The effect of inhaled nitric oxide and inhaled iloprost on hypoxaemia in a patient with pulmonary hypertension after pulmonary thrombarterectomy

Flondor, Michael; Merkel, Matthias; Hofstetter, Christian; Irlbeck, Michael; Frey, Lorenz; Zwißler, Bernhard

doi:10.1111/j.1365-2044.2006.04861.x

Cited by 27 publications

(15 citation statements)

References 21 publications

(28 reference statements)

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“…NO provides synergistic pulmonary vasodilatation with intravenous prostacyclin [258], inhaled iloprost [259], and oral sildenafil [260,261]. Limitations include accumulation of toxic metabolites, although this is not usually a clinically significant problem [206].…”

Section: Resultsmentioning

confidence: 99%

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

et al. 2010

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IntroductionPulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update on the management of PH and RV failure in adult critical care.MethodsA systematic review was performed, based on a search of the literature from 1980 to 2010, by using prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method.ResultsClinical studies of intensive care management of pulmonary vascular dysfunction were identified, describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators, and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (low-quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation (low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy.ConclusionsThis systematic review highlights that although some recommendations can be made to guide the critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality research is needed.

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Section: Resultsmentioning

confidence: 99%

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

et al. 2010

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“…It is important to avoid hypotension and reduced perfusion of the right coronary artery that can result in worsening right ventricular function. Reduction in PVR can be obtained in some patients with inhaled nitric oxide or inhaled iloprost [40,44,45] without an associated reduction in systemic blood pressure. Typically, patients being treated with PAH-specific therapies (prostacyclin analogues, phosphodiesterase-5 inhibitors and endothelin receptor antagonists) prior to surgery can have these medications discontinued in the operating room if PEA has resulted in a significant reduction in PVR.…”

Section: Post-operative Carementioning

confidence: 99%

Surgical treatment of chronic thromboembolic pulmonary hypertension

Jenkins

Madani

Mayer³

et al. 2012

Eur Respir J

159

119

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It is likely that chronic thromboembolic pulmonary hypertension (CTEPH) is more prevalent than currently recognised. Imaging studies are fundamental to decision making with respect to operability. All patients with suspected CTEPH should be referred to an experienced surgical centre. Currently, there is no risk scoring stratification system to guide operability assessment and it is predominantly based on surgical experience.The aim of pulmonary endarterectomy (PEA) is the removal of obstructive material to immediately reduce pulmonary vascular resistance. PEA affords the best chance of cure, but is difficult to perfect. Recognition and clearance of distal segmental and subsegmental disease is the main problem. The basic surgical techniques include: median sternotomy incision, cardiopulmonary bypass, arteriotomy incisions within pericardium, and a true endarterectomy with meticulous full distal dissection. Deep hypothermic circulatory arrest is recommended as the best means of reducing blood flow in the pulmonary artery to allow a clear field for dissection. In the recent PEACOG (PEA and COGnition) trial there was no evidence of cognitive impairment post-PEA.Reperfusion pulmonary oedema and residual pulmonary hypertension are unique postoperative complications post-PEA and are associated with increased mortality. However, inhospital mortality is now ,5% in experienced centres.KEYWORDS: Chronic thromboembolic pulmonary hypertension, deep hypothermic circulatory arrest, pulmonary artery, pulmonary endarterectomy, pulmonary vascular resistance, reperfusion lung injury C hronic thromboembolic pulmonary hypertension (CTEPH) remains under-diagnosed and carries a poor prognosis. The disease presents with nonspecific symptoms and general physicians may not be aware of the condition or the potential for treatment. Current medical treatment is, at best, palliative. Pulmonary endarterectomy (PEA) surgery offers the only chance of symptomatic and prognostic improvement and is curative in many patients with excellent long-term results.It is likely that CTEPH is much more prevalent than recognised. If 3.8% of patients develop CTEPH following an acute pulmonary embolism [1], then there could be as many as 12,000 to 15,000 new cases annually in the USA alone, but only about 200 pulmonary endarterectomies are actually performed. Despite increased understanding, even after the diagnosis of CTEPH is established, operability assessment can still be challenging. Operability is based on the pre-operative estimate of surgical classification [2] and the pre-operative estimation of probable post-operative pulmonary vascular resistance (PVR), both of which determine risk of intervention and probable outcome. The surgical classification is an intra-operative assessment and even the best modern imaging can only estimate the probable type of disease found during surgery, and it is not possible to

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“…Yapılan bir çalışmada, pulmoner tromboendarterektomi sonrası pulmoner hipertansiyonlu bir hastada hipoksemide inhale nitrik oksit ve inhale iloprost kombinasyonun standart tedavi başarısız olduğu durumlarda uygun olabileceğini ve sürekli bir kan gazı takibi ile etkinliğin gözlenebileceğini bildirilmiştir [20] .…”

Section: Discussionunclassified