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Matt Siuba
Zentensivist. ARDS, Mechanical Ventilation, RV, & Shock Enthusiast.

Brendan Riordan
Left-handed intensivist defending the right side of the heart. Often found ordering diuretics in the Cardiothoracic Surgery ICU or posting cat photos on twitter.
The Pre-brief
Re-join #ThePeoplesVentricle Defense League for Part 2 of acute cor pulmonale in ARDS. If you missed Part 1, get caught up here.
In this segment we discuss diagnostic and therapeutic approaches to ACP management.
Timestamps:
0:21 Introduction: Resistance is Futile
1:15 Prevention of ACP
9:09 Identifying ACP with invasive and non-invasive techniques (including POCUS)
15:42 Treatment of ACP
23:55 What about extracorporeal life support for ACP?
27:33 The Bottom Line
The Debrief
- ACP is best identified with POCUS, whether TTE or TEE. Invasive hemodynamic monitoring may play a role in select circumstances.
- Targets to monitor response to therapy are not well defined
- ACP prevention shares common ground with best practices for ARDS including lung-protective ventilation and prone position ventilation. This can be considered “RV-protective ventilation”.
- Reduction of preload (via diuresis or ultrafiltration) should be considered
- Afterload reduction is more challenging. Treat acid/base and gas exchange abnormalities as able. Inhaled pulmonary vasodilators are a physiologically appealing therapy for ACP but without strong evidence to support it.
- Inotropic therapy may be attempted, but is a bridge at best.
- Consider consultation with an experienced ARDS and extracorporeal life support center if the above was unsuccessful.
- National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564-75. doi: 10.1056/NEJMoa062200. Epub 2006 May 21. PMID: 16714767.
- Rosenberg AL, Dechert RE, Park PK, Bartlett RH; NIH NHLBI ARDS Network. Review of a large clinical series: association of cumulative fluid balance on outcome in acute lung injury: a retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med. 2009 Jan-Feb;24(1):35-46. doi: 10.1177/0885066608329850. Epub 2008 Dec 22. PMID: 19103612.
- Wanner PM, Filipovic M. The Right Ventricle-You May Forget it, but It Will Not Forget You. J Clin Med. 2020 Feb 5;9(2):432. doi: 10.3390/jcm9020432. PMID: 32033368; PMCID: PMC7074056.
- Andrew B. Lumb, Peter Slinger; Hypoxic Pulmonary Vasoconstriction: Physiology and Anesthetic Implications. Anesthesiology 2015; 122:932–946 doi: https://doi.org/10.1097/ALN.0000000000000569
- Ketabchi, F., Ghofrani, H.A., Schermuly, R.T. et al. Effects of hypercapnia and NO synthase inhibition in sustained hypoxic pulmonary vasoconstriction. Respir Res 13, 7 (2012). https://doi.org/10.1186/1465-9921-13-7
- Paternot A, Repessé X, Vieillard-Baron A. Rationale and Description of Right Ventricle-Protective Ventilation in ARDS. Respir Care. 2016 Oct;61(10):1391-6. doi: 10.4187/respcare.04943. Epub 2016 Aug 2. PMID: 27484108.
- Guérin, C., Matthay, M.A. Acute cor pulmonale and the acute respiratory distress syndrome. Intensive Care Med 42, 934–936 (2016). https://doi.org/10.1007/s00134-015-4197-z
- Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, Richard JC, Carvalho CR, Brower RG. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015 Feb 19;372(8):747-55. doi: 10.1056/NEJMsa1410639. PMID: 25693014.
- Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013 Jun 6;368(23):2159-68. doi: 10.1056/NEJMoa1214103. Epub 2013 May 20. PMID: 23688302.
- Bunge JJH, Caliskan K, Gommers D, Reis Miranda D. Right ventricular dysfunction during acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation. J Thorac Dis. 2018 Mar;10(Suppl 5):S674-S682. doi: 10.21037/jtd.2017.10.75. PMID: 29732186; PMCID: PMC5911554.
- de Asua, Ignacio, and Alex Rosenberg. “On the right side of the heart: Medical and mechanical support of the failing right ventricle.” Journal of the Intensive Care Society vol. 18,2 (2017): 113-120. doi:10.1177/1751143716684357
- Di Nicolò, P. The dark side of the kidney in cardio-renal syndrome: renal venous hypertension and congestive kidney failure. Heart Fail Rev 23, 291–302 (2018). https://doi.org/10.1007/s10741-018-9673-4
- https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20784/abnormal-central-venous-pressure-waveform-patterns
- https://derangedphysiology.com/main/cicm-primary-exam/required-reading/respiratory-system/Chapter%20064/factors-which-affect-pulmonary-vascular-resistance
PEER Reviewed by
Dr. Terren Trott
PEER Reviewed by
Dr. Steve Haywood
PEER Reviewed by
Dr. Aman Thind