Zamanian Roham T, Haddad Francois, Doyle Ramona L, Weinacker Ann B
Stanford University Medical Center, Stanford, CA, USA.
Crit Care Med. 2007 Sep;35(9):2037-50. doi: 10.1097/01.ccm.0000280433.74246.9e.
Pulmonary hypertension may be encountered in the intensive care unit in patients with critical illnesses such as acute respiratory distress syndrome, left ventricular dysfunction, and pulmonary embolism, as well as after cardiothoracic surgery. Pulmonary hypertension also may be encountered in patients with preexisting pulmonary vascular, lung, liver, or cardiac diseases. The intensive care unit management of patients can prove extremely challenging, particularly when they become hemodynamically unstable. The objective of this review is to discuss the pathogenesis and physiology of pulmonary hypertension and the utility of various diagnostic tools, and to provide recommendations regarding the use of vasopressors and pulmonary vasodilators in intensive care.
We undertook a comprehensive review of the literature regarding the management of pulmonary hypertension in the setting of critical illness. We performed a MEDLINE search of articles published from January 1970 to March 2007. Medical subject headings and keywords searched and cross-referenced with each other were: pulmonary hypertension, vasopressor agents, therapeutics, critical illness, intensive care, right ventricular failure, mitral stenosis, prostacyclin, nitric oxide, sildenafil, dopamine, dobutamine, phenylephrine, isoproterenol, and vasopressin. Both human and animal studies related to pulmonary hypertension were reviewed.
Pulmonary hypertension presents a particular challenge in critically ill patients, because typical therapies such as volume resuscitation and mechanical ventilation may worsen hemodynamics in patients with pulmonary hypertension and right ventricular failure. Patients with decompensated pulmonary hypertension, including those with pulmonary hypertension associated with cardiothoracic surgery, require therapy for right ventricular failure. Very few human studies have addressed the use of vasopressors and pulmonary vasodilators in these patients, but the use of dobutamine, milrinone, inhaled nitric oxide, and intravenous prostacyclin have the greatest support in the literature. Treatment of pulmonary hypertension resulting from critical illness or chronic lung diseases should address the primary cause of hemodynamic deterioration, and pulmonary vasodilators usually are not necessary.
在重症监护病房中，急性呼吸窘迫综合征、左心室功能障碍、肺栓塞等危重病患者以及心胸外科手术后患者可能会出现肺动脉高压。患有原发性肺血管、肺、肝或心脏疾病的患者也可能出现肺动脉高压。对这些患者的重症监护病房管理极具挑战性，尤其是当他们出现血流动力学不稳定时。本综述的目的是讨论肺动脉高压的发病机制和生理学以及各种诊断工具的效用，并提供关于在重症监护中使用血管升压药和肺血管扩张剂的建议。
我们对有关危重病情况下肺动脉高压管理的文献进行了全面综述。我们对1970年1月至2007年3月发表的文章进行了MEDLINE检索。相互检索和交叉引用的医学主题词和关键词有：肺动脉高压、血管升压药、治疗学、危重病、重症监护、右心室衰竭、二尖瓣狭窄、前列环素、一氧化氮、西地那非、多巴胺、多巴酚丁胺、去氧肾上腺素、异丙肾上腺素和血管加压素。对与肺动脉高压相关的人体和动物研究均进行了综述。
肺动脉高压给危重病患者带来了特殊挑战，因为诸如容量复苏和机械通气等典型治疗可能会使肺动脉高压和右心室衰竭患者的血流动力学恶化。失代偿性肺动脉高压患者，包括与心胸外科手术相关的肺动脉高压患者，需要针对右心室衰竭进行治疗。很少有人体研究探讨这些患者使用血管升压药和肺血管扩张剂的情况，但文献中对使用多巴酚丁胺、米力农、吸入一氧化氮和静脉注射前列环素的支持力度最大。由危重病或慢性肺部疾病引起的肺动脉高压治疗应针对血流动力学恶化的主要原因，通常不需要使用肺血管扩张剂。
