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Management Strategies for Patients with Pulmonary Hypertension in the Intensive Care Unit* Roham T

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Management Strategies for Patients with Pulmonary Hypertension in the Intensive Care Unit* Roham T Continuing Medical Education Article Management strategies for patients with pulmonary hypertension in the intensive care unit* Roham T. Zamanian, MD; Francois Haddad, MD; Ramona L. Doyle, MD; Ann B. Weinacker, MD LEARNING OBJECTIVES On completion of this article, the reader should be able to: 1. Explain the pathophysiology of pulmonary hypertension. 2. Describe treatment modalities for pulmonary hypertension. 3. Use this information in the clinical setting. Dr. Zamanian has disclosed that he is/was the recipient of grant/research funds from Entelligence-Actelion’s Young Investigators Program, is/was on the speakers’ bureau for Actelion, and was on the speakers’ bureau for Co-Therix, and Encysive. Dr. Doyle has disclosed that she is/was a consultant for Actelion, Encysive, and Gilead. Dr. Haddad has disclosed that he has no financial relationships with or interests in any commercial companies pertaining to this educational activity. Dr. Weinacker has disclosed that she was the recipient of grant/research funds from Lilly. The authors have disclosed that sildenafil has not been approved by the U.S. Food and Drug Administration for use in the treatment of pulmonary hypertension in critically ill patients. Please consult product labeling for the approved usage of this drug or device. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit. Objective: Pulmonary hypertension may be encountered in the intensive dopamine, dobutamine, phenylephrine, isoproterenol, and vasopressin. Both care unit in patients with critical illnesses such as acute respiratory distress human and animal studies related to pulmonary hypertension were reviewed. syndrome, left ventricular dysfunction, and pulmonary embolism, as well as Conclusions: Pulmonary hypertension presents a particular challenge in after cardiothoracic surgery. Pulmonary hypertension also may be encoun- critically ill patients, because typical therapies such as volume resuscitation tered in patients with preexisting pulmonary vascular, lung, liver, or cardiac and mechanical ventilation may worsen hemodynamics in patients with diseases. The intensive care unit management of patients can prove extremely pulmonary hypertension and right ventricular failure. Patients with decom- challenging, particularly when they become hemodynamically unstable. The pensated pulmonary hypertension, including those with pulmonary hyperten- objective of this review is to discuss the pathogenesis and physiology of sion associated with cardiothoracic surgery, require therapy for right ventric- pulmonary hypertension and the utility of various diagnostic tools, and to ular failure. Very few human studies have addressed the use of vasopressors provide recommendations regarding the use of vasopressors and pulmonary and pulmonary vasodilators in these patients, but the use of dobutamine, vasodilators in intensive care. milrinone, inhaled nitric oxide, and intravenous prostacyclin have the greatest Data Sources and Extraction: We undertook a comprehensive review of support in the literature. Treatment of pulmonary hypertension resulting from the literature regarding the management of pulmonary hypertension in the critical illness or chronic lung diseases should address the primary cause of setting of critical illness. We performed a MEDLINE search of articles pub- hemodynamic deterioration, and pulmonary vasodilators usually are not nec- lished from January 1970 to March 2007. Medical subject headings and keywords searched and cross-referenced with each other were: pulmonary essary. (Crit Care Med 2007; 35:2037–2050) hypertension, vasopressor agents, therapeutics, critical illness, intensive care, KEY WORDS: pulmonary hypertension; intensive care unit; vasopressor right ventricular failure, mitral stenosis, prostacyclin, nitric oxide, sildenafil, agents; nitric oxide; prostacyclin; right ventricular failure; dobutamine ulmonary hypertension is cally ill patients with hemodynamically citation (1). Appropriate therapy depends commonly encountered in the significant pulmonary hypertension re- on identifying the underlying cause and intensive care unit (ICU). Al- mains challenging. Patients with moder- hemodynamic effects of pulmonary hy- though new therapies for pul- ate to severe pulmonary hypertension can pertension. To reflect differences in Pmonary hypertension have emerged in deteriorate rapidly and are unlikely to pathophysiology, a revised World Health recent years, the management of criti- survive efforts at cardiopulmonary resus- Organization classification of pulmonary *See also p. 2210. & Critical Care Medicine, Associate Chair for Clinical MD, 300 Pasteur Drive, S102, Stanford, CA 94305–5110. Assistant Professor of Medicine (RTZ), Clinical In- Affairs, Department of Medicine (ABW), Stanford Uni- E-mail: [email protected] structor (FH), Pulmonary Hypertension Clinical Service, versity Medical Center, Stanford, CA. Copyright © 2007 by the Society of Critical Care Associate Professor, Co-Director, Vera Moulton Wall Supported, in part, by grants from Actelion (RZ, Medicine and Lippincott Williams & Wilkins Center for Pulmonary Vascular Disease (RLD), Associ- RLD) and United Therapeutics (RLD). ate Professor of Medicine (ABW), Division of Pulmonary Address requests for reprints to: Ann B. Weinacker, DOI: 10.1097/01.CCM.0000280433.74246.9E Crit Care Med 2007 Vol. 35, No. 9 2037 hypertension (Table 1) has been adopted Table 1. Revised clinical classification of pulmonary hypertension (Venice 2003) (2). The revised classification separates causes of pulmonary hypertension into 1. Pulmonary arterial hypertension (PAH) 1.1. Idiopathic (iPAH) those that primarily affect the pulmonary 1.2. Familial (FPAH) arterial tree (pulmonary arterial hyper- 1.3. Associated with (APAH) tension; PAH) or the pulmonary venous 1.3.1. Collagen vascular disease system, and those that affect the pulmo- 1.3.2. Congenital systemic-to-pulmonary shunts nary vasculature because of alterations in 1.3.3. Portal hypertension 1.3.4. HIV infection lung structure or function. This new clas- 1.3.5. Drugs and toxins sification thus provides a framework to 1.3.6. Other (thyroid disorders, glycogen storage disease, Gaucher disease, hereditary guide appropriate diagnosis and treat- hemorrhagic telangiectasia, hemoglobinopathies, myeloproliferative disorders, ment of pulmonary hypertension in crit- splenectomy) ically ill patients (2). 1.4. Associated with significant venous or capillary involvement 1.4.1. Pulmonary veno-occlusive disease (PVOD) Pulmonary hypertension is defined as 1.4.2. Pulmonary capillary hemangiomatosis (PCH) a systolic pulmonary artery pressure 1.5. Persistent pulmonary hypertension of the newborn (PAP) of Ͼ35 mm Hg, or, alternatively, as 2. Pulmonary hypertension with left heart disease a mean PAP of Ͼ25 mm Hg at rest or 2.1. Left-sided atrial or ventricular heart disease Ͼ30 mm Hg with exertion (2–4). Pulmo- 2.2. Left-sided valvular heart disease 3. Pulmonary hypertension associated with lung diseases and/or hypoxemia nary hypertension in the ICU may be due 3.1. Chronic obstructive pulmonary disease to preexisting pulmonary vascular dis- 3.2. Interstitial lung disease ease, lung disease, liver disease, or car- 3.3. Sleep-disordered breathing diac disease. Pulmonary hypertension 3.4. Alveolar hypoventilation disorders 3.5. Chronic exposure to high altitude also may be caused by critical illnesses 3.6. Developmental abnormalities such as acute respiratory distress syn- 4. Pulmonary hypertension due to chronic thrombotic and/or embolic disease drome (ARDS), acute left ventricular dys- 4.1. Thromboembolic obstruction of proximal pulmonary arteries function, and pulmonary embolism, or 4.2. Thromboembolic obstruction of distal pulmonary arteries may occur after cardiac or thoracic sur- 4.3. Non-thrombotic pulmonary embolism (tumor, parasites, foreign material) 5. Miscellaneous gery. In this paper we review the diagno- Sarciodosis, histiocytosis X, lymphangiomatosis, compression of pulmonary vessels sis and treatment of critically ill patients (adenopathy, tumor, fibrosing mediastinitis) with pulmonary hypertension of varying etiologies, and discuss strategies to treat HIV, human immunodeficiency virus. hemodynamic instability. Reproduced with permission from Simmoneau G, Galiè N, Rubin LJ, et al: Clinical classification of pulmonary hypertension. J Am Coll Cardiol 2004; 43:10S. PATHOGENESIS AND PHYSIOLOGY Pulmonary venous hypertension is typi- for PAH is thus based on re-establishing cally a result of left ventricular diastolic the balance in key molecular pathways Pulmonary hypertension encompasses dysfunction, valvular heart disease, or by increasing available nitric oxide and a spectrum of pathologies best character- pulmonary venous disorders. prostacyclin, or reducing the effects of ized by their anatomical location: precap- Multiple molecular pathways have endothelin-1 (Fig. 1). illary arteries and arterioles, alveoli and been implicated in the pathogenesis of The neurotransmitter serotonin and capillary beds, and postcapillary pulmo- PAH. Nitric oxide and prostacyclin are the serotonin receptor transporter also nary veins and venules. Idiopathic pul- endogenous vasodilators produced in have been implicated in the development monary arterial hypertension is the result the pulmonary vascular endothelium, of PAH. Some studies have linked high
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