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CLINICAL STUDIES

Expiratory flow limitation as a determinant of orthopnea in acute left heart failure

Alexandre Duguet, MD^*, Claudio Tantucci, MD^* , Olivier Lozinguez, MD, Richard Isnard, MD, Daniel Thomas, MD, Marc Zelter, MD, Jean-Philippe Derenne, MD^*, Joseph Milic-Emili, MD, PhD^|| and Thomas Similowski, MD, PhD^*

^* Laboratoire de Physiopathologie Respiratoire du Service de Pneumologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
Service de Cardiologie , Groupe Hospitalier Pitié-Salpêtrière, Paris, France
Laboratoire Central d’Exploration Fonctionnelle Respiratoire, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
Clinica di Semeiotica Medica, University of Ancona, Ancona, Italy
^|| Meakins-Christie Laboratories, McGill University, Montréal, Québec, Canada

Manuscript received June 22, 1999; revised manuscript received October 10, 1999, accepted November 18, 1999.

Reprint requests and correspondence: Dr. Thomas Similowski, Service de Pneumologie et de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, 47–83, Bd de l’Hôpital, 75651 Paris Cedex 13, France
thomas.similowski{at}psl.ap-hop-paris.fr

OBJECTIVES

To assess the contribution of expiratory flow limitation (FL) in orthopnea during acute left heart failure (LHF).

BACKGROUND

Orthopnea is typical of acute LHF, but its mechanisms are not completely understood. In other settings, such as chronic obstructive pulmonary disease, dyspnea correlates best with expiratory FL and can, therefore, be interpreted as, in part, the result of a hyperinflation-related increased load to the inspiratory muscles. As airway obstruction is common in acute LHF, postural FL could contribute to orthopnea.

METHODS

Flow limitation was assessed during quiet breathing by applying a negative pressure at the mouth throughout tidal expiration (negative expiratory pressure [NEP]). Flow limitation was assumed when expiratory flow did not increase during NEP. Twelve patients with acute LHF aged 40–98 years were studied seated and supine and compared with 10 age-matched healthy subjects.

RESULTS

Compared with controls, patients had rapid shallow breathing with slightly increased minute ventilation and mean inspiratory flow. Breathing pattern was not influenced by posture. Flow limitation was observed in four patients when seated and in nine patients when supine. In seven cases, FL was induced or aggravated by the supine position. This coincided with orthopnea in six cases. Only one out of the five patients without orthopnea had posture dependent FL. Control subjects did not exhibit FL in either position.

CONCLUSIONS

Expiratory FL appears to be common in patients with acute LHF, particularly so when orthopnea is present. Its postural aggravation could contribute to LHF-related orthopnea.

Abbreviations and Acronyms   cFL = complete flow limitation, or completely flow limited   COPD = chronic obstructive pulmonary disease   EF = ejection fraction   FL = flow limitation   LHF = left heart failure   LV = left ventricular   NEP = negative expiratory pressure   nFL = not flow limited, or absence of flow limitation   pFL = partial flow limitation, or partially flow limited   SpO2 = transcutaneous pulsed oxygen saturation

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