Background: Emergent endotracheal intubations (ETI) in pulmonary hypertension (PH) patients are associated with increased mortality. Post-intubation interventions that could increase survivability in this population have not been explored. We evaluate early clinical characteristics and complications following emergent endotracheal intubation and seek predictors of adverse outcomes during this post-intubation period. Methods: Retrospective cohort analysis of adult patients with groups 1 and 3 PH who underwent emergent intubation between 2005-2021 in medical and liver transplant ICUs at a tertiary medical center. PH patients were compared to non-PH patients, matched by Charlson Comorbidity Index. Primary outcomes were 24-h post-intubation and inpatient mortalities. Various 24-h post-intubation secondary outcomes were compared between PH and control cohorts. Results: We identified 48 PH and 110 non-PH patients. Pulmonary hypertension was not associated with increased 24-h mortality (OR 1.32, 95%CI 0.35-4.94, P = .18), but was associated with inpatient mortality (OR 4.03, 95%CI 1.29-12.5, P = .016) after intubation. Within 24 h post-intubation, PH patients experienced more frequent acute kidney injury (43.5% vs. 19.8%, P = .006) and required higher norepinephrine dosing equivalents (6.90 [0.13-10.6] mcg/kg/min, vs. 0.20 [0.10-2.03] mcg/kg/min, P = .037). Additionally, the median P/F ratio (PaO2/FiO2) was lower in PH patients (96.3 [58.9-201] vs. 233 [146-346] in non-PH, P = .001). Finally, a post-intubation increase in PaCO2 was associated with mortality in the PH cohort (post-intubation change in PaCO2 +5.14 ± 16.1 in non-survivors vs. −18.7 ± 28.0 in survivors, P = .007). Conclusions: Pulmonary hypertension was associated with worse outcomes after emergent endotracheal intubation than similar patients without PH. More importantly, our data suggest that the first 24 hours following intubation in the PH group represent a particularly vulnerable period that may determine long-term outcomes. Early post-intubation interventions may be key to improving survival in this population.

Management of critically sick patients with pulmonary arterial hypertension (PAH) is challenging and published data indicate increased intensive care unit (ICU) mortality in this population. Unfortunately, we do not have a full understanding of key weaknesses in managing critically ill PAH patients, and the identification of interventions that could lead to improved survival in PAH patients is largely missing. In this analysis, comparing a PAH cohort to a matched cohort of non-PAH patients, we evaluate the impact of emergent endotracheal intubation on short-and long-term outcomes in PAH.METHODS: Retrospective analysis of medical records of adult patients from a large academic center with groups 1 and 3 PAH who underwent emergent intubation in the period 2005-2021. The control group was composed of non-PAH patients who underwent emergent intubation over the same timeframe and were matched by Charlson comorbidity index (CCI) with the PAH cohort. Primary outcome was short-term mortality. Logistic regressions with propensity score weighting were used and p-values of <0.05 were considered statistically significant. RESULTS:We identified 48 PAH and 110 non-PAH CCI-matched patients. Combined cohort mean age was 55.2AE13.2, 53% were female and 53% were Caucasian. Major differences between groups were corrected by propensity score weighting. Intubation in the PAH cohort was not associated with increased 24-hour mortality (OR 1.46, 95%CI 0.35-6.09, P¼0.59), but was associated with death during hospital admission (OR 4.80, 95%CI 1.50-15.3, P¼0.008). Within 24 hours post-intubation, PAH patients experienced more frequent acute kidney injury (43.5% vs 19.8%, P¼0.006) and required a higher number of vasopressors (1.69AE1.30 vs 1.04AE1.01, P¼0.004) than non-PAH patients. At 24 hours post-intubation, mean FiO2 (66%AE22% vs 49%AE21% in non-PAH, P¼0.001) were higher in PAH patients. Inability to establish adequate ventilation following intubation was associated with mortality within the PAH cohort (change in PaCO2 þ5.14AE16.1 in non-survivors vs -18.7AE28.0 in survivors, P¼0.007).CONCLUSIONS: Our findings provide evidence for worsened outcomes in mechanically ventilated PAH patients in comparison to similar patients without PAH. More importantly, we show that the first 24 hours following intubation in the PAH group represent a particularly vulnerable period which may be crucial for their long-term outcomes.CLINICAL IMPLICATIONS: PAH patients represent a particularly vulnerable population in critical care settings. Emergent endotracheal intubation exposes these patients to increased risk of hemodynamic and respiratory deterioration which further impacts their outcomes. Our findings suggest that particular attention needs to be directed on PAH patients at the time of endotracheal intubation and early, post-intubation interventions may be of crucial relevance to improve survival in this population of patients.

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