How to Care for Critically Ill PE Patients

August 2, 2024

Written by Seth Walsh-Blackmore

Spoon Feed
Anticoagulation is the cornerstone of managing acute pulmonary embolism (PE), but initial management strategies in the intensive care unit (ICU) for sicker patients* with acute PE lack consensus guidelines. This reviews the available evidence and provides guidance.

Stuck between a lung and a heart space.
The central pathophysiology of PE is increased pulmonary vascular resistance (PVR) and subsequent impairment of right ventricle (RV) function via distension and increased wall stress.^1-4 Management should begin with assessment^5,6 and optimization of RV function.

Hemodynamic support:

• Norepinephrine is a good first choice as a vasopressor.
• Add vasopressin early if vasopressor requirements are escalating. Unlike alpha agonists, it increases systemic vascular resistance without increasing PVR.
• Inotropes support RV stroke volume against an increased PVR. Most agents also systematically vasodilate to some degree, which can be offset with any pressors, but vasopressin may be superior as it does not increase PVR.
• Tachycardia increases RV metabolic demand while decreasing coronary perfusion time, which may limit the use of beta-agonist inotropes.

Fluids and Diuresis:

• Avoid fluid boluses unless observing evidence of hypovolemia and RV underfilling.
• With evidence of RV congestion, a loop diuretic may improve RV function.

Pulmonary Vasodilators:

• Supplemental oxygen decreases PVR via inhibition of hypoxic vasoconstriction and may improve RV enlargement even in the absence of hypoxia.
• Consider inhaled nitric oxide (iNO) after oxygen and other supportive management if there is continued evidence of RV dysfunction.

Intubation:

• Patients with RV failure are at risk for peri-intubation hemodynamic collapse.
• Positive pressure ventilation increases PVR and may worsen RV function.
• Once intubated, use the lowest tidal volume and PEEP possible to avoid hypoxia and hypercapnia.

If all else fails:

• Venoarterial ECMO may be offered for hemodyamic support.

How will this change my practice?
Much of the cited evidence comes from small comparative and exploratory animal studies, leaving room for clinician judgment. Practicing bedside echo assessment of the RV will improve my PE management in any setting.

*high-risk or intermediate-high risk patients by ESC guidelines⁷

Another Spoonful
Following stabilization, we can consider emerging interventions for high-risk PE, such as catheter-directed lytics or thrombectomy, previously covered on JournalFeed. Also, refresh your bedside echo RV assessment with this video by Core Ultrasound.

Source
Management Strategies for Acute Pulmonary Embolism in the Intensive Care Unit. Chest. 2024 Jun 1:S0012-3692(24)00675-5. doi: 10.1016/j.chest.2024.04.032. Online ahead of print. PMID: 38830402

Reviewed by Bo Stubblefield

Works Cited

1. Matthews JC, McLaughlin V. Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev 2008;4:49-59.
2. Lyhne MD, Kline JA, Nielsen-Kudsk JE, Andersen A. Pulmonary vasodilation in acute pulmonary embolism – a systematic review. Pulm Circ 2020;10:2045894019899775.
3. Kostura M, Smalley C, Koyfman A, Long B. Right heart failure: A narrative review for emergency clinicians. Am J Emerg Med 2022;58:106-13.
4. Houston BA, Brittain EL, Tedford RJ. Right Ventricular Failure. The New England journal of medicine 2023;388:1111-25.
5. Dudzinski DM, Hariharan P, Parry BA, Chang Y, Kabrhel C. Assessment of Right Ventricular Strain by Computed Tomography Versus Echocardiography in Acute Pulmonary Embolism. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2017;24:337-43.
6. Carroll BJ, Heidinger BH, Dabreo DC, et al. Multimodality Assessment of Right Ventricular Strain in Patients With Acute Pulmonary Embolism. The American journal of cardiology 2018;122:175-81.
7. Konstantinides SV, Meyer G. The 2019 ESC Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism. European heart journal 2019;40:3453-5.