A narrative review on inhaled pulmonary vasodilators (iPVs) in perioperative pulmonary hypertension (PH) management was published recently in
Key points:
Background: Pulmonary hypertension significantly raises perioperative morbidity/mortality risk, especially in cardiac and high-risk non-cardiac surgery. Traditional IV vasodilators (nitroglycerin, sodium nitroprusside) lack pulmonary selectivity and cause systemic hypotension.
Established agents: The review compares five main inhaled options — nitric oxide (NO), nitroglycerin, prostacyclins (epoprostenol, treprostinil, iloprost), and inodilators (milrinone, levosimendan) — covering dosing, onset/half-life, side effects, and delivery considerations.
Perioperative pathophysiology: Discusses pulmonary hypertension crisis (acute right ventricle failure, hypotension, myocardial ischemia) and pre/intra/postoperative management strategies based on 2022 International Society for Heart and Lung Transplant (ISHLT) and 2023 American Heart Association (AHA) consensus statements.
Practical considerations: Covers delivery mode challenges, cost differences (nitric oxide is most expensive at ~$220/hr vs. inhaled epoprostanoids (IEPO)’s much lower cost), institutional availability, side-effect monitoring (e.g., methemoglobinemia with nitric oxide), and weaning strategies (particularly nitric oxide’s need for gradual taper to avoid rebound pulmonary hypertension).
Combination therapy: Combining agents with different mechanisms (e.g., milrinone + epoprostenol) shows promising synergistic hemodynamic effects, especially in moderate-severe pulmonary hypertension patients.
Emerging therapies: Seralutinib, inhaled vardenafil, MK-5475 (sGC stimulator), and serotonin antagonists (terguride) are discussed as investigational agents with early-phase trial data.
Conclusion: inhaled pulmonary vasodilators are a valuable, targeted tool for perioperative pulmonary hypertension management, but more high-quality trials are needed to establish standardized dosing and outcome-based protocols.
Read more at this link on the Journal of Heart and Lung Transplant (full text available in pdf format)
Citation
Klingbeil R, Hjalmarsson C, Colvin B …Inhaled pulmonary vasodilators in pulmonary hypertension: Perioperative use and clinical considerationsJHLT Open, 2026; 14