Heart–lung interaction in acute respiratory distress syndrome: Pathophysiological insights and stepwise lung- and right ventricular-protective management
Heart-lung interaction in ARDS
DOI:
https://doi.org/10.54205/ccc.v34.282063Keywords:
Acute respiratory distress syndrome, Prone positioning, Right ventricular dysfunction, Heart–lung interaction, Acute cor pulmonale, Right ventricular-protective managementAbstract
Acute respiratory distress syndrome (ARDS) imposes a substantial burden on right ventricular (RV) function through increased pulmonary vascular resistance driven by pulmonary vascular injury, hypoxemia, hypercapnia, and the mechanical effects of positive-pressure ventilation. In a subset of patients, this may progress to acute cor pulmonale and is associated with worse outcomes. This narrative review summarizes the pathophysiology of heart–lung interaction in ARDS, the respiratory and hemodynamic effects of prone positioning, and current RV-protective management strategies. Current guidelines support prone positioning in selected patients with moderate-to-severe ARDS, particularly those with severe hypoxemia despite optimized ventilatory support. The 2024 American Thoracic Society (ATS) guideline recommends prone positioning for >12 hours/day in severe ARDS, whereas the 2023 European Society of Intensive Care Medicine (ESICM) guideline and contemporary practice commonly support longer sessions of 16–18 hours, consistent with the PROSEVA protocol. Recent meta-analytic evidence suggests that extended prone positioning may improve oxygenation and reduce mortality, although optimal session duration, patient selection, and complication risk require further study. Prone positioning should be considered a central component of an integrated RV-protective approach that also includes lung-protective ventilation, minimization of driving pressure, individualized positive end-expiratory pressure (PEEP) titration, carbon dioxide control, hemodynamic assessment, and rescue therapies such as inhaled pulmonary vasodilators and veno-venous extracorporeal membrane oxygenation when indicated.
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