“Exercise Till You Cough Blood”

Abstract

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: In athletes, high capillary transmural pressures generated during exercise can cause mechanical failure of the thin alveolar blood-gas membrane, resulting in edema and then hemorrhage (1). Our case highlights this uncommon presentation of when the human lung behaves like that of a race horse. CASE PRESENTATION: A 19-year-old man with no prior medical history presented after developing shortness of breath and passing out during an intense game of basketball. His O2 saturation on presentation was 89%. Chest CT that revealed right-sided ground glass opacities. Bronchoscopy revealed sequentially bloodier aliquots of alveolar lavage, consist with alveolar hemorrhage. Electrocardiogram and echocardiogram were unremarkable, and extensive blood work ruled out connective tissue, vasculitic, infectious and drug-induced etiologies for alveolar hemorrhage. The hemoptysis subsided over the next day and the patient resumed exercise with no issues. Cardiopulmonary exercise testing, performed to elucidate an etiology or reproduce symptoms, was within normal limits (VO2 max of 45.9 ml/kg/min, 95% of predicted). DISCUSSION: Exercise induced pulmonary hemorrhage (EIPH) is a condition affecting virtually all horses, as they generate enormous cardiac outputs (CO) during galloping that require very high filling pressures, that in turn require an increase in pulmonary artery pressures of up to 120 mmHg (2). Likewise, in human athletes during intense exercise elevated pulmonary pressures needed to maintain high CO can produce alveolar edema (1). High capillary transmural pressures (>40 mmHg) can cause disruption of the capillary endothelium and alveolar epithelium leading to EIPH. Athletes can increase their CO more than six-fold. Additional pulmonary capillary bed recruitment and capillary distention mitigate sharp rises in pulmonary pressure. Increased hydrostatic capillary pressures occurring in susceptible individuals overwhelm these compensatory mechanisms. CONCLUSIONS: During intense exercise increase in capillary transmural pressures up to 40 mmHg expose the thin blood-gas membrane to enormous stresses. Exercise-induced pulmonary edema and EIPH are probably under recognized and reflect a spectrum of the response to intense exercise in the athlete. Reference #1: Ghio AJ at al. Exercise-induced pulmonary hemorrhage after running a marathon. Lung. 2006;184(6):331-3 Reference #2: Hopkins SR et al. Intense exercise impairs the integrity of the pulmonary blood-gas barrier in elite athletes. Am J Respir Crit Care Med. 1997;155(3):1090-4 DISCLOSURE: The following authors have nothing to disclose: Udit Chaddha, Ioan Puscas, Ahmet Baydur No Product/Research Disclosure Information