pulmonary hypertension in critical careintensivistenopleiding.org/downloads-19/files/rv failure en...

Pulmonary hypertension in critical care

ICU Fellowship Training Radboudumc

Pulmonary hypertension

mPAP ≥ 25 mmHg at rest assessed by RHC

PHT in critical careAcute/acute-on-chronic venous PHT

Secondary to LV failure with left atrial hypertension

Acute-on-chronic arterial PHT

Worsening of preexisting PHT due to natural progression, sepsis, ARDS, PE, drugs

Acute arterial PHT

Massive PE, ARDS, sepsis, drugs

Gayat E. Curr Opin Crit Care 2011;17:439-448

Normal RV

End-diastolic volume index 64 ± 13 ml/m2

Stroke volume index 43 ± 13 ml/m2

RVEF 62 ± 8 %

Redington AN. Br Heart J 1988;59:23-30

PEEP

0

5

10

15

Step 1

Step 2

Step 3

Air-filled pericardial balloon

REF thermodilution catheter

Pinsky MR. Am Rev Respir Dis 1992;146:681-687

12 patients after cardiac surgery

mL

0

35

70

105

140

PEEP (cm H2O)

0 5 10 15 0

EDV ESV

L/m

in

0

1

2

3

4

5

PEEP (cm H2O)

0 5 10 15 0

COm

mH

g

0

10

20

30

40

PEEP (cm H2O)

0 5 10 15 0

Pra (tm) SPpa (tm)

RVEF

0

0,1

0,2

0,3

0,4

0,5

PEEP (cm H2O)

0 5 10 15 0

RVEF

RV complianceNo consistent relationship

RV EDV and RVESVNormal slope 0.7

First conclusion• In normal right ventricle changes in EDV occur

below RV stressed volume

• Conformational changes in RV shape rather than myocardial fiber stretch

• RV preload (= RV wall stretch) is constant with variation in RVEDV) meaning RV preload is independent of RV EDV

RV EDV and RvEFLineair for every individual patient

Important consequence

• If increasing RV volume increases RV preload and thus RV distending pressure, the RV is either hypertrophied with diastolic dysfunction or over distend as in acute cor pulmonale

Implications• CVP can never be used to predict fluid responsiveness

• Changes in CVP are an excellent measure to show that fluid resuscitation has exceeded the normal RV unstressed volume operating range

• If cardiac output increases by Starling mechanism, RV ESV must also increase which by pericardial constraint limits the effect of volume resuscitation

• Nothing beneficial with RV hypertrophy

Sepsis and fluid responsiveness

Osman D. Crit Care Med 2007;35:64-68

Clinical implications• Central venous pressure is only elevated in disease

• If CVP rises after a fluid challenge and remains so: STOP - think about ACP

• For an increase in CO the RV must dilate - this limits the effect of fluid resuscitation

• RV hypertrophy is a deal with the devil

Normal RV P-V relationVo

lum

e (c

c)Pr

essu

re (

mm

Hg) Pr

essu

re (

mm

Hg)

Volume (cc × 10-1)Time (s)

Time (s)


39 ± 4% of SV ejected before peak RV pressure Poorly defined isovolumetric contraction phase

43 ± 9% of SV ejected during pressure fall Poorly defined isovolumetric relaxation phase

Normal LV PV relation

Volume (cc × 10-1)

Pres

sure

(×

10-1

mm

Hg

)


30 - 40% of RV output results from LV contraction

RV P-V relation with PHT

Pres

sure

(m

mH

g)

0

20

40

60

80

16080Volume (cc)

•Shape resembles normal LV •Decreased ejection during pressure rise and fall


PAP increase

RVEF ⬇ RV dilatation

Isovol. CP ⬆ Ejection time ⬆

MVO2 ⬆

RV ischemia

RCA mainly perfused in diastole

RV output ⬇

T3 insufficiency

LV preload ⬇

Cardiac output ⬇

Organ failure

Septal displacement

Right ventricular pressure ⬆

Open FO

Hypoxemia

RC blood flow

Zong PU. Exp Biol Med 2005;230:507

Extraction 75%

Extraction 50%

RC blood flow with PHT

Zong PU. Basic Res Cardiol 2002;97:392-398

Without NO blocked increase in MvO2 82% covered by increased flow

Gan C. Am J PhysiolHeart Circ Physiol 2006;290:H1528-1533End-diastole End-systole Early-diastole

Mild PHT induces LV diastolic dysfunction

E/E’

(lat

eral

)0

5

9

14

18

Control DD IPAH

** **

Kasner m. Am J Respir Crit Care Med 2012;186:181-189

Kasner m. Am J Respir Crit Care Med 2012;186:181-189

11% increase in cardiac output

Sztrymf B. Chest 2013

TreatmentTreat or avoid RVF (main cause of death)

Treat underlying cause of PHT

No guidelines for the ICU!

Volume managementVolume overload is common and may aggravate RV dysfunction

With a dilated RV and IV septum shift first try iv diuretics followed by hemofiltration often under inotropic support

VasopressorsNorepinephrine in case of severe systemic hypotension to improve RCA perfusion

Car

diac

Out

put (

L)

0,00

1,25

2,50

3,75

5,00

Baseline Pulmonary HT After fluid challenge After NE infusion

Bloo

d pr

essu

re

0

40

80

120

160

Baseline Pulmonary HT After fluid challenge After NE infusion

Ghignone M. Anesthesiology 1984;60:132-135

VasopressorsSBP

(mmHg)MPAP

(mmHg)PVRI

(D.s.cmMPAP/MAP

(%)PVRI/SVRI

(%)

Baseline 91 ± 11.8 31.4 ± 5.3 257.8 ± 84.4 44.2 ± 5.3 12.4 ± 4.8

NE dose 1 (30% ⬆ SAP) 131.0 ± 4 37.3 ± 7 340.9 ± 78.4 38.1 ± 9.9 11.7 ± 5.9

NE dose 2 (50% ⬆ SAP) 152 ± 3.2 41.3 ± 7.8 442 ± 228.3 37.7 ± 8.6 13.3 ± 4.3

N = 10 - cardiac surgery and pulmonary hypertensionKwak YL. Anaesthesia 2002;57:9-14

InotropesPDE inhibitors - strong recommendation

Levosimendan - only case records

Rieg AD. PLoS ONE 2013;8:e66195

Pre-constricted

Levosimendan and ARDS after sepsis

RCT Levosimendan (N=18) versus placebo (N=17)

Patients with septic ARDS (< 3 D)

Dose 0.2 μg/kg/min for 24 hours without loading dose

Primary endpoint ∆ RVEF after 24 hours

Morelli A. Crit Care Med 2006;34:2287-2293

Morelli A. Crit Care Med 2006;34:2287-2293

PHT in patients with ARDSLung damage per se (capillary destruction and obstruction by clots)

Muscularization by hypoxemia and hypercapnia

Mechanical ventilation with increased alveolar distending pressures

Mechanical ventilationPrevent hypoxia, hypercapnia and high transalveolar pressures

Low tidal volume ventilation with low levels of PEEP unless a severe reduction in FRC is present

Low Tv and RV functionARDS (N = 145) with PAC

RVF defined as MPAP > 25 mmHg, CVP > PCWP and SV < 30 ml/m2

Tv 8.8 ± 1.9 ml/kg and Pplat 26 ± 6 cmH2O

RVF in 9.6% - no mortality difference (68%)

RVF No RVF P-valueTv (ml/kg) 9.7 ± 2.8 8.6 ± 1.8 < 0.05P 28 ± 6 25 ± 6 0.41

Osman D. Intensive Care Med 2009;35:69-76

Tv and RV function

0

20

40

60

80

Plateau pressure Day 1 (cm H2O)

18-26 27-35 > 35

56

32

13

Mortality (%) RVF (%)

Mor

talit

y (%

)0

25

50

75

100

Plateau pressure Day 1 (cm H2O)

18-26 27-35 > 35

Normal RVF

ARDS (N = 352)Jardin F. Intensive Care Med 2007;33:444-447

TV and RV function

Intensive Care Med. 2013 Oct;39(10):1725-33

Inci

denc

e A

cute

Cor

Pu

lmon

ale

(%)

0

10

20

30

Boissier 2013 Lhéritier 2013Intensive Care Med. 2013 Oct;39(10):1734-42

Moderate to severe ARDS

N = 226 N = 200Risk: driving pressure ≥ 17 Risk: PaCO2 ≥ 60 mmHg

ACP is RV enlargement combined with systolic paradoxical septal motion

PVR and FRC

PVR may ↓ with recruitment (low FRC)

PVR may ↓ with abolishment of HPV

PVR may ↓ with PaCO2 ↓

Hypercapnia and ARDS

N = 11 Severe ARDS

22 - 23

PaCO2 52 pH 7.30

PaCO2 71 pH 7.17

PaCO2 75 pH 7.20

0

0,5

1

1,5

LP HP/HR HP/LR

1,281,19

1,11

0,85

0,64

RV/LV area ratioES eccentricity index

** ** ** **

pH only factor independently associated with RV/LV area ratio and ES EI

Mekontso Dessap A. Intensive Care Med 2009;35:1850-1858

ECCO2R?

Vieillard-Baron A. Intensive Care Med 2013;39:1836-1838

Vasodilators

IV vasodilators (NTG, Nitroprusside, PGE1) not recommended

Inhaled nitric oxide, prostacyclin (derivatives)

Sildenafil

NO or Iloprost inhalation?M

PAP

(mm

Hg)

30

40

50

60

70

80

Baseline 1 NO (40 ppm) Baseline 2 Iloprost (14-17 mcg)

CO

(l/m

in)

0

1

2

3

4

5

6


PVR

(dyn

es*s

ec*c

m-5

)

0

500

1000

1500

2000


Prostacyclin compared to NO significantly lowers MPAP and PVR

significantly increases CO

Hoeper MM. J Am Coll Cardiol 2000;35:176-182

Nebulized iloprost

Sawheny E. Chest 2013;144:55-62

ARDS (N = 20)

No effect on hemodynamic or pulmonary mechanics

Bridge to transplant

Granton J. Semin Respir Crit Care Med 2013;34:700-713

Conclusions

PHT results in early changes in right and left ventricular function

RVF determines outcome

With RVF fluid therapy is rarely effective

Milrinone + NE are the agents of choice

Iloprost inhalation is feasible in MV patients

pulmonary hypertension in critical careintensivistenopleiding.org/downloads-19/files/rv failure en...

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