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World J Crit Care Med. Mar 9, 2021; 10(2): 35-42
Published online Mar 9, 2021. doi: 10.5492/wjccm.v10.i2.35
Acute cor pulmonale in patients with acute respiratory distress syndrome: A comprehensive review
Kay Choong See
Kay Choong See, Department of Medicine, National University Hospital, Singapore 119228, Singapore
Author contributions: See KC collected the data and wrote the paper; See KC read and approved the final manuscript.
Conflict-of-interest statement: See KC declares no relevant conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kay Choong See, FCCP, FRCP, MBBS, MRCP, Doctor, Department of Medicine, National University Hospital, 1E Kent Ridge Rd, NUHS Tower Block Level 10, Singapore 119228, Singapore. kay_choong_see@nuhs.edu.sg
Received: December 6, 2020
Peer-review started: December 6, 2020
First decision: December 31, 2020
Revised: January 1, 2020
Accepted: January 28, 2021
Article in press: January 28, 2021
Published online: March 9, 2021
Processing time: 84 Days and 17 Hours
Abstract

Acute respiratory distress syndrome (ARDS)-related acute cor pulmonale (ACP) is found in 8%-50% of all patients with ARDS, and is associated with adverse hemodynamic and survival outcomes. ARDS-related ACP is an echocardiographic diagnosis marked by combined right ventricular dilatation and septal dyskinesia, which connote simultaneous diastolic (volume) and systolic (pressure) overload respectively. Risk factors include pneumonia, hypercapnia, hypoxemia, high airway pressures and concomitant pulmonary disease. Current evidence suggests that ARDS-related ACP is amenable to multimodal treatments including ventilator adjustment (aiming for arterial partial pressure of carbon dioxide < 60 mmHg, plateau pressure < 27 cmH2O, driving pressure < 17 cmH2O), prone positioning, fluid balance optimization and pharmacotherapy. Further research is required to elucidate the optimal frequency and duration of routine bedside echocardiography screening for ARDS-related ACP, to more clearly delineate the diagnostic role of transthoracic echocardiography relative to transesophageal echocardiography, and to validate current and novel therapies.

Keywords: Coronavirus; Critical care; Echocardiography; Hypertension; Pulmonary; Respiratory distress syndrome; Adult; Ventricular dysfunction; Right

Core Tip: Acute respiratory distress syndrome (ARDS)-related acute cor pulmonale (ACP) is associated with adverse hemodynamic and survival outcomes. It is an echocardiographic diagnosis marked by combined right ventricular dilatation and septal dyskinesia. Checking for ARDS-related ACP should be done in patients with ≥ 2 of 4 risk factors: Pneumonia, arterial partial pressure of oxygen-to-inspired oxygen fraction ratio < 150 mmHg, arterial partial pressure of carbon dioxide ≥ 48 mmHg, and driving pressure ≥ 18 cmH2O. Treatments include ventilator adjustment (aiming for arterial partial pressure of carbon dioxide < 60 mmHg, plateau pressure < 27 cmH2O, driving pressure < 17 cmH2O), prone positioning, fluid balance optimization and pharmacotherapy.