Acute cor pulmonale in patients with acute respiratory distress syndrome: A comprehensive review

Table 2 Management options for acute respiratory distress syndrome-related acute cor pulmonale

Management option	Details	Best supporting evidence
Ventilator adjustment	Limit end-inspiratory plateau pressure to 30 cmH2O. Target a tidal volume of 6-9 mL/kg. Positive end-expiratory pressure selected to improve oxygenation without requiring specific hemodynamic support, except for blood volume expansion	Observational study[5]
	Aim for partial pressure of carbon dioxide < 60 mmHg	Observational study[7]
	Aim for partial pressure of carbon dioxide < 48 mmHg	Observational study[14]
	Aim for plateau pressure < 27 cmH2O	Observational study[4]
	Aim for driving pressure < 17 cmH2O	Observational study[2]
Prone positioning	Ventilation in the prone position, especially for patients with refractory severe hypoxemia (P/F ratio < 100 mmHg)	Observational study[5,6,29]
Fluid balance optimization	Stop volume expansion	Expert opinion[22]
	Consider diuresis or fluid removal using hemofiltration	Expert opinion[28]
Pharmacotherapy	Pulmonary vasodilation using inhaled nitric oxide	Expert opinion[16]
	Pulmonary vasodilation using levosimendan	Pilot trial[23]
	Vasopressors to restore systemic blood pressure and to avoid right ventricular ischemia	Expert opinion[28]

ACP: Acute cor pulmonale; ARDS: Acute respiratory distress syndrome; P/F = Arterial partial pressure of oxygen/inspired oxygen fraction.