Recruitment of occluded vessels

Efforts should be made to optimize lung volume. Reinflation of atelectatic lung areas will improve arterial oxygenation and resolve hypoxic pulmonary vasoconstriction, thereby decreasing pulmonary vascular resistance. Mechanical ventilation is often required, but may be a two-edged sword as it affects pulmonary vessels differently depending on the actual lung volume and the level of positive airway pressure applied. If lung volume is high, any increase in airway pressure will further increase capillary resistance by direct mechanical compression. In addition, overinflation may aggravate alveolar epithelial and capillary injury and enhance pulmonary edema. In contrast, positive airway pressure reduces pulmonary vascular resistance in acute lung disease characterized by high extra-alveolar lung vessel resistance due to low lung volumes. The ventilatory pattern should be adjusted to achieve adequate arterial oxygenation and oxygen transport at the lowest airway pressure, while keeping alveoli open at end-expiration. Positioning (e.g. prone positioning, kinetic therapy) of the ventilated patient may also contribute to recruitment of non-ventilated lung in dependent lung regions. If significant pulmonary edema is present, fluid restriction and diuretics will alleviate vascular compression by reducing extravascular lung water. It is not clear whether patients with acute microvascular occlusion will benefit from systemic anticoagulation or antiplatelet agents.

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