Competition for Intrathoracic Space Reduces Lung Capacity in Patients With Chronic Heart Failure: A Radiographic Study

doi:10.1378/chest.130.1.164

Chest

Volume 130, Issue 1, July 2006, Pages 164-171

https://doi.org/10.1378/chest.130.1.164 Get rights and content

Background

The purpose of this study was to determine the influence of changes in cardiac size on total lung volume in patients with chronic heart failure compared to control subjects.

Methods

Forty-four patients and age-, gender-, and height-matched control participants were recruited. All participants underwent posteroanterior and lateral chest radiography for volumetric estimations of the total thoracic cavity (TTC), diaphragm, heart, and lungs. To assess the relationship between chronic heart failure severity and cardiac enlargement, patients with chronic heart failure were classified into groups based on New York Heart Association class, as follows: class I and II, n = 26 (group A); class III and IV, n = 18 (group B).

Results

There was no difference between the groups for TTC volume (TTCV) [p = 0.56]. Cardiac volumes were significantly different between all groups for both the absolute volumes (p < 0.001) were calculated as a percentage of TTCV (p < 0.001), with the largest cardiac volumes in group B (twice the volume of healthy control subjects). When expressed as a percentage of TTCV, there also was a clear reduction in lung volumes as a function of disease severity (p < 0.001).

Conclusions

The present study demonstrates a close relationship between the severity of heart failure and cardiac size. These changes in cardiac size within a closed thoracic cavity may pose significant constraints on the lungs, resulting in reductions in lung volumes that likely play a major role in the restrictive breathing patterns often reported in patients with chronic heart failure.

Section snippets

Population Characteristics

This retrospective analysis utilized data from 44 chronic heart failure patients from the database of the Mayo Clinic Heart Failure Service or the Cardiovascular Health Clinic (a preventive and rehabilitative center) from 2000 to 2004 (Table 1). Inclusion criteria included patients with a history of ischemic or dilated cardiomyopathy, stable heart failure symptoms (> 3 months), duration of heart failure symptoms > 1 year, left ventricular EF ≤ 35%, body mass index (BMI) < 35 kg/m², and

Population Characteristics

The clinical characteristics of each study group and the medications in use by the patients at the time of the study are reported in Table 1, Table 2, respectively. Notable differences between the groups include a significantly lower BMI for the control group compared to group A and group B (p < 0.05). These differences were due to a nonsignificant trend in the difference in body weight (p = 0.06) as opposed to differences in height. Also, the control group demonstrated significantly greater

Discussion

In this study, we found the following in patients with heart failure compared to control participants: (1) marked increases in cardiac size reaching twice that of healthy age- and gender-matched control participants; (2) a clear relationship between the severity of heart failure and increase in cardiac size; (3) and a negative correlation between the percentage of TTC occupied by lung and the percentage of TTC occupied by the heart. These findings demonstrate that a progressive increase in

Limitations

Importantly, a potential limitation to this study is the use of a single equation to estimate pulmonary blood and parenchymal tissue volumes in control subjects and patients with chronic heart failure. Understandably, the use of a single prediction equation may have a tendency to slightly underestimate actual volumes in this population. Until recently, pulmonary fluid accumulation was thought to be a chronic process occurring as a result of cardiac contractile insufficiency leading to elevated

Clinical Implications

Posteroanterior and lateral chest radiographs are common clinical procedures for patients with heart failure. By using volumetric analysis of radiographs, estimates can be made of changes in cardiac, lung, diaphragm, and total thoracic volume. The changes observed in cardiac size within a closed thoracic cavity may pose significant constraints on the lung, resulting in significant reductions in lung volumes and resulting in the restrictive breathing pattern often reported in heart failure

Acknowledgment

The authors thank Kathy O’Malley and Minelle LaPolice for their help in data acquisition and management.

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Hence, changes in cardiac function may directly influence lung function because of alterations in cardiac preload and afterload, including venous return and cardiac transmural pressure. Heart failure directly affects (1) lung mechanics because of congestion and increased heart size, which promote airway obstruction and lung restriction1,2; (2) high pulmonary pressures as well as pulmonary congestion contribute to remodeling of the pulmonary capillaries, increased ventilation-perfusion mismatch, and decreased alveolar-capillary diffusion3,4; and (3) disordered ventilatory control, including hyperventilation at rest, during exercise, and with sleep.5–7 These pulmonary system changes cause decreased breathing reserve combined with enhanced ventilation for a given metabolic demand (minute ventilation [VE]/pulmonary carbon dioxide output [Vco2] ratio) at rest and during exercise (further discussion in the topic is provided in Clinical and Physiological Implications of Negative Cardiopulmonary Interactions in Coexisting COPD-Heart Failure).7,8
Restrictive Lung Function Is Related to Sympathetic Hyperactivity in Patients With Heart Failure
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Citation Excerpt :
Many studies have suggested that in the presence of HF, the pulmonary system undergoes mild to moderate restrictive and obstructive changes in lung function.16–21 Although the causes of changes in lung function remain unclear, impaired lung function has been attributed to pulmonary edema due to elevated left atrial pressure,17 changes in alveolar capillary units due to chronically elevated left atrial pressure,18,19 increased cardiac size20 and pleural effusion,21 and respiratory muscle weakness.22,23 Pulmonary edema could decrease lung compliance in patients with HF.
Sympathoexcitation and impaired lung function are common in patients with severe heart failure (HF). However, the association between impaired lung function and sympathoexcitation remains unknown.
Muscle sympathetic nerve activity (MSNA) and clinical variables were determined in 83 HF patients with left ventricular ejection fraction (LVEF) <0.45. Restrictive and obstructive changes on spirometry were defined as reduced forced vital capacity (FVC) of <80% of predicted and a ratio of forced expiratory volume in the first second to FVC of <70%, respectively. Restrictive and obstructive changes were identified in 17 and 21 patients, respectively. MSNA was higher in patients with restrictive changes than in those without restrictive changes (84 vs 66 bursts per 100 beats; P < .01), but was similar in those with and without obstructive changes. Univariate analyses showed that FVC, estimated glomerular filtration rate (eGFR), specific activity scale, B-type natriuretic peptide level, LVEF, age, and use of aldosterone receptor blockers were significant predictors of MSNA burst incidence. Multivariate analysis revealed that FVC, LVEF, and eGFR were independent factors for increased burst incidence. Changes in FVC during follow-up negatively correlated with changes in burst rate (n = 11; P < .01).
Restrictive lung function was associated with increased sympathetic nerve activity independently from HF severity.
Effect of cardiac resynchronization therapy on pulmonary function in patients with heart failure
2013, American Journal of Cardiology
Pulmonary congestion due to heart failure causes abnormal lung function. Cardiac resynchronization therapy (CRT) is a proven effective treatment for heart failure. The aim of this study was to test the hypothesis that CRT promotes increased lung volumes, bronchial conductance, and gas diffusion. Forty-four consecutive patients with heart failure were prospectively investigated before and after CRT. Spirometry, gas diffusion (diffusing capacity for carbon monoxide), cardiopulmonary exercise testing, New York Heart Association class, brain natriuretic peptide, the left ventricular ejection fraction, left atrial volume, and right ventricular systolic pressure were assessed before and 4 to 6 months after CRT. Pre- and post-CRT measures were compared using either paired Student's t tests or Wilcoxon's matched-pair test; p values <0.05 were considered significant. Improved New York Heart Association class, left ventricular ejection fraction, left atrial volume, right ventricular systolic pressure, and brain natriuretic peptide were observed after CRT (p <0.05 for all). Spirometry after CRT demonstrated increased percentage predicted total lung capacity (90 ± 17% vs 96 ± 15%, p <0.01) and percentage predicted forced vital capacity (80 ± 19% vs 90 ± 19%, p <0.01). Increased percentage predicted total lung capacity was significantly correlated with increased peak exercise end-tidal carbon dioxide (r = 0.43, p = 0.05). Increased percentage predicted forced vital capacity was significantly correlated with decreased right ventricular systolic pressure (r = −0.30, p = 0.05), body mass index (r = −0.35, p = 0.02) and creatinine (r = −0.49, p = 0.02), consistent with an association of improved bronchial conductance and decreased congestion. Diffusing capacity for carbon monoxide did not significantly change. In conclusion, increased lung volumes and bronchial conductance due to decreased pulmonary congestion and increased intrathoracic space contribute to an improved breathing pattern and decreased hyperventilation after CRT. Persistent alveolar-capillary membrane remodeling may account for unchanged diffusing capacity for carbon monoxide.
Diagnosis and prognostic value of restrictive ventilatory disorders in the elderly: A systematic review of the literature
2012, Experimental Gerontology
Although less extensively studied compared to pulmonary obstructive diseases, restrictive lung disease (RLD) is highly prevalent and frequently disabling in the adult and, more, the elderly population. The underlying conditions may be either primarily pulmonary diseases, such as idiopathic pulmonary fibrosis, or non respiratory conditions secondarily affecting the lung, e. g. congestive heart failure, or else conditions affecting the lung expansion, e. g. obesity or rib cage deformity. The diagnosis is frequently based on the measurement of surrogate indexes such as the forced vital capacity (FVC) used as a proxy for total lung capacity (TLC). As a consequence, diagnosis of RLD is often characterized by poor specificity. In the elderly, worsening in the quality of life and poor prognosis are variably, but significantly, associated to RLD, being the underlying condition an important source of variability. Several causes of RLD are preventable and treatable conditions. A prompt identification of these conditions may allow to slow the decline of respiratory reserve and, thus, to preserve both personal independence and resistance to acute respiratory infections.
This review gives an update on the latest evidence available on the prevalence and the prognosis of RLD in the elderly. Studies were identified through systematic searches of the electronic database MEDLINE. Reference list of eligible papers were also manually searched.
Chest wall regional volume in heart failure patients during inspiratory loaded breathing
2012, Respiratory Physiology and Neurobiology
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The main symptoms of chronic heart failure (CHF) are dyspnea and fatigue (Jefferies and Towbin, 2010; Pina, 2003). Various studies have pointed out how these symptoms are related to abnormalities in respiratory muscles (Drexler et al., 1992; Coats, 1996) and the presence of cardiomegaly (Olson et al., 2006). Inspiratory muscle dysfunction has been reported as a reduction in the capacity to generate inspiratory muscle pressure and strength, a functional decline which can be attributed to histological and biochemical changes.
Were evaluated individuals divided into two groups: we studied chronic heart failure (CHF) (19 patients with CHF plus cardiomegaly) and control (12 healthy volunteers) during performance of inspiratory loaded breathing (ILB). We evaluated: spirometry, functional capacity through the six-minute walk test (6MWT), and distribution of thoracoabdominal volumes via optoelectronic plethysmography (OEP), namely volume variations of pulmonary rib cage (Vrc,p), abdominal rib cage (Vrc,a), and abdomen (Vab). In each compartment, the percentage contributions of right and left sides were also calculated. During ILB, patients with heart failure were characterized by a significant reduction of the Vrc,a volume variations compared to the control group. Correlations were found between left %Vrc,a on the left side measured during ILB and left ventricular ejection fraction (r = 0.468; p = 0.049), and dyspnea after the 6MWT (r = −0.878; p < 0.01).Then, patients with CHF and cardiomegaly are characterized by a reduced mobility in left part of the lower part of the rib cage, that contributes leading to increased perception of dyspnea during submaximal exercise.
Breathing strategy to preserve exercising cardiac function in patients with heart failure
2010, Medical Hypotheses
The heart and lungs are closely linked as they lie in series, share a common surface area and compete for space within the thoracic cavity. The heart and lungs are exposed to the similar changes in intrathoracic pressure, and reflexes within one organ can influence the other (i.e. vagal influence of lung inflation on heart rate). In patients with heart failure, these cardiopulmonary interactions may be altered due to decreased lung and left ventricular compliance, increased cardiac size, high cardiac filling pressure and altered receptor sensitivity to neural activation. Exercise further affects the cardiopulmonary interactions by stimulating an increase in the depth and frequency of breathing which accentuates the fluctuations in intrathoracic pressure, and by requiring large increases in stroke volume and heart rate in order to respond to the increased metabolic demand. Previous work from our laboratory suggested that patients with heart failure avoid high lung volumes during exercise, often at the expense of unnecessary large positive expiratory intrathoracic pressures resulting in significant wasted effort. Moreover, we also observed that voluntarily increases in lung volume in patients with heart failure induced a mild relative bradycardia, a response not observed in similar aged healthy individuals. Thus, we hypothesized that the rapid shallow low lung volume breathing, in combination with positive expiratory intrathoracic pressure, often adopted by patients with heart failure during exercise is an attempt to preserve, or even enhance, the cardiac response to exercise.

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Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

This work was supported in part by National Institutes of Health grants HL71478 and HL07111.

The authors of this manuscript do not have any conflicts of interest to disclose.

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Chest

Original ResearchCompetition for Intrathoracic Space Reduces Lung Capacity in Patients With Chronic Heart Failure: A Radiographic Study

Background

Methods

Results

Conclusions

Section snippets

Population Characteristics

Population Characteristics

Discussion

Limitations

Clinical Implications

Acknowledgment

Respir Med

Am J Cardiol

Chest

Chest

Am J Med

Am J Med

Comput Biol Med

Chest

Chest

Chest

Chest

Lancet

Serial pulmonary function in patients with acute heart failure

Arch Intern Med

Pulmonary function and respiratory muscle strength in chronic heart failure: comparison between ischaemic and idiopathic dilated cardiomyopathy

Heart

Original Research
Competition for Intrathoracic Space Reduces Lung Capacity in Patients With Chronic Heart Failure: A Radiographic Study