EMCrit Podcast EMCrit Podcast 273 - Inhaled Pulmonary Vasodilators
May 15, 2020
Sarah Krager, a critical care clinician specializing in right ventricular failure and pulmonary hypertension. She walks through bedside RV assessment, when invasive monitoring is useful, and practical choices between diuresis, inhaled nitric oxide, and nebulized milrinone. Listens for tips on delivery methods, rapid effects, and strategies for massive PE, ECMO prep, and when to avoid chronic PH meds in acute care.
AI Snips
Chapters
Transcript
Don't Swan Patients Routinely In The ED
- Avoid routine SwanGanz catheters in the ED because they are easy to misinterpret and risky to place.
- Reserve Swans for confirmed severe RV failure when you need detailed hemodynamics or simultaneous need for volume resuscitation.
Offload The Right Ventricle To Restore LV Preload
- In acute RV failure you want to offload the RV to improve LV preload; diuresis alone may not work immediately.
- The fastest way to lower pulmonary vascular resistance is an inhaled pulmonary vasodilator or removing triggers of pulmonary vasoconstriction.
Start Nitric Oxide On High Flow To Buy Time
- If available, start inhaled nitric oxide via high-flow nasal cannula at 20 ppm because it is simple to set up and can be continued through intubation.
- Expect clinical response within ~10 minutes; keep delivery uninterrupted to avoid rebound.