Download wheezing and insufficiency in pregnancy: was it bronchial or cardiac asthma? respiratory

EDITORIAL
wheezing and respiratory insufficiency in pregnancy:
was it bronchial or cardiac asthma?
J.C. Yernault
1989 issue of Chest, 'I'ENHoLDER and
the case of a 27 yr old pregnant
gestation who presented with
ng shortness of breath, cough
sputum, and wheezing. When hospi3), 1987, she was receiving therapy
inbalcd tcrbuLaiJne nnd oral lheophylwas begun two weeks earlier
.(unction tests had shown "reactive
, Unfortunately no figures are given to
to fully appreciate the meaning of that
to describe spirometric results. On
was afebrile, had tachycardia (124
(22 breaths per min). Diffuse bilatheard with dullness to percussion on
·were no heart murmurs, nor jugular
The chest X-ray showed bilateral
lower lobes and pleural effusions. No
e~l. Arterial blood gases showed
60.6 mmHg on 4 l oxygen by
nypocaJpma (Paco1 29.5 mmHg). The
the intensive care unit and treated
aminophylline and methylpredniof terbutaline and atropine. On
admission, a spirometry showed
defect (FVC 59% predicted, FEV /
a parallel 300 ml improvement in FVC
.5.
clearl y stated, I presume that the
was concurrent bronchial asthma and
patient without any past history of
improved steadily during
""">v•umzation and the chest film taken
normal. The authors were puzzled
.
obstructive pattern of severe
u to an out-of-proportion reduction
.,,.,,,""'"''v and inability for the patient to
their case history, I wonder whether
might not have been considered,
nuher than "bronchial" asthma. ActuCh~t issue, PtsoN et al. [2], describing
s•vcncss to inhaled methacholine in
left heart failure, remind us that the
ng is as characteristic of exleft ventricular failure as it is of
bronchial asthma, with dyspnoea present in their 12
patients (5 of them also complaining of chest tightness),
cough in 7 and wheezing in 9. Hypoxaemia was also
present in several of their patients during the acute phase
with the lowest measured Pao1 at 6.9 kPa (52 mmHg).
The chest X-ray, which was abnormal in all their patients during the exacerbation, returned to normal after
increased diuretic therapy in several of them. Significant
airway obstruction with reduced FEV 1 and FEV/FVC
was initially presem in 6/12 patients.
Several of the features of the patient described by
TENHoLDER and SoUrH-PAUL [1) including the chest Xray findings with bilateral pleural effusions [3, 4], are
thus compatible with a diagnosis of cardiac rather than
bronchial asthma. Admittedly, this is an unusual problem
in a young woman without a previously recognized heart
problem, but the hypothesis should at least have been
discussed because situations such as critical mitral regurgitation can present without audible murmur as recalled
by SCHREIBER et al. [5] also in the same Chest issue.
Moreover recent studies [6, 7] have emphasized the
limited reliability of physical signs for estimating the
pulmonary capillary wedge pressure in patients with
impaired left ventricular function. A raised jugular venous
pressure is a rather specific but poorly sensitive indicator
of heart failure [7), and other signs such as a third heart
sound or a displayed apex beat are difficult to appreciate
[8, 9]. In the presented case, a significant heart problem
cannot be excluded only on the basis of clinical data.
Similarly the improvement under therapy cannot be taken
as an argument pro bronchial rather than cardiac asthma,
because bed rest, oxygen and theophylline administration might have contributed to an improvement of the
haemodynamic status.
Moreover, wheezing cannot be equated with
bronchospasm nor wilh asthma [10]. It is produced when
oscillations of the airway wall occur, induced by an
acceleration of the gas flow through a narrowed lumen
and/or by dynamic compression. In so-called cardiac
asthma, narrowing of airway lumen most probably
results from congestion and oedema of the bronchial wall
[11). Following these lines, the bronchial hyperresponsiveness to inhaled methacholine observed in these
circumstances has been attributed to its vasodilating effect
on the bronchial arterioles [12].
To conclude, with the data that were summarized in
the above case presentation, I believe that no definite
diagnosis can be proposed, but that a simple diagnostic
I.C. YERNAULT
248
manoeuvre would have been very useful. Should a
thoracocentesis have been pcrfonned, the chemical analysis of the pleural Ouid demonsrraling a transudate might
have pcnniucd very strong arguments in favour of a
diagnosis of cardiac rather than bronchial asthma and
pneumonia, in which case an exudate would have been
expected.
Rererences
1. Tenholder MF, South-Paul JE. - Dyspnea in pregnancy.
Chest, 1989, 96, 381-382.
2. Pison C, Malo JL, Rouleau JL, Chal11oui J, Ohezzo H,
Malo J. - Bronchial hyperresponsivencss lO inhaled methacholine in subjects with chronic left hean failure at a time of
exacerbation and after increasing diuretic therapy. Chest, 1989,
96, 230-235.
3. Pist.olesi M. Miniali M, Milne ENC, Oiuntini C. - The
chest roentgenogram in pulmonary edema. Clin CMst Med,
1985, 6, 3 15- 344.
4. Wiener-Kronish JP, Berthiaume Y. Albertine KH.- Pleural effusions and pulmonary edema. Clin Chest Med, 1985, 6,
509-519.
S . Schteiber TL, Fisher I, Mangla A
"silent" milral regurgitat.ion. A potential'
refractory hean failure. Chest, 1989, 96
6. Editorial. - Clinical signs in heart fa'il
309- 3 10.
~.
7. Stevenson LW, Perloff JK. -The
physical signs for estimating hemodynamics
failure. JAMA, 1989. 261, 884-88.
8. lshmail AA, Wing S, Ferguson J, nut,e flb,_j
S, Aegel KM. - Interobserver agreement by
presence of a lhird heart sound in pauen11
heart failure. Chest, 1987, 91, 870-873,
9. O'Neill TW, Barry M. Smith
IM. - Diagnostic value of the apex be.t
410-411.
•
10. Yema.ult JC, Lenclud C. - Wheez.ing
Progress In asthryta and COPD. P. V
I.C. Yemault ed~. Amsterdam. Excerpta
61-69.
1t. Fi.~hman AP. - Cardiac asthma. A fresh
wheeze. N Engl J Med, 1989, 320, l346-I
l 2. Cabancs LR, Weber SN, Matran R, "ci!IWIIP
MO, Oegeorges ME, Lockhart A. siveness to methacholine in patients with
ventricular function. N Engl J Med, 1989, 320,