What is the best approach for intubating a patient with right ventricular (RV) failure?

Intubating a Patient with Right Ventricular Failure

When intubating a patient with right ventricular failure, non-invasive ventilation should be attempted first whenever possible, and if intubation is necessary, use an experienced cardiac anesthesiologist with arterial line monitoring, careful induction agents that maintain hemodynamic stability, and post-intubation ventilation with low tidal volumes and minimal PEEP. 1

Pre-Intubation Considerations

Hemodynamic Optimization

• Establish arterial line monitoring prior to intubation 1
• Consider fiberoptic awake intubation to avoid sympathetic stimulation 1
• Optimize preload before intubation:
  • If central venous pressure is low, give cautious fluid challenge (≤500 mL) 1
  • Avoid aggressive volume loading as it can worsen RV function 1
• Start vasopressors/inotropes before intubation:
  • Norepinephrine (0.05-3.3 μg/kg/min) as first-line vasopressor 1
  • Consider dobutamine (2.5-5.0 μg/kg/min) for RV contractility 1
  • Consider vasopressin to offset potential drop in SVR 1

Oxygenation Strategy

• Try non-invasive ventilation first whenever possible 1, 2
• High-flow nasal cannula or non-invasive ventilation should be preferred over intubation 1, 2
• Consider inhaled nitric oxide (5-40 ppm) or inhaled prostacyclin (10-50 ng/kg/min) before intubation to reduce RV afterload 1

Intubation Procedure

Induction Agents

• Avoid anesthetic drugs that cause hypotension 1
• Consider etomidate or ketamine in reduced doses with fentanyl pretreatment
• Have push-dose vasopressors immediately available

Intubation Technique

• Request assistance from an experienced cardiac anesthesiologist 1
• Consider rapid sequence intubation to minimize time with inadequate ventilation
• Maintain systemic blood pressure throughout the procedure
• Avoid excessive stimulation that could increase pulmonary vascular resistance

Post-Intubation Management

Ventilator Settings

• Use low tidal volumes (~6 mL/kg lean body weight) 1
• Keep plateau pressure <30 cmH2O 1
• Minimize PEEP (≤10 cmH2O if oxygenation allows) 1
• Avoid permissive hypercapnia as acidosis increases pulmonary vascular resistance 1
• Maintain SaO₂ >90% to prevent hypoxic pulmonary vasoconstriction 1

Hemodynamic Support

• Continue or titrate vasopressors and inotropes:
  • Norepinephrine to maintain systemic pressure 1
  • Dobutamine or milrinone for RV contractility 1
• Consider pulmonary vasodilators:
  • Inhaled nitric oxide (5-40 ppm) 1
  • Sildenafil (20 mg three times daily) 1
  • Monitor for rebound pulmonary hypertension when weaning inhaled agents 1

Common Pitfalls and Caveats

• Avoid excessive positive pressure ventilation: Positive pressure ventilation decreases venous return and increases RV afterload 1
• Prevent hypoxemia, hypercapnia, and acidosis: These conditions increase pulmonary vascular resistance 1
• Beware of volume overload: Excessive fluids can overdistend the RV and worsen ventricular interdependence 1
• Monitor for acute cor pulmonale: Watch for signs of worsening RV failure (rising CVP, falling cardiac output) 1
• Avoid high PEEP: Values above 15 cmH2O can promote overdistension and worsen RV function 1

Intubation in RV failure carries significant mortality risk, but with proper preparation, technique, and post-intubation management, these risks can be minimized while supporting the patient through their critical illness.