Hemodynamic and respiratory support in pulmonary embolism: a narrative review

Abstract

Pulmonary embolism is a common and potentially fatal disease, with a significant burden on health and survival. Right ventricular dysfunction and hemodynamic instability are considered two key determinants of mortality in pulmonary embolism, which can reach up to 65% in severe cases. Therefore, timely diagnosis and management are of paramount importance to ensure the best quality of care. However, hemodynamic and respiratory support, both major constituents of management in pulmonary embolism, associated with cardiogenic shock or cardiac arrest, have been given little attention in recent years, in favor of other novel advances such as systemic thrombolysis or direct oral anticoagulants. Moreover, it has been implied that current recommendations regarding this supportive care lack enough robustness, further complicating the problem. In this review, we critically discuss and summarize the current literature concerning the hemodynamic and respiratory support in pulmonary embolism, including fluid therapy, diuretics, pharmacological support with vasopressors, inotropes and vasodilators, oxygen therapy and ventilation, and mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation and right ventricular assist devices, while also providing some insights into contemporary research gaps.

Pulmonary artery air embolism with consequent primary respiratory alkalosis and secondary metabolic alkalosis following ventilation therapy: A case report

“…The management of patients may depend on the size of the air embolism and clinical symptoms of the patient, ranging from high-flow oxygen treatment and changing the patient's position to more drastic management such as cardiac massage and air suctioning with a large-lumen guiding catheter. [4,9,10] In our case, the patient already had some shortness of breath when he presented to the emergency department, which was most likely due to a right upper lobe segmental pulmonary artery embolism. However, his worsening respiratory complaints within the first hour following CECT are likely attributable to air embolisms within the pulmonary arteries.…”

Cánula nasal de alto flujo en tromboembolia pulmonar de alto riesgo: reporte de caso

“…La tromboembolia pulmonar ocasiona que una cantidad considerable del flujo sanguíneo regional se desvíe a zonas menos embolizadas, dejando alvéolos con relaciones ventilación/perfusión alteradas; este es el mecanismo más importante de generación de hipoxemia 1 . El empeoramiento de la hipoxia puede hacer pensar en la necesidad de ventilación mecánica invasiva, pero esta debe ser el último recurso, dado que la presión intratorácica positiva disminuye el retorno venoso y empeora la disfunción ventricular derecha, llevando a choque y aumentando significativamente la mortalidad 2,3 . La CNAF es un dispositivo que proporciona oxígeno tibio y humidificado a flujos altos con una fracción confiable de oxígeno inspirado 4 .…”

Mechanical Circulatory Support Devices in Patients with High-Risk Pulmonary Embolism

“…PE impacts nearly 900,000 individuals annually in the United States (US) [ 9 ], resulting in an estimated 100,000 deaths each year [ 10 ]. Early hospitalization and 30-day mortality are driven by multiple factors, chief among them the presence of right ventricular dysfunction and/or hemodynamic instability [ 4 , 11 , 12 , 13 , 14 ]. The survival rate for patients with severe pulmonary embolism who require extracorporeal membrane oxygenation device (ECMO) ranges between 38% and 67% [ 15 , 16 , 17 , 18 ].…”