Management of pulmonary vasodilator therapy in patients with pulmonary arterial hypertension during critical illness

Abstract

Pulmonary arterial hypertension (PAH) is commonly treated with pulmonary arteriolar vasodilator therapy. When a patient on PAH medication is admitted to intensive care, determining how to manage their medication during the critical illness is often complicated. There may be considerations related to the inability to take medication by mouth, related to acute renal failure or acute liver injury, related to altered mental status or delirium, or related to hypotension and bacteremia. Decisions of how to manage these medications can have a major impact on the patient's clinical course. Presently, provider experience is the major tool in navigating the decisions regarding these medications. In this review, we offer our recommendations of how to manage PAH patients with critical illness who are on PAH medications. These recommendations include how to deliver medications via feeding tubes, how to dose medications in the setting of acute renal failure or acute liver failure, and how to manage medications during hypotension or when a tunneled catheter needs to be removed.

Figure 1

Standardization of inhaled epoprostenol in our electronic record system and the Aeroneb method of delivery. (A) Dosage of inhaled epoprostenol as ordered through our electronic medical record. Concentrations and dosages selected to minimize bag changes and to improve safety. IBW, ideal body weight. (B) Left: our set-up for delivering inhaled epoprostenol through an aeroneb on patients with mechanical ventilation. Right: the Aeroneb (Aerogen Ltd, Dangan, Galway, Ireland) in relation to tubing placed after the ventilator filter. This position was found with repeated trial and error to optimize aerosol delivery without significant deposition in ventilator tubing.