Key messages

• Acute pulmonary microvascular occlusion may be present in several diseases commonly encountered in critically ill patients and may involve arterioles, capillaries, and venules.

• Mechanisms include active vasoconstriction, microthrombosis, microembolism, endothelial edema, mechanical compression, and vascular remodeling.

• Hemodynamic and gas exchange deterioration may result (e.g. right heart failure, hypoxemia).

• Diagnosis requires analysis of underlying diseases, exclusion of macrovascular lesions, and careful evaluation of both pulmonary circulation and gas exchange.

• Management focuses on recruitment of occluded vessels (e.g. by optimizing lung volume, positioning, fluid restriction) and dilation of constricted vessels (e.g. by increasing PaO2, decreasing PaCO2, alkalinization, intravenous or inhaled vasodilators).

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