Lightning rounds 74: Inhaled pulmonary vasodilators, with Matt Siuba

Inhaled pulmonary vasodilators, primarily nitric oxide and epoprostenol, serve as critical tools for managing right heart failure and refractory hypoxemia, yet their clinical utility remains nuanced. While these agents provide effective afterload reduction for patients with pulmonary hypertension, their impact on ARDS outcomes is often marginal, frequently leading to unnecessary, long-term administration. Clinicians should prioritize titratable, goal-directed therapy rather than passive usage, discontinuing agents promptly if no physiological improvement occurs. Distinguishing between inhaled and systemic prostacyclins is vital, as the latter are significantly more potent and essential for managing Group 1 pulmonary arterial hypertension. While nebulized milrinone or nitroglycerin offer potential alternatives in specific scenarios, they remain secondary options. Ultimately, successful management requires precise patient phenotyping and a clear clinical endpoint to avoid the logistical and financial burdens of "chicken soup" prescribing practices.