Letter to the Editor
Dyspnea in a Pneumonectomized Patient
Disnea en paciente neumonectomizado
Oriol Plans Galvána,
, Ignasi Garcia-Olivéb, Maria Sol Pratsb, Elena Ferrer Sistachc, Eduard Fernández-Nofreriasc, Juan Ruiz Manzanob
Corresponding author
a Servicio de Medicina Intensiva y Crítica, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
b Servicio de Neumología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
c Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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paciente neumonectomizado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 625 "Ancho" => 1301 "Tamanyo" => 113702 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Spectroscopy image in hemodynamics unit. Unfolded Amplatzer<span class="elsevierStyleSup">®</span> Cribriform 25<span class="elsevierStyleHsp" style=""></span>mm occluded before release in the interatrial septum (A). Transesophageal echocardiogram 3-dimensional image showing device after percutaneous closure of the PFO (B).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of 72-year-old man, former smoker, with moderate chronic obstructive pulmonary disease (post-bronchodilator FEV<span class="elsevierStyleInf">1</span> 69%), and previous left pneumonectomy for squamous cell lung cancer with invasion of the pulmonary artery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">He presented in the emergency department of our hospital 2 months post-surgery with progressively worsening dyspnea, even on minimal exertion, aggravated in a sitting or upright posture.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical signs included tachypnea, oxygen saturation (SatO<span class="elsevierStyleInf">2</span>) 88%, <span class="elsevierStyleSmallCaps">d</span>-dimer 1226<span class="elsevierStyleHsp" style=""></span>ng/ml, and arterial blood gases pH 7.42, pO<span class="elsevierStyleInf">2</span> 65.1<span class="elsevierStyleHsp" style=""></span>mmHg, <span class="elsevierStyleItalic">p</span>CO<span class="elsevierStyleInf">2</span> 31.2<span class="elsevierStyleHsp" style=""></span>mmHg and HCO<span class="elsevierStyleInf">3</span> 20.1<span class="elsevierStyleHsp" style=""></span>mmol/l. Post-surgical changes were seen on chest X-ray, and no signs of pulmonary embolism were found on lung scintigraphy/SPECT-CT.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the patient's history of lung surgery and oxygen desaturation in an upright posture, platypnea–orthodeoxia syndrome (POS) was suspected.</p><p id="par0025" class="elsevierStylePara elsevierViewall">SatO<span class="elsevierStyleInf">2</span> was tested in supine and sitting positions, showing a significant fall in hypoxemia in an upright posture (from 93% to 88% with nasal cannulas at 4<span class="elsevierStyleHsp" style=""></span>l/min). Transthoracic echocardiography (TTE) with bubble study revealed a right-to-left shunt due to a patent foramen ovale (PFO). These findings were confirmed by transesophageal echocardiography (TEE).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient underwent heart surgery for percutaneous closure of the PFO, using the Amplatzer<span class="elsevierStyleSup">®</span> Cribriform occluder (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Successful placement of the device and absence of residual shunt was confirmed with TEE. In subsequent follow-ups, the patient's dyspnea was fully resolved and standing SatO<span class="elsevierStyleInf">2</span> was normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">POS is an unusual phenomenon, consisting of dyspnea in an upright posture, which diminishes in recumbency (platypnea), accompanied by increased blood oxygen levels in that posture (orthodeoxia).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Causes of POS can be divided into 3 groups, depending on the pathogenesis: cardiac, pulmonary or other.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Two components are required in cardiac POS, one being anatomical (common in all patients) and the other functional. The anatomical component must involve an intracardiac communication causing shunt. The most common defect in the general population and in POS patients is PFO. PFO does not generally cause disease because it causes left-to-right shunt, but this reverses in the presence of certain functional changes.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The most common functional components include ascending aorta aneurysm, pneumonectomies (most often right-sided) and lobectomies, pericardial and myocardial disease, and tricuspid valve disease. The reduction in blood flow experienced in recumbency causes the shunt to diminish, with the consequent rise in SatO<span class="elsevierStyleInf">2</span>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A high level of suspicion is needed in the diagnosis of POS, and a careful anamnesis is essential if it is to be identified.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The most simple, but no less important, examination is the determination of SatO<span class="elsevierStyleInf">2</span> in different postures. Definitive diagnosis of cardiac POS is reached with bubble-contrast TEE, which produces fewer false-positives than TTE. Both tests may be normal when the patient is supine, or if microbubble contrast medium is administered via an upper limb. This is because in PFO, the flow is received primarily by the inferior vena cava.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Cardiac POS treatment consists of closing the PFO with Amplatzer<span class="elsevierStyleSup">®</span> devices, resulting in resolution of symptoms<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> and normal SatO<span class="elsevierStyleInf">2</span> in an upright posture.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Galván OP, Garcia-Olivé I, Prats MS, Sistach EF, Fernández-Nofrerias E, Manzano JR. Disnea en paciente neumonectomizado. Arch Bronconeumol. 2015;51:524–525.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 625 "Ancho" => 1301 "Tamanyo" => 113702 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Spectroscopy image in hemodynamics unit. Unfolded Amplatzer<span class="elsevierStyleSup">®</span> Cribriform 25<span class="elsevierStyleHsp" style=""></span>mm occluded before release in the interatrial septum (A). Transesophageal echocardiogram 3-dimensional image showing device after percutaneous closure of the PFO (B).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Platypnea–orthodeoxia syndrome in interatrial right to left shunt postpneumonectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "V. Bellato" 1 => "S. Brusa" 2 => "J. Balazova" 3 => "S. Marescotti" 4 => "D. de Caria" 5 => "G. Bordone" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Minerva Anestesiol" "fecha" => "2008" "volumen" => "74" "paginaInicial" => "271" "paginaFinal" => "275" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18356806" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome platipnea–ortodeoxia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "O.D. López Gastón" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Medicina (B. Aires)" "fecha" => "2005" "volumen" => "65" "paginaInicial" => "268" "paginaFinal" => "272" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Importance of platypnea orthodeoxia in the differential diagnosis of dyspnea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Takase" 1 => "Y. Tanaka" 2 => "H. Hattori" 3 => "M. Ishihara" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intern Med" "fecha" => "2010" "volumen" => "51" "paginaInicial" => "1651" "paginaFinal" => "1652" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22790121" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Platypnoea–orthodeoxia syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Kuber" 1 => "H. Gibbs" 2 => "P. Garrahy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2000" "volumen" => "83" "paginaInicial" => "221" "paginaFinal" => "223" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10648502" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unusual treatment of patent foramen ovale after pneumonectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "W.N. Welvaart" 1 => "A. Becker" 2 => "J.T. Marcus" 3 => "A. Vonk-Noordegraaf" 4 => "J.W.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 5 | 11 |
| 2024 October | 36 | 15 | 51 |
| 2024 September | 43 | 19 | 62 |
| 2024 August | 51 | 42 | 93 |
| 2024 July | 37 | 20 | 57 |
| 2024 June | 51 | 24 | 75 |
| 2024 May | 71 | 27 | 98 |
| 2024 April | 27 | 28 | 55 |
| 2024 March | 34 | 13 | 47 |
| 2024 February | 26 | 30 | 56 |
| 2023 March | 4 | 5 | 9 |
| 2023 February | 30 | 25 | 55 |
| 2023 January | 28 | 29 | 57 |
| 2022 December | 52 | 30 | 82 |
| 2022 November | 39 | 20 | 59 |
| 2022 October | 48 | 44 | 92 |
| 2022 September | 30 | 33 | 63 |
| 2022 August | 32 | 36 | 68 |
| 2022 July | 24 | 38 | 62 |
| 2022 June | 35 | 38 | 73 |
| 2022 May | 27 | 23 | 50 |
| 2022 April | 32 | 32 | 64 |
| 2022 March | 47 | 33 | 80 |
| 2022 February | 31 | 38 | 69 |
| 2022 January | 38 | 34 | 72 |
| 2021 December | 37 | 36 | 73 |
| 2021 November | 38 | 53 | 91 |
| 2021 October | 38 | 49 | 87 |
| 2021 September | 26 | 43 | 69 |
| 2021 August | 34 | 35 | 69 |
| 2021 July | 23 | 27 | 50 |
| 2021 June | 36 | 46 | 82 |
| 2021 May | 38 | 43 | 81 |
| 2021 April | 47 | 158 | 205 |
| 2021 March | 37 | 40 | 77 |
| 2021 February | 31 | 32 | 63 |
| 2021 January | 22 | 28 | 50 |
| 2020 December | 22 | 30 | 52 |
| 2020 November | 20 | 18 | 38 |
| 2020 October | 10 | 18 | 28 |
| 2020 September | 13 | 11 | 24 |
| 2020 August | 25 | 17 | 42 |
| 2020 July | 32 | 20 | 52 |
| 2020 June | 73 | 18 | 91 |
| 2020 May | 39 | 12 | 51 |
| 2020 April | 33 | 28 | 61 |
| 2020 March | 21 | 13 | 34 |
| 2020 February | 29 | 23 | 52 |
| 2020 January | 26 | 23 | 49 |
| 2019 December | 29 | 22 | 51 |
| 2019 November | 28 | 21 | 49 |
| 2019 October | 21 | 11 | 32 |
| 2019 September | 34 | 7 | 41 |
| 2019 August | 28 | 15 | 43 |
| 2019 July | 26 | 19 | 45 |
| 2019 June | 23 | 12 | 35 |
| 2019 May | 35 | 23 | 58 |
| 2019 April | 49 | 25 | 74 |
| 2019 March | 47 | 19 | 66 |
| 2019 February | 34 | 27 | 61 |
| 2019 January | 36 | 16 | 52 |
| 2018 December | 37 | 19 | 56 |
| 2018 November | 42 | 15 | 57 |
| 2018 October | 86 | 23 | 109 |
| 2018 September | 36 | 9 | 45 |
| 2018 May | 12 | 0 | 12 |
| 2018 April | 44 | 7 | 51 |
| 2018 March | 34 | 9 | 43 |
| 2018 February | 55 | 5 | 60 |
| 2018 January | 136 | 8 | 144 |
| 2017 December | 86 | 9 | 95 |
| 2017 November | 27 | 7 | 34 |
| 2017 October | 18 | 8 | 26 |
| 2017 September | 21 | 9 | 30 |
| 2017 August | 17 | 5 | 22 |
| 2017 July | 17 | 9 | 26 |
| 2017 June | 31 | 18 | 49 |
| 2017 May | 34 | 21 | 55 |
| 2017 April | 33 | 11 | 44 |
| 2017 March | 18 | 9 | 27 |
| 2017 February | 9 | 4 | 13 |
| 2017 January | 11 | 5 | 16 |
| 2016 December | 23 | 12 | 35 |
| 2016 November | 36 | 8 | 44 |
| 2016 October | 38 | 13 | 51 |
| 2016 September | 32 | 20 | 52 |
| 2016 August | 40 | 6 | 46 |
| 2016 July | 27 | 11 | 38 |
| 2016 June | 1 | 0 | 1 |
| 2016 May | 0 | 8 | 8 |
| 2016 April | 0 | 2 | 2 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 1 | 2 | 3 |
| 2016 January | 0 | 7 | 7 |
| 2015 October | 2 | 1 | 3 |
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