Question for intensivists regarding theoretical vs observed risk tolerance. How much consideration or pause (if any) are you given when starting inhaled pulmonary vasodilators for refractory hypoxemia if the patient has concurrent left heart dysfunction? #MedSky #EMIMCC #CritCareSky #CardioSky - ThreadSky

cnemehmd.bsky.social • 76 days ago

Question for intensivists regarding theoretical vs observed risk tolerance. How much consideration or pause (if any) are you given when starting inhaled pulmonary vasodilators for refractory hypoxemia if the patient has concurrent left heart dysfunction?

#MedSky #EMIMCC #CritCareSky #CardioSky

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load-dependent.bsky.social•75 days ago

Thoughts @lordofthelungs.bsky.social ?

lordofthelungs.bsky.social•75 days ago

I feel like you and I would bore everyone on rounds. For just hypoxia, there's no role for inhaled vasodilators for me. either overcome with the vent or they go on ecmo.

load-dependent.bsky.social•75 days ago

#cccsky

ed-intensivism.bsky.social•76 days ago

I think if you're aggressively managing volume effectively it's more of a theoretical risk. My more experienced CV intensivist faculty don't put much weight into that risk, but I've found nonintensivist cardiomyopathy teams seemed to be much more fearful of it.

pulmcrit.bsky.social•75 days ago

I kinda feel like this is more of an issue with systemic pulmonary vasodilators (esp longer acting oral agents) than inhaled pulmonary vasodilators?

is there any actual evidence about this?

load-dependent.bsky.social•75 days ago

I don’t quite follow, if it’s pulmoary hypertension and hypoxia primarily sec to left sided pressure, then systemic makes more sense than isolated pulmonary vasodilation?

erskinejames.bsky.social•75 days ago

Agree with you. If isolated rv dysfunction, inhaled vasodilators are great. But if lv dysfunction, need to reduce lv filling pressures before working on the pulmonary artery (either through diuresis or decreasing afterload or both)

cnemehmd.bsky.social•75 days ago

I couldn’t find anything convincing, mostly theoretical physiology descriptions. The narrative review from 2021 didn’t really touch on it. Have heard people say they don’t think twice about it & a few that felt they got burned on a couple anecdotal cases. So was curious how people felt about it here

jessestringer.bsky.social•75 days ago

I don't worry so much about it in my peds CVICU, but in absence of RV dysfunction/pulm HTN consider pulm vasodilators for V/Q matching purposes to be more of a salvage therapy attempt. Regardless would pay close attention to volume status, LV afterload and follow MVO2/NIRs to follow LV.

shettyvu.bsky.social•75 days ago

I really don’t use inhaled vasodilators for hypoxemia. I am not convinced it improves outcomes. I only use it for RV dysfunction. Also, if there is concurrent LV dysfunction then the question always is if we’ve diuresed enough.

chriscarrollmd.bsky.social•75 days ago

Same. In theory I don’t use inhaled vasodilators for hypoxemia unless I have pulmonary HTN or it’s a bridge to ECMO. In practice, they get started more than I’d like

emilyfri.bsky.social•75 days ago

Yes to both of these approaches.

deannamarie208.bsky.social•75 days ago

Probably same here

deannamarie208.bsky.social•75 days ago

But I am pretty strict about stopping if there isn’t an immediate effect

cnemehmd.bsky.social•75 days ago

Yeah, I wouldn’t call it a routine therapy for the same reason that the evidence isn’t quite there. But I feel like it’s reached for with enough frequency as salvage therapy that I was curious to get some thoughts on this. I’ve heard really mixed opinions on the safety profile and not much evidence.

emilymoin.com•75 days ago

I think you'll find a similar risk distribution profile for basically every salvage therapy we use for moribund patients (most will try but a few feel like they've been burned). If we're in "can't get O2 to the brain" territory I'll try it, but I don't use it just to pretty the numbers.

cnemehmd.bsky.social•75 days ago

Personally, I think this is an incredibly fair way to think about it and probably the right take re: salvage maneuvers

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