Circulation, Vol 86, 12-21, Copyright © 1992 by American Heart Association
IS Anand, Y Chandrashekhar, R Ferrari, R Sarma, R Guleria, SK Jindal, PL Wahi, PA Poole-Wilson and P Harris
BACKGROUND. The pathogenesis of salt and water accumulation in patients
with chronic obstructive pulmonary disease is unclear and may differ from
that in patients with congestive heart failure due to myocardial disease.
This study was undertaken to investigate some of the mechanisms involved.
METHODS AND RESULTS. Hemodynamics, water and electrolyte spaces, renal
function, and plasma hormone concentrations were measured in nine patients
with edema due to chronic obstructive pulmonary disease and in six patients
after recovery. Mean cardiac output (3.8 +/- 0.26 l/min.m2) was normal, but
right atrial (11 +/- 1 mm Hg) and mean pulmonary arterial (41 +/- 3 mm Hg)
pressures were increased. Mean pulmonary arterial wedge pressure (11 +/- 1
mm Hg) was normal. Pulmonary vascular resistance (8.6 +/- 1.3 mm
Hg.min.m2/l) was increased, but systemic vascular resistance (19.3 +/- 1.3
mm Hg.min.m2/l) and mean arterial pressure (83 +/- 4 mm Hg) were low. All
patients were hypoxemic (PaO2, 40 +/- 2 mm Hg) and hypercapnic (PaCO2, 60
+/- 2 mm Hg). There was a significant increase in total body water (+21%),
extracellular volume (+45%), plasma volume (+45%), blood volume (+88%), and
exchangeable sodium (+38.2%). Renal plasma flow was severely reduced
(-63.2%), but glomerular filtration rate was only mildly decreased (-32%).
Significant increases were seen in plasma norepinephrine (3.5-fold normal),
renin activity (7.6-fold normal), vasopressin (twice normal), atrial
natriuretic peptide (9.4-fold normal), growth hormone (10.7-fold normal),
and cortisol (1.9-fold normal). After recovery, the PaO2 increased (50 +/-
3 mm Hg) and PaCO2 fell (45 +/- 4 mm Hg), and the patients became free from
edema. All the body compartments returned toward normal, although they did
not entirely reach normal values. Renal plasma flow increased
significantly, and glomerular filtration became normal. Right atrial and
pulmonary arterial pressures and pulmonary vascular resistance decreased (p
less than 0.01). Cardiac output decreased but not significantly. Blood
pressure increased but not significantly. However, systemic vascular
resistance increased significantly to a normal value. CONCLUSIONS. We
conclude that patients with edema due to chronic obstructive pulmonary
disease have severe retention of salt and water, reduction in renal blood
flow and glomerular filtration, and neurohormonal activation similar to
that seen in patients with edema due to myocardial disease. However, unlike
the latter, in chronic obstructive pulmonary disease cardiac output is
normal, and systemic vascular resistance and arterial blood pressure are
low. This probably is due to the vasodilator properties of hypercapnia. The
consequent low arterial blood pressure may be the stimulus for the
neurohormonal activation and retention of salt and water.
ARTICLES
Pathogenesis of congestive state in chronic obstructive pulmonary disease. Studies of body water and sodium, renal function, hemodynamics, and plasma hormones during edema and after recovery
Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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