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Vol. 67, No. 1, 2000
Issue release date: January–February 2000
Respiration 2000;67:98–100
(DOI:10.1159/000029472)

Trepopnea due to Recurrent Lung Cancer

Tsunezuka Y.a · Sato H.a · Tsukioka T.a · Shimizu H.b
Departments of aThoracic Surgery and bRadiology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
email Corresponding Author

Abstract

Trepopnea is a condition whereby breathing may be comfortable in one position but difficult or labored in another. A unique case with trepopnea due to recurrent lung cancer with right main pulmonary artery stenosis and left main bronchus obstruction is presented. The patient had developed trepopnea 3 months earlier, but developed orthopnea shortly before he was admitted to our hospital. An emergent wall stent implantation was performed via the right femoral vein in the sitting position with the patient’s leg stretched out. The symptoms and respiratory function improved after stent implantation.

Copyright © 2000 S. Karger AG, Basel


 Outline


 goto top of outline Key Words

  • Pulmonary artery stenosis
  • Lung cancer
  • Stent
  • Trepopnea

 goto top of outline Abstract

Trepopnea is a condition whereby breathing may be comfortable in one position but difficult or labored in another. A unique case with trepopnea due to recurrent lung cancer with right main pulmonary artery stenosis and left main bronchus obstruction is presented. The patient had developed trepopnea 3 months earlier, but developed orthopnea shortly before he was admitted to our hospital. An emergent wall stent implantation was performed via the right femoral vein in the sitting position with the patient’s leg stretched out. The symptoms and respiratory function improved after stent implantation.

Copyright © 2000 S. Karger AG, Basel


goto top of outline introduction

Trepopnea is an uncommon pattern of breathlessness that occurs exclusively in a lateral body position. Originally described in patients with heart disease, it is thought to result from distortion of the great vessels in one posture versus the other. It has also been described in patients with pulmonary disease and related to the observation that patients with unilateral lung disease have lower oxygen tension when they lie on the lateral side with the affected lung down. We report an interesting case of lung cancer with a complaint of trepopnea, and will discuss the unique physiology of this case.

 

goto top of outline case report

A 57-year-old male patient developed progressive shortness of breath over a 3-month period. The symptom was most severe in the right lateral position, but improved when lying on his left side. He noted a choking sensation when lying in the supine or right lateral position and dyspnea when he visited the emergency department of Ishikawa Prefectural Central Hospital. Three years earlier, he had undergone a left lower lobectomy for poorly differentiated squamous cell carcinoma of the lung (pT1N0M0). Physical examination on admission revealed tachycardia and tachypnea. The breath sounds were diminished with a coarse crackle over the left upper lung field. The second heart sound was split. Arterial blood gas analysis in the sitting position demonstrated PaO2 of 68.5 mm Hg and oxygen saturation of 92.4% in room air, which improved to 90.4 mm Hg and 96.0% in 100% oxygen. In the supine position or right lateral position, oxygen saturation rapidly decreased to 70% even when 100% oxygen inhalation was given, so he could not lie down. Especially in the right lateral position, the patient complained about severe dyspnea, oxygen saturation decreased to less than 50% when 100% oxygen inhalation was given. Respiratory function studies revealed obstructive change with FVC of 3.22 liters (predicted 3.43), FEV1.0/FVC ratio of 56.2% (predicted 69.8) and MMF of 1.01 liters/s (predicted 3.51 liters). Chest X-ray suggested stenosis of the left main bronchus. Enhanced helical computed tomography (CT) of the chest in the left hemilateral position showed right main pulmonary artery and left main bronchus stenosis (fig. 1). These findings indicated recurrent lung cancer with mediastinal lymph node metastasis. ECG demonstrated no abnormalities other than sinus tachycardia and pulmonary P wave. A metallic expandable stent was inserted into the main right pulmonary artery via the right femoral vein in the sitting position because he could not remain in the supine position due to dyspnea. He sat in a reclining chair and his right leg was stretched to establish a flat right inguinal region. The technique of stent implantation was previously described in detail [1]. The procedure was performed under local anesthesia. After achieving venous access, heparin was administered (50 U/kg) intravenously, and the activated clotting time maintained above 250 s. A guidewire with a polyethylene angiographic catheter (JB-1-5.0B, 100 cm, Cook, USA) was placed in the proximal right pulmonary artery over the stenotic segment after pulmonary artery angiography. A wall stent with a delivery device system, 50 mm long, 10 mm in diameter (8 Fr, Schneider, USA) was used. Soon after stent implantation, symptoms improved and he could lay in the supine position and sleep well 3 days later. Five days following implantation, bronchoscopic examinations revealed 80% obstruction of the left main bronchus due to lung cancer. Histological examinations of biopsy specimens obtained using a bronchofiber revealed squamous cell carcinoma corresponding to primary lung cancer that had been resected 3 years earlier. One week later, he underwent radiation therapy with a total of 72 Gy for interbronchial cancer of the left main bronchus and mediastinal metastasis. After radiation therapy, the left main bronchus was open and stenosis of the right main pulmonary artery was patent with the stent (fig. 2). Respiratory function studies revealed improvement with FVC of 3.22 liters, FEV1.0/FVC ratio of 78.9% and MMF of 2.47 liters/s. Two months after discharge, the patient did not complain of dyspnea and could sleep well in the supine and right lateral positions.

FIG01

Fig. 1. Computed tomography of the chest shows right main pulmonary and left main bronchial stenosis caused by mediastinal recurrence of lung cancer.

FIG02

Fig. 2. Computed tomography of the chest after stent implantation and radiation therapy showed the pulmonary artery and the bronchus are open.

 

goto top of outline discussion

The term ‘trepopnea’, first used to express difficulty in breathing while lying on one side, is derived from the Greek words ‘trepin’, to turn, and ‘pnea’ to breathe [2]. In general, trepopnea is a striking symptom with marked dyspnea and oxygen desaturation in the affected lateral position. The present case is interesting because the patient’s shortness of breath was aggravated in the right lateral position and improved when lying on the left side, despite severe left main bronchus stenosis.

This case exhibited mediastinal lymph node swelling due to lung cancer metastasis. In addition to the left main bronchus stenosis, the right main pulmonary artery stenosis induced severe dyspnea due to ventilation/perfusion disequilibrium. The result was that the patient felt a choking sensation especially when lying on his right side despite the left pulmonary disease. In general, trepopnea is attributed to heart disease, and has also been found in patients with pulmonary disease [3, 4, 5]. Blood flow to the left pulmonary artery was clearly inhibited in the right lateral position due to gravity because the right main pulmonary artery was stenotic. This finding demonstrates that circulatory dynamics strongly influence respiratory symptoms, such as dyspnea. We thought that the symptom was due to the stenotic right pulmonary artery unable to accommodate the increased flow to the right lung caused by the hypoxic vasoconstriction of the left lung and the consequent shunt to the right lung.

The symptoms in our patient did not improve immediately after stent implantation. The symptom reduced gradually, and disappeared 3 days later. These findings may have been due to the large volume of right-to-left shunting already presented in the left lung and the functional inability of the right pulmonary vessels to keep up with the rapid increase in blood flow.


 goto top of outline References
  1. O’Laughlin MP: Catheterization treatment of stenosis and hypoplasia of pulmonary arteries. Pediatr Cardiol 1998;19:48–56.
  2. Wood FC: Trepopnea. Arch Intern Med 1959;104:966.
  3. Winters WL Jr, Cartes F, McDonough M, et al: Venoarterial shunting from inferior vena cava to left atrium in atrial septal defects with normal heart pressures. Am J Cardiol 1967;19:293–300.

    External Resources

  4. Mercho N, Stoller JL, White RD, et al: Right-to-left interatrial shunt causing platypnea after pneumonectomy: A recent experience and diagnostic value of dynamic magnetic resonance imaging. Chest 1994;105:931–933.
  5. Alfaifi S, Lapinsky SE: Trepopnea due to interatrial shunt following lung resection. Chest 1998;113:1726–1727.

 goto top of outline Author Contacts

Yoshio Tsunezuka, MD, PhD
Department of Thoracic Surgery
Ishikawa Prefectural Central Hospital
Kanazawa, 920-8530 (Japan)
Tel. +81 76 237 8211, Fax +81 76 238 2337, E-Mail tsune@ipch.kanazawa.ishikawa.jp


 goto top of outline Article Information

Received: Received: November 20, 1998
Accepted after revision: April 6, 1999
Number of Print Pages : 3
Number of Figures : 2, Number of Tables : 0, Number of References : 5


 goto top of outline Publication Details

Respiration (International Review of Thoracic Diseases)
Founded 1944 as ‘Schweizerische Zeitschrift für Tuberkulose und Pneumonologie’ by E. Bachmann, M. Gilbert, F. Häberlin, W. Löffler, P. Steiner and E. Uehlinger, continued 1962–1967 as ‘Medicina Thoracalis’

Vol. 67, No. 1, Year 2000 (Cover Date: January-February 2000)

Journal Editor: C.T. Bolliger, Cape Town
ISSN: 0025–7931 (print), 1423–0356 (Online)

For additional information: http://www.karger.com/journals/res


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Trepopnea is a condition whereby breathing may be comfortable in one position but difficult or labored in another. A unique case with trepopnea due to recurrent lung cancer with right main pulmonary artery stenosis and left main bronchus obstruction is presented. The patient had developed trepopnea 3 months earlier, but developed orthopnea shortly before he was admitted to our hospital. An emergent wall stent implantation was performed via the right femoral vein in the sitting position with the patient’s leg stretched out. The symptoms and respiratory function improved after stent implantation.

Copyright © 2000 S. Karger AG, Basel



 goto top of outline Author Contacts

Yoshio Tsunezuka, MD, PhD
Department of Thoracic Surgery
Ishikawa Prefectural Central Hospital
Kanazawa, 920-8530 (Japan)
Tel. +81 76 237 8211, Fax +81 76 238 2337, E-Mail tsune@ipch.kanazawa.ishikawa.jp


 goto top of outline Article Information

Received: Received: November 20, 1998
Accepted after revision: April 6, 1999
Number of Print Pages : 3
Number of Figures : 2, Number of Tables : 0, Number of References : 5


 goto top of outline Publication Details

Respiration (International Review of Thoracic Diseases)
Founded 1944 as ‘Schweizerische Zeitschrift für Tuberkulose und Pneumonologie’ by E. Bachmann, M. Gilbert, F. Häberlin, W. Löffler, P. Steiner and E. Uehlinger, continued 1962–1967 as ‘Medicina Thoracalis’

Vol. 67, No. 1, Year 2000 (Cover Date: January-February 2000)

Journal Editor: C.T. Bolliger, Cape Town
ISSN: 0025–7931 (print), 1423–0356 (Online)

For additional information: http://www.karger.com/journals/res


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. O’Laughlin MP: Catheterization treatment of stenosis and hypoplasia of pulmonary arteries. Pediatr Cardiol 1998;19:48–56.
  2. Wood FC: Trepopnea. Arch Intern Med 1959;104:966.
  3. Winters WL Jr, Cartes F, McDonough M, et al: Venoarterial shunting from inferior vena cava to left atrium in atrial septal defects with normal heart pressures. Am J Cardiol 1967;19:293–300.

    External Resources

  4. Mercho N, Stoller JL, White RD, et al: Right-to-left interatrial shunt causing platypnea after pneumonectomy: A recent experience and diagnostic value of dynamic magnetic resonance imaging. Chest 1994;105:931–933.
  5. Alfaifi S, Lapinsky SE: Trepopnea due to interatrial shunt following lung resection. Chest 1998;113:1726–1727.