Session to explore unique challenges of PAH in critical care

The outcome for critical care patients with decompensated pulmonary arterial hypertension (PAH) is often very poor, with sparse literature on managing the condition inside an ICU and wide variations in procedures and treatments between institutions.

During CHEST 2026, experts will attempt to close some of those gaps in knowledge and practice in the session When PAH Goes Off the Curve: Managing the Extreme Cases in the ICU at 11:15 am MST on Wednesday, October 21, in the Phoenix Convention Center.

Farah Kazzaz, MD, a pulmonary disease and critical care specialist at UT Health Houston, will chair the session and provide an overview on diagnosing PAH in critical care situations, with an emphasis on defining rapid deterioration and identifying signs of PAH through various clinical measurements.

“A lot of the existing literature on PAH focuses on identifying and managing it in outpatient treatment,” she said. “There is very little literature on how to manage arterial hypertension in the ICU, which is where you will have acute or chronic right ventricular failure.”

Because PAH often presents in patients 20 to 35 years old who might otherwise seem entirely healthy, Dr. Kazzaz said, it is often mistaken for asthma or postpartum complications, particularly in smaller hospitals or institutions that might lack some diagnostic tools or have had less exposure to the condition previously.

“In the ICU, you need to keep a high index of suspicion for PAH and look for it even if it is not showing as such,” Dr. Kazzaz said.

Namita Sood, MBBS, FCCP, will examine the latest literature and clinical approaches in using medication therapy for the stabilization of acute or chronic deterioration due to PAH, with a specific emphasis on how this differs from outpatient approaches and how it should integrate the expertise of multidisciplinary teams.

Abdul Khan, MBBS, will explain the role of oxygenation and airway management for severe PAH, covering some of the intense debate about the correct type and threshold criteria for vasopressors, as well as the situations when intubation is necessary.

Jonah Rubin, MD, FCCP, will present real-world case studies and discuss mechanical support and transplant procedures in patients with decompensated PAH.

Dr. Kazzaz said she expects significant discussions around the guidelines for mechanical support among patients with PAH in an ICU.

“The use of mechanical devices in PAH patients is not a well-known area of research or practice,” she said, “and there is some controversy about [their] use, which varies widely depending on a specific center and their comfort level with it, as well as about which devices to use and how to establish end points for the use of the device.”

Dr. Kazzaz hopes attendees will leave the session with ideas to strengthen or rethink their own approaches to PAH in critical care situations. In addition, attendees should be empowered to initiate wider, cross-disciplinary discussions about PAH in their own institutions.

“If someone comes in with acute cardiogenic shock due to hypertension, then we want to get our cardiovascular surgeons on board from the beginning in case this patient will need a mechanical circulatory device. Or, with pregnant or postpartum patients, we consult with maternal fetal medicine or with the OBs from the start,” Dr. Kazzaz said. “So we hear from everyone and learn how they look at the same case from a different perspective. We have multidisciplinary calls to go over updates and backup plans—this cross-sectional approach is one of the most key aspects of care for PAH in an ICU.”