1
|
Strickland B, Stuart Harris N. Adapting nitric oxide: A review of its foundation, uses in austere medical conditions, and emerging applications. Nitric Oxide 2024; 146:58-63. [PMID: 38583684 DOI: 10.1016/j.niox.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024]
Abstract
Nitric oxide was first identified as a novel and effective treatment for persistent pulmonary hypertension of the newborn (PPHN), and has since been found to be efficacious in treating acute respiratory distress syndrome (ARDS) and pulmonary hypertension. Physicians and researchers have also found it shows promise in resource-constrained settings, both within and outside of the hospital, such as in high altitude pulmonary edema (HAPE) and COVID-19. The treatment has been well tolerated in these settings, and is both efficacious and versatile when studied across a variety of clinical environments. Advancements in inhaled nitric oxide continue, and the gas is worthy of investigation as physicians contend with new respiratory and cardiovascular illnesses, as well as unforeseen logistical challenges.
Collapse
Affiliation(s)
- Brian Strickland
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA.
| | - N Stuart Harris
- Division of Wilderness Medicine, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
2
|
Xiao S, Yuan Z, Huang Y. The Potential Role of Nitric Oxide as a Therapeutic Agent against SARS-CoV-2 Infection. Int J Mol Sci 2023; 24:17162. [PMID: 38138990 PMCID: PMC10742813 DOI: 10.3390/ijms242417162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
The global coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become the greatest worldwide public health threat of this century, which may predispose multi-organ failure (especially the lung) and death despite numerous mild and moderate symptoms. Recent studies have unraveled the molecular and clinical characteristics of the infectivity, pathogenicity, and immune evasion of SARS-CoV-2 and thus improved the development of many different therapeutic strategies to combat COVID-19, including treatment and prevention. Previous studies have indicated that nitric oxide (NO) is an antimicrobial and anti-inflammatory molecule with key roles in pulmonary vascular function in the context of viral infections and other pulmonary disease states. This review summarized the recent advances of the pathogenesis of SARS-CoV-2, and accordingly elaborated on the potential application of NO in the management of patients with COVID-19 through antiviral activities and anti-inflammatory properties, which mitigate the propagation of this disease. Although there are some limits of NO in the treatment of COVID-19, it might be a worthy candidate in the multiple stages of COVID-19 prevention or therapy.
Collapse
Affiliation(s)
| | | | - Yi Huang
- National Biosafety Laboratory, Chinese Academy of Sciences, Wuhan 430020, China
| |
Collapse
|
3
|
Zhao Y, Li C, Zhang S, Cheng J, Liu Y, Han X, Wang Y, Wang Y. Inhaled nitric oxide: can it serve as a savior for COVID-19 and related respiratory and cardiovascular diseases? Front Microbiol 2023; 14:1277552. [PMID: 37849924 PMCID: PMC10577426 DOI: 10.3389/fmicb.2023.1277552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
Nitric oxide (NO), as an important gaseous medium, plays a pivotal role in the human body, such as maintaining vascular homeostasis, regulating immune-inflammatory responses, inhibiting platelet aggregation, and inhibiting leukocyte adhesion. In recent years, the rapid prevalence of coronavirus disease 2019 (COVID-19) has greatly affected the daily lives and physical and mental health of people all over the world, and the therapeutic efficacy and resuscitation strategies for critically ill patients need to be further improved and perfected. Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator, and some studies have demonstrated its potential therapeutic use for COVID-19, severe respiratory distress syndrome, pulmonary infections, and pulmonary hypertension. In this article, we describe the biochemistry and basic characteristics of NO and discuss whether iNO can act as a "savior" for COVID-19 and related respiratory and cardiovascular disorders to exert a potent clinical protective effect.
Collapse
Affiliation(s)
- Yifan Zhao
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Cheng Li
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Shuai Zhang
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Jiayu Cheng
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Yucheng Liu
- Department of Family and Community Medicine, Feinberg School of Medicine, McGaw Medical Center of Northwestern University, Chicago, IL, United States
| | - Xiaorong Han
- Department of Special Care Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yinghui Wang
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Yonggang Wang
- Department of Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
4
|
Mekontso Dessap A, Papazian L, Schaller M, Nseir S, Megarbane B, Haudebourg L, Timsit JF, Teboul JL, Kuteifan K, Gainnier M, Slama M, Houeto P, Lecourt L, Mercat A, Vieillard-Baron A. Inhaled nitric oxide in patients with acute respiratory distress syndrome caused by COVID-19: treatment modalities, clinical response, and outcomes. Ann Intensive Care 2023; 13:57. [PMID: 37368036 DOI: 10.1186/s13613-023-01150-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) has been widely used in patients with COVID-19-related acute respiratory distress syndrome (C-ARDS), though its physiological effects and outcome are debated in this setting. The objective of this cohort study was to describe the modalities of iNO use, clinical response, and outcomes in a large cohort of C-ARDS patients. METHODS Multicentre, retrospective cohort study conducted in France. RESULTS From end February to December 2020, 300 patients (22.3% female) were included, 84.5% were overweight and 69.0% had at least one comorbidity. At ICU admission, their median (IQR) age, SAPS II, and SOFA score were 66 (57-72) years, 37 (29-48), and 5 (3-8), respectively. Patients were all ventilated according to a protective ventilation strategy, and 68% were prone positioned before iNO initiation. At iNO initiation, 2%, 37%, and 61% of patients had mild, moderate, and severe ARDS, respectively. The median duration of iNO treatment was 2.8 (1.1-5.5) days with a median dosage of 10 (7-13) ppm at initiation. Responders (PaO2/FiO2 ratio improving by 20% or more) represented 45.7% of patients at 6 h from iNO initiation. The severity of ARDS was the only predictive factor associated with iNO response. Among all evaluable patients, the crude mortality was not significantly different between responders at 6 h and their counterparts. Of the 62 patients with refractory ARDS (who fulfilled extracorporeal membrane oxygenation criteria before iNO initiation), 32 (51.6%) no longer fulfilled these criteria after 6 h of iNO. The latter showed significantly lower mortality than the other half (who remained ECMO eligible), including after confounder adjustment (adjusted OR: 0.23, 95% CI 0.06, 0.89, p = 0.03). CONCLUSIONS Our study reports the benefits of iNO in improving arterial oxygenation in C-ARDS patients. This improvement seems more relevant in the most severe cases. In patients with ECMO criteria, an iNO-driven improvement in gas exchange was associated with better survival. These results must be confirmed in well-designed prospective studies.
Collapse
Affiliation(s)
- Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri-Mondor, AP-HP, 94010, Créteil, France.
- CARMAS research group, Univ Paris Est Créteil, Faculté de Santé, 94010, Créteil, France.
- IMRB, INSERM, Univ Paris Est Créteil, 94010, Créteil, France.
| | - Laurent Papazian
- Médecine Intensive Réanimation, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de vie EA 3279, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, 13015, Marseille, France
| | | | - Saad Nseir
- Department of Intensive Care Medicine, Critical Care Center, CHU of Lille, 59000, Lille, France
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM MURS-1144, University of Paris, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Luc Haudebourg
- Service de Pneumologie et Réanimation Médicale du Département R3S, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, Paris, France
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Hospital and U1137, IAME Université Paris-Cité, AP-HP, 75018, Paris, France
| | - Jean-Louis Teboul
- Service de Medecine Intensive-Reanimation, Hôpital de Bicêtre, AP-HP, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Khaldoun Kuteifan
- Service de Réanimation Médicale, Groupe Hospitalier de la Région Mulhouse Sud Alsace, 68100, Mulhouse, France
| | - Marc Gainnier
- Réanimation des Urgences, Hôpital de La Timone, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Michel Slama
- Medical Intensive Care Unit, CHU Sud Amiens, Amiens, France
| | | | | | - Alain Mercat
- Department of Intensive Care, University of Angers, Angers, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, Ambroise Paré Hospital, AP-HP, Boulogne-Billancourt, France
- Inserm UMR 1018, Équipe 5, CESP, Villejuif, France
| |
Collapse
|
5
|
Redaelli S, Pozzi M, Giani M, Magliocca A, Fumagalli R, Foti G, Berra L, Rezoagli E. Inhaled Nitric Oxide in Acute Respiratory Distress Syndrome Subsets: Rationale and Clinical Applications. J Aerosol Med Pulm Drug Deliv 2023; 36:112-126. [PMID: 37083488 PMCID: PMC10402704 DOI: 10.1089/jamp.2022.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 03/13/2023] [Indexed: 04/22/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition, characterized by diffuse inflammatory lung injury. Since the coronavirus disease 2019 (COVID-19) pandemic spread worldwide, the most common cause of ARDS has been the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Both the COVID-19-associated ARDS and the ARDS related to other causes-also defined as classical ARDS-are burdened by high mortality and morbidity. For these reasons, effective therapeutic interventions are urgently needed. Among them, inhaled nitric oxide (iNO) has been studied in patients with ARDS since 1993 and it is currently under investigation. In this review, we aim at describing the biological and pharmacological rationale of iNO treatment in ARDS by elucidating similarities and differences between classical and COVID-19 ARDS. Thereafter, we present the available evidence on the use of iNO in clinical practice in both types of respiratory failure. Overall, iNO seems a promising agent as it could improve the ventilation/perfusion mismatch, gas exchange impairment, and right ventricular failure, which are reported in ARDS. In addition, iNO may act as a viricidal agent and prevent lung hyperinflammation and thrombosis of the pulmonary vasculature in the specific setting of COVID-19 ARDS. However, the current evidence on the effects of iNO on outcomes is limited and clinical studies are yet to demonstrate any survival benefit by administering iNO in ARDS.
Collapse
Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Matteo Pozzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Marco Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca’ Granda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Respiratory Care Department, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| |
Collapse
|
6
|
Dragoi L, Siuba MT, Fan E. Lessons learned in mechanical ventilation/oxygen support in COVID19. Clin Chest Med 2022; 44:321-333. [PMID: 37085222 PMCID: PMC9678831 DOI: 10.1016/j.ccm.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The clinical spectrum of severe acute respiratory syndrome coronavirus-2 infection ranges from asymptomatic infection or mild respiratory symptoms to pneumonia, with severe cases leading to acute respiratory distress syndrome with multiorgan involvement. The clinical management of patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) changed over the course of the pandemic, being adjusted as more evidence became available. This article will review how the ventilatory management of COVID-19 ARDS evolved and will conclude with current evidence-based recommendations.
Collapse
|
7
|
Alqahtani JS, Aldhahir AM, Al Ghamdi SS, AlBahrani S, AlDraiwiesh IA, Alqarni AA, Latief K, Raya RP, Oyelade T. Inhaled Nitric Oxide for Clinical Management of COVID-19: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12803. [PMID: 36232100 PMCID: PMC9566710 DOI: 10.3390/ijerph191912803] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Severe COVID-19 is associated with hypoxemia and acute respiratory distress syndrome (ARDS), which may predispose multiorgan failure and death. Inhaled nitric oxide (iNO) is a clinical vasodilator used in the management of acute respiratory distress syndrome (ARDS). This study evaluated the response rate to iNO in patients with COVID-19-ARDS. METHOD We searched Medline and Embase databases in May 2022, and data on the use of iNO in the treatment of ARDS in COVID-19 patients were synthesized from studies that satisfied predefined inclusion criteria. A systematic synthesis of data was performed followed by meta-analysis. We performed the funnel plot and leave-one-out sensitivity test on the included studies to assess publication bias and possible exaggerated effect size. We compared the effect size of the studies from the Unites States with those from other countries and performed meta-regression to assess the effect of age, year of publication, and concomitant vasodilator use on the effect size. RESULTS A total of 17 studies (including 712 COVID-19 patients) were included in this systematic review of which 8 studies (involving 265 COVID-19 patients) were subjected to meta-analysis. The overall response rate was 66% (95% CI, 47-84%) with significantly high between-studies heterogeneity (I2 = 94%, p < 0.001). The funnel plot showed publication bias, although the sensitivity test using leave-one-out analysis showed that removing any of the study does not remove the significance of the result. The response rate was higher in the Unites States, and meta-regression showed that age, year of publication, and use of concomitant vasodilators did not influence the response rate to iNO. CONCLUSION iNO therapy is valuable in the treatment of hypoxemia in COVID-19 patients and may improve systemic oxygenation in patients with COVID-19-ARDS. Future studies should investigate the mechanism of the activity of iNO in COVID-19 patients to provide insight into the unexplored potential of iNO in general ARDS.
Collapse
Affiliation(s)
- Jaber S. Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam 34313, Saudi Arabia
| | - Abdulelah M. Aldhahir
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia
| | - Shouq S. Al Ghamdi
- Anesthesia Technology Department, Prince Sultan Military College of Health Sciences, Dammam 34313, Saudi Arabia
| | - Salma AlBahrani
- Department of Internal Medicine, King Fahad Military Medical Complex, Dhahran 31932, Saudi Arabia
| | - Ibrahim A. AlDraiwiesh
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam 34313, Saudi Arabia
| | - Abdullah A. Alqarni
- Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah 22254, Saudi Arabia
| | - Kamaluddin Latief
- Global Health and Health Security Department, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
- Centre for Family Welfare, Faculty of Public Health, University of Indonesia, Depok 16424, Indonesia
| | - Reynie Purnama Raya
- Institute for Global Health, Faculty of Population Health Sciences, University College London, London NW3 2PF, UK
- Faculty of Science, Universitas ‘Aisyiyah Bandung, Bandung 40264, Indonesia
| | - Tope Oyelade
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London NW3 2PF, UK
| |
Collapse
|
8
|
Khokher W, Malhas SE, Beran A, Iftikhar S, Burmeister C, Mhanna M, Srour O, Rashid R, Kesireddy N, Assaly R. Inhaled Pulmonary Vasodilators in COVID-19 Infection: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 37:1370-1382. [PMID: 35915994 PMCID: PMC9346441 DOI: 10.1177/08850666221118271] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: Inhaled pulmonary vasodilators (IPVD) have been
previously studied in patients with non-coronavirus disease-19 (COVID-19)
related acute respiratory distress syndrome (ARDS). The use of IPVD has been
shown to improve the partial pressure of oxygen in arterial blood
(PaO2), reduce fraction of inspired oxygen (FiO2)
requirements, and ultimately increase PaO2/FiO2 (P/F)
ratios in ARDS patients. However, the role of IPVD in COVID-19 ARDS is still
unclear. Therefore, we performed this meta-analysis to evaluate the role of IPVD
in COVID-19 patients. Methods: Comprehensive literature search of
PubMed, Embase, Web of Science and Cochrane Library databases from inception
through April 22, 2022 was performed for all published studies that utilized
IPVD in COVID-19 ARDS patients. The single arm studies and case series were
combined for a 1-arm meta-analysis, and the 2-arm studies were combined for a
2-arm meta-analysis. Primary outcomes for the 1-arm and 2-arm meta-analyzes were
change in pre- and post-IPVD P/F ratios and mortality, respectively. Secondary
outcomes for the 1-arm meta-analysis were change in pre- and post-IPVD positive
end-expiratory pressure (PEEP) and lung compliance, and for the 2-arm
meta-analysis the secondary outcomes were need for endotracheal intubation and
hospital length of stay (LOS). Results: 13 single arm retrospective
studies and 5 case series involving 613 patients were included in the 1-arm
meta-analysis. 3 studies involving 640 patients were included in the 2-arm
meta-analysis. The pre-IPVD P/F ratios were significantly lower compared to
post-IPVD, but there was no significant difference between pre- and post-IPVD
PEEP and lung compliance. The mortality rates, need for endotracheal intubation,
and hospital LOS were similar between the IPVD and standard therapy groups.
Conclusion: Although IPVD may improve oxygenation, our
investigation showed no benefits in terms of mortality compared to standard
therapy alone. However, randomized controlled trials are warranted to validate
our findings.
Collapse
Affiliation(s)
- Waleed Khokher
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Saif-Eddin Malhas
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Azizullah Beran
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Saffa Iftikhar
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Cameron Burmeister
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Mohammed Mhanna
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Omar Srour
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Rakin Rashid
- Department of Internal Medicine, 22519Mercy Catholic Medical Center, Darby, PA, USA
| | - Nithin Kesireddy
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Ragheb Assaly
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA.,Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH, USA
| |
Collapse
|