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Xu F, Li W. Delivery exogenous nitric oxide via cardiopulmonary bypass in pediatric cardiac surgery reduces the duration of postoperative mechanical ventilation-A meta-analysis of randomized controlled trials. Heliyon 2023; 9:e19007. [PMID: 37636442 PMCID: PMC10447988 DOI: 10.1016/j.heliyon.2023.e19007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 08/04/2023] [Indexed: 08/29/2023] Open
Abstract
Objectives Cardiopulmonary bypass (CPB) is a major part of cardiac surgery that provokes systemic inflammatory reactions, myocardial ischemia, and ischemia and reperfusion damage. The aim of this study is to summarize the available evidence and evaluate whether exogenous nitric oxide administered via CPB circuits can improve recovery after cardiac surgery in children. Method A comprehensive search of the PubMed Medline, Ovid, Cochrane Library and Embase databases was conducted in September 2022. Only randomized controlled trials that compared nitro oxide with placebo or standard care were included. Results This pooled analysis included 5 RCTs containing 1642 patients. There were significant differences in the duration of postoperative mechanical ventilation between the nitric oxide group and the control group (mean difference -5.645 h; 95% CL = -9.978, -1.313; P = 0.01). Meta-analysis of the length of ICU stay and hospital stay showed no significant differences. Conclusion Delivering nitric oxide via CPB in pediatric cardiac surgery has an effect on reducing the duration of mechanical ventilation. Considering the small effect size, we should be cautious and think comprehensively in clinical practice.
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Affiliation(s)
- Fei Xu
- Corresponding author. Department of Anesthesiology, Chengdu Women's and Children's Central Hospital, Chengdu, 610031, Sichuan, China.
| | - Weina Li
- Department of Anesthesiology, Chengdu Women's and Children's Central Hospital, Chengdu, 610031, Sichuan, China
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Sardo S, Osawa EA, Finco G, Gomes Galas FRB, de Almeida JP, Cutuli SL, Frassanito C, Landoni G, Hajjar LA. Nitric Oxide in Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2018; 32:2512-2519. [PMID: 29703580 DOI: 10.1053/j.jvca.2018.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate the efficacy and safety of perioperative administration of nitric oxide in cardiac surgery. DESIGN Meta-analysis of randomized controlled trials (RCTs). PARTICIPANTS Cardiac surgery patients. INTERVENTIONS A search of Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE for RCTs that compared nitric oxide with placebo or other comparators. MEASUREMENTS AND MAIN RESULTS The primary outcome was intensive care unit (ICU) stay, and secondary outcomes were mortality, duration of mechanical ventilation, and reduction of mean pulmonary artery pressure. The study included 18 RCTs comprising 958 patients. The authors calculated the pooled odds ratio (OR) and the mean difference (MD) with random-effects model. Quantitative synthesis of data demonstrated a clinically negligible reduction in the length of ICU stay (MD -0.38 days, confidence interval CI [-0.65 to -0.11]; p = 0.005) and mechanical ventilation duration (MD -4.81 hours, CI [-7.79 to -1.83]; p = 0.002) compared with all control interventions with no benefit on mortality. CONCLUSIONS Perioperative delivery of inhaled nitric oxide resulted to be of no or minimal benefit in patients with pulmonary hypertension undergoing cardiac surgery. Large, randomized trials are needed to further assess its effect on major clinical outcomes and its cost-effectiveness.
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Affiliation(s)
- Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Eduardo Atsushi Osawa
- Intensive Care Unit, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gabriele Finco
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | | | | | - Salvatore Lucio Cutuli
- Department of Anesthesiology and Intensive Care, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University of Milan, Milan, Italy.
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Raut MS, Maheshwari A. Inhaled nitric oxide, methemoglobinemia, and route of delivery. Saudi J Anaesth 2017; 11:364. [PMID: 28757849 PMCID: PMC5516511 DOI: 10.4103/sja.sja_82_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Monish S Raut
- Department of Cardiac Anaesthesia, Sir Ganga Ram Hospital, New Delhi, India
| | - Arun Maheshwari
- Department of Cardiac Anaesthesia, Sir Ganga Ram Hospital, New Delhi, India
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Pezone MJ, Wakim MG, Denton RJ, Gamero LG, Roscigno RF, Gilbert RJ, Lovich MA. Nitrogen dioxide reducing ascorbic acid technologies in the ventilator circuit leads to uniform NO concentration during inspiration. Nitric Oxide 2016; 58:42-50. [PMID: 27264784 DOI: 10.1016/j.niox.2016.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/19/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
Abstract
Conventional inhaled NO systems deliver NO by synchronized injection or continuous NO flow in the ventilator circuitry. Such methods can lead to variable concentrations during inspiration that may differ from desired dosing. NO concentrations in these systems are generally monitored through electrochemical methods that are too slow to capture this nuance and potential dosing error. A novel technology that reduces NO2 into NO via low-resistance ascorbic-acid cartridges just prior to inhalation has recently been described. The gas volume of these cartridges may enhance gas mixing and reduce dosing inconsistency throughout inhalation. The impact of the ascorbic-acid cartridge technology on NO concentration during inspiration was characterized through rapid chemiluminescence detection during volume control ventilation, pressure control ventilation, synchronized intermittent mandatory ventilation and continuous positive airway pressure using an in vitro lung model configured to simulate the complete uptake of NO. Two ascorbic acid cartridges in series provided uniform and consistent dosing during inspiration during all modes of ventilation. The use of one cartridge showed variable inspiratory concentration of NO at the largest tidal volumes, whereas the use of no ascorbic acid cartridge led to highly inconsistent NO inspiratory waveforms. The use of ascorbic acid cartridges also decreased breath-to-breath variation in SIMV and CPAP ventilation. The ascorbic-acid cartridges, which are designed to convert NO2 (either as substrate or resulting from NO oxidation during injection) into NO, also provide the benefit of minimizing the variation of inhaled NO concentration during inspiration. It is expected that the implementation of this method will lead to more consistent and predictable dosing.
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Affiliation(s)
- Matthew J Pezone
- Department of Anesthesiology, Pain Medicine, and Critical Care, Steward St. Elizabeth's Medical Center, 736 Cambridge Street CMP-2, Boston, MA 02134, USA
| | - Matthew G Wakim
- Department of Anesthesiology, Pain Medicine, and Critical Care, Steward St. Elizabeth's Medical Center, 736 Cambridge Street CMP-2, Boston, MA 02134, USA
| | | | | | | | - Richard J Gilbert
- Department of Chemistry and Chemical Biology, Northeastern University, 334 Huntington Ave., Boston, MA 02115, USA
| | - Mark A Lovich
- Department of Anesthesiology, Pain Medicine, and Critical Care, Steward St. Elizabeth's Medical Center, 736 Cambridge Street CMP-2, Boston, MA 02134, USA.
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5
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Akter F, Coghlan G, de Mel A. Nitric oxide in paediatric respiratory disorders: novel interventions to address associated vascular phenomena? Ther Adv Cardiovasc Dis 2016; 10:256-70. [PMID: 27215618 DOI: 10.1177/1753944716649893] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Nitric oxide (NO) has a significant role in modulating the respiratory system and is being exploited therapeutically. Neonatal respiratory failure can affect around 2% of all live births and is responsible for over one third of all neonatal mortality. Current treatment method with inhaled NO (iNO) has demonstrated great benefits to patients with persistent pulmonary hypertension, bronchopulmonary dysplasia and neonatal respiratory distress syndrome. However, it is not without its drawbacks, which include the need for patients to be attached to mechanical ventilators. Notably, there is also a lack of identification of subgroups amongst abovementioned patients, and homogeneity in powered studies associated with iNO, which is one of the limitations. There are significant developments in drug delivery methods and there is a need to look at alternative or supplementary methods of NO delivery that could reduce current concerns. The addition of NO-independent activators and stimulators, or drugs such as prostaglandins to work in synergy with NO donors might be beneficial. It is of interest to consider such delivery methods within the respiratory system, where controlled release of NO can be introduced whilst minimizing the production of harmful byproducts. This article reviews current therapeutic application of iNO and the state-of-the-art technology methods for sustained delivery of NO that may be adapted and developed to address respiratory disorders. We envisage this perspective would prompt active investigation of such systems for their potential clinical benefit.
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Affiliation(s)
- Farhana Akter
- UCL Centre for Nanotechnology and Regenerative Medicine; Division of Surgery and Interventional Science, UCL, UK
| | - Gerry Coghlan
- Pulmonary Hypertension Unit, Royal Free London NHS Foundation Trust, UK
| | - Achala de Mel
- Lecturer in Regenerative Medicine, UCL Centre for Nanotechnology and Regenerative Medicine, Division of Surgery and Interventional Science, University College London, Royal Free NHS Trust Hospital, 9th Floor, Room 355, Pond Street, London NW3 2QG, UK
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6
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Heinonen E, Meriläinen P, Högman M. Administration of nitric oxide into open lung regions: delivery and monitoring. Br J Anaesth 2003; 90:338-42. [PMID: 12594148 DOI: 10.1093/bja/aeg081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pulsed administration of nitric oxide has proven effective in relieving pulmonary hypertension and in improving oxygenation. With this delivery method the nitric oxide administration to low ventilated lung regions is avoided with subsequent enhancement in oxygenation. This study presents (i) pulsed administration technique for nitric oxide during artificial ventilation, (ii) evaluation of the delivery in an animal model, and (iii) validation of the delivery device in a laboratory setting. METHODS Nitric oxide was delivered in four different pulse volumes synchronously with inspiration. The delivery was monitored with a fast responding high sensitivity nitric oxide monitor and nitric oxide uptake was calculated. Pulse delivery dose range, accuracy of the delivered dose, and stability of successive doses were analysed in a laboratory setting. RESULTS Uptake of the delivered nitric oxide was 87-92%. Measured nitric oxide pulse concentration was 1.6-fold the delivery concentration, calculated as the ratio of nitric oxide flow to inspiration flow. Dose accuracy and stability were both 5% or 3 nmol in the validated range of 3-1000 nmol. CONCLUSION With pulsed administration nitric oxide therapy can be directed to well-ventilated lung regions. Avoiding administration to the anatomic dead space eliminates nitric oxide exhalation effectively, which makes the method optimal for nitric oxide therapy in a rebreathing circuit. The required dose range from paediatric to adult is covered by the delivery device with a single nitric oxide gas supply.
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Affiliation(s)
- E Heinonen
- Department of Medical Cell Biology, Section of Integrative Physiology, Uppsala University, Box 571,SE-751 23 Uppsala, Sweden.
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7
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Taylor MB, Christian KG, Patel N, Churchwell KB. Methemoglobinemia: Toxicity of inhaled nitric oxide therapy. Pediatr Crit Care Med 2001; 2:99-101. [PMID: 12797897 DOI: 10.1097/00130478-200101000-00019] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Elevation in methemoglobin is a known toxicity of inhaled nitric oxide (NO) therapy. This article describes two significant episodes of methemoglobinemia. These cases illustrate the probable cause and the treatment strategies for the potential for delivery of high concentrations of NO, resulting in methemoglobinemia with moderate and even low-dose delivered NO. We propose mechanisms for this occurrence and means of prevention.
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Affiliation(s)
- M B Taylor
- Division of Pediatric Critical Care and Anesthesia (Drs. Taylor, Patel, and Churchwell) and the Department of Cardiac and Thoracic Surgery (Dr. Christian), Vanderbilt University Medical Center, Nashville, TN
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8
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Sieffert E, Ducros L, Losser MR, Payen DM. Inhaled nitric oxide fraction is influenced by both the site and the mode of administration. J Clin Monit Comput 1999; 15:509-17. [PMID: 12578049 DOI: 10.1023/a:1009971712989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Inhaled nitric oxide (NO) can be delivered continuously or sequentially (= during inspiration) at different locations of the ventilation circuit. We have tested the influence of locations, modes of NO administration and the ratio of the inspiratory time over the respiratory cycle time (I/I + E ratio) on the accuracy of NO fractions, delivered by 2 devices: Opti-NO and Flowmeter. METHODS We used a simplified lung model consisting of a ventilation circuit with a Y piece, a tracheal tube, a 150 ml dead-space volume and a 5 liter balloon. Three fractions (3, 6, 9 ppm) were administered continuously or sequentially, in controlled volume, in 4 different sites on the inspiratory branch above the Y piece: i) just after the water trap, ii) just before the Y piece; below the Y piece: iii) just after the Y piece, iv) into the endotracheal tube. In addition, different I/I + E ratios (25, 33, 50, 80%) were studied. The delivered NO fractions were measured in the balloon by chemiluminescence (CLD 700, Ecophysics). A linear regression analysis was used to test the relationship between administered and measured NO fractions for the 3 fractions (3, 6 and 9 ppm) in sequential and continuous modes. Intercept values were compared to zero and slopes to the identity line. RESULTS When NO was administered in the continuous mode upstream the Y piece, NO fractions measured in the balloon corresponded to the administered fractions. In contrast, below the Y piece, the measured NO fractions were significantly lower than the administered NO fractions. In the sequential mode, above and below the Y piece, the delivered NO fractions were within the manufacturer's range. CONCLUSIONS For the continuous NO delivery, locations above the Y piece are mandatory. However, locations below the Y piece imposes a sequential system, which can also be used for the sites located above the Y piece.
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Affiliation(s)
- E Sieffert
- Département d'Anesthésie-Réanimation & SMUR, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, 2 rue Ambroise Paré, 75475 Paris Cedex 10, France
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9
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Totapally BR, Raszynski A, Sussmane J, Hultquist K, Hernandez J, Andreoulakis N, Wolfsdorf J. Nitric oxide and nitrogen dioxide concentrations during in vitro high-frequency oscillatory ventilation. J Crit Care 1999; 14:141-9. [PMID: 10527252 DOI: 10.1016/s0883-9441(99)90027-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study was to measure nitric oxide (NO) and nitrogen dioxide (NO2) concentrations, at various ventilatory settings and sampling sites, during in vitro inhaled NO and high-frequency oscillatory ventilation therapy [iNO-HFOV]. MATERIALS AND METHODS We used a high-frequency oscillatory ventilator (model 3100A, SensorMedics, Yorba Linda, CA), a test lung (model VT-2A Ventilator Tester, Bio-Tek Instruments, Inc., Winooski, VT), nitric oxide delivery and NO/NO2 monitoring (Pulmonox II, Pulmonox, Tofield, Canada), and scavenging systems in this study. The ventilator frequency, amplitude, and inspired oxygen concentration were systematically changed at a fixed flow of NO. The concentrations of NO and NO2, sampled at four sites, were determined by an electrochemical method (Pulmonox II). The NO and NO2 concentrations were measured at the proximal part of the inspiratory limb (site 1), near the Y-piece (site 2), the carina of the test lung (site 3), and the bellows of the test lung (site 4). RESULTS The concentration of NO decreased significantly (P < .001) from the proximal port (site 11 of the inspiratory circuit (86.16 +/- 0.38 ppm) through the lung bellows (site 4) (70.08 +/- 0.23 ppm). The concentration of NO2 increased significantly (P < .001) from site 1 (3.25 +/- 0.04 ppm) through site 4 (19.4 +/- 0.19 ppm). However, the total concentration of NO + NO2 (NOx) remained unchanged at both site 1 and site 4. Increasing the frequency and amplitude of the ventilator significantly altered NO and NO2 concentrations. The NO2 concentration increased significantly (P < .0001) from 5.6 ppm to 18.1 ppm at site 4 when the fraction of inspired oxygen was increased from 0.25 to 0.93. The NO2 concentration also increased significantly (P < .0001) from 0.6 ppm to 18.7 when NO concentrations were independently increased from 12 ppm to 80 ppm. CONCLUSIONS During HFOV, the concentrations of NO and NO2 vary between sampling sites and also are influenced by the frequency, amplitude, and inspired oxygen concentration. NO2 concentrations in the lung were significantly increased above commonly accepted toxic concentrations during ventilation with high concentrations of NO (80 ppm) and high fractional concentrations of oxygen. The excessive increase in NO2 concentration at the "alveolar" level in our test lung model warrants confirmation in an in vivo model.
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Affiliation(s)
- B R Totapally
- Division of Critical Care Medicine, Miami Children's Hospital, FL 33155, USA
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10
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Kuhlen R, Busch T, Max M, Reyle-Hahn M, Falke KJ, Rossaint R. Fluctuations of inspired concentrations of nitric oxide and nitrogen dioxide during mechanical ventilation. Crit Care 1999; 3:1-6. [PMID: 11056715 PMCID: PMC29005 DOI: 10.1186/cc298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/1997] [Revised: 06/05/1998] [Accepted: 06/16/1998] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND: Nitric oxide (NO) is a very reactive agent with potentially toxic oxidation products such as nitrogen dioxide (NO2). Therefore, during NO inhalation a constant inspired concentration and accurate measurement of NO and NO2 concentrations are essential. The objective of this study was to test the NO concentrations at various positions along the inspiratory limb of the breathing circuit using a recently developed system to administer NO in phase with inspiratory flow during mechanical ventilation (Servo 300 NO-A, Siemens, Sweden). Furthermore, we tested whether an active heating system would interfere with inspired NO concentrations. RESULTS: A sharp decline in the NO concentration was found between the respirator's inspiratory outlet and more distal points along the inspiratory limb of the circuit. This finding was most evident when an active heating system was mounted between those points. CONCLUSIONS: The concentrations of NO and NO2 should be measured as near to the patient as possible, as significant fluctuations of these concentrations might be found along the inspiratory limb of the respiratory circuit especially when an active heating system is used.
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Affiliation(s)
- Ralf Kuhlen
- Department of Anaesthesiology, University Hospital, Medical
School, RWTH Aachen, Germany
| | - Thilo Busch
- Department of Anaesthesiology and
Intensive Care Medicine, Virchow Hospital, Medical School,
Humboldt University Berlin, Germany
| | - Martin Max
- Department of Anaesthesiology, University Hospital, Medical
School, RWTH Aachen, Germany
| | - Matthias Reyle-Hahn
- Department of Anaesthesiology, University Hospital, Medical
School, RWTH Aachen, Germany
| | - Konrad J Falke
- Department of Anaesthesiology and
Intensive Care Medicine, Virchow Hospital, Medical School,
Humboldt University Berlin, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital, Medical
School, RWTH Aachen, Germany
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11
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Kirmse M, Hess D, Fujino Y, Kacmarek RM, Hurford WE. Delivery of inhaled nitric oxide using the Ohmeda INOvent Delivery System. Chest 1998; 113:1650-7. [PMID: 9631807 DOI: 10.1378/chest.113.6.1650] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES We evaluated the Ohmeda INOvent Nitric Oxide Delivery System, which uses an inspiratory flow sensor to inject a synchronized and proportional nitric oxide (NO) flow into the mechanical ventilator circuit. This system should deliver a constant NO concentration independent of ventilator mode, minute ventilation, fraction of inspired oxygen, or ventilator brand. It should also minimize nitrogen dioxide (NO2) formation. METHODS NO delivery by the INOvent and a premixing NO delivery system were compared using two ventilators (Puritan-Bennett 7200 and Servo 900C). NO concentration was measured within the trachea of an attached lung model using a fast-response chemiluminescence NO analyzer. NO concentration was also measured in the inspiratory limb using the electrochemical analyzer of the INOvent. For three NO concentrations (2, 5, and 20 ppm), the ventilators were set for constant flow volume control ventilation, pressure control ventilation, and spontaneous breathing with pressure support ventilation or synchronized intermittent mandatory ventilation. Different tidal volumes (300, 500, 750, and 1,000 mL) and inspiratory times (1 and 2 s) were evaluated. NO2 formation for both ventilators and delivery systems were evaluated at 20 ppm and 95% O2-. RESULTS Regardless of ventilatory pattern, both systems delivered a constant NO concentration. The error between the target and the delivered NO dose for the INOvent was -1.3+/-3.6% with the Puritan-Bennett 7200 and -3.9+/-4.3% with the Servo 900C. For the premixing system, the error was -5.5+/-4.8% with the Puritan-Bennett 7200 and -6.7+/-6.2% with the Servo 900C. NO2 concentrations were 0.5+/-0.1 ppm during NO delivery by the INOvent, 5.8+/-1.6 ppm when NO was premixed with air, 0.3+/-0.1 ppm when NO was premixed with N2. CONCLUSION The INOvent provides a constant NO concentration independent of the ventilatory pattern, and NO2 formation is minimal.
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Affiliation(s)
- M Kirmse
- Department of Anesthesia & Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston 02114, USA
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12
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Francoe M, Troncy E, Blaise G. Inhaled nitric oxide: technical aspects of administration and monitoring. Crit Care Med 1998; 26:782-96. [PMID: 9559620 DOI: 10.1097/00003246-199804000-00033] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Clinical applications of inhaled nitric oxide (NO) therapy resulted in the development of delivery systems and monitoring devices applicable to routine clinical care. This article presents the various components necessary for an adequate clinical use of inhaled NO, and discusses the NO gas mixture cylinders, inhaled NO delivery techniques and specifications, monitoring devices, and ending with an exhaustive description of the scavengers of nitrogen oxides (NOx). DATA SOURCES Computerized search (CURRENT CONTENTS, MEDLINE) of published original research and review articles (approximately 200), conference abstracts and compendiums up to May 1997 (approximately 50), personal files, and contact with expert informants. STUDY SELECTION Technical, experimental, and clinical reports were selected from the recent English, French, German, and Spanish literature, if pertinent to the administration or monitoring of inhaled NO. DATA EXTRACTION The authors extracted all applicable data. DATA SYNTHESIS The production of NO gas mixture cylinders must be certified with respect to gas purity, stability, and concentration (limits between 100 and 1000 ppm), guaranteed calibration, and specific color. An ideal inhaled NO delivery device requires a synchronized delivery, a minimal production of nitrogen dioxide (NO2), and should be simple to use (verification, calibration, convenient flushing, cylinder change possible while in use and a simple alarm setting) with full information (high and low alarms and available precision monitoring of NO, NO2, and O2). Emergency and transport systems must be readily available. The choice of the monitoring device (chemiluminescence or electrochemistry) should be made based on the knowledge of their strength and weakness for a particular clinical application. Finally, scavengers of NOx should be used with caution until specific filters are proven safe and effective. CONCLUSIONS The great expectancies generated by inhaled NO action have led researchers to design personal inhaled NO delivery systems, but only with mitigated results. At present, medical companies are finding a financial interest in designing a delivery system which will suit the needs of clinicians and this, along with official governmental approval, will only then permit the use of inhaled NO safely and on a larger scale.
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Affiliation(s)
- M Francoe
- Department of Anesthesia, Centre Hospitalier de l'Université de Montréal, Pavillon Notre-Dame, PQ, Canada
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13
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Sydow M, Bristow F, Zinserling J, Allen SJ. Flow-proportional administration of nitric oxide with a new delivery system: inspiratory nitric oxide concentration fluctuation during different flow conditions. Chest 1997; 112:496-504. [PMID: 9266890 DOI: 10.1378/chest.112.2.496] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the accuracy of a flow-proportional delivery system and the pattern of inspiratory nitric oxide (NO) concentration during different flow conditions. DESIGN Laboratory study in a lung model. SETTING University experimental laboratory. SUBJECT With a new delivery system, NO was administered proportional to the inspiratory flow into the inspiratory circuit to deliver a NO concentration of 10 and 30 ppm to a test lung during different ventilatory modes (volume-controlled ventilation [VCV], pressure-controlled ventilation [PCV], and airway pressure release ventilation [APRV]) with a fraction of inspired oxygen (FIO2) of 1.0. INTERVENTIONS During VCV and PCV, the flow pattern was varied to achieve tidal volumes of 300, 600, and 900 mL, respectively, with inspiratory to expiratory time ratios of 1:3, 1:2, and 1:1. APRV was studied at a minute volume of 6, 12, and 18 L. Nitric oxides (NOx [NO+NO2]) and nitric dioxide (NO2) were monitored by chemiluminescence and electrochemical analysis. As the NO/N2 gas mixture is the only nitrogen source during ventilation with an FIO2 analyzer. RESULTS During all flow conditions, NOx concentration was stable but slightly higher than expected. Measured and expected mean concentrations differed <9% (mean, <4%). Inspiratory NOx concentration fluctuation derived from N2 concentration was significantly higher than expected at higher flow rates, but this difference was not detected by chemiluminescence or electrochemical analysis. The NO2 production was not affected by the flow rate and was always < or =0.2 ppm (NO, 10 ppm) and < or =1.9 ppm (NO, 30 ppm). CONCLUSION The tested NO delivery module administered stable mean inspiratory NO concentrations. Although inspiratory NO concentration fluctuates depending on the inspiratory flow rate, this delivery device allows stable NO administration without requiring adjustments when ventilator settings are changed.
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Affiliation(s)
- M Sydow
- Department of Anesthesiology, UT Houston Medical School, USA
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