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Papolos AI, Kenigsberg BB, Austin DR, Barnett CF. Management of the peri-intubation period in patients with pulmonary arterial hypertension and respiratory failure. Curr Cardiol Rep 2024; 26:815-820. [PMID: 38913233 DOI: 10.1007/s11886-024-02081-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE OF REVIEW The endotracheal intubation of patients with pulmonary arterial hypertension (PAH) in respiratory distress is a highly morbid procedure that can precipitate hemodynamic collapse. Here we review our strategy for confronting this difficult clinical situation. RECENT FINDINGS There are no clinical trials that explore best practices in the management of patients with PAH and respiratory failure. Here we provide a practical approach to respiratory support, inopressor and pulmonary vasodilator selection, hemodynamic considerations, point-of-care ultrasound monitoring, and endotracheal intubation in patients with PAH in respiratory failure.
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Affiliation(s)
- Alexander I Papolos
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.
- Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Daniel R Austin
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Anesthesiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Christopher F Barnett
- Division of Cardiology, University of California-San Francisco School of Medicine, San Francisco, CA, USA
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Ostad S, Sugarman J, Alkhodair A, Liang J, Mielniczuk LM, Hambly N, Helmersen D, Hirani N, Thakrar M, Varughese R, Norena M, Kularatne M, Swiston JR, Kapasi A, Weatherald J, Brunner NW. Association Between the Pulmonary Artery Pulsatility Index and Prognosis in Pulmonary Arterial Hypertension: A Multicentre Study. CJC Open 2023; 5:545-553. [PMID: 37496788 PMCID: PMC10366663 DOI: 10.1016/j.cjco.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/19/2023] [Indexed: 07/28/2023] Open
Abstract
Background Risk stratification is fundamental in the management of pulmonary arterial hypertension (PAH). Pulmonary artery pulsatility index (PAPi), defined as pulmonary arterial pulse pressure divided by right atrial pressure (RAP), is a hemodynamic index shown to predict acute right ventricular (RV) dysfunction in several settings. Our objective was to test the prognostic utility of PAPi in a diverse multicentre cohort of patients with PAH. Methods A multicentre retrospective cohort study of consecutive adult patients with a new diagnosis of PAH on right heart catheterization between January 2016 and December 2020 was undertaken across 4 major centres in Canada. Hemodynamic data, clinical data, and outcomes were collected. The association of PAPi and other hemodynamic variables with mortality was assessed by receiver-operating characteristic curves and Cox proportional hazards modeling. Results We identified 590 patients with a mean age of 61.4 ± 15.5 years, with 66.3% being female. A low PAPi (defined as < 5.3) was associated with higher mortality at 1 year: 10.2% vs 5.2% (P = 0.02). In a multivariable model including age, sex, body mass index, and functional class, a low PAPi was associated with mortality at 1 year (area under the curveof 0.64 (95% confidence interval 0.55-0.74). However, high RAP (> 8 mm Hg) was similarly predictive of mortality, with an area under the curve of 0.65. Conclusion PAPi was associated with mortality in a large incident PAH cohort. However, the discriminative value of PAPi was not higher than that of RAP alone.
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Affiliation(s)
- Sam Ostad
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Sugarman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Alkhodair
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jiaming Liang
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa M. Mielniczuk
- Department of Medicine, Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Nathan Hambly
- Department of Medicine, Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | - Doug Helmersen
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Naushad Hirani
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mitesh Thakrar
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rhea Varughese
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Monica Norena
- Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Mithum Kularatne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John R. Swiston
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ali Kapasi
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Weatherald
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan W. Brunner
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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Prognostic Value of Pulmonary Artery Pulsatility Index in Right Ventricle Failure-Related Mortality in Inoperable Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 11:jcm11102735. [PMID: 35628862 PMCID: PMC9147458 DOI: 10.3390/jcm11102735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/15/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an ominous disease leading to progressive right ventricular failure (RVF) and death. There is no reliable risk stratification strategy for patients with CTEPH. The pulmonary artery pulsatility index (PAPI) is a novel hemodynamic index that predicts the occurrence RVF. We aimed to investigate prognostic value of PAPI in inoperable CTEPH. Consecutive patients with inoperable CTEPH were enrolled. PAPI was calculated from baseline right heart catheterization data. A prognostic cut-off value was determined, and characteristics of low- and high-PAPI groups were compared. The association between risk assessment and survival was also evaluated. We included 50 patients (mean age 64 ± 12.2 years, 60% female). The number of deaths was 12 (24%), and the mean follow-up time was 52 ± 19.3 months. The established prognostic cut-off value for PAPI was 3.9. The low-PAPI group had significantly higher mean values of mean atrial pressure (14.9 vs. 7.8, p = 0.0001), end-diastolic right ventricular pressure (16.5 vs. 11.2, p = 0.004), and diastolic pulmonary artery pressure (35.8 vs. 27.7, p = 0.0012). The low-PAPI group had lower survival as compared to high-PAPI (log-rank p < 0.0001). PAPI was independently associated with survival and may be applicable for risk stratification in inoperable CTEPH.
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