Pulmonary hypertension in chronic obstructive pulmonary disease

Hipertensión pulmonar en la enfermedad pulmonar obstructiva crónica

Published 2010-06-01

Open | Download
PDF (Spanish) FLIP
Issue
Vol. 22 No. 2 (2010)
Section
Revisión de tema
How to Cite
Pulmonary hypertension in chronic obstructive pulmonary disease.
rev. colomb. neumol. [Internet]. 2010 Jun. 1 [cited 2024 Dec. 4];22(2):42-57.
DOI
license

Ninguna publicación, nacional o extranjera, podrá reproducir ni traducir sus artículos ni sus resúmenes sin previa autorización escrita del editor; sin embargo  los usuarios pueden descargar la información contenida en ella, pero deben darle atribución o reconocimiento de propiedad intelectual, deben usarlo tal como está, sin derivación alguna.

Carlos E. Aguirre Franco
Residente de Neumología de último año, Universidad de La Sabana, Fundación Neumológica Colombiana. Bogotá, Colombia.
    Carlos A. Torres-Duque
    Neumólogo, Director Departamento de Investigación y Docencia. Fundación Neumológica Colombiana. Profesor, Universidad de La Sabana. Bogotá, Colombia
      Show authors biography

      Pulmonary hypertension (PH) is a relatively common complication of chronic obstructive pulmonary disease (COPD). Its appearance during the course of COPD is associated with a worsened prognosis, due to reduced life expectancy and greater use of healthcare resources. Although a well-defined lineal relationship has not been shown, the prevalence of PH in patients with COPD is higher in cases characterized by greater obstruction and severity. PH is infrequent in cases of mild and moderate COPD. In cases of COPD, PH is generally mild or moderate, and seldom impairs right ventricular function. In many cases it is not apparent during rest, and manifests itself during exercise. PH can be severe or "out of proportion" with the severity of COPD. In this situation, the possibility of associated conditions should be explored, although COPD might be the only final explanation. There is scarce knowledge about the prevalence and behavior of PH in patients with COPD residing at intermediate and high altitudes (>2.500 meters above sea level), which is a common situation in Latin America and Asia. PH in COPD is not exclusively related with hypoxia/hypoxemia and hypercapnia. The mechanical disturbances
      related with COPD (hyperinflation and high alveolar pressure) and inflammation may prevail as causes of endothelial injury and remodeling of pulmonary circulation, which contribute to increased pulmonary vascular pressure and resistance.

      The appearance of signs of cor pulmonale indicates advanced PH. This condition should therefore be suspected early when dyspnea, hypoxemia, and impairment of diffusion are not in keeping with the degree of obstruction. PH is confirmed by Doppler echocardiography. Right heart catheterization may be justified in selected cases. Long-term oxygen therapy is the only intervention proven to be temporarily useful. Conventional vasodilators do not produce
      medium- or long-term improvement and can be detrimental to the ventilation-perfusion relation. Neither do the newer therapies for PH appear to be a therapeutic option, except in cases of "out of proportion" PH, in which other factors besides COPD could be present. Lack of knowledge about the behavior of PH in patients with COPD residing at intermediate and high altitudes opens a field for research on oxygen- and drug-therapies in these conditions.

      Article visits 1022 | PDF visits 176

      Downloads

      Download data is not yet available.
      1. GOLD. Global initiative for chronic obstructive lung disease.Global Strategy for Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (Update 2009). www.goldcopd.com.
      2. Menezes AM, Pérez-Padilla R, Jardim JR, et al. Chronic obstructive pulmonary disease in five Latin American cities (The PLATINO study): a prevalence study. Lancet 2005; 366:1875-81.
      3. Mannino DM, Buist AS. Global burden of COPD: risk factors, prevalence, and future trends. Lancet 2007; 370(9589): 765-73.
      4. Caballero A, Torres-Duque C., Jaramillo C., Bolívar F, Sanabria F, Osorio P, Orduz C, Guevara DP, Maldonado D. Prevalence of COPD in five Colombian cities situated at low, medium, and high altitude (PREPOCOL study). Chest 2008; 133: 343-9.
      5. Pauwels RA, Rabe KF. Burden and clinical features of chronic obstructive pulmonary disease (COPD). Lancet 2004; 364:613-20.
      6. Hurd S. The Impact of COPD on Lung Health Worldwide: Epidemiology and Incidence Chest 2000; 117: 1S-4S
      7. Christopher JL Murray DPhil, Alan D Lopez PhD. Alternative projections of mortality and disability by cause 1990-2020: Glo- bal Burden of Disease Study. Lancet 1997; 349: 1498-504.
      8. Park VMH, Rosenson RS, Rubin LJ, Tapson VF, Farber H, Lindner JR, et al. Thoracic Society, Inc.; and the Pulmonary Hypertension Association in Collaboration with the American College of Chest Physicians; American Expert Consensus Documents and the American Heart Association Developed Report of the American College of Cardiology Foundation Task Force on ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension: J Am ColL Cardiol 2009; 53: 1573-619.
      9. Scharf SM, Iqbal M, Keller C, Criner G, Lee S, Fessler HE. Hemodynamic characterization of patients with severe emphysema. Am J Respir Crit Care Med 2002; 166: 314-22.
      10. Doi M, Nakano K, Hiramoto T, et al. Significance of pulmonary artery pressure in emphysema patients with mild-to-moderate hypoxemia. Respiratory Medicine 2003; 97: 915-20.
      11. Thabut G, Dauriat G, Stern JB, et al. Pulmonary hemodynamics in advanced COPD candidates for lung volume reduction surgery or lung transplantation. Chest 2005; 127: 1531-6.
      12. Kessler R, Faller M, Weitzenblum E, et al. «Natural history» of pulmonary hypertension in a series of 131 patients with chronic obstructive lung disease. Am J Respir Crit Care Med 2001;164:219-24.
      13. Chaouat A, Bugnet AS, Kadaoui N, et al. Severe pulmonary hypertension and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005; 172: 189-94.
      14. Weitzenblum E, Sautegeau A, Ehrhart M, Mammosser M, Hirth C, Roegel E. Long-term course of pulmonary arterial pressure in chronic obstructive pulmonary disease. Am Rev Respir Dis 1984; 130: 993-8.
      15. Kessler R, Faller M, Fourgaut G, Mennecier B, Weitzenblum E. Predictive factors of hospitalization for acute exacerbation in a series of 64 patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159: 158-64.
      16. Barberà JA, Peinado VI, Santos S. Pulmonary hypertension in chronic obstructive pulmonary disease. Eur Respir J 2003 ;21:892-905
      17. Sin DD, Paul SF. Is Systemic Inflammation Responsible for Pulmonary Hypertension in COPD? Chest 2006; 130: 310-2.
      18. Scharf SM, Iqbal M, Keller C, Criner G, Lee S, Fessler HE. National Emphysema Treatment Trial (NETT) Group. Hemodynamic characterization of patients with severe emphysema. Am J Respir Crit Care Med 2002; 166: 314-22.
      19. Portillo K, Torralba Y, Blanco I, Pizarro S, Gómez F. Característi- cas de la hemodinámica pulmonar en la enfermedad pulmonar obstructiva crónica. Arch Bronconeumol 2008; 44: 15-6.
      20. Bratel T. Pulmonary circulation in Chronic Obstructive Pulmonary Disease (COPD). Clin Pulmon Med 2010; 17: 116-6.
      21. Barberà JA, Blanco I. Pulmonary Hypertension in Patients with Chronic Obstructive Pulmonary Disease: Advances in Pathophysiology and Management. Drugs 2009; 69: 1153-71.
      22. Jason X, Yuan J. Hypoxic Pulmonary Vasoconstriction: Cellular and Molecular Mechanisms. New York: Kluwer Academic Publishers; 2004. p. 3.
      23. RaniereVM, Dambrosio M, Birenza N. Intrinsic PEEP and cardiopulmonary interaction in patients with COPD and acute ventilatory failure. Eur Respir J 1996; 9: 1283-92.
      24. McFarlane PA, Gardaz JP, Sykes MK. CO2 and mechanical factors reduce blood flow in a collapsed lung lobe. J Appl Physiol 1984;57(3): 739-43.
      25. Jyothula S, Safda Z. Update on pulmonary hypertension complicating chronic obstructive pulmonary disease. Int J COPD 2009; 4: 351-63.
      26. Yu AY, Frid MG, Shimoda LA, Wiener CM, Stenmark K, Semenza GL. Temporal, spatial, and oxygen-regulated expression of hypoxia-inducible factor-1 in the lung. Am J Physiol 1998; 275: L818-26.
      27. Semenza GL. HIF-1: mediator of physiological and pathophysiological responses to hypoxia. J Appl Physiol 2000;88: 1474-80.
      28. Hu J, Discher DJ, Bishopric NH, Webster KA. Hypoxia regulates expression of the endothelin-1 gene through a proximal hypoxia- inducible factor-1 binding site on the antisense strand. Biochem Biophys Res Commun 1998; 245: 894-9.
      29. Defouilloy C, Teiger E, Sediame S, et al. Polycythemia impairs vasodilator response to acetylcholine in patients with chronic hypoxemic lung disease. Am J Respir Crit Care Med 1998; 157:1452-60.
      30. Deem S, Swenson ER, Alberts MK, Hedges RG, Bishop MJ. Red- blood-cell augmentation of hypoxic pulmonary vasoconstriction. Hematocrit dependence and the importance of nitric oxide. Am J Crit Care Med 1998; 157: 1181-6.
      31. Deem S, Berg JT, Kerr ME, Swenson ER. Effects of theRBC membrane and increased perfusate viscosity on hypoxic pulmonary vasoconstriction. J Appl Physiol 2000; 88: 1520-8.
      32. Biernacki W, Gould GA, Whyte KF, Flenley DC. Pulmonary hemodynamics, gas exchange, and the severity of emphysema as assessed by quantitative CT scan in chronic bronchitis and emphysema. Am Rev Respir Dis 1989; 139: 1509-15.
      33. Joppa P, Petrasova D, Stancak B, et al. Systemic inflammation in patients with COPD and pulmonary hypertension. Chest 2006;130: 326-33.
      34. De Torres JP, Cordoba-Lanus E, Lopez-Aguilar C, et al. C-reactive protein levels and clinically important predictive outcomes in stable COPD patients. Eur Respir J 2006; 27: 902-7.
      35. Hoeper MM, Welte T. Systemic Inflammation,COPD, and Pulmonary Hypertension. Chest 2007; 131; 634-5.
      36. Peinado VI, Barberá JA, Abate P, Ramírez J, Roca J, Santos S, Rodriguez-Roisin R. Inflammatory reaction in pulmonary muscu- lar arteries of patients with mild chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 159: 1605-11.
      37. Barberá JA, Riverola A, Roca J, Ramírez J, Wagner PD, Ros D, et al. Pulmonary vascular abnormalities and ventilation-perfusion relationships in mild chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1994; 149: 423-9.
      38. Melgosa M, Peinado VI, Santos S, et al. Expression of endothelial nitric oxide synthase (eNOS) and endothelin-1 (ET-1) in pulmonary arteries of patients with severe COPD. Eur Respir J 2003; 22: 20s-25s
      39. Barberá JA, Peinado VI, Santos S, et al. Reduced expression of endothelial nitric oxide synthase in pulmonary arteries of smokers. Am J Respir Crit Care Med 2001; 164 (4): 709-13.
      40. Haniuda M, Kubo K, Fujimoto K, et al. Effects of pulmonary artery remodeling on pulmonary circulation after lung volume reduction surgery. Thorac Cardiovasc Surg 2003; 51: 154-8.
      41. Elwing J, Panos RJ. Pulmonary hypertension associated with COPD. Int JCOPD 2008; 3: 55-70.
      42. Sekhon HS, Wright JL, Churg A. Cigarette smoke causes rapid cell proliferation in small airways and associated pulmonary arteries. Am J Physiol 1994; 267:L557-L563.
      43. Peinado VI, Barberá JA, Ramírez J, et al. Endothelial dysfunction in pulmonary arteries of patients with mild COPD. Am J Physiol 1998; 274: L908-L913.
      44. Weitzenblum E, Chaouat A, Kessler R y Canuet M. Overlap Syndrome Obstructive Sleep Apnea in Patients with Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc 2008; 5:237–241,
      45. Castaldi PJ, Hersh CP, Reillr JJ, Silverman E K. Genetic associations with hypoxemia and pulmonary arterial pressure in COPD. Chest 2009; 135: 737-44.
      46. Eddahibi S, Chaouat A, Morrell N, et al. Polymorphism of the serotonin transporter gene and pulmonary hypertension in chronic obstructive pulmonary disease. Circulation 2003; 108:1839-44.
      47. Yildiz P, Oflaz H, Cine N, et al. Gene polymorphisms of endothelial nitric oxide synthase enzyme associated with pulmonary hypertension in patients with COPD. Respir Med 2003; 97: 1282-88.
      48. Santos S, Peinado VI, Ramirez J, et al. Characterization of pulmonary vascular remodelling in smokers and patients with mild COPD. Eur Respir J 2002; 19: 632-8.
      49. Weitzenblum E, Sautegeau A, Ehrhart M, Mammosser M, Hirth C, Roegel E. Long-term course of pulmonary arterial pressure in chronic obstructive pulmonary disease. Am Rev Respir Dis 1984;130: 993-8.
      50. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med 1980; 93: 391-8.
      51. Timms RM, Khaja FU, Williams GW.Hemodynamic response to oxygen therapy in chronic obstructive pulmonary disease. Ann Intern Med 1985; 102: 29-36.
      52. Zielinski J, Tobiasz M, Hawrylkiewicz I, Sliwinski P, Palasiewicz G. Effects of Long-term Oxygen Therapy on Pulmonary Hemodynamics in COPD Patients. A 6-Year Prospective Study. Chest 1981; 113: 65-70.
      53. Weitzenblum E. Chronic cor pulmonale. Heart 2003; 89: 225-30.
      54. Weitzenblum E, Chaouat A. Review Series: Heart and Lung Disease, Cor pulmonale. Chronic Respiratory Disease 2009; 6:177-85.
      55. Macnee W. Pathophysiology of cor pulmonale in chronic obstructive pulmonary. Part one. Am J Respir CritCare Med 1994;150: 833-42.
      56. Barr RG, Bluemke DA, Ahmed FS, et al. Percent emphysema, airflow obstruction, and impaired left ventricular filling. N Eng J Med 2010; 362: 217-27.
      57. Macnee W. Pathophysiology of cor pulmonale in chronic obstructive pulmonary. Part two. Am J Respir Crit Care Med. 1994; 150: 1158- 68.
      58. McGoon M, Gutterman D, Steen V, et al.Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004; 126:14S-34S.
      59. Salvaterra CG, Rubin LJ. Investigation and management of pulmonary hypertension in chronic obstructive pulmonary disease. Am Rev Respir Dis 1993; 148: 1414-7.
      60. Chhabra SK, De S. Clinical significance of hilar thoracic index and width of right descending branch of pulmonary artery in chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci 2004; 46: 91-9.
      61. Tan RT, Kuzo R, Goodman LR, et al. 1998. Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease. Chest 1998; 113: 1250-6.
      62. Bush A, Gray H, Denison D M. Diagnosis of pulmonary hypertension from radiographic estimates of pulmonary arterial size. Thorax 1988; 43:127-31.
      63. Harrigan RA, Jones K. ABC of clinical electrocardiography. Conditions affecting the right side of the heart. BMJ 2002; 324:1201-4.
      64. Consuegra J. El electrocardiograma aplicado al diagnóstico clí- nico. Primera edición Editorial Imagen gráfica limitada. Bogotá 1987. p. 19- 21.
      65. Chung EK. Diagnóstico del EKG. Segunda Edición. J & C edicio- nes medicas, Barcelona 2003: p. 58-60.
      66. Van Dijk AP, Torbicki A. More on the noninvasive diagnosis of pulmonary hypertension: Doppler echocardiography revisited. Eur Respir J 1995 ; 8:1445-9.
      67. Arcasoy SM, Christie JD, Ferrari VA, et al. Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. Am J Respir Crit Care Med 2003;167:735-40.
      68. Yoc PG, Popp RI. Noninvasive estimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation. Circulation 1984; 70:657-62.
      69. Berger M, Haimowitz A, Van Tosh A, BerdoffRL, Goldberg E.Quantitative assessment of pulmonary hypertension in patients with tricuspid regurgitation using continuous wave Doppler ultrasound. J Am CoIl Cardiol 1985; 6 :359-65
      70. Currie PJ, Seward JB, Chan KL, Fyfe DA, Hagler DJ, Mair DD, et al. Continuous wave Doppler determination of right ventricular pressure: a simultaneous Doppler-catheterization study in 127 patients. J Am CoIl Cardiol 1985; 6: 750-56.
      71. Skjaerpe T, Hatle L. Noninvasive estimation ofsystolic pressure in the right ventricle in patients with tricuspid regurgitation. Eur Heart J 1986; 7: 704-10.
      72. Laaban JP, Diebold B, Zelinski R, Lafay M, H Raffoul H, Rochemaure J. Noninvasive estimation of systolic pulmonary artery pressure using Doppler echocardiography in patients with chronic obstructive pulmonary disease. Chest 1989; 96:1258-62.
      73. Tramarin R, Torbicki A, Marchandise B, Laaban JP, Morpurgo M. Doppler echocardiographic evaluation of pulmonary artery pressure in chronic obstructive pulmonary disease. A European multicentre study. Working Group on Noninvasive Evaluation of Pulmonary Artery Pressure. European Office of the World Health Organization, Copenhagen. Eur Heart J 1991; 12:103-11.
      74. Higham MA, Dawson D, Joshi J, Nihoyannopoulos P, Morrell NW. Utility of echocardiography in assessment of pulmonary hypertension secondary to COPD. Eur Respir J 2001; 17:350-5.
      75. Ben-Dor I, Kramer MR, Raccah A, Iakobishvilli Z, Shitrit D, Sahar G, Hasdai D. Echocardiography versus right-sided heart catheterization among lung transplantation candidates. Ann Thorac Surg 2006; 81 :1056-60.
      76. Vizza CD, Lynch JP, Ochoa LL, Richardson G, Trulock EP. Right and left ventricular dysfunction in patients with severe emphysema. Chest 1998; 113: 576-83.
      77. Fisher MR, Criner GJ, Fishman AP, Hassoun PM, Minai OA, Scharf SM, et al. NETT Research Group. Estimating pulmonary artery pressures by echocardiography in patients with emphysema. Eur Respir J 2007; 30:914-21.
      78. Burgess MI, Mogulkoc N, Bright-Thomas RJ, Bishop P, Egan JJ, Ray SG. Comparison of echocardiographic markers of right ventricular function in determining prognosis in chronic pulmonary disease. J Am Soc Echocardiogr 2002; 15: 633-9.
      79. Himelman RB, Struve SN, Brown JK, Namnum P, Schiller NB. Improved recognition of cor pulmonale in patients with severe chronic obstructive pulmonary disease. Am J Med 1988; 84: 891-8.
      80. Matsuyama W, Ohkubo R, Michizono K, Abe M, Nakamura Y, Kawabata M, et al. Usefulness of transcutaneous Doppler jugular venous echo to predict pulmonary hypertension in COPD patients. Eur Respir J 2001; 17: 1128-31.
      81. Asociación Colombiana de Neumología y Cirugía de Tórax. Villaquiran C, Dueñas R et al. Guías para el diagnóstico y trata- miento de la hipertensión arterial pulmonar. Documento de con- senso colombiano. Rev Colomb Neumol 2010; 16 supl): 1-129.
      82. Gratziou C. Review of current smoking cessation guidelines. Eur Respir Mon 2008; 42: 35-43.
      83. Jiménez-Ruiz CA. Psychological and behavioural interventions for smoking cessation. Eur Respir Mon 2008; 42: 61-73.
      84. Jiménez-Ruiz CA.Pharmacological treatment for smoking cessation. Eur Respir Mon 2008; 42: 74-97.
      85. Páez N, Aguiar P, Casas A. Cesación del tabaquismo. Pers- pectiva Neumológica 2009; 9:1-4.
      86. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med 1980; 93: 391-8.
      87. Medical Research Council Working Party: Long-term domiciliary oxygen therapy. Lancet. 1981; 1:681-6.
      88. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004 ;23(6): 932-46.
      89. Sims MW, Margolis DJ, Localio AR, Panettieri RA, Kawut SM, Christie JD. Impact of Pulmonary Artery Pressure on Exercise Function in Severe COPD. Chest 2009; 136: 412-9.
      90. Gonzalez M, Barrero M, Maldonado D. The major limitation to exercise performance in COPD patients at the altitude of Bo- gotá (2640m)is hypoxemia. Chest 2009; 136: 62S.
      91. Fujimoto K, Matsuzawa Y, Yamaguchi S, Koizumi T, Kubo K. Benefits of oxygen on exercise performance and pulmonary hemodynamics in patients with COPD and mild hypoxemia. Chest 2002; 122: 457-63.
      92. Barberà JA, Blanco I. Pulmonary hypertension in patients with chronic obstructive pulmonary disease: advances in pathophysiology and management. Drugs 2009; 69: 1153-71.
      93. Bales MJ, Timpe EM. Respiratory stimulant use in chronic obstructive pulmonary disease. Ann Pharmacother 2004;38(10): 1722-5.
      94. Packer M. Therapeutic application of calcium-channel antagonists for pulmonary hypertension. Am J Cardiol 1985; 55: 196B-201B.
      95. Gassner A, Sommer G, Fridrich L, Magometschnigg D, Priol A.Differential therapy with calcium antagonists in pulmonary hypertension secondary to COPD. Hemodynamic effects of nifedipine, diltiazem, and verapamil. Chest 1990; 98:829-34.
      96. Croom K F and Curran M P. Sildenafil. A Review of its use in pulmonary arterial hypertension. Drugs 2008; 68: 383-97.
      97. Madden BP, Allenby M, Loke TK, Sheth A.A potential role for sildenafil in the management of pulmonary hypertension in patients with parenchymal lung disease. Vascul Pharmacol 2006; 44:372-6.
      98. Chapman TH, Wilde M, Sheth A, Madden BP. Sildenafil therapy in secondary pulmonary hypertension: Is there benefit in prolonged use. Vascul Pharmacol 2009; 51:90-5.
      99. Holverda RS, Bogaard HJ, Marcus JT, Smit HJ, Westerhof N, Postmus PE, et al. Sildenafil treatment in COPD does not affect stroke volume or exercise capacity. Pulm Pharmacol Ther 2008;21: 558-564
      100. Blanco I, Gimeno E, Munoz PA, Pizarro S, Gistau C, Rodriguez- Roisin R, et al. Hemodynamic and Gas Exchange Effects of Sildenafil in Patients with Chronic Obstructive Pulmonary Disease and Pulmonary Hypertension. Am J Respir Crit Care Med 2010; 181: 270-8.
      101. Stolz D, Rasch H, Linka A, Di Valentino M, Meyer A, Brutsche M, et al. A randomised, controlled trial of bosentan in severe COPD. Eur Respir J 2008; 32: 619-628.
      102. Valerio G, Bracciale P, D’Agostino AG. Effect of bosentan upon pulmonary hypertension in chronic obstructive pulmonary disease. Ther Adv Respir Dis 2009; 3; 15-21.
      103. Hegewald MJ, Elliott G. Sustained Improvement with Iloprost in a COPD Patient with Severe Pulmonary Hypertension. Chest 2009; 135: 536-44.
      104. Richalet JP, Rivera M, Maignan M, Pham I, Privat C, León-Vellarde F. Pulmonary hypertension and Monge´s disease. PVIR review 2009; 1: 114-9.
      105. González-García M, Barrero M, Maldonado D. Exercise Limitation in Patients with Chronic Obstructive Pulmonary Disease at the Altitude of Bogota (2640 m): Breathing Pattern and Arterial Gases at Rest and Peak Exercise. Arch Bronconeumol 2004; 40(2): 54-61.

      Information

      Journal history

      Keywords

      Directories and indexes

      Funding

      Support + Info: Here

       

       

      Google Scholar profile

      Most read in the last 30 days

      Current Issue

      QR code

      Sistema OJS 3.4.0.7 - Metabiblioteca |