The Right Ventricle in ARDS

doi:10.1016/j.chest.2017.02.019

Chest

Volume 152, Issue 1, July 2017, Pages 181-193

https://doi.org/10.1016/j.chest.2017.02.019 Get rights and content

ARDS is associated with poor clinical outcomes, with a pooled mortality rate of approximately 40% despite best standards of care. Current therapeutic strategies are based on improving oxygenation and pulmonary compliance while minimizing ventilator-induced lung injury. It has been demonstrated that relative hypoxemia can be well tolerated, and improvements in oxygenation do not necessarily translate into survival benefit. Cardiac failure, in particular right ventricular dysfunction (RVD), is commonly encountered in moderate to severe ARDS and is reported to be one of the major determinants of mortality. The prevalence rate of echocardiographically evident RVD in ARDS varies across studies, ranging from 22% to 50%. Although there is no definitive causal relationship between RVD and mortality, severe RVD is associated with increased mortality. Factors that can adversely affect RV function include hypoxic pulmonary vasoconstriction, hypercapnia, and invasive ventilation with high driving pressure. It might be expected that early diagnosis of RVD would be of benefit; however, echocardiographic markers (qualitative and quantitative) used to prospectively evaluate the right ventricle in ARDS have not been tested in adequately powered studies. In this review, we examine the prognostic implications and pathophysiology of RVD in ARDS and discuss available diagnostic modalities and treatment options. We aim to identify gaps in knowledge and directions for future research that could potentially improve clinical outcomes in this patient population.

Section snippets

Definitions

There are various definitions for RVD and RV failure (RVF) in the literature, with the terms being used interchangeably at times. According to the American Society of Echocardiography (ASE), RVD is present when the parameters to quantify RV function are less than the lower value of the normal range: tricuspid annular plane systolic excursion (TAPSE) < 17 mm, pulsed Doppler S wave < 9.5 cm/s, RV fractional area change (RVFAC) < 35%, and RV ejection fraction < 45%. RVFAC has been used to grade

Epidemiology and Prognosis

The reported incidence of RVD in ARDS varies across studies (22%-50%) (Table 1).15, 16, 17, 18, 19, 20, 21, 22, 23, 24 Although there is no robust evidence to support a definitive causal relationship between RVD and mortality in ARDS, it has been shown that RVD has a negative impact on the course of ARDS and that severe RVD is associated with increased mortality even during lung-protective mechanical ventilation.

In a prospective multicenter study (N = 200), Lhéritier et al¹⁹ showed that

Pathophysiology

The right ventricle is responsible for maintaining adequate pulmonary perfusion pressure to deliver desaturated mixed venous blood to the respiratory membrane and low systemic venous pressure to prevent organ congestion. The right ventricle is sensitive to changes in afterload because it is anatomically adapted for the generation of low-pressure perfusion.11, 26

Hemodynamic Monitoring

Standard hemodynamic monitoring can provide direct and indirect evidence suggesting the development of acute RVD. It is important to identify and diagnose patients with RVD early so that interventions aimed at reducing sequelae may be initiated.

Arterial line monitoring can detect the development of pulse pressure variation (PPV) and allows real-time BP monitoring. PPV refers to dynamic changes of arterial pulse pressure (systolic blood pressure – diastolic blood pressure) induced by mechanical

Treatment

The treatment of RVD can be divided into several physiological targets, including optimizing RV preload, increasing RV contractility, and reducing RV afterload. Extracorporeal life support (venovenous or venoarterial extracorporeal membrane oxygenation [ECMO], extracorporeal CO₂ removal [ECCO₂R]) may be considered as rescue therapy in refractory cases of ARDS and RVF.

Conclusions

RVD and RVF are associated with adverse outcomes in patients with ARDS. Understanding the pathophysiology of RVD and the altered cardiopulmonary interactions in ARDS is crucial for the bedside management of these patients. Future research should focus on validation of clinical risk scoring systems to select patients at risk of RVD, immediate assessment by echocardiography, and early implementation of therapeutic measures, such as early pulmonary vasodilation and prone positioning, that may

Acknowledgments

Financial/Nonfinancial disclosures: None declared.

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Contemporary Reviews in Critical Care MedicineThe Right Ventricle in ARDS

Section snippets

Definitions

Epidemiology and Prognosis

Pathophysiology

Hemodynamic Monitoring

Treatment

Conclusions

Acknowledgments

Lancet

J Am Soc Echocardiogr

Chest

Chest

Chest

J Crit Care

Chest

J Crit Care

Clin Chest Med

Chest

Chest

J Am Soc Echocardiogr

J Am Coll Cardiol

Br J Anaesth

Chest

J Surg Res

J Cardiothorac Vasc Anesth

Chest

Chest

Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome

N Engl J Med

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network

N Engl J Med

Prone positioning in severe acute respiratory distress syndrome

N Engl J Med

Comparison of two fluid-management strategies in acute lung injury

N Engl J Med

Neuromuscular blockers in early acute respiratory distress syndrome

N Engl J Med

Has mortality from acute respiratory distress syndrome decreased over time? A systematic review

Am J Respir Crit Care Med

Conservative versus liberal oxygenation targets for mechanically ventilated patients. A pilot multicenter randomized controlled trial

Am J Respir Crit Care Med

Acute respiratory distress syndrome: the heart side of the moon

Curr Opin Crit Care

Right heart failure in acute respiratory distress syndrome: an unappreciated albeit a potential target for intervention in the management of the disease

Indian J Crit Care Med

Pathophysiology of right ventricular failure

Crit Care Med

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

J Am Soc Echocardiogr

Early detection of right ventricular dysfunction using transthoracic echocardiography in ARDS: a more objective approach

Echocardiography

Echocardiographic parameters of right ventricular function predict mortality in acute respiratory distress syndrome: a pilot study

Pulm Circ

Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact

Intensive Care Med

Pulmonary vascular dysfunction in refractory acute respiratory distress syndrome before veno-venous extracorporeal membrane oxygenation

Acta Anaesthesiol Scand

Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study

Intensive Care Med

Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome

Intensive Care Med

Right ventricular function during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome

Crit Care Med

Pulmonary vascular dysfunction is associated with poor outcomes in patients with acute lung injury

Am J Respir Crit Care Med

Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome

Intensive Care Med

Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis

Crit Care Med

Acute respiratory distress syndrome: the Berlin Definition

JAMA

Acute right heart syndrome in the critically ill patient

Heart Lung Vessel

Pulmonary vascular remodeling in adult respiratory distress syndrome

Am Rev Respir Dis

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

Crit Care

Right ventricular function in acute disease states: pathophysiologic considerations

Contemporary Reviews in Critical Care Medicine
The Right Ventricle in ARDS