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Management strategies for patients with pulmonary hypertension in the intensive care unit*

Zamanian, Roham T. MD; Haddad, Francois MD; Doyle, Ramona L. MD; Weinacker, Ann B. MD

doi: 10.1097/01.CCM.0000280433.74246.9E
Continuing Medical Education Article

Objective: Pulmonary hypertension may be encountered in the intensive care unit in patients with critical illnesses such as acute respiratory distress syndrome, left ventricular dysfunction, and pulmonary embolism, as well as after cardiothoracic surgery. Pulmonary hypertension also may be encountered in patients with preexisting pulmonary vascular, lung, liver, or cardiac diseases. The intensive care unit management of patients can prove extremely challenging, particularly when they become hemodynamically unstable. The objective of this review is to discuss the pathogenesis and physiology of pulmonary hypertension and the utility of various diagnostic tools, and to provide recommendations regarding the use of vasopressors and pulmonary vasodilators in intensive care.

Data Sources and Extraction: We undertook a comprehensive review of the literature regarding the management of pulmonary hypertension in the setting of critical illness. We performed a MEDLINE search of articles published from January 1970 to March 2007. Medical subject headings and keywords searched and cross-referenced with each other were: pulmonary hypertension, vasopressor agents, therapeutics, critical illness, intensive care, right ventricular failure, mitral stenosis, prostacyclin, nitric oxide, sildenafil, dopamine, dobutamine, phenylephrine, isoproterenol, and vasopressin. Both human and animal studies related to pulmonary hypertension were reviewed.

Conclusions: Pulmonary hypertension presents a particular challenge in critically ill patients, because typical therapies such as volume resuscitation and mechanical ventilation may worsen hemodynamics in patients with pulmonary hypertension and right ventricular failure. Patients with decompensated pulmonary hypertension, including those with pulmonary hypertension associated with cardiothoracic surgery, require therapy for right ventricular failure. Very few human studies have addressed the use of vasopressors and pulmonary vasodilators in these patients, but the use of dobutamine, milrinone, inhaled nitric oxide, and intravenous prostacyclin have the greatest support in the literature. Treatment of pulmonary hypertension resulting from critical illness or chronic lung diseases should address the primary cause of hemodynamic deterioration, and pulmonary vasodilators usually are not necessary.

Assistant Professor of Medicine (RTZ), Clinical Instructor (FH), Pulmonary Hypertension Clinical Service, Associate Professor, Co-Director, Vera Moulton Wall Center for Pulmonary Vascular Disease (RLD), Associate Professor of Medicine (ABW), Division of Pulmonary & Critical Care Medicine, Associate Chair for Clinical Affairs, Department of Medicine (ABW), Stanford University Medical Center, Stanford, CA.

Supported, in part, by grants from Actelion (RZ, RLD) and United Therapeutics (RLD).

Address requests for reprints to: Ann B. Weinacker, MD, 300 Pasteur Drive, S102, Stanford, CA 94305–5110. E-mail: annw@stanford.edu

© 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins