Evaluation and management of pulmonary hypertension in the emergency department setting

Background: Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance and pul- monary arterial pressure and is associated with signi ficant morbidity and mortality. Objective: This narrative review evaluates PH, outlines the complex pathophysiologic derangements, and ad- dresses the emergency department (ED) management of this patient population. Discussion: Approximately 10 -20% of individuals in the United States suffer from PH. Each year nearly 12,000 PH patients seek care in the ED for a variety of symptoms which may or may not be related to PH. There are 5 classes of PH, some of which respond to particular therapies outlined in this review. As presenting complaints are fre- quently vague and non-speci fic, emergency physicians must recognize manifestations of PH and complications related to PH to deliver appropriate care. Early imaging with chest radiograph, bedside echocardiogram, and computed tomography can assist in determining the underlying etiology of PH exacerbation. Restarting oral or intravenous PH medications that may have been discontinued is crucial in initial management. Immense care should be taken to avoid hypoxia and hypercarbia as well as maintaining right ventricular preload support. In ad- dition to correction of underlying precipitants, judicious vasopressor and inotrope use can help to correct path- ophysiology and avoid further airway intervention. Conclusions: An understanding of the pathophysiology of PH and available emergency treatments can assist emergency clinicians in reducing the immediate morbidity and mortality associated with this disease. Restarting maintenance PH medications and proper selection of vasopressors and inotropes will bene fit decompensating patients with PH.