RECOVERY FROM CIRCULATORY SHOCK IN SEVERE PRIMARY PULMONARY-HYPERTENSION (PPH) WITH AEROSOLIZATION OF ILOPROST

Objective:The treatment of decompensated right ventricular failure wit h vasodilators is difficult due to reduced systemic pressure and/or ve ntilation/perfusion (V/Q) mismatch with hypoxemia. In a recent study w e demonstrated that inhaled vasodilatory prostanoids may offer a new s trategy to achieve pulmonary selective vasodilatation and improvement of right ventricular function. We applied this new approach to a patie nt with circulatory shock due to primary pulmonary hypertension (PPH), complicated by a pulmonary infiltrate, who did not tolerate intraveno us prostacyclin. Design: Case report. Setting: Intensive Care Unit (IC U) Medizinische Klinik Giessen, Germany. Patient: A 45-year-old woman with PPH presenting with decompensated right heart failure (ascites, p leural effusion), circulatory shock and commencing renal and hepatic f ailure, despite maximum therapy including the use of catecholamines. I ntervention: Intermittent inhalation of aerosolized iloprost, the stab le analogue of prostacyclin, and comparison to inhaled nitric oxide (N O). Subsequent long-term therapy with aerosolized iloprost, 150 mu g/d ay. Measurements and results: In response to inhaled iloprost, pulmona ry arterial pressure (PAP) decreased from 65 to 61 mmHg, cardiac index (CI) increased from 1.25 to 1.85 l/min per m(2), and pulmonary vascul ar resistance (PVR) decreased from 2416 to 1549 dyn/s per cm(5) while inhaled NO decreased the PVP from 2280 to 1920 dyn/s per cm(5) without a decrease in PAP. Both of these interventions increased the arterial pO(2) but did not change the systemic arterial pressure. In contrast, intravenous prostacyclin was not tolerated, due to systemic side effe cts. During repeated inhalations with iloprost, the baseline hemodynam ics and gas exchange improved dramatically and renal and liver functio ns normalized. During 1 year of continued therapy, the clinical status improved very much, concomitant with improved hemodynamics, and the p atient has been taken off the transplantation list. Conclusions: Inhal ation of aerosolized iloprost may offer a new lifesaving strategy in n ear desperate cases of pulmonary hypertension in which intravenous pro stacyclin cannot be applied due to severe side effects.