The Right Ventricle in ARDS

Abstract

ARDS is associated with poor clinical outcomes, with a pooled mortality rate of approximately 40% despite best standards of care. Current therapeutic strategies are based on improving oxygenation and pulmonary compliance while minimizing ventilator-induced lung injury. It has been demonstrated that relative hypoxemia can be well tolerated, and improvements in oxygenation do not necessarily translate into survival benefit. Cardiac failure, in particular right ventricular dysfunction (RVD), is commonly encountered in moderate to severe ARDS and is reported to be one of the major determinants of mortality. The prevalence rate of echocardiographically evident RVD in ARDS varies across studies, ranging from 22% to 50%. Although there is no definitive causal relationship between RVD and mortality, severe RVD is associated with increased mortality. Factors that can adversely affect RV function include hypoxic pulmonary vasoconstriction, hypercapnia, and invasive ventilation with high driving pressure. It might be expected that early diagnosis of RVD would be of benefit; however, echocardiographic markers (qualitative and quantitative) used to prospectively evaluate the right ventricle in ARDS have not been tested in adequately powered studies. In this review, we examine the prognostic implications and pathophysiology of RVD in ARDS and discuss available diagnostic modalities and treatment options. We aim to identify gaps in knowledge and directions for future research that could potentially improve clinical outcomes in this patient population.

Point-of-care ultrasound and COVID-19

“…15 Focused echocardiography may infl uence volume management, ventilator management (for right ventricle protection), assessment of the need for proneposition ventilation, and titration of inotropes and vasopressors. [16][17][18] Point-of-care echocardiography performed by the bedside clinician may obviate the need for comprehensive echocardiography, reducing resource use and risk of infection spread. 2…”

Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome: A pilot study

“…Echocardiography has opened a new window in the management of Acute Respiratory Distress Syndrome (ARDS patients) . Different morphological and functional changes in right ventricle (RV) can be detected in these patients, even if the pathophysiological mechanism(s) or the clinical impact of these alterations is not to date fully elucidated .…”

“…Its development was reported to be related also to high pressures of ventilation, and consequently, an echo‐guided strategy for protection of the right ventricle was proposed, integrating echocardiographic assessment to the ventilation strategy Nowadays, in the era of protective ventilation, the incidence of acute cor pulmonale has dramatically reduced and the modified ventilatory strategy may have affected the panorama of echocardiographic abnormalities in ARDS. However, RV dilatation/dysfunction is one of the major determinant of hemodynamic instability in ARDS which is known to be associated with higher mortality …”

“…However, RV dilatation/dysfunction is one of the major determinant of hemodynamic instability in ARDS which is known to be associated with higher mortality. 1,8,9 Myocardial deformation (strain) imaging is a novel echocardiographic technique to assess RV myocardial function and, unlike other echo techniques, to define subtle RV dysfunction. 10,11 RV strain of the free wall has been reported to hold prognostic value in different disease conditions such as heart failure and pulmonary hypertension [12][13][14][15] while no data are so far available in patients with ARDS.…”

The Imperfect Cytokine Storm

“…Nonetheless, it may be prohibitive in heart failure patients on LVAD support. Prone positioning could result in complications such as compression of outflow graft and driveline, impaired venous return from increased thoracic pressure, hardware malpositioning, and worsening RV hemodynamics [9,10]. There may be additional anxiety for staff caring for COVID-19 patients, not otherwise familiar with LVAD management.…”