🫁 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.
Pulmonary Hypertensive Crisis/Acute RV Failure
Main problem
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.
Decision support for licensed clinicians only; not a substitute for clinical judgement, diagnosis or local protocols.