The Overlooked ICU Challenges In Managing Pulmonary Hypertension

Pulmonary hypertension is one of those diagnoses that most ICU clinicians know exists, but very few feel completely comfortable managing. It rarely comes in neatly labelled. Instead, it hides behind other problems, such as respiratory failure, sepsis, worsening shock, and only becomes obvious when things stop responding the way they should.

 

In the ICU, pulmonary hypertension is less about numbers on a report and more about behaviour. Patients behave differently. Fluids do not help the way we expect. Vasopressors seem to fix blood pressure but not perfusion. Ventilation improves oxygenation but somehow makes the circulation worse. When that pattern appears, pulmonary hypertension is often part of the story.

 

Pulmonary Hypertension Is Usually Not the Main Diagnosis

 

In day-to-day ICU practice, pulmonary hypertension is almost always secondary. It comes with chronic lung disease, left heart failure, pulmonary embolism, ARDS, severe pneumonia, or prolonged ventilation. Sometimes it is known before admission. Often, it is not.

 

Because it is rarely the primary reason for admission, it does not get early attention. The focus stays on infection, oxygenation, or shock. Meanwhile, pulmonary pressures rise, the right ventricle struggles, and routine ICU decisions start having unintended effects.

 

This is why pulmonary hypertension is so often recognised late—not because clinicians miss it entirely, but because it does not shout.

 

The Right Ventricle Is the Real Problem

 

Pulmonary hypertension matters in the ICU mainly because of what it does to the right ventricle. That point is easy to say and surprisingly easy to forget in practice.

 

The right ventricle does not tolerate increased afterload well. When pulmonary vascular resistance rises, the RV dilates quickly. Contractility falls. Forward flow drops. And once that happens, everything else follows—hypotension, congestion, worsening renal function, rising lactate.

 

What makes this difficult is that early RV failure does not always look dramatic. Blood pressure may still be “acceptable”. Oxygen saturation may not be alarming. But perfusion is already compromised.

 

If the right ventricle is not actively considered, management decisions tend to drift in the wrong direction.

 

Fluid Therapy Pitfalls in Pulmonary Hypertension

 

Few things are as automatic in the ICU as giving fluids. Low blood pressure? Give fluids. Rising lactate? Give fluids. Poor urine output? Give fluids. In pulmonary hypertension, this reflex often causes harm.

 

Extra fluid increases right ventricular filling pressures without improving output. The RV stretches, the septum shifts, and left ventricular filling drops. Cardiac output falls further. The patient looks volume overloaded and shocked at the same time.

 

CVP (central venous pressure) numbers do not help much here. Neither does urine output alone. Without looking at the right ventricle, fluid therapy becomes a blind intervention.

 

Many ICU clinicians have seen this pattern, even if they did not label it as pulmonary hypertension at the time.

 

Vasopressors Can Make Things Worse

 

Vasopressors are another area where pulmonary hypertension complicates standard practice. Raising systemic blood pressure feels reassuring, but in these patients, it does not always translate into better circulation.

 

Some vasoactive agents increase pulmonary vascular resistance. That extra afterload further stresses the right ventricle. Blood pressure improves on the monitor, but cardiac output does not. Tissue perfusion remains poor.

 

This mismatch between numbers and physiology is frustrating and dangerous. It leads to escalation rather than reassessment.

 

Managing shock in pulmonary hypertension requires more thought than simply chasing a target MAP.

 

Ventilation Is Not Just About the Lungs

 

Mechanical ventilation plays a major role in pulmonary hypertension, whether we intend it to or not.

 

High airway pressures, excessive PEEP (Positive End-Expiratory Pressure), and lung overdistension increase pulmonary vascular resistance. At the same time, intrathoracic pressure rises, and venous return falls. Oxygenation may improve, but circulation suffers.

 

This becomes especially challenging in ARDS, where lung-protective ventilation is essential. In patients with pulmonary hypertension, ventilator settings must constantly be weighed against their effect on the right heart.

 

There is no single “correct” setting here, only continuous adjustment and close observation.

 

Intubation Is a High-Risk Moment

 

If there is one moment that exposes pulmonary hypertension in the ICU, it is intubation.

 

Induction removes sympathetic tone. Apnea causes brief hypoxia. Airway pressures rise. For a right ventricle already under stress, this can be enough to cause sudden collapse.

 

Many clinicians have experienced a patient who looked stable before intubation and deteriorated immediately afterward. In retrospect, pulmonary hypertension and RV failure often explain why. These patients require planning, not just technical skill.

 

Diagnosis Is Often Late, Not Absent

 

Bedside echocardiography is widely available, but interpretation varies. Right ventricular dilation, septal flattening, or reduced RV function may be noted without fully changing management.

 

The challenge is not seeing the problem; it is knowing what to do with it.

 

Without structured training in right heart physiology, pulmonary hypertension remains something that is “noticed” rather than actively managed.

 

Why Outcomes Are Worse

 

Patients with pulmonary hypertension consistently do worse in the ICU. They stay ventilated longer, require more vasoactive support, and have higher mortality.

 

This is not always because the disease is severe. Often, it is because early management unintentionally worsens right ventricular function.

 

Pulmonary hypertension punishes delayed recognition.

 

Why Many Clinicians Feel Underprepared

 

Most ICU training focuses heavily on left ventricular failure, sepsis algorithms, and lung mechanics. Right ventricular physiology and pulmonary vascular disease receive far less attention.

 

As a result, many clinicians learn to manage pulmonary hypertension through experience rather than structured education. That learning curve is steep and sometimes costly.

 

Where Advanced Critical Care Training Helps

 

Managing pulmonary hypertension well requires comfort with physiology, not just protocols. It requires understanding how ventilation, fluids, and drugs interact with the right heart.

 

This level of thinking does not develop overnight. It comes from guided learning, mentorship, and exposure to complex cases.

 

The Role of the Critical Care Medicine Fellowship by Medvarsity

 

The Critical Care Medicine Fellowship by Medvarsity is designed for clinicians dealing with real ICU complexity, not idealised cases. It places strong emphasis on cardiopulmonary interactions, right ventricular dysfunction, and decision-making in unstable patients.

 

Through expert mentorship and clinical observership, the fellowship helps doctors connect physiology to bedside practice, particularly in challenging scenarios like pulmonary hypertension.

 

For clinicians working in busy ICUs, this kind of structured upskilling helps bridge the gap between theory and reality. Pulmonary hypertension does not need dramatic symptoms to cause harm. In the ICU, it quietly alters how patients respond to almost everything we do.

 

Recognising it early, respecting right ventricular physiology, and adapting management accordingly can change outcomes. As ICU care becomes more complex, training that prepares clinicians for these nuances becomes increasingly important.