Critical care management of pulmonary arterial hypertension in pregnancy: the pre-, peri- and post-partum stages

The mortality rate of pulmonary hypertension in pregnancy is 25%–56%. Pulmonary arterial hypertension is the highest incidence among this group, especially in young women. Despite clear recommendation of pregnancy avoidance, certain groups of patients are initially diagnosed during the gestational age step into the third trimester. While the presence of right ventricular failure in early gestation is usually trivial, it can be more severe in the late trimester. Current evidence shows no consensus in the management and serious precautions for each stage of the pre-, peri- and post-partum periods of this specific group. Pulmonary hypertension-targeted drugs, mode of delivery, type of anesthesia, and some avoidances should be planned among a multidisciplinary team to enhance maternal and fetal survival opportunities. Sudden circulatory collapse from cardiac decompensation during the peri- and post-partum phases is detrimental, and mechanical support such as extracorporeal membrane oxygenation should be considered for mitigating hemodynamics and extending cardiac recovery time. Our review aims to explain the pathophysiology of pulmonary arterial hypertension and summarize the current evidence for critical management and precautions in each stage of pregnancy

Effect of noninvasive respiratory support on interstitial lung disease with acute respiratory failure: A systematic review and meta-analysis

# Background Primary studies have demonstrated the effectiveness of noninvasive respiratory supports, including noninvasive positive pressure ventilation (NIPPV) and high flow nasal cannula (HFNC), for improving oxygenation and ventilation in patients with interstitial lung diseases (ILDs) and acute respiratory failure (ARF). These studies have not been synthesized and are not included in current practice guidelines. This systematic review with meta-analysis synthesizes studies that compared the effectiveness of NIPPV, HFNC and conventional oxygen therapy (COT) for improving oxygenation and ventilation in ILD patients with ARF. # Methods MEDLINE, EMBASE and the Cochrane Library searches were conducted from inception to August 2023. An additional search of relevant primary literature and review articles was also performed. A random effects model was used to estimate the PF ratio (ratio of arterial oxygen partial pressure to fractional inspired oxygen), PaCO~2~ (partial pressure of carbon dioxide), mortality, intubation rate and hospital length of stay. # Results Ten studies were included in the systematic review and meta-analysis. Noninvasive respiratory supports demonstrated a significant improvement in PF ratio compared to conventional oxygen therapy (COT); the mean difference was 55.92 (95% CI $$18.85-92.99$$; *p*=0.003). Compared to HFNC, there was a significant increase in PF ratio in NIPPV (mean difference 0.45; 95% CI $$0.12--0.79$$; *p*=0.008). There were no mortality and intubation rate benefits when comparing NIPPV and HFNC; the mean difference was 1.1; 95% CI $$0.83-1.44$$; *p*=0.51 and 1.86; 95% CI $$0.42-8.33$$; *p*=0.42, respectively. In addition, there was a significant decrease in hospital length of stay in HFNC compared to NIPPV (mean difference 9.27; 95% Cl $$1.45 -- 17.1$$; *p*=0.02). # Conclusions Noninvasive respiratory supports might be an alternative modality in ILDs with ARF. NIPPV demonstrated a potential to improve the PF ratio compared to HFNC. There was no evidence to support the benefit of NIPPV or HFNC in terms of mortality and intubation rate