Question: HeIlo,

Im looking for some advice from a cardiac specialist. I know that I should seek advice from my treating physician but I am just after some guidance. Here is my history.

I am a 72 year old male with history of right pneumonectomy due to TB back in 1960. As a result of this procedure I have been under treatment for COPD since then. I have lived a full life and managed very well with my condition. I have no other medical conditions.
A few years ago I had an acute exacerbation of my condition and was found to be in type II respiratory failure. I have been a chronic CO2 retainer since. Regardless of this, I have managed well on nebulised bronchodialators and nebulised steroids.
Last year I had another acute exacerbation and was admitted into hospital where I was put under the care of a new Respiratory Consultant. This consultant put me on home BIPAP therapy designed to manage my CO2 retention. I use this non invasive ventilator 8-9 hours per day (so usually over night). Once again, whilst on the BIPAP therapy, I have previously been managing well and still active.

Last month I began to progressively become more and more breathless on exertion. At rest I was fine with my sats in high 90’s. But on slight exertion I would desaturate to the 80’s and become dyspnoeic. I do not feel faint and have not suffered syncope. At its worst I got peripheral eodema – swelling in my ankles and feet with pitting. My hands also became swollen. This resolved after a few days. Currently I have no peripheral eodema. I am fantastic at rest and have even clocked my resting sats at 99%. But on exertion I become very very breathless. Even when walking across the room. I also feel pressure around my chest sometimes. This isn’t acute pain or radiating pain or crushing pain associated with MI or angina. This is just a dull, long lasting feeling of weight on my chest. It is worse when I lie down. In fact I am unable to lie down.

I spoke to my respiratory consultant about this and he ordered an echo. I had my echo last week. I am very interested to see if there is evidence of CHF or Pulmonary hypertension. I am yet to hear from my consultant but he implied that the next step would be to put me on ambulatory oxygen. He said the respiratory nurses will deal with that and that I was to see him in 6 months for a review appointment.

Now here is where I would like my guidance.
I am a bit worried that my doctors will put me on ambulatory oxygen to relieve the symptoms without trying to resolve the underlying condition. I am also worried that wont get to talk to a doctor about the results of my echo. If my echo shows evidence of CHF or Pulmonary hypertension, should I be requesting that pharmacological intervention (ACE inhibitors, digoxin, diuretics, ect) be carried out to relieve the strain and load on my heart which may relieve the breathlessness? Or should I just accept the fact that I have to carry round oxygen wherever I go? Is oxyen a first line treatment? Should I be speaking to a cardiologist or is a respiratory specialist adequate to manage my condition?
I just want some information at hand for when I have this discussion with the department.
What I have also noticed is that previously, my usual resting HR was between 95-105. Tachy for normal people but it seemed to be normal for me, on account of my one lung. Recently my HR is always low at 70-80. Even when breathless and exerting myself it rarely goes as high as it used to. Am I showing signs of decompensation? Is my heart no longer able to compensate and keep up?

We don’t have the results of my echo yet, but what are my options?

Thank you for your help.

Hello Dr. Thank you for your kind and informative reply.

Just to correct a couple of things.

I am not on oxygen therapy currently. I do not use oxygen. I use BIPAP non invasive ventilation for 8 hours at home to manage my CO2 retention.

I am already on Azithromicin 3 times a week as prohylaxis. And i also take annual flu vaccine.


Below are my Echo Results. I wonder if you would be kind enough to advise me based on the results and also my history above, and advise me on my options, in your opinion.

Just to summarize.

My resting sats range between 96% - 99%
Resting HR between 77-88

Sats on exertion drop to 84-88%
HR rises to 100

No current peripheral Oedama.
Feeling of weight on my chest especially when supine.
No acute chest pain.
No nausea, dizziness, syncope, etc.

MANY MANY THANKS

ECHO RESULTS:

Interpretation Summary
LV systolic function low normal-mildly inco-ordinate septum.
Grade II diastolic dysfunction.
RV radial systolic function mildly reduced, RV longitudinal function normal.

Left Ventricle
The left ventricle is normal in size. There is normal left ventricular wall thickness. Left ventricular systolic function is low normal. Mildly inco-ordinate septum. Est EF 50-55%. The transmitral spectral Doppler flow is suggestive of pseudonormalisation

Right Ventricle
The right ventricle is normal size. There is normal right ventricular wall thickness. Rv longitudinal function within normal limits. RV radial function appears mildly reduced.

Atria
LA appears normal size in relation to LV. RA appears normal size in relation to RV.

Mitral Valve
Opens well. Leaflets thin and pliable. No mitral regurgitation noted

Tricuspid Valve
Tricuspid valve leaflets open well. Leaflets thin and pliable. There is trace tricuspid regurgitation. Unable to measure PAPs and Jet.

Aortic Valve
Unable to clearly image 3 leaflets, RCC and NCC thin and pliable LCC not imaged to assess. No aortic regurgitation is present.

Pulmonic Valve
The pulmonic valve is not well visualised. Normal velocities on Doppler. Mild pulmonic valvular regurgitation.

Great Vessels.
The aortic root is normal size.

MMode/2D Measurements & Calculations
IVSd 0.77cm (<1.2cm)
LVIDd 2.5cm (2.4-5.6cm)
LVFWd (<1.2cm)

As always you are very informative and clear. I thank you for this.

Just a correction - my EF is 50-55% (not 55-60%). This is on the mild side of defficient i understand.

I will feel comfortable discussing my options with my specialist now that i have your valuable information. If you dont mind, i will let you know what he says.

One more thing.
Is it true that pharmacological intervention (diuretics, ACE inhibitors, etc) for cardiac dysfuntion of this type is only proven effective for systolic dysfunction? And i gather my dysfuntion is dyastolic? Have you been able to treat patients with similar symptoms and condition and has it reduced their breathlesness? I know cases cannot be compared and this would only be anecdotal evidence, but i am interested to know if diuretics (in the absence of existing pitting eodema) can help with the dyspnea.

I really hope the specialist decides to intervene in the hope that my quality of life improves and i am able to become mobile again. The breathlessness is too much, but all the more surprising to see my sats so high at rest.

Thanks once again.

Many thanks again for your prompt and informative reply. You really are a great help.

I wanted to update you on my discussion with my respiratory consultant today.
He says that he is happy with my echo and see's no evidence of elevated pressures around the heart. He says there is no indication of Pulmonary Hypertension. He is also happy with my lung function. He is writing to my GP to advice him accordingly of this and has concluded that no intervention is required.

I am seriously considering getting a second opinion from a private cardiac specialist. I have a good relationship with my respiratory consultant and i respect him alot. However i am surprised that he is happy to leave me for another 6 months by saying "everything is fine" when i am hardly able to lie back supine (due to feeling of pressure and weight on my chest and breathlessness) and that i desaturate so drasticallly on minimal exertion. In light of this, i wonder if i may benefit with an opinion from someone like yourself (Cardiac specialist).

My respiratory consultant has concluded no need for LTOT (Long term O2) and no need for pharmacological management. Based on my previous and recent history and based on my echo results, would you neccesarily agree with this?

I look forward to your insight.

Many thanks once again.