Recovery from circulatory shock in severe primary pulmonary hypertension (PPH) with aerosolization of iloprost

• Published in: Intensive care medicine 1998-06, Vol.24 (6), p.631-634
• Main Authors: OLSCHEWSKI, H, GHOFRANI, H. A, WALMRATH, D, TEMMESFELD-WOLLBRÜCK, B, GRIMMINGER, F, SEEGER, W
• Format: Article
• Language: English
• Subjects: Administration, Inhalation; Aerosols; Aerosols - therapeutic use; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Ascites; Biological and medical sciences; Blood pressure; Catecholamines; Congestive heart failure; Emergency and intensive respiratory care; Female; Gas exchange; Hemodynamics; Humans; Hypertension; Hypertension, Pulmonary - complications; Hypoxemia; Iloprost - administration & dosage; Iloprost - therapeutic use; Inhalation; Intensive care; Intensive care medicine; Intravenous administration; Medical sciences; Middle Aged; Nitric oxide; Nitric Oxide - therapeutic use; Oxygen - blood; Patients; Pleural effusion; Prostacyclin; Prostaglandins; Pulmonary hypertension; Renal failure; Respiration; Right ventricular failure; Shock (Circulatory); Shock - drug therapy; Shock - etiology; Side effects; Therapy; Transplantation; Vasodilation; Vasodilator Agents - administration & dosage; Vasodilator Agents - therapeutic use; Ventilation; Ventricle; Ventricular Dysfunction, Right - drug therapy; Ventricular Dysfunction, Right - etiology
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s001340050628

The treatment of decompensated right ventricular failure with vasodilators is difficult due to reduced systemic pressure and/or ventilation/perfusion (V/Q) mismatch with hypoxemia. In a recent study we demonstrated that inhaled vasodilatory prostanoids may offer a new strategy to achieve pulmonary selective vasodilatation and improvement of right ventricular function. We applied this new approach to a patient with circulatory shock due to primary pulmonary hypertension (PPH), complicated by a pulmonary infiltrate, who did not tolerate intravenous prostacyclin. Case report. Intensive Care Unit (ICU), Medizinische Klinik Giessen, Germany. A 45-year-old woman with PPH presenting with decompensated right heart failure (ascites, pleural effusion), circulatory shock and commencing renal and hepatic failure, despite maximum therapy including the use of catecholamines. Intermittent inhalation of aerosolized iloprost, the stable analogue of prostacyclin, and comparison to inhaled nitric oxide (NO). Subsequent long-term therapy with aerosolized iloprost, 150 microg/day. In response to inhaled iloprost, pulmonary arterial pressure (PAP) decreased from 65 to 61 mmHg, cardiac index (CI) increased from 1.25 to 1.85 l/min per m2, and pulmonary vascular resistance (PVR) decreased from 2416 to 1549 dyn/s per cm5 while inhaled NO decreased the PVR from 2280 to 1920 dyn/s per cm5 without a decrease in PAP. Both of these interventions increased the arterial pO2 but did not change the systemic arterial pressure. In contrast, intravenous prostacyclin was not tolerated, due to systemic side effects. During repeated inhalations with iloprost, the baseline hemodynamics and gas exchange improved dramatically and renal and liver functions normalized. During 1 year of continued therapy, the clinical status improved very much, concomitant with improved hemodynamics, and the patient has been taken off the transplantation list. Inhalation of aerosolized iloprost may offer a new life-saving strategy in near desperate cases of pulmonary hypertension in which intravenous prostacyclin cannot be applied due to severe side effects.