Introduction: Pulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV)
failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be
difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and
reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update
on the management of PH and RV failure in adult critical care.
Methods: A systematic review was performed, based on a search of the literature from 1980 to 2010, by using
prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method.
Results: Clinical studies of intensive care management of pulmonary vascular dysfunction were identified,
describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators,
and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with
pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close
monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (lowquality
evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) lowdose
vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation
(low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular
dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III
inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation
(low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance.
7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and
improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect
profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality
evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary
vascular dysfunction awaiting definitive therapy.
Conclusions: This systematic review highlights that although some recommendations can be made to guide the
critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this
review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality
research is needed.