Right Ventricular-Protective Strategies in Pulmonary Embolism With Cardiopulmonary Failure: Prone Positioning and Mechanical Ventilation.

OBJECTIVE: We describe a reproducible bedside strategy to unload the right ventricle (RV) and improve oxygenation after systemic thrombolysis in intubated patients with pulmonary embolism (PE) and cardiopulmonary failure (category E1+R) in centers without extracorporeal membrane oxygenation. KEY STEPS: Confirm category E1+R PE and give weight-adjusted systemic thrombolysis. Use restrictive fluids and a diuretic to decongest the RV. Use vasopressors and minimal sedation to maintain arterial pressure and perfusion. Apply RV-protective ventilation: zero positive end-expiratory pressure, low tidal volume, controlled hyperventilation. Correct acidosis toward mild alkalemia with sodium bicarbonate. Add prone positioning as rescue for refractory hypoxemia. POTENTIAL PITFALLS: Potential pitfalls include post-thrombolysis bleeding, positive end-expiratory pressure-induced RV afterload, airway or line dislodgment during prone positioning, propofol-related hypotension, and overventilation despite embolic dead space. TAKE-HOME MESSAGE: In category E1+R PE, this RV-protective strategy can support the patient through the perithrombolysis period of greatest severity in centers without extracorporeal membrane oxygenation.