to be normal for me, on account of my one lung. Recently my HR is always low at 70-80. Even when breathless and exerting myself it rarely goes as high as it used to. Am I showing signs of decompensation? Is my heart no longer able to compensate and keep up?

We don’t have the results of my echo yet, but what are my options?

Thank you for your help.
Posted Tue, 12 Jun 2012 in Hypertension and Heart Disease
Answered by Dr. Ravindra L Kulkarni 52 minutes later
I am pleased to know that you are taking really good care about your health parameters and your knowledge is also good.

What I can summarize from your history is

1 COPD with chronic type 2 respiratory failure on daily oxygen therapy
2 developing signs of congestive heart failure like edema, breathlessness even on moderate exertion.

2D echo test is really essential to know
Right ventricle size
Pulmonary hypertension
LV functioning and its pumping ability as Ejection fraction.

This echo information will be useful to determine medical management.

Plan for management in such cases include
1 oxygen therapy - which you are already on, but as disease is progressing and you de saturate even on mild exertion like walking in room, Respiratory consultant had advised ambulatory oxygen. I feel you should get started with this, but as we get echocardiography reports, you may have option of adding few more medicines and again shift back to 6-8 hours of oxygen treatment.

2 patient education plays more important role in home based management of respiratory failure cases. So there was advice of nurse to monitor this.

3 Continue bronchodilator and nebulisation treatment as advised by chest physician.

4 consider a prophylactic vaccination against chest infection after discussing with your primary chest physician. This is to prevent infection, which is commonest risk factor for de compensation in chronic heart failure.

5 As you are having pedal edema, diuretics after consultation will be useful if taken on daily basis.

6 Other drugs like ARB, ACEI, digoxin, and vasodilators needs to be considered if your physician agrees to it or feels the need of it after your echocardiography evaluation.

Hope this updates will help you.
Please feel free to ask any query if you have.
Do discuss your Echocardiography report once available.

Wish you a good Health.
Above answer was peer-reviewed by
Follow-up: History of pneumonectomy due to TB. On home BIPAP therapy. Is there evidence of CHF or Pulmonary hypertension? 2 days later
Hello Dr. Thank you for your kind and informative reply.

Just to correct a couple of things.

I am not on oxygen therapy currently. I do not use oxygen. I use BIPAP non invasive ventilation for 8 hours at home to manage my CO2 retention.

I am already on Azithromicin 3 times a week as prohylaxis. And i also take annual flu vaccine.

Below are my Echo Results. I wonder if you would be kind enough to advise me based on the results and also my history above, and advise me on my options, in your opinion.

Just to summarize.

My resting sats range between 96% - 99%
Resting HR between 77-88

Sats on exertion drop to 84-88%
HR rises to 100

No current peripheral Oedama.
Feeling of weight on my chest especially when supine.
No acute chest pain.
No nausea, dizziness, syncope, etc.



Interpretation Summary
LV systolic function low normal-mildly inco-ordinate septum.
Grade II diastolic dysfunction.
RV radial systolic function mildly reduced, RV longitudinal function normal.

Left Ventricle
The left ventricle is normal in size. There is normal left ventricular wall thickness. Left ventricular systolic function is low normal. Mildly inco-ordinate septum. Est EF 50-55%. The transmitral spectral Doppler flow is suggestive of pseudonormalisation

Right Ventricle
The right ventricle is normal size. There is normal right ventricular wall thickness. Rv longitudinal function within normal limits. RV radial function appears mildly reduced.

LA appears normal size in relation to LV. RA appears normal size in relation to RV.

Mitral Valve
Opens well. Leaflets thin and pliable. No mitral regurgitation noted

Tricuspid Valve
Tricuspid valve leaflets open well. Leaflets thin and pliable. There is trace tricuspid regurgitation. Unable to measure PAPs and Jet.

Aortic Valve
Unable to clearly image 3 leaflets, RCC and NCC thin and pliable LCC not imaged to assess. No aortic regurgitation is present.

Pulmonic Valve
The pulmonic valve is not well visualised. Normal velocities on Doppler. Mild pulmonic valvular regurgitation.

Great Vessels.
The aortic root is normal size.

MMode/2D Measurements & Calculations
IVSd 0.77cm (<1.2cm)
LVIDd 2.5cm (2.4-5.6cm)
LVFWd (<1.2cm)
Answered by Dr. Ravindra L Kulkarni 14 hours later
I am pleased to know that previous answer had helped you.
Regarding your queries

1 I got your point that presently you are not oxygen therapy but Noninvasive ventilation for 6-8 hrs a day. But as you develop breathlessness on exertion and de saturate with exertion, your chest physician has suggested ambulatory oxygen therapy. This is mainly with the idea to maintain good oxygen saturation and it is also useful in slow down the progress of chronic respiratory failure disease progress when continued over a long period.

2 It is good to know that you are taking prophylactic antibiotic and had also taken vaccination. Please continue that.

3 Regarding Echo cardiography report, there is mild septal hypokinesia and EF 55-60 %. This is not a serious observation as LV ejection fraction is in normal limits and is acceptable.
Do discuss need of low dose diuretics on regular basis. This will help in reducing breathlessness on exertion .It also improves LV functioning. It is good to know that RA RV is within normal limits and there is no pulmonary hypertension.

I hope this information will help you.
Please feel free to discuss any queries if you have.
Wish you a good health.
Above answer was peer-reviewed by
Follow-up: History of pneumonectomy due to TB. On home BIPAP therapy. Is there evidence of CHF or Pulmonary hypertension? 13 hours later
As always you are very informative and clear. I thank you for this.

Just a correction - my EF is 50-55% (not 55-60%). This is on the mild side of defficient i understand.

I will feel comfortable discussing my options with my specialist now that i have your valuable information. If you dont mind, i will let you know what he says.

One more thing.
Is it true that pharmacological intervention (diuretics, ACE inhibitors, etc) for cardiac dysfuntion of this type is only proven effective for systolic dysfunction? And i gather my dysfuntion is dyastolic? Have you been able to treat patients with similar symptoms and condition and has it reduced their breathlesness? I know cases cannot be compared and this would only be anecdotal evidence, but i am interested to know if diuretics (in the absence of existing pitting eodema) can help with the dyspnea.

I really hope the specialist decides to intervene in the hope that my quality of life improves and i am able to become mobile again. The breathlessness is too much, but all the more surprising to see my sats so high at rest.

Thanks once again.
Answered by Dr. Ravindra L Kulkarni 10 hours later
Thanks for writing back.
I got your point. By mistake, I read your EF as 55-60 % . As correct ejection fraction is 50-55% , I still believe this is in the acceptable range and indicates good left ventricular functioning . Mild septal hypokinesia indicates systolic element of LV dysfunction.

I agree with your observation of diuretics and ACEI in cardiac dysfunction. But I still believe based on clinical experience, diuretics will benefit in your case .

As regards to my own experience in treating similar cases, I have seen patients improving over a period of time or at least they maintain their health in steady state. Also, fluctuations in general health or repeated episodes of LV dysfunction are minimized .

It is good that you are maintaining normal saturation at rest.

Please feel free to discuss any more queries that you may have.
Wish you good health .
Above answer was peer-reviewed by
Follow-up: History of pneumonectomy due to TB. On home BIPAP therapy. Is there evidence of CHF or Pulmonary hypertension? 4 hours later
Many thanks again for your prompt and informative reply. You really are a great help.

I wanted to update you on my discussion with my respiratory consultant today.
He says that he is happy with my echo and see's no evidence of elevated pressures around the heart. He says there is no indication of Pulmonary Hypertension. He is also happy with my lung function. He is writing to my GP to advice him accordingly of this and has concluded that no intervention is required.

I am seriously considering getting a second opinion from a private cardiac specialist. I have a good relationship with my respiratory consultant and i respect him alot. However i am surprised that he is happy to leave me for another 6 months by saying "everything is fine" when i am hardly able to lie back supine (due to feeling of pressure and weight on my chest and breathlessness) and that i desaturate so drasticallly on minimal exertion. In light of this, i wonder if i may benefit with an opinion from someone like yourself (Cardiac specialist).

My respiratory consultant has concluded no need for LTOT (Long term O2) and no need for pharmacological management. Based on my previous and recent history and based on my echo results, would you neccesarily agree with this?

I look forward to your insight.

Many thanks once again.
Answered by Dr. Ravindra L Kulkarni 58 minutes later
Thanks for writing back.
I also believe that your 2D Echocardiography test is essentially with in normal limits .
Decision of not to have long term oxygen therapy is based on clinical examination and his judgement .
With due regards to treating physician , patients can always seek a second opinion . It is routine especially when there is long term management of disease .
You can very well have second opinion for review of treatment .
Mostly, the line of treatment will remain the same .
I would want you to consider a second opinion from a respiratory Consultant, as your heart's status and functioning is with in normal range .

I hope the discussion will be useful to you .
Wish you good health .
Above answer was peer-reviewed by
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