Advanced airway management and respiratory care in decompensated pulmonary hypertension

Abstract

Meticulous risk stratification is essential when considering intubation of a patient with decompensated pulmonary hypertension (dPH). It is paramount to understand both the pathophysiology of dPH (and associated right ventricular failure) and the complications related to a high-risk intubation before attempting the procedure. There are few recommendations in this area and the literature, guiding these recommendations, is limited to expert opinion and very few case reports/case series. This review will discuss the complex pathophysiology of dPH, the complications associated with intubation, the debates surrounding induction agents, and the available options for the intubation procedure, with specific emphasis on the emerging role for awake fiberoptic intubation. All patients should be evaluated for candidacy for veno-arterial extracorporeal membrane oxygen as a bridge to recovery, lung transplantation, or pulmonary endarterectomy prior to intubation. Only an experienced proceduralist who is both comfortable with high-risk intubations and the pathophysiology of dPH should perform these intubations.

Inhaled Milrinone via HFNC as a Postextubation Cardiopulmonary Elixir: Case Series and Review of Literature

“…Of relevance to PH predisposed cohort, HFNC by avoiding positive pressure ventilation not only avoids pulmonary vessel compression but also circumvents hypoxic pulmonary vasoconstriction that decrescents right ventricular preload as well. 10 Even from a strict cardiac perioperative perspective, Kumar et al very recently proposed role of HFNC in postoperative acyanotic CHD patients, where the authors reported improvement in postextubation partial pressure of oxygen/fraction of inspired oxygen concentration (P a O 2 /FiO 2 ). 11 While our patients were postoperative adults with congenital heart disease patient akin to the Kumar et al study, 11 the additional attributes such as a previous history of COVID-19 infection, collapsed lung lobe, intraoperative PH crisis, and recent tapering of iNO implied an accentuated risk in our setting.…”

Inhaled Milrinone via HFNC as a Postextubation Cardiopulmonary Elixir: Case Series and Review of Literature

“…Of relevance to PH predisposed cohort, HFNC by avoiding positive pressure ventilation not only avoids pulmonary vessel compression but also circumvents hypoxic pulmonary vasoconstriction that decrescents right ventricular (RV) preload as well. 10 Even from a strict cardiac perioperative perspective, Kumar et al very recently proposed role of HFNC in postoperative acyanotic CHD patients, where the authors reported improvement in postextubation partial pressure of oxygen/fraction of inspired oxygen concentration (PaO 2 /FiO 2 ). 11 While our patients were postoperative adult CHD patient akin to the Kumar et al study, 11 the additional attributes such as a previous history of COVID-19 infection, collapsed lung lobe, intraoperative PH crisis, and recent tapering of iNO, implied an accentuated risk in our setting.…”

Right Ventricular Failure

“…Positive end-expiratory pressure (PEEP) can improve oxygenation but may increase alveolar distention, worsen pulmonary vascular resistance, and increase RV afterload. 7,8…”