RV Dysfunction and Severe Atelectasis: A Case of Competing Pathologies Requiring ARDS Strategies

Introduction: This is a unique case of competing pathologies: how to safely balance RV dysfunction with COPD and worsening atelectasis. Adequate vent management of one would unfortunately worsen the other. To balance the pathologies, the patient's unique physiology was considered and ARDs strategies were employed. Patient was proned and a Time Controlled Adaptive Ventilation (TCAV) method was used for prolonged recruitment which eventually improved the patient's status. We successfully employed strategies reserved for acute respiratory distress syndrome (ARDS)in a non-ARDS patient to overcome severe atelectasis and RV failure.


Description: Here is a unique case of ventilator management in a patient with past medical history of RV systolic dysfunction, COPD, and PH. Following intubation for refractory hypercapnia using low tidal volume ventilation (TV 6 mL/kg IBW), the patient’s hypercapnia improved but their oxygenation worsened. Oxygenation worsened and FiO₂ requirements increased to 100% while PaO₂ remained below 60 mmHg. PEEP titration was limited by worsening hypotension and signs of RV strain on bedside ultrasound. We attempted diuresis to improve the patient's right heart function to little success.

The patient was transitioned to a TCAV protocol, employing prolonged inspiratory times to facilitate alveolar recruitment while maintaining relatively low peak pressures. In conjunction, prone positioning was initiated for 16 hours per day over 2 consecutive days. Following prone sessions, oxygenation improved significantly (PaO₂/FiO₂ ratio improved from 60 to 180). Transthoracic echo post-intervention demonstrated improved RV systolic function and decreased septal flattening. Patient was eventually safely extubated on hospital day 7 and discharged.


Discussion: Both excessively low and high PEEPs can increase pulmonary vascular resistance, impair pulmonary circulation, and compromise RV function, ultimately leading to circulatory failure. In this case, we explored different magnitudes in PEEP and all were met with no improvement in the patient's hemodynamics. We eventually explored ARDs ventilatory strategies in a non-ARDs patient. These strategies ultimately improved the patient's hemodynamics, RV failure, and atelactasis, and patient was able to be safely extubated.