Treatment of pulmonary congestion
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Treatment of Pulmonary Congestion: Current Strategies and Emerging Therapies
Traditional Approaches to Pulmonary Congestion Treatment
Diuretics and Vasodilators
Pulmonary congestion, a hallmark of heart failure, has traditionally been managed by reducing pulmonary capillary hydrostatic pressure. This is typically achieved through the use of diuretics, which decrease total intravascular volume, and vasodilators, which reduce afterload2. These methods aim to alleviate the symptoms by lowering the pressure that forces fluid out of the capillaries and into the lung tissue.
Sublingual Nitroglycerin
In cases of acute pulmonary congestion, particularly in patients with valvular heart disease, sublingual nitroglycerin (SNG) has proven effective. SNG rapidly decreases systolic pulmonary arterial pressure and pulmonary capillary wedge pressure, leading to significant symptom relief within minutes4.
Novel Therapeutic Targets
TRPV4 Channel Blockade
Recent studies have identified the transient receptor potential vanilloid 4 (TRPV4) channel as a novel target for reducing lung water. TRPV4 regulates fluid transit across the pulmonary capillary interface and its blockade has shown promise in reducing lung congestion independent of pulmonary capillary hypertension1 2. This approach addresses the active endothelial signaling pathways that contribute to increased vascular permeability and edema formation under conditions of elevated pulmonary pressures2.
Carperitide
Carperitide, a treatment used in Japan for acute heart failure, has shown efficacy in reducing pulmonary congestion. In patients with moderate to severe congestion, carperitide significantly decreased the rate of remaining congestion at discharge and improved long-term outcomes, including reduced rates of death and rehospitalization5.
Non-Invasive Monitoring and Management
Lung Ultrasound
Lung ultrasound has emerged as a reliable technique for estimating lung water and detecting asymptomatic lung congestion, particularly in patients with chronic kidney disease (CKD) and heart failure. This method allows for the early identification and management of pulmonary congestion, potentially improving patient outcomes by preventing acute exacerbations7.
Remote Dielectric Sensing (ReDS)
ReDS technology offers a non-invasive method to quantify lung fluid content and monitor pulmonary congestion. This technology has shown high reliability in identifying elevated pulmonary capillary wedge pressure, making it a valuable tool for managing heart failure patients and optimizing therapies such as adaptive servo-ventilation (ASV)8.
Advanced Therapies
Cardiac Resynchronization Therapy (CRT)
CRT has been shown to improve pulmonary function in heart failure patients by increasing lung volumes and bronchial conductance, thereby reducing pulmonary congestion. This therapy enhances overall cardiac function, which in turn alleviates the symptoms of lung congestion and improves exercise capacity9.
Sacubitril/Valsartan
In patients with acute myocardial infarction complicated by reduced left ventricular ejection fraction and pulmonary congestion, sacubitril/valsartan has demonstrated efficacy in reducing B-lines, a marker of lung congestion, over time. This reduction is associated with improved cardiac structure and function, highlighting the potential of this therapy in managing pulmonary congestion post-myocardial infarction10.
Conclusion
The treatment of pulmonary congestion has evolved from traditional diuretics and vasodilators to include novel targets like the TRPV4 channel and advanced therapies such as CRT and sacubitril/valsartan. Non-invasive monitoring techniques like lung ultrasound and ReDS technology are enhancing the ability to manage and treat pulmonary congestion effectively. These advancements offer promising avenues for improving patient outcomes in heart failure and other conditions associated with pulmonary congestion.
Sources and full results
Most relevant research papers on this topic
Targeting pulmonary capillary permeability to reduce lung congestion in heart failure: a randomized, controlled pilot trial
TRPV4 blockade shows potential as a safe and effective treatment for reducing lung congestion in heart failure patients, independent of pulmonary capillary hypertension.
RCTA novel strategy for the management of lung congestion: targeting TRPV4 channel, the ‘gate keeper’ of pulmonary capillary permeability
Targeting TRPV4, the 'gate keeper' of pulmonary capillary permeability, may be a promising strategy for managing lung congestion in heart failure patients.
Pulmonary Congestion and Its Treatment.—I
Pulmonary Congestion and Its Treatment?i. Bv Sir Benjamin Ward Richardson, M.D., F.R.S. Fbom the various observations made in the previous papers in this journal, all bearing upon the lesser circulation, I am naturally led to consider the treatment of pulmonary congestion. If nothing had been said bearing upon the physics of this question, sufficient has arisen in the last two months to attract practical attention. In the late epidemic we have been doing very little more than meet the symptoms of congestion of the lungs, congestion being almost synonymous with what is called influenza. I have not met with a single case of the disease that could be
Relief of pulmonary congestion by sublingual nitroglycerin in patients with mitral valve disease.
Sublingual nitroglycerin effectively relieves acute pulmonary congestion in patients with valvular heart disease, improving clinical symptoms and reducing systolic pulmonary arterial pressure.
Case ReportEffects of Carperitide on Degree of Pulmonary Congestion in Treatment of Acute Heart Failure.
Carperitide is associated with more effective decongestion in acute heart failure patients with moderate-severe pulmonary congestion and better long-term prognosis.
Observational StudyAnti-inflammatory actions of herbal medicines in a model of chronic obstructive pulmonary disease induced by cigarette smoke.
Herbal medicines show synergistic and protective effects in reducing inflammation and preventing lung damage in a cigarette smoke-induced chronic obstructive pulmonary disease model.
RCT
Animal Study
Rigorous JournalDetecting and Treating Lung Congestion with Kidney Failure.
Lung ultrasound can safely relieve lung congestion in kidney failure patients, but does not significantly reduce the risk of death, nonfatal myocardial infarction, and decompensated heart failure.
Assessment of pulmonary congestion is of prime importance
ASV therapy improves pulmonary congestion and reduces readmissions and medical costs in chronic heart failure patients, with noninvasive tools like remote dielectric sensing potentially replacing invasive approaches.
Rigorous JournalEffect of cardiac resynchronization therapy on pulmonary function in patients with heart failure.
Cardiac resynchronization therapy (CRT) improves lung volumes and bronchial conductance in heart failure patients, leading to improved breathing patterns and decreased hyperventilation.
Non-RCTTrajectory and correlates of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction: Insights from PARADISE-MI.
Pulmonary congestion in acute myocardial infarction patients decreases from baseline to follow-up, with worse congestion associated with prognostically important echocardiographic markers.
Observational Study