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Kamenshchikov NO, Safaee Fakhr B, Kravchenko IV, Dish AY, Podoksenov YK, Kozlov BN, Kalashnikova TP, Tyo MA, Anfinogenova ND, Boshchenko AA, Berra L. Assessment of continuous low-dose and high-dose burst of inhaled nitric oxide in spontaneously breathing COVID-19 patients: A randomized controlled trial. Nitric Oxide 2024; 149:41-48. [PMID: 38880198 DOI: 10.1016/j.niox.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/23/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) showed to improve oxygenation at low doses by reducing intrapulmonary shunt and to display antiviral properties at high doses. To assess the safety and potential benefits, we designed an exploratory clinical trial comparing low-dose with intermittent high-dose iNO to only intermittent high-dose iNO in hypoxemic COVID-19 patients. METHODS In this single-center interventional non-inferiority randomized trial (ClinicalTrials.gov, NCT04476992), twenty oxygen-dependent COVID-19 patients were randomly assigned to the high-dose (200 ppm for 30 min) + continuous low-dose (20 ppm) iNO group (iNO200/20) or the high-dose iNO group (iNO200). Methemoglobinemia (MetHb) assessed 48 h after iNO initiation was the primary endpoint. Reverse-transcription polymerase chain reaction for SARS-CoV-2, inflammatory markers during hospitalization, and heart ultrasounds during the iNO200 treatments were evaluated. RESULTS MetHb difference between iNO groups remained within the non-inferiority limit of 3 %, indicating comparable treatments despite being statistically different (p-value<0.01). Both groups presented similar SpO2/FiO2 ratio at 48 h (iNO200 vs. iNO200/20 341[334-356] vs. 359 [331-380], respectively, p-value = 0.436). Both groups showed the same time to SARS-CoV-2 negativization, hospital length of stay, and recovery time. iNO-treated patients showed quicker SARS-CoV-2 negativization compared to a similar group of non-iNO patients (HR 2.57, 95%CI 1.04-6.33). During the 228 treatments, iNO200 and iNO200/20 groups were comparable for safety, hemodynamic stability, and respiratory function improvement. CONCLUSIONS iNO200/20 and iNO200 are equally safe in non-intubated patients with COVID-19-induced respiratory failure with regards to MetHb and NO2. Larger studies should investigate whether iNO200/20 leads to better outcomes compared to non-iNO treated patients.
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Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Bijan Safaee Fakhr
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
| | - Igor V Kravchenko
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | | | - Yuri K Podoksenov
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Boris N Kozlov
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Tatiana P Kalashnikova
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Mark A Tyo
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Nina D Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Alla A Boshchenko
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA; Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA.
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Bessas NC, Christine de Souza Arantes E, Cassani NM, Aquino Ruiz UE, Santos IA, Silva Martins DO, Costa Oliveira AL, Antoniucci GA, de Oliveira AHC, DeFreitas-Silva G, Gomes Jardim AC, Galvão de Lima R. Influence of diimine bidentate ligand in the nitrosyl and nitro terpyridine ruthenium complex on the HSA/DNA interaction and antiviral activity. Nitric Oxide 2024; 147:26-41. [PMID: 38614230 DOI: 10.1016/j.niox.2024.04.006] [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: 09/30/2023] [Revised: 12/05/2023] [Accepted: 04/09/2024] [Indexed: 04/15/2024]
Abstract
Nitric oxide (NO) acts in different physiological processes, such as blood pressure control, antiparasitic activities, neurotransmission, and antitumor action. Among the exogenous NO donors, ruthenium nitrosyl/nitro complexes are potential candidates for prodrugs, due to their physicochemical properties, such as thermal and physiological pH stability. In this work, we proposed the synthesis and physical characterization of the new nitro terpyridine ruthenium (II) complexes of the type [RuII(L)(NO2)(tpy)]PF6 where tpy = 2,2':6',2″-terpyridine; L = 3,4-diaminobenzoic acid (bdq) or o-phenylenediamine (bd) and evaluation of influence of diimine bidentate ligand NH.NHq-R (R = H or COOH) in the HSA/DNA interaction as well as antiviral activity. The interactions between HSA and new nitro complexes [RuII(L)(NO2)(tpy)]+ were evaluated. The Ka values for the HSA-[RuII(bdq)(NO2)(tpy)]+ is 10 times bigger than HSA-[RuII(bd)(NO2)(tpy)]+. The sites of interaction between HSA and the complexes via synchronous fluorescence suppression indicate that the [RuII(bdq)(NO2)(tpy)]+ is found close to the Trp-241 residue, while the [RuII(bd)(NO2)(tpy)]+ complex is close to Tyr residues. The interaction with fish sperm fs-DNA using direct spectrophotometric titration (Kb) and ethidium bromide replacement (KSV and Kapp) showed weak interaction in the system fs-DNA-[RuII(bdq)(NO)(tpy)]+. Furthermore, fs-DNA-[RuII(bd)(NO2)(tpy)]+ and fs-DNA-[RuII(bd)(NO)(tpy)]3+ system showed higher intercalation constant. Circular dichroism spectra for fs-DNA-[RuII(bd)(NO2)(tpy)]+ and fs-DNA-[RuII(bd)(NO)(tpy)]3+, suggest semi-intercalative accompanied by major groove binding interaction modes. The [RuII(bd)(NO2)(tpy)]+ and [RuII(bd)(NO)(tpy)]3+ inhibit replication of Zika and Chikungunya viruses based in the nitric oxide release under S-nitrosylation reaction with cysteine viral.
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Affiliation(s)
- Naiara Cristina Bessas
- Instituto de Química, Universidade Federal de Uberlândia, Avenida João Naves de Avila, 2121, 38400-902, Uberlândia, MG, Brazil
| | | | - Natasha Marques Cassani
- Laboratory of Antiviral Research, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - Uriel Enrique Aquino Ruiz
- Laboratory of Antiviral Research, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - Igor Andrade Santos
- Laboratory of Antiviral Research, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - Daniel Oliveira Silva Martins
- Laboratory of Antiviral Research, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil; Instituto de Ciências Exatas e Naturais Do Pontal, ICENP, Universidade Federal de Uberlândia, Rua Vinte, 1600, 38304-402, Tupã, Ituiutaba, MG, Brazil
| | - Ana Laura Costa Oliveira
- Laboratory of Antiviral Research, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - Giovanna André Antoniucci
- Laboratory of Antiviral Research, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - Arthur Henrique Cavalcante de Oliveira
- Departamento de Química, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, CEP 14040-901, Ribeirão Preto, SP, Brazil
| | - Gilson DeFreitas-Silva
- Departamento de Química, Instituto de Ciências Exatas, Universidade Federal de Minas Gerais, 31.270-901, Belo Horizonte, MG, Brazil
| | - Ana Carolina Gomes Jardim
- Laboratory of Antiviral Research, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - Renata Galvão de Lima
- Instituto de Química, Universidade Federal de Uberlândia, Avenida João Naves de Avila, 2121, 38400-902, Uberlândia, MG, Brazil; Instituto de Ciências Exatas e Naturais Do Pontal, ICENP, Universidade Federal de Uberlândia, Rua Vinte, 1600, 38304-402, Tupã, Ituiutaba, MG, Brazil.
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3
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Zhou X, Su W, Bao Q, Cui Y, Li X, Yang Y, Yang C, Wang C, Jiao L, Chen D, Huang J. Nitric Oxide Ameliorates the Effects of Hypoxia in Mice by Regulating Oxygen Transport by Hemoglobin. High Alt Med Biol 2024. [PMID: 38743636 DOI: 10.1089/ham.2023.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
Xiaoying Zhou, Wenting Su, Quanwei Bao, Yu Cui, Xiaoxu Li, Yidong Yang, Chengzhong Yang, Chengyuan Wang, Li Jiao, Dewei Chen, and Jian Huang. Nitric oxide ameliorates the effects of hypoxia in mice by regulating oxygen transport by hemoglobin. High Alt Med Biol. 00:00-00, 2024.-Hypoxia is a common pathological and physiological phenomenon in ischemia, cancer, and strenuous exercise. Nitric oxide (NO) acts as an endothelium-derived relaxing factor in hypoxic vasodilation and serves as an allosteric regulator of hemoglobin (Hb). However, the ultimate effects of NO on the hematological system in vivo remain unknown, especially in extreme environmental hypoxia. Whether NO regulation of the structure of Hb improves oxygen transport remains unclear. Hence, we examined whether NO altered the oxygen affinity of Hb (Hb-O2 affinity) to protect extremely hypoxic mice. Mice were exposed to severe hypoxia with various concentrations of NO, and the survival time, exercise capacity, and other physical indexes were recorded. The survival time was prolonged in the 5 ppm NO (6.09 ± 1.29 minutes) and 10 ppm NO (6.39 ± 1.58 minutes) groups compared with the 0 ppm group (4.98 ± 1.23 minutes). Hypoxia of the brain was relieved, and the exercise exhaustion time was prolonged when mice inhaled 20 ppm NO (24.70 ± 6.87 minutes vs. 20.23 ± 6.51 minutes). In addition, the differences in arterial oxygen saturation (SO2%) (49.64 ± 7.29% vs. 42.90 ± 4.30%) and arteriovenous SO2% difference (25.14 ± 8.95% vs. 18.10 ± 6.90%) obviously increased. In ex vivo experiments, the oxygen equilibrium curve (OEC) left shifted as P50 decreased from 43.77 ± 2.49 mmHg (0 ppm NO) to 40.97 ± 1.40 mmHg (100 ppm NO) and 38.36 ± 2.78 mmHg (200 ppm NO). Furthermore, the Bohr effect of Hb was enhanced by the introduction of 200 ppm NO (-0.72 ± 0.062 vs.-0.65 ± 0.051), possibly allowing Hb to more easily offload oxygen in tissue at lower pH. The crystal structure reveals a greater distance between Asp94β-His146β in nitrosyl -Hb(NO-Hb), NO-HbβCSO93, and S-NitrosoHb(SNO-Hb) compared to tense Hb(T-Hb, 3.7 Å, 4.3 Å, and 5.8 Å respectively, versus 3.5 Å for T-Hb). Moreover, hydrogen bonds were less likely to form, representing a key limitation of relaxed Hb (R-Hb). Upon NO interaction with Hb, hydrogen bonds and salt bridges were less favored, facilitating relaxation. We speculated that NO ameliorated the effects of hypoxia in mice by promoting erythrocyte oxygen loading in the lung and offloading in tissues.
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Affiliation(s)
- Xiaoying Zhou
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Wenting Su
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Quanwei Bao
- Department of Emergency Medicine, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yu Cui
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Xiaoxu Li
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Yidong Yang
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Chengzhong Yang
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Chengyuan Wang
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Li Jiao
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Dewei Chen
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
| | - Jian Huang
- Department of High Altitude Physiology and Pathology, College of High Altitude Military Medicine, Army Medical University, Chongqing, China
- High Altitude Medical Research Center, PLA, Chongqing, China
- Key Laboratory of High Altitude and Frigidzone Medical Surpport, PLA, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education, Chongqing, China
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4
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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.
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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
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Masood M, Singh P, Hariss D, Khan F, Yameen D, Siraj S, Islam A, Dohare R, Mahfuzul Haque M. Nitric oxide as a double-edged sword in pulmonary viral infections: Mechanistic insights and potential therapeutic implications. Gene 2024; 899:148148. [PMID: 38191100 DOI: 10.1016/j.gene.2024.148148] [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: 09/19/2023] [Revised: 12/21/2023] [Accepted: 01/05/2024] [Indexed: 01/10/2024]
Abstract
In the face of the global pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), researchers are tirelessly exploring novel therapeutic approaches to combat coronavirus disease 2019 (COVID-19) and its associated complications. Nitric oxide (NO) has appeared as a multifaceted signaling mediator with diverse and often contrasting biological activities. Its intricate biochemistry renders it a crucial regulator of cardiovascular and pulmonary functions, immunity, and neurotransmission. Perturbations in NO production, whether excessive or insufficient, contribute to the pathogenesis of various diseases, encompassing cardiovascular disease, pulmonary hypertension, asthma, diabetes, and cancer. Recent investigations have unveiled the potential of NO donors to impede SARS-CoV- 2 replication, while inhaled NO demonstrates promise as a therapeutic avenue for improving oxygenation in COVID-19-related hypoxic pulmonary conditions. Interestingly, NO's association with the inflammatory response in asthma suggests a potential protective role against SARS-CoV-2 infection. Furthermore, compelling evidence indicates the benefits of inhaled NO in optimizing ventilation-perfusion ratios and mitigating the need for mechanical ventilation in COVID-19 patients. In this review, we delve into the molecular targets of NO, its utility as a diagnostic marker, the mechanisms underlying its action in COVID-19, and the potential of inhaled NO as a therapeutic intervention against viral infections. The topmost significant pathway, gene ontology (GO)-biological process (BP), GO-molecular function (MF) and GO-cellular compartment (CC) terms associated with Nitric Oxide Synthase (NOS)1, NOS2, NOS3 were arginine biosynthesis (p-value = 1.15 x 10-9) regulation of guanylate cyclase activity (p-value = 7.5 x 10-12), arginine binding (p-value = 2.62 x 10-11), vesicle membrane (p-value = 3.93 x 10-8). Transcriptomics analysis further validates the significant presence of NOS1, NOS2, NOS3 in independent COVID-19 and pulmonary hypertension cohorts with respect to controls. This review investigates NO's molecular targets, diagnostic potentials, and therapeutic role in COVID-19, employing bioinformatics to identify key pathways and NOS isoforms' significance.
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Affiliation(s)
- Mohammad Masood
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Prithvi Singh
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Daaniyaal Hariss
- Department of Biosciences, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Faizya Khan
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Daraksha Yameen
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Seerat Siraj
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Asimul Islam
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Ravins Dohare
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Mohammad Mahfuzul Haque
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
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Di Fenza R, Shetty NS, Gianni S, Parcha V, Giammatteo V, Safaee Fakhr B, Tornberg D, Wall O, Harbut P, Lai PS, Li JZ, Paganoni S, Cenci S, Mueller AL, Houle TT, Akeju O, Bittner EA, Bose S, Scott LK, Carroll RW, Ichinose F, Hedenstierna M, Arora P, Berra L. High-Dose Inhaled Nitric Oxide in Acute Hypoxemic Respiratory Failure Due to COVID-19: A Multicenter Phase II Trial. Am J Respir Crit Care Med 2023; 208:1293-1304. [PMID: 37774011 PMCID: PMC10765403 DOI: 10.1164/rccm.202304-0637oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/28/2023] [Indexed: 10/01/2023] Open
Abstract
Rationale: The effects of high-dose inhaled nitric oxide on hypoxemia in coronavirus disease (COVID-19) acute respiratory failure are unknown. Objectives: The primary outcome was the change in arterial oxygenation (PaO2/FiO2) at 48 hours. The secondary outcomes included: time to reach a PaO2/FiO2.300mmHg for at least 24 hours, the proportion of participants with a PaO2/FiO2.300mmHg at 28 days, and survival at 28 and at 90 days. Methods: Mechanically ventilated adults with COVID-19 pneumonia were enrolled in a phase II, multicenter, single-blind, randomized controlled parallel-arm trial. Participants in the intervention arm received inhaled nitric oxide at 80 ppm for 48 hours, compared with the control group receiving usual care (without placebo). Measurements and Main Results: A total of 193 participants were included in the modified intention-to-treat analysis. The mean change in PaO2/FiO2 ratio at 48 hours was 28.3mmHg in the intervention group and 21.4mmHg in the control group (mean difference, 39.1mmHg; 95% credible interval [CrI], 18.1 to 60.3). The mean time to reach a PaO2/FiO2.300mmHg in the interventional group was 8.7 days, compared with 8.4 days for the control group (mean difference, 0.44; 95% CrI, 23.63 to 4.53). At 28 days, the proportion of participants attaining a PaO2/FiO2.300mmHg was 27.7% in the inhaled nitric oxide group and 17.2% in the control subjects (risk ratio, 2.03; 95% CrI, 1.11 to 3.86). Duration of ventilation and mortality at 28 and 90 days did not differ. No serious adverse events were reported. Conclusions: The use of high-dose inhaled nitric oxide resulted in an improvement of PaO2/FiO2 at 48 hours compared with usual care in adults with acute hypoxemic respiratory failure due to COVID-19.
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Affiliation(s)
- Raffaele Di Fenza
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Naman S. Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stefano Gianni
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Vibhu Parcha
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Valentina Giammatteo
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Daniel Tornberg
- Department of Clinical Sciences and
- Department of Anesthesia and Intensive Care and
| | - Olof Wall
- Department of Clinical Sciences and
- Department of Clinical Science and Education, Sodersxjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Piotr Harbut
- Department of Clinical Sciences and
- Department of Anesthesia and Intensive Care and
| | - Peggy S. Lai
- Pulmonary and Critical Care Medicine, Department of Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Jonathan Z. Li
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sabrina Paganoni
- Sean M. Healey and AMG Center for ALS
- Neurological Clinical Research Institute
- Harvard Medical School, Boston, Massachusetts
| | - Stefano Cenci
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Ariel L. Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Research Center
- Harvard Medical School, Boston, Massachusetts
| | - Timothy T. Houle
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Research Center
- Harvard Medical School, Boston, Massachusetts
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Somnath Bose
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Louie K. Scott
- Critical Care Medicine, Department of Medicine, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Ryan W. Carroll
- Division of Pediatric Critical Care Medicine, Department of Pediatrics
- Harvard Medical School, Boston, Massachusetts
| | - Fumito Ichinose
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Harvard Medical School, Boston, Massachusetts
| | | | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Respiratory Care Services, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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7
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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.
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Affiliation(s)
| | | | - Yi Huang
- National Biosafety Laboratory, Chinese Academy of Sciences, Wuhan 430020, China
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8
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Hibbert TM, Whiteley M, Renshaw SA, Neill DR, Fothergill JL. Emerging strategies to target virulence in Pseudomonas aeruginosa respiratory infections. Crit Rev Microbiol 2023:1-16. [PMID: 37999716 DOI: 10.1080/1040841x.2023.2285995] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023]
Abstract
Pseudomonas aeruginosa is an opportunistic pathogen that is responsible for infections in people living with chronic respiratory conditions, such as cystic fibrosis (CF) and non-CF bronchiectasis (NCFB). Traditionally, in people with chronic respiratory disorders, P. aeruginosa infection has been managed with a combination of inhaled and intravenous antibiotic therapies. However, due in part to the prolonged use of antibiotics in these people, the emergence of multi-drug resistant P. aeruginosa strains is a growing concern. The development of anti-virulence therapeutics may provide a new means of treating P. aeruginosa lung infections whilst also combatting the AMR crisis, as these agents are presumed to exert reduced pressure for the emergence of drug resistance as compared to antibiotics. However, the pipeline for developing anti-virulence therapeutics is poorly defined, and it is currently unclear as to whether in vivo and in vitro models effectively replicate the complex pulmonary environment sufficiently to enable development and testing of such therapies for future clinical use. Here, we discuss potential targets for P. aeruginosa anti-virulence therapeutics and the effectiveness of the current models used to study them. Focus is given to the difficulty of replicating the virulence gene expression patterns of P. aeruginosa in the CF and NCFB lung under laboratory conditions and to the challenges this poses for anti-virulence therapeutic development.
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Affiliation(s)
- Tegan M Hibbert
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Marvin Whiteley
- School of Biological Sciences, Georgia Institute of Technology, Centre for Microbial Dynamics and Infection, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Stephen A Renshaw
- The Bateson Centre and Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Daniel R Neill
- Division of Molecular Microbiology, School of Life Sciences, University of Dundee, Dundee, UK
| | - Joanne L Fothergill
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
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9
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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.
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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
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10
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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.
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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
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11
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Inhaled Nitric Oxide for the Treatment of Acute Bronchiolitis: A Multicenter Randomized Controlled Clinical Trial to Evaluate Dose Response. Ann Am Thorac Soc 2023; 20:236-244. [PMID: 36169967 DOI: 10.1513/annalsats.202103-348oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Rationale: Inhaled nitric oxide (iNO) has potential antiinflammatory, antimicrobial, and antiviral properties for patients with lower respiratory tract infections. Objectives: We compared the safety and efficacy of iNO administered in two concentrations in addition to standard supportive treatment (SST) compared with SST alone with the aim of improving clinical outcomes of infants with bronchiolitis. Methods: In this prospective, multicenter, double-blind, randomized controlled study, 89 infants hospitalized with moderate to severe bronchiolitis were randomly assigned to three treatment groups: 150 ppm NO plus SST (group 1), 85 ppm NO plus SST (group 2), and the control treatment (O2/air plus SST) (group 3). Treatment was given for 40 minutes, four times each day, for up to 5 days. The primary endpoint was time to reach "fit for discharge." This was a composite endpoint composed of both reaching a sustained oxygen saturation ≥92% on room air and reaching a clinical score ⩽5. Secondary endpoints included time to reach sustained oxygen saturation ≥92% on room air, time to clinical score ⩽5, and time to hospital discharge. Safety was assessed by the number of treatment-related adverse events (AEs) or serious AEs. Time-to-event efficacy outcomes were analyzed using a Cox proportional hazards regression model. Hazard ratios (HR) describe how many times more likely an individual is to experience an event, if such an individual receives NO rather than the control treatment during the observational period. Results: Group 1 demonstrated significant efficacy for time to reach fit to discharge compared with groups 2 (HR, 2.11; P = 0.041) and 3 (HR, 2.32; P = 0.049). Group 1 also demonstrated significant efficacy for time to hospital discharge compared with groups 2 (HR, 2.01; P = 0.046) and 3 (HR, 2.28; P = 0.043). No significant differences were observed between groups 2 and 3 for either endpoint. There were no differences between treatment groups in time to reach a clinical score ⩽5. The iNO therapy was well tolerated, with no treatment-related serious AEs. Conclusions: Treatment with high-dose intermittent iNO at 150 ppm showed reduced time to clinical improvement compared with 85 ppm or control treatment of hospitalized infants with acute bronchiolitis. The 150-ppm iNO dose is well tolerated, with significant benefit compared with both standard therapy and 85 ppm iNO, improving respiratory outcomes and reducing length of stay. Clinical trial registered with www.clinicaltrials.gov (NCT04060979).
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12
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Chavda VP, Patel AB, Vora LK, Singla RK, Shah P, Uversky VN, Apostolopoulos V. Nitric Oxide and its Derivatives Containing Nasal Spray and Inhalation Therapy for the Treatment of COVID-19. Curr Pharm Des 2022; 28:3658-3670. [PMID: 36284382 DOI: 10.2174/1381612829666221024124848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/11/2022] [Accepted: 09/26/2022] [Indexed: 01/28/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major health concern worldwide and has evolved into different variants. SARS-CoV-2 possesses a spike glycoprotein on its envelope that binds to the angiotensin-converting enzyme 2 (ACE-2) receptor of the host cell via the receptor-binding domain (RBD) in the upper respiratory tract. Since the SARS-CoV-2 virus variants change the severity of the diesease and treatment scenarios, repurposing current medicines may provide a quick and appealing method with established safety features. The efficacy and safety of antiviral medicines against the coronavirus disease 2019 (COVID-19) have been investigated, and several of them are now undergoing clinical studies. Recently, it has been found that nitric oxide (NO) shows antiviral properties against SARS-CoV-2 and prevents the virus from binding to a host cell. In addition, NO is a well-known vasodilator and acts as an important coagulation mediator. With the fast-track development of COVID-19 treatments and vaccines, one avenue of research aimed at improving therapeutics is exploring different forms of drug delivery, including intranasal sprays and inhalation therapy. The nasal mucosa is more prone to be the site of infection as it is in more direct contact with the physical environment via air during inhalation and exhalation. Thus, the use of exogenous nasal NO therapy via the intranasal route displays a distinct advantage. Therefore, the objective of this review is to summarize the relevant actions of NO via the intranasal spray and inhalation delivery, its mechanism of action, and its use in the treatment of COVID-19.
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Affiliation(s)
- Vivek P Chavda
- Department of Pharmaceutics and Pharmaceutical Technology, LM College of Pharmacy, Ahmedabad - 380009, India
| | - Aayushi B Patel
- Department of Pharmaceutics and Pharmaceutical Technology, LM College of Pharmacy, Ahmedabad - 380009, India
| | - Lalitkumar K Vora
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, U.K
| | - Rajeev K Singla
- Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Xinchuan Road 2222, Chengdu, Sichuan, China.,School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab-144411, India
| | - Priyal Shah
- Department of Pharmaceutics and Pharmaceutical Technology, LM College of Pharmacy, Ahmedabad - 380009, India
| | - Vladimir N Uversky
- Department of Molecular Medicine and Byrd Alzheimer's Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Vasso Apostolopoulos
- Institute for Health and Sport, Victoria University, Melbourne VIC 3030, Australia
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13
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Oza PP, Kashfi K. Utility of NO and H 2S donating platforms in managing COVID-19: Rationale and promise. Nitric Oxide 2022; 128:72-102. [PMID: 36029975 PMCID: PMC9398942 DOI: 10.1016/j.niox.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/01/2022] [Accepted: 08/10/2022] [Indexed: 01/08/2023]
Abstract
Viral infections are a continuing global burden on the human population, underscored by the ramifications of the COVID-19 pandemic. Current treatment options and supportive therapies for many viral infections are relatively limited, indicating a need for alternative therapeutic approaches. Virus-induced damage occurs through direct infection of host cells and inflammation-related changes. Severe cases of certain viral infections, including COVID-19, can lead to a hyperinflammatory response termed cytokine storm, resulting in extensive endothelial damage, thrombosis, respiratory failure, and death. Therapies targeting these complications are crucial in addition to antiviral therapies. Nitric oxide and hydrogen sulfide are two endogenous gasotransmitters that have emerged as key signaling molecules with a broad range of antiviral actions in addition to having anti-inflammatory properties and protective functions in the vasculature and respiratory system. The enhancement of endogenous nitric oxide and hydrogen sulfide levels thus holds promise for managing both early-stage and later-stage viral infections, including SARS-CoV-2. Using SARS-CoV-2 as a model for similar viral infections, here we explore the current evidence regarding nitric oxide and hydrogen sulfide's use to limit viral infection, resolve inflammation, and reduce vascular and pulmonary damage.
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Affiliation(s)
- Palak P Oza
- Department of Molecular, Cellular and Biomedical Sciences, Sophie Davis School of Biomedical Education, City University of New York School of Medicine, New York, NY, 10031, USA
| | - Khosrow Kashfi
- Department of Molecular, Cellular and Biomedical Sciences, Sophie Davis School of Biomedical Education, City University of New York School of Medicine, New York, NY, 10031, USA; Graduate Program in Biology, City University of New York Graduate Center, New York, 10091, USA.
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14
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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.
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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
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15
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Al Sulaiman K, Korayem GB, Altebainawi AF, Al Harbi S, Alissa A, Alharthi A, Kensara R, Alfahed A, Vishwakarma R, Al Haji H, Almohaimid N, Al Zumai O, Alrubayan F, Asiri A, Alkahtani N, Alolayan A, Alsohimi S, Melibari N, Almagthali A, Aljahdali S, Alenazi AA, Alsaeedi AS, Al Ghamdi G, Al Faris O, Alqahtani J, Al Qahtani J, Alshammari KA, Alshammari KI, Aljuhani O. Evaluation of inhaled nitric oxide (iNO) treatment for moderate-to-severe ARDS in critically ill patients with COVID-19: a multicenter cohort study. Crit Care 2022; 26:304. [PMID: 36192801 PMCID: PMC9527729 DOI: 10.1186/s13054-022-04158-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/04/2022] [Indexed: 11/07/2022] Open
Abstract
Background Inhaled nitric oxide (iNO) is used as rescue therapy in patients with refractory hypoxemia due to severe COVID-19 acute respiratory distress syndrome (ARDS) despite the recommendation against the use of this treatment. To date, the effect of iNO on the clinical outcomes of critically ill COVID-19 patients with moderate-to-severe ARDS remains arguable. Therefore, this study aimed to evaluate the use of iNO in critically ill COVID-19 patients with moderate-to-severe ARDS. Methods This multicenter, retrospective cohort study included critically ill adult patients with confirmed COVID-19 treated from March 01, 2020, until July 31, 2021. Eligible patients with moderate-to-severe ARDS were subsequently categorized into two groups based on inhaled nitric oxide (iNO) use throughout their ICU stay. The primary endpoint was the improvement in oxygenation parameters 24 h after iNO use. Other outcomes were considered secondary. Propensity score matching (1:2) was used based on the predefined criteria. Results A total of 1598 patients were screened, and 815 were included based on the eligibility criteria. Among them, 210 patients were matched based on predefined criteria. Oxygenation parameters (PaO2, FiO2 requirement, P/F ratio, oxygenation index) were significantly improved 24 h after iNO administration within a median of six days of ICU admission. However, the risk of 30-day and in-hospital mortality were found to be similar between the two groups (HR: 1.18; 95% CI: 0.77, 1.82; p = 0.45 and HR: 1.40; 95% CI: 0.94, 2.11; p= 0.10, respectively). On the other hand, ventilator-free days (VFDs) were significantly fewer, and ICU and hospital LOS were significantly longer in the iNO group. In addition, patients who received iNO had higher odds of acute kidney injury (AKI) (OR (95% CI): 2.35 (1.30, 4.26), p value = 0.005) and hospital/ventilator-acquired pneumonia (OR (95% CI): 3.2 (1.76, 5.83), p value = 0.001). Conclusion In critically ill COVID-19 patients with moderate-to-severe ARDS, iNO rescue therapy is associated with improved oxygenation parameters but no mortality benefits. Moreover, iNO use is associated with higher odds of AKI, pneumonia, longer LOS, and fewer VFDs. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04158-y.
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Affiliation(s)
- Khalid Al Sulaiman
- grid.415254.30000 0004 1790 7311Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.449346.80000 0004 0501 7602Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O.Box 84428, Riyadh, 11671 Saudi Arabia ,Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
| | - Ghazwa B. Korayem
- grid.449346.80000 0004 0501 7602Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O.Box 84428, Riyadh, 11671 Saudi Arabia
| | - Ali F. Altebainawi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Hail, Saudi Arabia
| | - Shmeylan Al Harbi
- grid.415254.30000 0004 1790 7311Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman Alissa
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Abdullah Alharthi
- grid.415254.30000 0004 1790 7311Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Raed Kensara
- grid.415254.30000 0004 1790 7311Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Amjaad Alfahed
- grid.449346.80000 0004 0501 7602Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O.Box 84428, Riyadh, 11671 Saudi Arabia
| | - Ramesh Vishwakarma
- grid.418936.10000 0004 0610 0854Statistics Department, European Organization for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Hussain Al Haji
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Naif Almohaimid
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Omar Al Zumai
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Fahad Alrubayan
- grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulmajid Asiri
- grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nasser Alkahtani
- grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulaziz Alolayan
- grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Samiah Alsohimi
- grid.412126.20000 0004 0607 9688Pharmaceutical Services Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia ,grid.415271.40000 0004 0573 8987Phamacy Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Nawal Melibari
- grid.412125.10000 0001 0619 1117Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Alaa Almagthali
- grid.412126.20000 0004 0607 9688Pharmaceutical Services Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Seba Aljahdali
- grid.412125.10000 0001 0619 1117Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abeer A. Alenazi
- grid.415989.80000 0000 9759 8141Pharmaceutical Care Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Alawi S. Alsaeedi
- grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghassan Al Ghamdi
- grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Omar Al Faris
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Joud Alqahtani
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Jalal Al Qahtani
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khalid A. Alshammari
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Hail, Saudi Arabia
| | - Khalil I. Alshammari
- grid.440750.20000 0001 2243 1790Department of Internal Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- grid.412125.10000 0001 0619 1117Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
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High-Dose Inhaled Nitric Oxide for the Treatment of Spontaneously Breathing Pregnant Patients With Severe Coronavirus Disease 2019 (COVID-19) Pneumonia. Obstet Gynecol 2022; 140:195-203. [PMID: 35852269 PMCID: PMC9994457 DOI: 10.1097/aog.0000000000004847] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/21/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To evaluate whether the use of inhaled nitric oxide (iNO)200 improves respiratory function. METHODS This retrospective cohort study used data from pregnant patients hospitalized with severe bilateral coronavirus disease 2019 (COVID-19) pneumonia at four teaching hospitals between March 2020 and December 2021. Two cohorts were identified: 1) those receiving standard of care alone (SoC cohort) and 2) those receiving iNO200 for 30 minutes twice daily in addition to standard of care alone (iNO200 cohort). Inhaled nitric oxide, as a novel therapy, was offered only at one hospital. The prespecified primary outcome was days free from any oxygen supplementation at 28 days postadmission. Secondary outcomes were hospital length of stay, rate of intubation, and intensive care unit (ICU) length of stay. The multivariable-adjusted regression analyses accounted for age, body mass index, gestational age, use of steroids, remdesivir, and the study center. RESULTS Seventy-one pregnant patients were hospitalized for severe bilateral COVID-19 pneumonia: 51 in the SoC cohort and 20 in the iNO200 cohort. Patients receiving iNO200 had more oxygen supplementation-free days (iNO200: median [interquartile range], 24 [23-26] days vs standard of care alone: 22 [14-24] days, P=.01) compared with patients in the SoC cohort. In the multivariable-adjusted analyses, iNO200 was associated with 63.2% (95% CI 36.2-95.4%; P<.001) more days free from oxygen supplementation, 59.7% (95% CI 56.0-63.2%; P<.001) shorter ICU length of stay, and 63.6% (95% CI 55.1-70.8%; P<.001) shorter hospital length of stay. No iNO200-related adverse events were reported. CONCLUSION In pregnant patients with severe bilateral COVID-19 pneumonia, iNO200 was associated with a reduced need for oxygen supplementation and shorter hospital stay.
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Safety and practicality of high dose inhaled nitric oxide in emergency department COVID-19 patients. Am J Emerg Med 2022; 58:5-8. [PMID: 35623183 PMCID: PMC9066706 DOI: 10.1016/j.ajem.2022.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 04/05/2022] [Accepted: 04/29/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator and mild bronchodilator that has been shown to improve systemic oxygenation, but has rarely been administered in the Emergency Department (ED). In addition to its favorable pulmonary vascular effects, in-vitro studies report that NO donors can inhibit replication of viruses, including SARS Coronavirus 2 (SARS-CoV-2). This study evaluated the administration of high-dose iNO by mask in spontaneously breathing emergency department (ED) patients with respiratory symptoms attributed to Coronavirus disease 2019 (COVID-19). METHODS We designed a randomized clinical trial to determine whether 30 min of high dose iNO (250 ppm) could be safely and practically administered by emergency physicians in the ED to spontaneously-breathing patients with respiratory symptoms attributed to COVID-19. Our secondary goal was to learn if iNO could prevent the progression of mild COVID-19 to a more severe state. FINDINGS We enrolled 47 ED patients with acute respiratory symptoms most likely due to COVID-19: 25 of 47 (53%) were randomized to the iNO treatment group; 22 of 47 (46%) to the control group (supportive care only). All patients tolerated the administration of high-dose iNO in the ED without significant complications or symptoms. Five patients receiving iNO (16%) experienced asymptomatic methemoglobinemia (MetHb) > 5%. Thirty-four of 47 (72%) subjects tested positive for SARS-CoV-2: 19 of 34 were randomized to the iNO treatment group and 15 of 34 subjects to the control group. Seven of 19 (38%) iNO patients returned to the ED, while 4 of 15 (27%) control patients did. One patient in each study arm was hospitalized: 5% in iNO treatment and 7% in controls. One patient was intubated in the iNO group. No patients in either group died. The differences between these groups were not significant. CONCLUSION A single dose of iNO at 250 ppm was practical and not associated with any significant adverse effects when administered in the ED by emergency physicians. Local disease control led to early study closure and prevented complete testing of COVID-19 safety and treatment outcomes measures.
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High Doses of Inhaled Nitric Oxide as an Innovative Antimicrobial Strategy for Lung Infections. Biomedicines 2022; 10:biomedicines10071525. [PMID: 35884830 PMCID: PMC9312466 DOI: 10.3390/biomedicines10071525] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 11/24/2022] Open
Abstract
Since the designation of nitric oxide as “Molecule of the Year” in 1992, the scientific and clinical discoveries concerning this biomolecule have been greatly expanding. Currently, therapies enhancing the release of endogenous nitric oxide or the direct delivery of the exogenous compound are recognized as valuable pharmacological treatments in several disorders. In particular, the administration of inhaled nitric oxide is routinely used to treat patients with pulmonary hypertension or refractory hypoxemia. More recently, inhaled nitric oxide has been studied as a promising antimicrobial treatment strategy against a range of pathogens, including resistant bacterial and fungal infections of the respiratory system. Pre-clinical and clinical findings have demonstrated that, at doses greater than 160 ppm, nitric oxide has antimicrobial properties and can be used to kill a broad range of infectious microorganisms. This review focused on the mechanism of action and current evidence from in vitro studies, animal models and human clinical trials of inhaled high-dose nitric oxide as an innovative antimicrobial therapy for lung infections.
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19
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Gianni S, Valsecchi C, Berra L. Therapeutic Gases and Inhaled Anesthetics as Adjunctive Therapies in Critically Ill Patients. Semin Respir Crit Care Med 2022; 43:440-452. [PMID: 35533689 DOI: 10.1055/s-0042-1747966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The administration of exogenous oxygen to support adequate gas exchange is the cornerstone of respiratory care. In the past few years, other gaseous molecules have been introduced in clinical practice to treat the wide variety of physiological derangement seen in critical care patients.Inhaled nitric oxide (NO) is used for its unique selective pulmonary vasodilator effect. Recent studies showed that NO plays a pivotal role in regulating ischemia-reperfusion injury and it has antibacterial and antiviral activity.Helium, due to its low density, is used in patients with upper airway obstruction and lower airway obstruction to facilitate gas flow and to reduce work of breathing.Carbon monoxide (CO) is a poisonous gas that acts as a signaling molecule involved in many biologic pathways. CO's anti-inflammatory and antiproliferative effects are under investigation in the setting of acute respiratory distress and idiopathic pulmonary fibrosis.Inhaled anesthetics are widely used in the operative room setting and, with the development of anesthetic reflectors, are now a valid option for sedation management in the intensive care unit.Many other gases such as xenon, argon, and hydrogen sulfide are under investigation for their neuroprotective and cardioprotective effects in post-cardiac arrest syndrome.With all these therapeutic options available, the clinician must have a clear understanding of the physiologic basis, therapeutic potential, and possible adverse events of these therapeutic gases. In this review, we will present the therapeutic gases other than oxygen used in clinical practice and we will describe other promising therapeutic gases that are in the early phases of investigation.
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Affiliation(s)
- Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carlo Valsecchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Ninham B, Reines B, Battye M, Thomas P. Pulmonary surfactant and COVID-19: A new synthesis. QRB DISCOVERY 2022; 3:e6. [PMID: 37564950 PMCID: PMC10411325 DOI: 10.1017/qrd.2022.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/24/2022] [Accepted: 04/05/2022] [Indexed: 11/06/2022] Open
Abstract
Chapter 1 COVID-19 pathogenesis poses paradoxes difficult to explain with traditional physiology. For instance, since type II pneumocytes are considered the primary cellular target of SARS-CoV-2; as these produce pulmonary surfactant (PS), the possibility that insufficient PS plays a role in COVID-19 pathogenesis has been raised. However, the opposite of predicted high alveolar surface tension is found in many early COVID-19 patients: paradoxically normal lung volumes and high compliance occur, with profound hypoxemia. That 'COVID anomaly' was quickly rationalised by invoking traditional vascular mechanisms-mainly because of surprisingly preserved alveolar surface in early hypoxemic cases. However, that quick rejection of alveolar damage only occurred because the actual mechanism of gas exchange has long been presumed to be non-problematic, due to diffusion through the alveolar surface. On the contrary, we provide physical chemical evidence that gas exchange occurs by an process of expansion and contraction of the three-dimensional structures of PS and its associated proteins. This view explains anomalous observations from the level of cryo-TEM to whole individuals. It encompasses results from premature infants to the deepest diving seals. Once understood, the COVID anomaly dissolves and is straightforwardly explained as covert viral damage to the 3D structure of PS, with direct treatment implications. As a natural experiment, the SARS-CoV-2 virus itself has helped us to simplify and clarify not only the nature of dyspnea and its relationship to pulmonary compliance, but also the fine detail of the PS including such features as water channels which had heretofore been entirely unexpected. Chapter 2 For a long time, physical, colloid and surface chemistry have not intersected with physiology and cell biology as much as we might have hoped. The reasons are starting to become clear. The discipline of physical chemistry suffered from serious unrecognised omissions that rendered it ineffective. These foundational defects included omission of specific ion molecular forces and hydration effects. The discipline lacked a predictive theory of self-assembly of lipids and proteins. Worse, theory omitted any role for dissolved gases, O2, N2, CO2, and their existence as stable nanobubbles above physiological salt concentration. Recent developments have gone some way to explaining the foam-like lung surfactant structures and function. It delivers O2/N2 as nanobubbles, and efflux of CO2, and H2O nanobubbles at the alveolar surface. Knowledge of pulmonary surfactant structure allows an explanation of the mechanism of corona virus entry, and differences in infectivity of different variants. CO2 nanobubbles, resulting from metabolism passing through the molecular frit provided by the glycocalyx of venous tissue, forms the previously unexplained foam which is the endothelial surface layer. CO2 nanobubbles turn out to be lethal to viruses, providing a plausible explanation for the origin of 'Long COVID'. Circulating nanobubbles, stable above physiological 0.17 M salt drive various enzyme-like activities and chemical reactions. Awareness of the microstructure of Pulmonary Surfactant and that nanobubbles of (O2/N2) and CO2 are integral to respiratory and circulatory physiology provides new insights to the COVID-19 and other pathogen activity.
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Affiliation(s)
- Barry Ninham
- Materials Physics (formerly Department of Applied Mathematics), Research School of Physics, Australian National University, Canberra, ACT2600, Australia
- School of Science, University of New South Wales, Northcott Drive, Campbell, Canberra, ACT2612, Australia
| | - Brandon Reines
- Materials Physics (formerly Department of Applied Mathematics), Research School of Physics, Australian National University, Canberra, ACT2600, Australia
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, 5607 Baum Blvd, Pittsburgh, PA15206, USA
| | | | - Paul Thomas
- Materials Physics (formerly Department of Applied Mathematics), Research School of Physics, Australian National University, Canberra, ACT2600, Australia
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Redaelli S, Magliocca A, Malhotra R, Ristagno G, Citerio G, Bellani G, Berra L, Rezoagli E. Nitric oxide: Clinical applications in critically ill patients. Nitric Oxide 2022; 121:20-33. [PMID: 35123061 PMCID: PMC10189363 DOI: 10.1016/j.niox.2022.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 12/19/2022]
Abstract
Inhaled nitric oxide (iNO) acts as a selective pulmonary vasodilator and it is currently approved by the FDA for the treatment of persistent pulmonary hypertension of the newborn. iNO has been demonstrated to effectively decrease pulmonary artery pressure and improve oxygenation, while decreasing extracorporeal life support use in hypoxic newborns affected by persistent pulmonary hypertension. Also, iNO seems a safe treatment with limited side effects. Despite the promising beneficial effects of NO in the preclinical literature, there is still a lack of high quality evidence for the use of iNO in clinical settings. A variety of clinical applications have been suggested in and out of the critical care environment, aiming to use iNO in respiratory failure and pulmonary hypertension of adults or as a preventative measure of hemolysis-induced vasoconstriction, ischemia/reperfusion injury and as a potential treatment of renal failure associated with cardiopulmonary bypass. In this narrative review we aim to present a comprehensive summary of the potential use of iNO in several clinical conditions with its suggested benefits, including its recent application in the scenario of the COVID-19 pandemic. Randomized controlled trials, meta-analyses, guidelines, observational studies and case-series were reported and the main findings summarized. Furthermore, we will describe the toxicity profile of NO and discuss an innovative proposed strategy to produce iNO. Overall, iNO exhibits a wide range of potential clinical benefits, that certainly warrants further efforts with randomized clinical trials to determine specific therapeutic roles of iNO.
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Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Giuseppe Ristagno
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neuroscience Department, NeuroIntensive Care Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy.
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22
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Simple and sensitive nitric oxide biosensor based on the electrocatalysis of horseradish peroxidase on AuNPs@metal-organic framework composite-modified electrode. Mikrochim Acta 2022; 189:162. [PMID: 35348908 PMCID: PMC8961095 DOI: 10.1007/s00604-022-05268-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/08/2022] [Indexed: 11/14/2022]
Abstract
Fe-based metal–organic framework (MIL-101(Fe)) was synthesized through a simple solvothermal synthesis and then used to prepare the AuNPs-decorated MIL-101(Fe) nanocomposite (APPPM(Fe)) by a multi-step layer-by-layer assembly process. Benefited from the porous structure of MIL-101(Fe) and the multilayer assemble process, the loading amount of AuNPs on APPPM(Fe) was enhanced and exhibited a fine biocompatible interface and high conductivity. Through the intense Au–S bond, high loading amount of horseradish peroxidase was immobilized on APPPM(Fe) and the native bioactivity of HRP was kept to realize its direct electrochemistry. From the electrochemical kinetics, the constructed biosensor displayed fast electron transfer and good electrocatalysis activity for the detection of nitric oxide (NO) with wide linear range from 0.033 to 5370 μM and a low detection limit of 0.01 μM (3 σ) as well as fine stability, reproducibility and specificity. According to results of real sample analysis, the proposed electrochemical biosensor offers fast and simple detection of NO in real serum. Therefore, the present strategy definitely provided a potential application prospect in NO clinic detection and disease therapy.
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23
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Targeting Arginine in COVID-19-Induced Immunopathology and Vasculopathy. Metabolites 2022; 12:metabo12030240. [PMID: 35323682 PMCID: PMC8953281 DOI: 10.3390/metabo12030240] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 01/27/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) represents a major public health crisis that has caused the death of nearly six million people worldwide. Emerging data have identified a deficiency of circulating arginine in patients with COVID-19. Arginine is a semi-essential amino acid that serves as key regulator of immune and vascular cell function. Arginine is metabolized by nitric oxide (NO) synthase to NO which plays a pivotal role in host defense and vascular health, whereas the catabolism of arginine by arginase to ornithine contributes to immune suppression and vascular disease. Notably, arginase activity is upregulated in COVID-19 patients in a disease-dependent fashion, favoring the production of ornithine and its metabolites from arginine over the synthesis of NO. This rewiring of arginine metabolism in COVID-19 promotes immune and endothelial cell dysfunction, vascular smooth muscle cell proliferation and migration, inflammation, vasoconstriction, thrombosis, and arterial thickening, fibrosis, and stiffening, which can lead to vascular occlusion, muti-organ failure, and death. Strategies that restore the plasma concentration of arginine, inhibit arginase activity, and/or enhance the bioavailability and potency of NO represent promising therapeutic approaches that may preserve immune function and prevent the development of severe vascular disease in patients with COVID-19.
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24
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Kamenshchikov NO, Berra L, Carroll RW. Therapeutic Effects of Inhaled Nitric Oxide Therapy in COVID-19 Patients. Biomedicines 2022; 10:biomedicines10020369. [PMID: 35203578 PMCID: PMC8962307 DOI: 10.3390/biomedicines10020369] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 01/08/2023] Open
Abstract
The global COVID-19 pandemic has become the largest public health challenge of recent years. The incidence of COVID-19-related acute hypoxemic respiratory failure (AHRF) occurs in up to 15% of hospitalized patients. Antiviral drugs currently available to clinicians have little to no effect on mortality, length of in-hospital stay, the need for mechanical ventilation, or long-term effects. Inhaled nitric oxide (iNO) administration is a promising new non-standard approach to directly treat viral burden while enhancing oxygenation. Along with its putative antiviral affect in COVID-19 patients, iNO can reduce inflammatory cell-mediated lung injury by inhibiting neutrophil activation, lowering pulmonary vascular resistance and decreasing edema in the alveolar spaces, collectively enhancing ventilation/perfusion matching. This narrative review article presents recent literature on the iNO therapy use for COVID-19 patients. The authors suggest that early administration of the iNO therapy may be a safe and promising approach for the treatment of COVID-19 patients. The authors also discuss unconventional approaches to treatment, continuous versus intermittent high-dose iNO therapy, timing of initiation of therapy (early versus late), and novel delivery systems. Future laboratory and clinical research is required to define the role of iNO as an adjunct therapy against bacterial, viral, and fungal infections.
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Affiliation(s)
- Nikolay O. Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 634012 Tomsk, Russia
- Correspondence:
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA;
| | - Ryan W. Carroll
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA;
- Division of Pediatric Critical Care Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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25
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Juhász L, Tallósy SP, Nászai A, Varga G, Érces D, Boros M. Bioactivity of Inhaled Methane and Interactions With Other Biological Gases. Front Cell Dev Biol 2022; 9:824749. [PMID: 35071248 PMCID: PMC8777024 DOI: 10.3389/fcell.2021.824749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/14/2021] [Indexed: 01/04/2023] Open
Abstract
A number of studies have demonstrated explicit bioactivity for exogenous methane (CH4), even though it is conventionally considered as physiologically inert. Other reports cited in this review have demonstrated that inhaled, normoxic air-CH4 mixtures can modulate the in vivo pathways involved in oxidative and nitrosative stress responses and key events of mitochondrial respiration and apoptosis. The overview is divided into two parts, the first being devoted to a brief review of the effects of biologically important gases in the context of hypoxia, while the second part deals with CH4 bioactivity. Finally, the consequence of exogenous, normoxic CH4 administration is discussed under experimental hypoxia- or ischaemia-linked conditions and in interactions between CH4 and other biological gases, with a special emphasis on its versatile effects demonstrated in pulmonary pathologies.
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Affiliation(s)
- László Juhász
- Institute of Surgical Research, Faculty of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Szabolcs Péter Tallósy
- Institute of Surgical Research, Faculty of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anna Nászai
- Institute of Surgical Research, Faculty of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Gabriella Varga
- Institute of Surgical Research, Faculty of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Dániel Érces
- Institute of Surgical Research, Faculty of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Mihály Boros
- Institute of Surgical Research, Faculty of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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