The prostacyclins are pulmonary vasodilators frequently used in patients with acute respiratory distress syndrome (ARDS) and decompensated right ventricular (RV) failure. However, there is scarce evidence regarding the efficacy of aerosolized prostacyclins for the treatment of RV failure in critically-ill patients. We aim to describe our experience with the use of aerosolized epoprostenol and iloprost in critically-ill patients with RV failure.
Retrospective analysis of patients admitted to Oklahoma University Health Sciences Center between 08/2015–08/2017. Patients were ≥ 18 years old, had a diagnosis of RV failure and received an aerosolized prostacyclin for at least 4 hours. Changes in hemodynamics (changes in norepinephrine [NE] requirements or equivalent pressor dose) and gas-exchange (changes in PaO2/FiO2 ratio) were assessed at 24h and 48h, as surrogates of pulmonary vasodilation. Chi-square and ANOVA analysis were used for comparison of data, as appropriate.
Forty-two patients were identified. Mean age 53.47±3.00, 57% male, 26% concomitant ARDS. Epoprostenol was used more frequently than iloprost (63 vs. 37%, p=0.0021). NE requirements were higher in the epoprostenol subgroup (28.75±6.08 mcg/min vs. 6.5±8.6, p=0.0304). There were statistically significant improvements in hemodynamics with iloprost (NE dose 4.5, 0 and 0 mcg/min at baseline, 24h and 48h, p=0.0352) but not with epoprostenol (21.67, 20 and 18.33 mcg/min, p=NS). There were improvements in PaO2/FiO2 with epoprostenol (90.59, 124.08 and 122.54 at baseline, 24h and 48h, p=0.0431) but no major changes with iloprost. In-hospital survival was 33.33% for epoprostenol and 57.14% for iloprost (p=0.3106).
The use of aerosolized prostacyclins in critically-ill patients with RV dysfunction is associated with improvements in vasopressor requirements and gas-exchange. Iloprost was associated with improvements in hemodynamics however this could be related to a more profound shock state in the epoprostenol subgroup. Further studies are needed to compare the efficacy of both prostacyclins in the treatment of decompensated RV dysfunction.