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Peer-reviewedCC BYJHLT Open

Inhaled pulmonary vasodilators in pulmonary hypertension: Perioperative use and clinical considerations

  • Rebecca Klingbeil, DNP1
  • Clara Hjalmarsson, MD, PhD2
  • Bailey Colvin, PharmD3
  • Katherine Kozarek, MD4
  • Anna Bovill Shapiro, MD5
5 affiliations
  1. 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Corresponding author: Rebecca Klingbeil, DNP, 4500 San Pablo Road, Jacksonville, FL 32246.
  2. 2Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
  3. 3Division of Clinical Pharmacy, Advanced Heart Failure & Pulmonary Hypertension, J.W. Ruby Memorial Hospital, Morgantown, WV
  4. 4Department of Anesthesiology, University of Wisconsin, Madison, WI
  5. 5Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
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Abstract

Pulmonary hypertension (PH) is a hemodynamic and pathophysiologic condition associated with increased perioperative morbidity and mortality, particularly in patients undergoing cardiac or high-risk non-cardiac surgery. Inhaled pulmonary vasodilators (iPVs) offer a targeted strategy to reduce pulmonary vascular resistance (PVR) and improve right ventricular (RV) function while minimizing systemic hypotension. Traditional vasodilators such as nitroglycerin and sodium nitroprusside lack pulmonary specificity and can exacerbate systemic hypotension. Inhaled agents including nitric oxide (NO), epoprostenol (iEPO), iloprost, milrinone (iMIL) and levosimendan provide selective pulmonary vasodilation with more favorable hemodynamic profiles. This narrative review summarizes current evidence and clinical considerations for the use of iPVs in the perioperative management of PH and discusses pharmacokinetics, delivery mechanisms, adverse effects, and logistical considerations for these agents. New emerging PH therapies are included based on early clinical trial data as they have the potential to impact perioperative care in the future. Overall, iPVs represent a valuable tool in the perioperative care of patients with PH. Continued research is needed to refine clinical protocols, evaluate emerging agents, and establish outcome-based evidence for their routine use.

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Cite

BibTeXRIS
BibTeX
@article{rebeccaklingbeil2026inhaled,
  title = {{Inhaled pulmonary vasodilators in pulmonary hypertension: Perioperative use and clinical considerations}},
  author = {Rebecca Klingbeil, DNP and Clara Hjalmarsson, MD, PhD and Bailey Colvin, PharmD and Katherine Kozarek, MD and Anna Bovill Shapiro, MD},
  journal = {JHLT Open},
  year = {2026},
  month = nov,
  doi = {10.1016/j.jhlto.2026.100627},
  url = {https://doi.org/10.1016/j.jhlto.2026.100627},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - Inhaled pulmonary vasodilators in pulmonary hypertension: Perioperative use and clinical considerations
AU  - Rebecca Klingbeil, DNP
AU  - Clara Hjalmarsson, MD, PhD
AU  - Bailey Colvin, PharmD
AU  - Katherine Kozarek, MD
AU  - Anna Bovill Shapiro, MD
PY  - 2026
DA  - 2026/11/05
JO  - JHLT Open
DO  - 10.1016/j.jhlto.2026.100627
UR  - https://doi.org/10.1016/j.jhlto.2026.100627
AB  - Pulmonary hypertension (PH) is a hemodynamic and pathophysiologic condition associated with increased perioperative morbidity and mortality, particularly in patients undergoing cardiac or high-risk non-cardiac surgery. Inhaled pulmonary vasodilators (iPVs) offer a targeted strategy to reduce pulmonary vascular resistance (PVR) and improve right ventricular (RV) function while minimizing systemic hypotension. Traditional vasodilators such as nitroglycerin and sodium nitroprusside lack pulmonary specificity and can exacerbate systemic hypotension. Inhaled agents including nitric oxide (NO), epoprostenol (iEPO), iloprost, milrinone (iMIL) and levosimendan provide selective pulmonary vasodilation with more favorable hemodynamic profiles. This narrative review summarizes current evidence and clinical considerations for the use of iPVs in the perioperative management of PH and discusses pharmacokinetics, delivery mechanisms, adverse effects, and logistical considerations for these agents. New emerging PH therapies are included based on early clinical trial data as they have the potential to impact perioperative care in the future. Overall, iPVs represent a valuable tool in the perioperative care of patients with PH. Continued research is needed to refine clinical protocols, evaluate emerging agents, and establish outcome-based evidence for their routine use.
SN  - 2950-1334
ER  -