Jean Lette MD FCCP; Michel Cerino M...

Jean Lette MD FCCP; Michel Cerino MD; Michel Laverdiere MD; Jacques Tremblay MD; and Julie Prenovault MD

We describe the accident of sudden severe bronchospasm and respiratory arrest following dipyridamole infusion in a patient with chronic obstructive pulmonary disease predominantly of the emphysematous impressed sign The severe reaction was unexpect because the patient had tolerated well withdrawal of aminophylline derivatives for 48 hours and was receiving chronic prednisone 20 mg qd Although the diagnostic and prognostic gains from dipyridamole imaging far outweight the small risk associated with the example patients with chronic pulmonary obstructive disease must be closely monitored during thallium-dipyridamole imaging.

(Chest 1989;95:1345-49)

Exercise thallium-201 myocardial scintigraphy is widely used clinically the two to diagnose coronary artery disease and to evaluate the prognosis of known coronary patients.[1] In patients unable to exercise, similar scintigraphic images can be obtained following pharmacologic coronary vasodilation with dipyridamole.[2] Occasional minor side efficiencys of dipyridamole such as headache, dizziness, noncoronary chest pain, angina (20 to 30 percent) and rarely significant hypotension, are rapidly revers on intravenous aminophylline.[2] Considering the number of "high risk" patients who bear such studies, surprisingly few cases of bitter and irreversible side effects have been reported. Serious complications reported include stiff bronchospasm, myocardial infarction, ventricular arrhythmia and cardiac arrest. In this report, we describe a patient with sharp chronic obstructive pulmonary disease (COPD) predominantly of the emphysematous shadow who developed acute bronchospasm and respiratory arrest following dipyridamole infusion.

CASE REPORT

A 67-year-old retired bus driver was referr for pulmonary evaluation for possible bullectomy. There was a 40-year history of chronic obstructive pulmonary disease which had deteriorated in the preceeding five years, and a six-month history of atypical chest pain considered to be angina pectoris. The patient was treated with long-acting aminophylline derivatives and salbutamol PO ipratropium bromide (Atrovent) aerosols qid, prednisone 20 mg qd and sublingual nitroglycerin prn upon physical examination, he was dyspneic at quiescence the pulse rate was 80 and regular, the vital current pressure 130/80 mm Hg, and the respiratory rate was 24 Auscultation revealed decreased air inlet and a few rhonchi bilaterally. Resting ECG was normal. Chest x-ray film (Fig 1) and thoracic comput tomography (Fig 2) revealed bilateral emphysema with upper lobe predominance, a calcified granuloma in the right lower lobe, and small, calcified lymph nodes in the right hilar area. Pulmonary function ordeals (Table 1) showed severe COPD with depressed diffusion and normal blood gases as seen in emphysema. He was referr for thallium-dipyridamole imaging to clarify the nature of the chest pain. All aminophylline derivatives, coffee and tea were discontinued 48 hours prior to the experiment without consequent clinical deterioration of his respiratory status. The patient was stable and the auscultation unchanged prior to dipyridamole infusion. He remained asymptomatic over the infusion, during which he performed a handgrip exercise, with a 10 beat by means of minute increment in heart rate and stable posterity pressure. Five minutes after the infusion of 056 mg/kg of dipyridamole, he rapidly unfolded severe dyspnea, bronchospasm which faded in intensity as air hall diminished, and central and peripheral cyanosis. Respiratory arrest followed within couple minutes, despite the prompt administration of couple intravenous doses of 125 mg aminophylline. The ECG monitor showed sinus verse with no ST-T change in every part the entire episode. The patient was immediately intubated, ventilated and transferred to the intensive care unit forward hydrocortisone 2-sodium succinate (Solu-Cortef) and an aminophylline drip. The bronchospasm gradually resolv and he was extubated three hours later. conclusions of chest x-ray examination, serial ECG and cardiac enzyme determinations were unremarkable. Unfortunately, this incident no other than confirmed the patient's mistrust of doctors, and he discharged himself from the hospital against medical advice the following day.

DISCUSSION

Thallium-dipyridamole imaging is widely used in clinical practice. Angina pectoris and noncoronary chest pain take place in 20-25 percent of patients, on the contrary are rapidly reversed with administration of aminophylline.[3,4] chaste and irreversible cardiac side drifts are uncommon: there were no complications of myocardial infarction, sustained arrhythmia or death in 293 consecutive studies through Homma et al,[5] in 337 consecutive patients (including 101 from one side of to the other the age of 70) reported by dint of Lam et al,[6] and 93 consecutive patients reported through Gerson et al.[7] Homma et al report individual case of severe bronchospasm requiring intubation in an asthmatic patient.[5] The series of Lam et al includes single in kind case of prolonged myocardial ischemia requiring coronary angioplasty and seven other cases of "severe ischemic response" defined as sharp recurrent or persistent chest pain lasting 15 minutes or more, all of which be agreeable toed to intravenous aminophylline and sublingual nitroglycerin.[6] Isolated cases of ventricular fibrillation[8] and cardiac arrest with following myocardial infarction[9] have been reported. across 10,000 patients have undergone thallium-dipyridamole imaging as of June 1988 remarkably few coronary deaths (approximately three) have been reported to date (personal communication, Dr Alan Rohansky, Boeringher Ingelheim, June 1988) We describe the accident of acute bronchospasm followed on respiratory arrest in a patient with chronic obstructive pulmonary disease. Experiments in succession isolated rat lung suggest that of that kind episodes may be caused at dipyridamole inhibition of pulmonary uptake of prostaglandin [Esub2] a bronchodilator.[10] The unusual deterioration of our patient after dipyridamole infusion strike one as beings somewhat surprising, as both the clinical examination and pulmonary function standards supported the diagnosis of chronic obstructive pulmonary disease predominantly of the emphysematous mark rather than reversible small airways disease. This case demonstrates that unadorned bronchospasm and the need for intubation during thallium-dipyridamole imaging can appear not only in true asthmatics, unless also in the whole representation of chronic obstructive pulmonary disease. Many center "protect" of the like kind patients with steroids during the 48-hour aminophylline withdrawal period, further as illustrated in our case, this does not put forward any guarantee that no similar complication will occur. Despite these reservations, united must emphasize that thallium-dipyridamole imaging is widely used and reports of serious and irreversible cardiac and pulmonary side weights are distinctly scarce. We believe that if there is any clinical suspicion of coronary artery disease, the diagnostic and prognostic gains from thallium-dipyridamole imaging (with bring to a period monitoring) outweigh the small risk attached to the test