🫁 Pulmonary Hypertensive Crisis/Acute RV Failure
This tool outlines ICU management of pulmonary hypertensive crisis and acute right ventricular failure: optimizing RV preload and afterload, lowering pulmonary vascular resistance, and maintaining systemic perfusion.
Keep RV preload appropriate, lower PVR, augment RV contractility, and maintain SVR > PVR to prevent RV ischemia; never abruptly stop home PAH-targeted therapy. (original synthesis · not guideline verbatim)
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When to use
Use when a PH patient deteriorates with hypotension, hypoxia/hypercapnia, tachyarrhythmia, or impending intubation, to organize support around preserving the right ventricle and keeping SVR above PVR.
How it works
Management by problem: hypotension (norepinephrine + dobutamine/milrinone, inhaled NO/epoprostenol); hypoxia/hypercapnia (correct triggers, lung-protective ventilation); arrhythmia (restore sinus rhythm, AV synchrony); peri-intubation (pre-start vasopressors, minimal sedation).
Key points
- Keep RV preload appropriate, lower PVR, augment RV contractility, and maintain SVR > PVR to prevent RV ischemia; never abruptly stop home PAH-targeted therapy. (original synthesis · not guideline verbatim)
- Norepinephrine is the preferred vasopressor (raises PVR less than phenylephrine); inhaled NO or epoprostenol selectively lowers PVR without systemic hypotension.
- Intubation can precipitate sudden, hard-to-reverse collapse; for drug-refractory cases consider VA-ECMO as a bridge.
References
- Hoeper MM, Granton J. Intensive care unit management of patients with severe pulmonary hypertension and right heart failure. Am J Respir Crit Care Med 2011.
- Humbert M, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022.
Worked calculation
The values below come from this tool's own example placeholders and are computed server-side with the formula shown on this page, so the arithmetic can be checked quickly. It demonstrates how to substitute values only — it is not clinical advice and not a real case.
| Main problem | Hypotension/RV failure with low output |
|---|
→PH crisis managementSee management points
- Vasopressors (maintain SVR > PVR)：Norepinephrine first-line (raises PVR less than phenylephrine); low-dose vasopressin as adjunct (lowers PVR, avoid high dose); avoid phenylephrine (raises PVR); dopamine with caution (higher mortality)
- Inotropes：Dobutamine (low dose ≤ 5 μg/kg/min, lowers PVR; may cause tachycardia/hypotension, needs a vasopressor) or milrinone (PDE-3 inhibitor, pulmonary vasodilation but systemic hypotension, needs a vasopressor); levosimendan may be considered
- Lower pulmonary vascular resistance：Inhaled NO or inhaled epoprostenol/iloprost (selective, no systemic hypotension); for treatment-naïve severe PAH, IV epoprostenol first-line (used by PH specialists under monitoring)
Frequently asked questions
- What is Pulmonary Hypertensive Crisis/Acute RV Failure?
- This tool outlines ICU management of pulmonary hypertensive crisis and acute right ventricular failure: optimizing RV preload and afterload, lowering pulmonary vascular resistance, and maintaining systemic perfusion.
- How is Pulmonary Hypertensive Crisis/Acute RV Failure calculated? What is the core formula?
- Management by problem: hypotension (norepinephrine + dobutamine/milrinone, inhaled NO/epoprostenol); hypoxia/hypercapnia (correct triggers, lung-protective ventilation); arrhythmia (restore sinus rhythm, AV synchrony); peri-intubation (pre-start vasopressors, minimal sedation).
- When is Pulmonary Hypertensive Crisis/Acute RV Failure used?
- Use when a PH patient deteriorates with hypotension, hypoxia/hypercapnia, tachyarrhythmia, or impending intubation, to organize support around preserving the right ventricle and keeping SVR above PVR.
- What are the key clinical points for Pulmonary Hypertensive Crisis/Acute RV Failure?
- Keep RV preload appropriate, lower PVR, augment RV contractility, and maintain SVR > PVR to prevent RV ischemia; never abruptly stop home PAH-targeted therapy. (original synthesis · not guideline verbatim) Norepinephrine is the preferred vasopressor (raises PVR less than phenylephrine); inhaled NO or epoprostenol selectively lowers PVR without systemic hypotension. Intubation can precipitate sudden, hard-to-reverse collapse; for drug-refractory cases consider VA-ECMO as a bridge.
- What are the limits and cautions when using Pulmonary Hypertensive Crisis/Acute RV Failure?
- For licensed clinicians and clinical researchers. Interpret results with history, investigations and local protocols; not a diagnosis or prescription, and not a substitute for multidisciplinary decision-making or local guidelines.
- How is Pulmonary Hypertensive Crisis/Acute RV Failure calculated in practice? Can you show a worked example?
- Inputs: Main problem Hypotension/RV failure with low output → Result: PH crisis management See management points（Vasopressors (maintain SVR > PVR): Norepinephrine first-line (raises PVR less than phenylephrine); low-dose vasopressin as adjunct (lowers PVR, avoid high dose); avoid phenylephrine (raises PVR); dopamine with caution (higher mortality), Inotropes: Dobutamine (low dose ≤ 5 μg/kg/min, lowers PVR; may cause tachycardia/hypotension, needs a vasopressor) or milrinone (PDE-3 inhibitor, pulmonary vasodilation but systemic hypotension, needs a vasopressor); levosimendan may be considered, Lower pulmonary vascular resistance: Inhaled NO or inhaled epoprostenol/iloprost (selective, no systemic hypotension); for treatment-naïve severe PAH, IV epoprostenol first-line (used by PH specialists under monitoring)）