Pulmonary Hypertension in the Critically Ill

 PHTN: mean pulmonary artery pressure >20

 Most common cause of PHTN is left heart dz
 Classifications
o Idiopathic pulmonary HTN
o PHTN due to left heart dz
o PHTN due to lung dz and/or hypoxia
o Chronic thromboembolic pulmonary HTN
o Other
 Evaluation
o Dyspnea: most presenting complaint
o Syncope
o Hoarseness (RV compressing on shit)
o If known PHTN, how bad is it?
 Can tell by how many meds they’re taking; whether its PO or IV
 Therapy for PHTN
o CCB (dilt, nifedipine)
o Endothelin receptor antagonists (bosentan)
o Phosphodiesterase inhibitors (sildenafil)
o IV prostenoid therapy (epoprostenol, iloprost, trepostinil)
 Usually getting the meds from a pump
 Emergency evaluation of PHTN pt
o Considerations
 Hypoxemic resp failure
 Pulmonary hemorrhage
 Hypotension/shock from right heart failure

 Management
o Manage hypoxia/hypercapnia
  Caution with NIPPV as this can decrease venous return exacerbating RV
function and overall cardiovascular function
o Manage hypotension
 Most RV failure associated w/ volume overload
 Low volume boluses (250cc-500cc) and frequent clinical reassessment are
essential
 Vasopressors (can start early as fluid will worsen shit); can add an
inotrope
 Levophed 1st line
 Vasopressin next (increases SVR, decreases pulmonary vascular
resistance)
 Dobutamine (increases CO, decreases PVR but causes tachycardia
and systemic vasodilation)
 Milrinone
o Check for dysrhythmias
 These folks tolerate tachycardia poorly due to decreased
ventricular filling time and further reduction in cardiac output
 Do not tolerate BB or CCB
 Cardioversion is preferred approach
o Check for a pump
 Don’t turn of pump
 Rebound elevation in pulmonary artery pressure can occur if IV
catheter is removed, damaged, or pump stops working
o Check for precipitants
 PE, COPD exacerbation, medication noncompliance, sepsis,
hypovolemia, anemia
o Reduce RV afterload
o Intubation in PHTN
 Last resort
 These RSI meds can make shit worse
 Awake intubation preferred
 If you must use RSI, can use etomidate and roc
 Have push dose pressors available or just go ahead and give
 Low TV, low plateau pressure, minimal PEEP