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Contemporary Reviews in Critical Care Medicine |

Acute Cor Pulmonale in ARDSAcute Cor Pulmonale in ARDS: Rationale for Protecting the Right Ventricle

Xavier Repessé, MD; Cyril Charron, MD; Antoine Vieillard-Baron, MD, PhD
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From the Section Thorax-Vascular Disease-Abdomen-Metabolism (Drs Repessé, Charron, and Vieillard-Baron), Intensive Care Unit, Ambroise-Paré, Hôpitaux Universitaires Paris Ile-de-France Ouest, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt; and Faculty of Medicine Paris Ile-de-France Ouest (Dr Vieillard-Baron), Université de Versailles Saint-Quentin-en-Yvelines, Saint-Quentin en Yvelines, France.

CORRESPONDENCE TO: Antoine Vieillard-Baron, MD, PhD, Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Ambroise-Paré, Hôpitaux Universitaires Paris Ile-de-France Ouest, 9, avenue Charles-de-Gaulle 92100 Boulogne-Billancourt; e-mail: antoine.vieillard-baron@apr.aphp.fr


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(1):259-265. doi:10.1378/chest.14-0877
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The ventilatory strategy for ARDS has been regularly amended over the last 40 years as knowledge of the pathophysiology of ARDS has increased. Initially focused mainly on the lung with the objectives of “opening the lung” and optimizing arterial oxygen saturation, this strategy now also takes into account pulmonary vascular injury and its effects on the right ventricle and on hemodynamics. Hemodynamic devices now available at the bedside, such as echocardiography, allow intensivists to evaluate respiratory settings according to right ventricular tolerance. Here, we review the pathophysiology of pulmonary vascular dysfunction in ARDS, consider the beneficial and deleterious effects of mechanical ventilation, describe the incidence and meaning of acute cor pulmonale based on recent studies in large series of patients, and propose a new, although not strictly validated, approach based on the protection of both the lung and right ventricle. One of our conclusions is that evaluating the right ventricle may help intensivists to assess the balance between recruitment and overdistension induced by the ventilatory strategy. Prone positioning with its beneficial effects on the lung and also on hemodynamics (the right ventricle) is a good illustration of this. Readers should be aware that most of the information given in this article reflects the point of view of the authors. Although based on clinical observations, clinical studies, and well-known pathophysiology, there is no evidence-based medicine to support this clinical commentary. Other approaches may be favored, in which case our article should be read as another attempt to help intensivists to improve management of ARDS.

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