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Ware LR, Kim CS, Szumita PM, DeGrado JR. A Narrative Review on the Administration of Inhaled Prostaglandins in Critically Ill Adult Patients With Acute Respiratory Distress Syndrome. Ann Pharmacother 2024; 58:533-548. [PMID: 37589097 DOI: 10.1177/10600280231194539] [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] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE To describe the effect of inhaled prostaglandins on both oxygenation and mortality in critically ill patients with acute respiratory distress syndrome (ARDS), with a focus on safety and efficacy in coronavirus disease 2019 (COVID-19)-associated ARDS and non-COVID-19 ARDS. DATA SOURCES A literature search of MEDLINE was performed using the following search terms: inhaled prostaglandins, inhaled epoprostenol, inhaled nitric oxide, ARDS, critically ill. All abstracts were reviewed. STUDY SELECTION AND DATA EXTRACTION Relevant English-language reports and studies conducted in humans between 1980 and June 2023 were considered. DATA SYNTHESIS Data regarding inhaled prostaglandins and their effect on oxygenation are limited but show a benefit in patients who respond to therapy, and data pertaining to their effect on mortality is scarce. Concerns exist regarding the formulation of inhaled epoprostenol (iEPO) utilized in addition to modes of medication delivery; however, the limited data surrounding their use have shown a reasonable safety profile. Other avenues and beneficial effects may exist with inhaled prostaglandins, such as use in COVID-19-associated ARDS or non-COVID-19 ARDS patients undergoing noninvasive mechanical ventilation or during patient transport. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The use of inhaled prostaglandins can be considered in critically ill patients with COVID-19-associated ARDS or non-COVID-19 ARDS who are experiencing difficulties with oxygenation refractory to nonpharmacologic strategies. CONCLUSIONS The use of iEPO and other inhaled prostaglandins requires further investigation to fully elucidate their effects on clinical outcomes, but it appears these medications may have a potential benefit in COVID-19-associated ARDS and non-COVID-19 ARDS patients with refractory hypoxemia but with little effect on mortality.
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Affiliation(s)
- Lydia R Ware
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Christine S Kim
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Paul M Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeremy R DeGrado
- Department of Pharmacy, Brigham and Women's 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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3
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Foroshani S, Airo M, Levine A, Frishman WH, Aronow WS, Lanier GM. COVID-19 and Pulmonary Hypertension: An Interesting Dynamic. Cardiol Rev 2024:00045415-990000000-00220. [PMID: 38400720 DOI: 10.1097/crd.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
The dynamic between pulmonary hypertension (PH) and COVID-19 has been under investigation since 2020, early in the pandemic. Although the pathophysiology of PH has been well-studied, new discoveries regarding the multisystemic effects of COVID-19 are still being uncovered. The cardiopulmonary effects of COVID-19 have led investigators to inquire about the interplay between these 2 conditions. Several factors are suggested to contribute to an increased risk of developing PH after infection with SARS-CoV-2. This includes cytokine storm, acute respiratory distress syndrome, and fibrotic changes seen in post-COVID-19 lung disease. Additionally, it has been proposed that certain medications used to treat PH may be applied to patients suffering from the cardiopulmonary complications of COVID-19. This review will focus on the interplay between COVID-19 and PH, with a special focus on the risk of developing PH after SARS-CoV-2 infection and the outcomes of patients with preexisting PH who are diagnosed with COVID-19. The potential benefits of utilizing off-label PH medications for COVID-19 patients will also be discussed.
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Affiliation(s)
- Saam Foroshani
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Michael Airo
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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4
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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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Michelson AP, Lyons PG, Nguyen NM, Reynolds D, McDonald R, McEvoy CA, Despotovic V, Brody SL, Kollef MH, Kraft BD. Use of Inhaled Epoprostenol in Patients With COVID-19 Receiving Humidified, High-Flow Nasal Oxygen Is Associated With Progressive Respiratory Failure. CHEST CRITICAL CARE 2023; 1:100019. [PMID: 38516615 PMCID: PMC10956404 DOI: 10.1016/j.chstcc.2023.100019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND The clinical benefit of using inhaled epoprostenol (iEpo) through a humidified high-flow nasal cannula (HHFNC) remains unknown for patients with COVID-19. RESEARCH QUESTION Can iEpo prevent respiratory deterioration for patients with positive SARS-CoV-2 findings receiving HHFNC? STUDY DESIGN AND METHODS This multicenter retrospective cohort analysis included patients aged 18 years or older with COVID-19 pneumonia who required HHFNC treatment. Patients who received iEpo were propensity score matched to patients who did not receive iEpo. The primary outcome was time to mechanical ventilation or death without mechanical ventilation and was assessed using Kaplan-Meier curves and Cox proportional hazard ratios. The effects of residual confounding were assessed using a multilevel analysis, and a secondary analysis adjusted for outcome propensity also was performed in a multivariable model that included the entire (unmatched) patient cohort. RESULTS Among 954 patients with positive SARS-CoV-2 findings receiving HHFNC therapy, 133 patients (13.9%) received iEpo. After propensity score matching, the median number of days until the composite outcome was similar between treatment groups (iEpo: 5.0 days [interquartile range, 2.0-10.0 days] vs no-iEpo: 6.5 days [interquartile range, 2.0-11.0 days]; P = .26), but patients who received iEpo were more likely to meet the composite outcome in the propensity score-matched, multilevel, and multivariable unmatched analyses (hazard ratio, 2.08 [95% CI, 1.73-2.50]; OR, 4.72 [95% CI, 3.01-7.41]; and OR, 1.35 [95% CI, 1.23-1.49]; respectively). INTERPRETATION In patients with COVID-19 receiving HHFNC therapy, use of iEpo was associated with the need for invasive mechanical ventilation.
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Affiliation(s)
- Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO.; Department of Medicine, the Institute for Informatics, Washington University School of Medicine, Saint Louis, MO
| | - Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Nguyet M Nguyen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Rachel McDonald
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Colleen A McEvoy
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Vladimir Despotovic
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Steven L Brody
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
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6
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Ghadimi K, Cappiello JL, Wright MC, Levy JH, Bryner BS, DeVore AD, Schroder JN, Patel CB, Rajagopal S, Shah SH, Milano CA. Inhaled Epoprostenol Compared With Nitric Oxide for Right Ventricular Support After Major Cardiac Surgery. Circulation 2023; 148:1316-1329. [PMID: 37401479 PMCID: PMC10615678 DOI: 10.1161/circulationaha.122.062464] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 06/06/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Right ventricular failure (RVF) is a leading driver of morbidity and death after major cardiac surgery for advanced heart failure, including orthotopic heart transplantation and left ventricular assist device implantation. Inhaled pulmonary-selective vasodilators, such as inhaled epoprostenol (iEPO) and nitric oxide (iNO), are essential therapeutics for the prevention and medical management of postoperative RVF. However, there is limited evidence from clinical trials to guide agent selection despite the significant cost considerations of iNO therapy. METHODS In this double-blind trial, participants were stratified by assigned surgery and key preoperative prognostic features, then randomized to continuously receive either iEPO or iNO beginning at the time of separation from cardiopulmonary bypass with the continuation of treatment into the intensive care unit stay. The primary outcome was the composite RVF rate after both operations, defined after transplantation by the initiation of mechanical circulatory support for isolated RVF, and defined after left ventricular assist device implantation by moderate or severe right heart failure according to criteria from the Interagency Registry for Mechanically Assisted Circulatory Support. An equivalence margin of 15 percentage points was prespecified for between-group RVF risk difference. Secondary postoperative outcomes were assessed for treatment differences and included: mechanical ventilation duration; hospital and intensive care unit length of stay during the index hospitalization; acute kidney injury development including renal replacement therapy initiation; and death at 30 days, 90 days, and 1 year after surgery. RESULTS Of 231 randomized participants who met eligibility at the time of surgery, 120 received iEPO, and 111 received iNO. Primary outcome occurred in 30 participants (25.0%) in the iEPO group and 25 participants (22.5%) in the iNO group, for a risk difference of 2.5 percentage points (two one-sided test 90% CI, -6.6% to 11.6%) in support of equivalence. There were no significant between-group differences for any of the measured postoperative secondary outcomes. CONCLUSIONS Among patients undergoing major cardiac surgery for advanced heart failure, inhaled pulmonary-selective vasodilator treatment using iEPO was associated with similar risks for RVF development and development of other postoperative secondary outcomes compared with treatment using iNO. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03081052.
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Affiliation(s)
- Kamrouz Ghadimi
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, and the Clinical Research Unit (K.G., M.C.W., J.H.L.), Duke University School of Medicine, Durham, NC
| | | | - Mary Cooter Wright
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, and the Clinical Research Unit (K.G., M.C.W., J.H.L.), Duke University School of Medicine, Durham, NC
| | - Jerrold H Levy
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, and the Clinical Research Unit (K.G., M.C.W., J.H.L.), Duke University School of Medicine, Durham, NC
- Department of Surgery, Adult Cardiac Surgery Section (J.H.L., B.S.B., J.N.S., C.A.M.), Duke University School of Medicine, Durham, NC
| | - Benjamin S Bryner
- Department of Surgery, Adult Cardiac Surgery Section (J.H.L., B.S.B., J.N.S., C.A.M.), Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology (A.D.D., C.B.P., S.R., S.H.S.), Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Adult Cardiac Surgery Section (J.H.L., B.S.B., J.N.S., C.A.M.), Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology (A.D.D., C.B.P., S.R., S.H.S.), Duke University School of Medicine, Durham, NC
| | - Sudarshan Rajagopal
- Department of Medicine, Division of Cardiology (A.D.D., C.B.P., S.R., S.H.S.), Duke University School of Medicine, Durham, NC
| | - Svati H Shah
- Department of Medicine, Division of Cardiology (A.D.D., C.B.P., S.R., S.H.S.), Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery, Adult Cardiac Surgery Section (J.H.L., B.S.B., J.N.S., C.A.M.), Duke University School of Medicine, Durham, NC
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7
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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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Torbic H, Saini A, Harnegie MP, Sadana D, Duggal A. Inhaled Prostacyclins for Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Crit Care Explor 2023; 5:e0931. [PMID: 37303944 PMCID: PMC10256381 DOI: 10.1097/cce.0000000000000931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Studies evaluating inhaled prostacyclins for the management of acute respiratory distress syndrome (ARDS) have produced inconsistent results regarding their effect on oxygenation. The purpose of this systematic review and meta-analysis was to evaluate the change in the Pao2/Fio2 ratio after administration of an inhaled prostacyclin in patients with ARDS. DATA SOURCES We searched Ovid Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, Scopus, and Web of Science. STUDY SELECTION We included abstracts and trials evaluating administration of inhaled prostacyclins in patients with ARDS. DATA EXTRACTION Change in the Pao2/Fio2 ratio, Pao2, and mean pulmonary artery pressure (mPAP) were extracted from included studies. Evidence certainty and risk of bias were evaluated using Grading of Recommendations Assessment, Development, and Evaluation and the Cochrane Risk of Bias tool. DATA SYNTHESIS We included 23 studies (1,658 patients) from 6,339 abstracts identified by our search strategy. The use of inhaled prostacyclins improved oxygenation by increasing the Pao2/Fio2 ratio from baseline (mean difference [MD], 40.35; 95% CI, 26.14-54.56; p < 0.00001; I2 = 95%; very low quality evidence). Of the eight studies to evaluate change in Pao2, inhaled prostacyclins also increased Pao2 from baseline (MD, 12.68; 95% CI, 2.89-22.48 mm Hg; p = 0.01; I2 = 96%; very low quality evidence). Only three studies evaluated change in mPAP, but inhaled prostacyclins were found to improve mPAP from baseline (MD, -3.67; 95% CI, -5.04 to -2.31 mm Hg; p < 0.00001; I2 = 68%; very low quality evidence). CONCLUSIONS In patients with ARDS, use of inhaled prostacyclins improves oxygenation and reduces pulmonary artery pressures. Overall data are limited and there was high risk of bias and heterogeneity among included studies. Future studies evaluating inhaled prostacyclins for ARDS should evaluate their role in ARDS subphenotypes, including cardiopulmonary ARDS.
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Affiliation(s)
| | - Aftabh Saini
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA
| | | | - Divyajot Sadana
- Department of Critical Care, Cleveland Clinic, Cleveland, OH
| | - Abhijit Duggal
- Department of Critical Care, Cleveland Clinic, Cleveland, OH
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9
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Nasrullah A, Virk S, Shah A, Jacobs M, Hamza A, Sheikh AB, Javed A, Butt MA, Sangli S. Acute Respiratory Distress Syndrome and the Use of Inhaled Pulmonary Vasodilators in the COVID-19 Era: A Narrative Review. Life (Basel) 2022; 12:1766. [PMID: 36362921 PMCID: PMC9695622 DOI: 10.3390/life12111766] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 09/03/2023] Open
Abstract
The Coronavirus disease (COVID-19) pandemic of 2019 has resulted in significant morbidity and mortality, especially from severe acute respiratory distress syndrome (ARDS). As of September 2022, more than 6.5 million patients have died globally, and up to 5% required intensive care unit treatment. COVID-19-associated ARDS (CARDS) differs from the typical ARDS due to distinct pathology involving the pulmonary vasculature endothelium, resulting in diffuse thrombi in the pulmonary circulation and impaired gas exchange. The National Institute of Health and the Society of Critical Care Medicine recommend lung-protective ventilation, prone ventilation, and neuromuscular blockade as needed. Further, a trial of pulmonary vasodilators is suggested for those who develop refractory hypoxemia. A review of the prior literature on inhaled pulmonary vasodilators in ARDS suggests only a transient improvement in oxygenation, with no mortality benefit. This narrative review aims to highlight the fundamental principles in ARDS management, delineate the fundamental differences between CARDS and ARDS, and describe the comprehensive use of inhaled pulmonary vasodilators. In addition, with the differing pathophysiology of CARDS from the typical ARDS, we sought to evaluate the current evidence regarding the use of inhaled pulmonary vasodilators in CARDS.
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Affiliation(s)
- Adeel Nasrullah
- Division of Pulmonology and Critical Care, Allegheny Health Network, Pittsburgh, PA 15212, USA
| | - Shiza Virk
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Aaisha Shah
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Max Jacobs
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Amina Hamza
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87106, USA
| | - Anam Javed
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Muhammad Ali Butt
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15512, USA
| | - Swathi Sangli
- Division of Pulmonology and Critical Care, Allegheny Health Network, Pittsburgh, PA 15212, USA
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10
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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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11
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Avdeev SN. COVID-19: Opportunities to Improve Prognosis. HERALD OF THE RUSSIAN ACADEMY OF SCIENCES 2022; 92:404-411. [PMID: 36091855 PMCID: PMC9447977 DOI: 10.1134/s1019331622040025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/03/2022] [Accepted: 03/10/2022] [Indexed: 06/15/2023]
Abstract
COVID-19 is characterized by a severe course in approximately 5‒10% of patients, who require admittance to the intensive care unit and mechanical ventilation, which is associated with a very high risk of a poor prognosis. At present, in real clinical practice, in managing severe patients with COVID-19, noninvasive ventilation (NIV) is widely used (in some countries, up to 60% of all methods of respiratory support). In most studies on the effectiveness of NIV in hypoxemic acute respiratory failure in patients with COVID-19, the need for tracheal intubation and hospital mortality with the use of NIV averaged 20-30%, which suggests the rather high efficiency of this method. The COVID-19 pandemic has given a powerful impetus to the widespread use of prone positioning among nonintubated patients with acute respiratory failure caused by COVID-19. Several studies have shown that prone positioning can reduce the need for mechanical ventilation and hospital mortality. Medications that have proven effective in severe forms of COVID-19 include remdesivir, systemic glucocorticoids, tocilizumab, baricitinib, and anticoagulants. Among the new promising areas of drug therapy, noteworthy is the use of thiol-containing drugs (N-acetylcysteine), inhaled surfactant, and inhaled prostacyclin analogues.
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Affiliation(s)
- S. N. Avdeev
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Pulmonology Research Institute, Federal Medical‒Biological Agency, Moscow, Russia
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12
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Khokher W, Malhas SE, Beran A, Iftikhar S, Burmeister C, Mhanna M, Srour O, Rashid R, Kesireddy N, Assaly R. Inhaled Pulmonary Vasodilators in COVID-19 Infection: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 37:1370-1382. [PMID: 35915994 PMCID: PMC9346441 DOI: 10.1177/08850666221118271] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: Inhaled pulmonary vasodilators (IPVD) have been
previously studied in patients with non-coronavirus disease-19 (COVID-19)
related acute respiratory distress syndrome (ARDS). The use of IPVD has been
shown to improve the partial pressure of oxygen in arterial blood
(PaO2), reduce fraction of inspired oxygen (FiO2)
requirements, and ultimately increase PaO2/FiO2 (P/F)
ratios in ARDS patients. However, the role of IPVD in COVID-19 ARDS is still
unclear. Therefore, we performed this meta-analysis to evaluate the role of IPVD
in COVID-19 patients. Methods: Comprehensive literature search of
PubMed, Embase, Web of Science and Cochrane Library databases from inception
through April 22, 2022 was performed for all published studies that utilized
IPVD in COVID-19 ARDS patients. The single arm studies and case series were
combined for a 1-arm meta-analysis, and the 2-arm studies were combined for a
2-arm meta-analysis. Primary outcomes for the 1-arm and 2-arm meta-analyzes were
change in pre- and post-IPVD P/F ratios and mortality, respectively. Secondary
outcomes for the 1-arm meta-analysis were change in pre- and post-IPVD positive
end-expiratory pressure (PEEP) and lung compliance, and for the 2-arm
meta-analysis the secondary outcomes were need for endotracheal intubation and
hospital length of stay (LOS). Results: 13 single arm retrospective
studies and 5 case series involving 613 patients were included in the 1-arm
meta-analysis. 3 studies involving 640 patients were included in the 2-arm
meta-analysis. The pre-IPVD P/F ratios were significantly lower compared to
post-IPVD, but there was no significant difference between pre- and post-IPVD
PEEP and lung compliance. The mortality rates, need for endotracheal intubation,
and hospital LOS were similar between the IPVD and standard therapy groups.
Conclusion: Although IPVD may improve oxygenation, our
investigation showed no benefits in terms of mortality compared to standard
therapy alone. However, randomized controlled trials are warranted to validate
our findings.
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Affiliation(s)
- Waleed Khokher
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Saif-Eddin Malhas
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Azizullah Beran
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Saffa Iftikhar
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Cameron Burmeister
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Mohammed Mhanna
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Omar Srour
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Rakin Rashid
- Department of Internal Medicine, 22519Mercy Catholic Medical Center, Darby, PA, USA
| | - Nithin Kesireddy
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA
| | - Ragheb Assaly
- Department of Internal Medicine, 89021University of Toledo, Toledo, OH, USA.,Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH, USA
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Chavez S, Brady WJ, Gottlieb M, Carius BM, Liang SY, Koyfman A, Long B. Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation. Am J Emerg Med 2022; 58:43-51. [PMID: 35636042 PMCID: PMC9106422 DOI: 10.1016/j.ajem.2022.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved. OBJECTIVE This narrative review provides emergency clinicians with a focused update of the resuscitation and airway management of COVID-19. DISCUSSION Patients with COVID-19 and septic shock should be resuscitated with buffered/balanced crystalloids. If hypotension is present despite intravenous fluids, vasopressors including norepinephrine should be initiated. Stress dose steroids are recommended for patients with severe or refractory septic shock. Airway management is the mainstay of initial resuscitation in patients with COVID-19. Patients with COVID-19 and ARDS should be managed similarly to those ARDS patients without COVID-19. Clinicians should not delay intubation if indicated. In patients who are more clinically stable, physicians can consider a step-wise approach as patients' oxygenation needs escalate. High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) are recommended over elective intubation. Prone positioning, even in awake patients, has been shown to lower intubation rates and improve oxygenation. Strategies consistent with ARDSnet can be implemented in this patient population, with a goal tidal volume of 4-8 mL/kg of predicted body weight and targeted plateau pressures <30 cm H2O. Limited data support the use of neuromuscular blocking agents (NBMA), recruitment maneuvers, inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation (ECMO). CONCLUSION This review presents a concise update of the resuscitation strategies and airway management techniques in patients with COVID-19 for emergency medicine clinicians.
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Affiliation(s)
- Summer Chavez
- The University of Texas at Houston Health Science Center, Department of Emergency Medicine, 6431 Fannin, 2nd Floor JJL, Houston, TX 77030, United States of America
| | - William J. Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | | | - Stephen Y. Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, United States of America,Corresponding author at: 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States of America
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14
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More questions than answers for the use of inhaled nitric oxide in COVID-19. Nitric Oxide 2022; 124:39-48. [PMID: 35526702 PMCID: PMC9072755 DOI: 10.1016/j.niox.2022.05.001] [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: 02/25/2022] [Revised: 04/08/2022] [Accepted: 05/03/2022] [Indexed: 12/14/2022]
Abstract
Inhaled nitric oxide (iNO) is a potent vasodilator approved for use in term and near-term neonates, but with broad off-label use in settings including acute respiratory distress syndrome (ARDS). As an inhaled therapy, iNO reaches well ventilated portions of the lung and selectively vasodilates the pulmonary vascular bed, with little systemic effect due to its rapid inactivation in the bloodstream. iNO is well documented to improve oxygenation in a variety of pathological conditions, but in ARDS, these transient improvements in oxygenation have not translated into meaningful clinical outcomes. In coronavirus disease 2019 (COVID-19) related ARDS, iNO has been proposed as a potential treatment due to a variety of mechanisms, including its vasodilatory effect, antiviral properties, as well as anti-thrombotic and anti-inflammatory actions. Presently however, no randomized controlled data are available evaluating iNO in COVID-19, and published data are largely derived from retrospective and cohort studies. It is therefore important to interpret these limited findings with caution, as many questions remain around factors such as patient selection, optimal dosing, timing of administration, duration of administration, and delivery method. Each of these factors may influence whether iNO is indeed an efficacious therapy - or not - in this context. As such, until randomized controlled trial data are available, use of iNO in the treatment of patients with COVID-19 related ARDS should be considered on an individual basis with sound clinical judgement from the attending physician.
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15
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Poonam PBH, Koscik R, Nguyen T, Rikhi S, Lin HM. Nitric oxide versus epoprostenol for refractory hypoxemia in Covid-19. PLoS One 2022; 17:e0270646. [PMID: 35759496 PMCID: PMC9236233 DOI: 10.1371/journal.pone.0270646] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 06/14/2022] [Indexed: 11/21/2022] Open
Abstract
Objective To compare the efficacy and outcomes with inhaled nitric oxide (iNO) and inhaled epoprostenol (iEPO) in patients with refractory hypoxemia due to COVID-19. Design Retrospective Cohort Study. Setting Single health system multicenter academic teaching hospitals. Patients OR subjects Age group of 18–80 years admitted to the medical ICU. Interventions Mechanically ventilated patients with COVID-19 infection, who received either iNO or iEPO between March 1st, 2020, and June 30th, 2020. Measurements and main results The primary outcome was the change in the PaO2/FiO2 (P/F) ratio 1 hour after initiation of pulmonary vasodilator therapy. Secondary outcomes include P/F ratios on days 1–3 after initiation, positive response in P/F ratio (increase of at least 20% in PaO2), total days of treatment, rebound hypoxemia (if there was a drop in oxygen saturation after treatment was stopped), ventilator free days (if any patient was extubated), days in ICU, days to extubation, days to tracheostomy, mortality days after intubation, 30-day survival and mortality. 183 patients were excluded, as they received both iNO and iEPO. Of the remaining 103 patients, 62 received iEPO and 41 received iNO. The severity of ARDS was similar in both groups. Change in P/F ratio at one hour was 116 (70.3) with iNO and 107 (57.6) with iEPO (Mean/SD). Twenty-two (53.7%) patients in the iNO group and 25 (40.3%) in the iEPO group were responders to pulmonary vasodilators n(%)(p = 0.152) (more than 20% increase in partial pressure of oxygen, Pao2), and 18 (43.9%) and 31 (50%) patients in the iNO and iEPO group (p = 0.685), respectively, had rebound hypoxemia. Only 7 patients in the cohort achieved ventilator free days (3 in the iEPO group and 4 in iNO group). Conclusions We found no significant difference between iNO and iEPO in terms of change in P/F ratio, duration of mechanical ventilation, ICU, in-hospital mortality in this cohort of mechanically ventilated patients with COVID-19. Larger, prospective studies are necessary to validate these results.
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Affiliation(s)
- Pai B. H. Poonam
- Department of Anesthesia, Perioperative and Pain Medicine, Mount Sinai West-Morningside Hospitals, New York, NY, United States of America
- * E-mail:
| | - Rebecca Koscik
- Department of Anesthesia, NYU Langone Health, New York, NY, United States of America
| | - Trong Nguyen
- Department of Anesthesia, Perioperative and Pain Medicine, Mount Sinai West-Morningside Hospitals, New York, NY, United States of America
| | - Shefali Rikhi
- Department of Anesthesia, Perioperative and Pain Medicine, Mount Sinai West-Morningside Hospitals, New York, NY, United States of America
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Mount Sinai West-Morningside Hospitals, New York, NY, United States of America
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16
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Toomey D, O'Brien M, Hayes BD, Wilcox S. A retrospective review of implementation of an inhaled epoprostenol protocol in the emergency department. Am J Emerg Med 2022; 58:210-214. [PMID: 35709539 DOI: 10.1016/j.ajem.2022.06.009] [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: 03/02/2022] [Revised: 05/27/2022] [Accepted: 06/03/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Inhaled epoprostenol is a selective pulmonary vasodilator that has shown a potentially broad number of applications in the management of critically ill patients. To date, the vast majority of the literature with regard to efficacy, indications for use, and adverse effects of inhaled epoprostenol is focused on use of this agent in critical care settings, with relatively little literature describing use of inhaled epoprostenol in the Emergency Department. This retrospective review sought to examine instances in which inhaled epoprostenol was administered in the Emergency Department of a tertiary-care, Level I trauma center following implementation of a clinical pathway for administration of this medication for cases of refractory hypoxemia, RV dysfunction, and refractory hypoxemia. Primary outcomes were monitoring for adverse effects (i.e. hypotension), trend in FiO2 requirement over time, and clinical indication for initiation of inhaled epoprostenol. METHODS An automated review was performed to query cases in which inhaled epoprostenol had been initiated in the Emergency Department following adoption of the inhaled epoprostenol clinical pathway. Cases were excluded if the medication was initiated in the prehospital setting, ordered but not administered, or administered for a period of <1 h. Vital signs and co-administration of vasopressors were followed before and following epoprostenol administration to assess for change over time. Clinical indication of epoprostenol administration was assessed via manual chart review. RESULTS Inhaled epoprostenol was administered in 20 instances, with 15 cases ultimately meeting inclusion criteria. There were no cases of clinically significant hypotension (MAP <65) in any of the cases in which inhaled epoprostenol was administered in the Emergency Department, and mean vasopressor requirement did not increase over time. A majority of patients saw a reduction in FiO2 requirement following administration of inhaled epoprostenol. The most common indication for initiation of inhaled epoprostenol based on manual chart review was pulmonary embolism. DISCUSSION In this review of cases in which inhaled epoprostenol was administered following adoption of a clinical pathway for medication administration, there were no cases of hypotension or other adverse effects that appear to be attributable to medication administration. Pulmonary embolism and refractory hypoxemia were the most common noted indications for administration of inhaled epoprostenol. Further research is warranted regarding development of clinical protocols for administration of inhaled pulmonary vasodilators in the Emergency Department setting.
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Affiliation(s)
- David Toomey
- Department of Emergency Medicine, Massachusetts General Hospital, United States of America.
| | - Michael O'Brien
- Department of Emergency Medicine, Massachusetts General Hospital, United States of America
| | - Bryan D Hayes
- Department of Emergency Medicine, Massachusetts General Hospital, United States of America
| | - Susan Wilcox
- Department of Emergency Medicine, Massachusetts General Hospital, United States of America; Department of Critical Care Medicine, Massachusetts General Hospital, United States of America
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17
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Pawar SS, Wilcox ME, van Haren FM. Inhaled pulmonary vasodilators in severe COVID-19: Don't hold your breath. J Crit Care 2022; 69:153988. [PMID: 35093675 PMCID: PMC8798495 DOI: 10.1016/j.jcrc.2022.153988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/11/2022] [Indexed: 12/31/2022]
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18
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Chiles JW, Vijaykumar K, Darby A, Goetz RL, Kane LE, Methukupally AR, Gandotra S, Russell DW, Whitson MR, Kelmenson D. Use of inhaled epoprostenol with high flow nasal oxygen in non-intubated patients with severe COVID-19. J Crit Care 2022; 69:153989. [PMID: 35217371 PMCID: PMC8863404 DOI: 10.1016/j.jcrc.2022.153989] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/18/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022]
Abstract
Purpose Acute lung injury associated with COVID-19 contributes significantly to its morbidity and mortality. Though invasive mechanical ventilation is sometimes necessary, the use of high flow nasal oxygen may avoid the need for mechanical ventilation in some patients. For patients approaching the limits of high flow nasal oxygen support, addition of inhaled pulmonary vasodilators is becoming more common but little is known about its effects. This is the first descriptive study of a cohort of patients receiving inhaled epoprostenol with high flow nasal oxygen for COVID-19. Materials and methods We collected clinical data from the first fifty patients to receive inhaled epoprostenol while on high flow nasal oxygen at our institution. We compared the characteristics of patients who did and did not respond to epoprostenol addition. Results The 18 patients that did not stabilize or improve following initiation of inhaled epoprostenol had similar rates of invasive mechanical ventilation as those who improved or stabilized (50% vs 56%). Rates of mortality were not significantly different between the two groups (17% and 31%). Conclusions In patients with COVID-19 induced hypoxemic respiratory failure, the use of inhaled epoprostenol with high flow nasal oxygen is feasible, but physiologic signs of response were not related to clinical outcomes.
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Affiliation(s)
- Joe W Chiles
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Kadambari Vijaykumar
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Adrienne Darby
- Department of Pharmacy, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Ryan L Goetz
- Department of Medicine, Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Lauren E Kane
- Department of Pharmacy, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Abhishek R Methukupally
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Sheetal Gandotra
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Derek W Russell
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America; Birmingham Veterans Affairs Medical Center, Birmingham, AL, United States of America
| | - Micah R Whitson
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America; Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Daniel Kelmenson
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
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19
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Lubinsky AS, Brosnahan SB, Lehr A, Elnadoury O, Hagedorn J, Garimella B, Bender MT, Amoroso N, Artigas A, Bos LDJ, Kaufman D. Inhaled pulmonary vasodilators are not associated with improved gas exchange in mechanically ventilated patients with COVID-19: A retrospective cohort study. J Crit Care 2022; 69:153990. [PMID: 35180636 PMCID: PMC8847100 DOI: 10.1016/j.jcrc.2022.153990] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 01/19/2023]
Abstract
Purpose Measure the effect of inhaled pulmonary vasodilators on gas exchange in mechanically ventilated patients with COVID-19. Methods A retrospective observational cohort study at three New York University Hospitals was performed including eighty-four mechanically ventilated SARS Cov-2 nasopharyngeal PCR positive patients, sixty nine treated with inhaled nitric oxide (iNO) and fifteen with inhaled epoprostenol (iEPO). The primary outcomes were change in PAO2:FIO2 ratio, oxygenation Index (OI), and ventilatory ratio (VR) after initiation of inhaled pulmonary vasodilators. Results There was no significant change in PAO2:FIO2ratio after initiation of iNO (mean − 4.1, 95% CI -17.3-9.0, P = 0.54) or iEPO (mean − 3.4, 95% CI -19.7-12.9, P = 0.66), in OI after initiation of iNO (mean 2.1, 95% CI-0.04-4.2, P = 0.054) or iEPO (mean − 3.4, 95% CI -19.7-12.9, P = 0.75), or in VR after initiation of iNO (mean 0.17, 95% CI -0.03-0.36, P = 0.25) or iEPO (mean 0.33, 95% CI -0.0847-0.74, P = 0.11). PAO2:FIO2, OI and VR did not significantly change over a five day period starting the day prior to drug initiation in patients who received either iNO or iEPO assessed with a fixed effects model. Conclusion Inhaled pulmonary vasodilators were not associated with significant improvement in gas exchange in mechanically ventilated patients with COVID-19.
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Affiliation(s)
- Anthony Steven Lubinsky
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America.
| | - Shari B Brosnahan
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Andrew Lehr
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Ola Elnadoury
- New York University Langone Brooklyn Hospital, 150 55(th) Street, Brooklyn, NY 11220, United States of America
| | - Jacklyn Hagedorn
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Bhaskara Garimella
- New York University Langone Brooklyn Hospital, 150 55(th) Street, Brooklyn, NY 11220, United States of America
| | - Michael T Bender
- New York University, Long Island School of Medicine, 259 1(st) Street, Mineola, NY 11501, United States of America
| | - Nancy Amoroso
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
| | - Antonio Artigas
- Critical Care Center, Corporacion Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomus University of Barcelona, Parc Tauli 1, 08208 Sabadell, Spain
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, location AMC, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - David Kaufman
- New York University Langone Health, 550 1(st) Ave, New York, NY 10016, United States of America
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20
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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: 21] [Impact Index Per Article: 10.5] [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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21
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Abstract
The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges in critical care medicine, including extreme demand for intensive care unit (ICU) resources and rapidly evolving understanding of a novel disease. Up to one-third of hospitalized patients with COVID-19 experience critical illness. The most common form of organ failure in COVID-19 critical illness is acute hypoxemic respiratory failure, which clinically presents as acute respiratory distress syndrome (ARDS) in three-quarters of ICU patients. Noninvasive respiratory support modalities are being used with increasing frequency given their potential to reduce the need for intubation. Determining optimal patient selection for and timing of intubation remains a challenge. Management of mechanically ventilated patients with COVID-19 largely mirrors that of non-COVID-19 ARDS. Organ failure is common and portends a poor prognosis. Mortality rates have improved over the course of the pandemic, likely owing to increasing disease familiarity, data-driven pharmacologics, and improved adherence to evidence-based critical care.
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Affiliation(s)
- Jennifer C Ginestra
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA; , , ,
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA
| | - Oscar J L Mitchell
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA; , , ,
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - George L Anesi
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA; , , ,
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA; , , ,
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22
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Niss HL, Mohamed A, Berry TP, Saettele TM, Haines MM, Thomas EL. Evaluation of Continuous Inhaled Epoprostenol in the Treatment of Acute Respiratory Distress Syndrome, Including Patients With SARS-CoV-2 Infection. Ann Pharmacother 2022; 56:1093-1099. [DOI: 10.1177/10600280211069182] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) management is primarily supportive. Pulmonary vasodilators, such as inhaled epoprostenol (iEPO), have been shown to improve PaO2:FiO2 (PF) and are used as adjunctive therapy. Objective To identify the positive response rate and variables associated with response to iEPO in adults with ARDS. A positive response to iEPO was defined as a 10% improvement in PF within 6 hours. Methods This retrospective study included adults with ARDS treated with iEPO. The primary endpoint was the variables associated with a positive response to iEPO. Secondary endpoints were positive response rate and the change in PF and SpO2:FiO2 within 6 hours. Statistical analysis included multivariable regression. Results Three hundred thirty-one patients were included. As baseline PF increased, the odds of responding to iEPO decreased (odds ratio [OR], 0.752, 95% CI, 0.69-0.819, p < 0.001). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related ARDS (OR 0.478, 95% CI, 0.281-0.814, p = 0.007) was associated with decreased odds of a positive response to iEPO. The total population had a 68.3% positive response rate to iEPO. SARS-CoV-2-related ARDS and non-SARS-CoV-2-related ARDS had a 59.5% and 72.7% positive response rate, respectively. iEPO significantly improved PF (71 vs 95, P < 0.001) in the whole population. Conclusion and Relevance iEPO was associated with a positive effect in a majority of moderate-to-severe ARDS patients, including patients with SARS-CoV-2-related ARDS. Lower baseline PF and non-SARS-CoV-2-related ARDS were significantly associated with a positive response to iEPO. The ability to predict which patients will respond to iEPO can facilitate better utilization.
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Affiliation(s)
- Hannah L. Niss
- Saint Luke’s Hospital of Kansas City, Kansas City, MO, USA
| | - Adham Mohamed
- Saint Luke’s Hospital of Kansas City, Kansas City, MO, USA
| | | | | | - Michelle M. Haines
- Saint Luke’s Hospital of Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
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23
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Imtiaz K, Jodeh W, Sudekum D, DiGiovine B, Hecht J. The Use of Inhaled Epoprostenol for Acute Respiratory Distress Syndrome Secondary Due To COVID-19: a Case Series. J Crit Care Med (Targu Mures) 2022; 8:33-40. [PMID: 35274053 PMCID: PMC8852286 DOI: 10.2478/jccm-2021-0037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 09/27/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Inhaled epoprostenol (iEpo) is a pulmonary vasodilator used to treat refractory respiratory failure, including that caused by Coronavirus 2019 (COVID-19) pneumonia. Aim of Study To describe the experience at three teaching hospitals using iEpo for severe respiratory failure due to COVID-19 and evaluate its efficacy in improving oxygenation. Methods Fifteen patients were included who received iEpo, had confirmed COVID-19 and had an arterial blood gas measurement in the 12 hours before and 24 hours after iEpo initiation. Results Eleven patients received prone ventilation before iEpo (73.3%), and six (40%) were paralyzed. The partial pressure of arterial oxygen to fraction of inspired oxygen (P/F ratio) improved from 95.7 mmHg to 118.9 mmHg (p=0.279) following iEpo initiation. In the nine patients with severe ARDS, the mean P/F ratio improved from 66.1 mmHg to 95.7 mmHg (p=0.317). Ultimately, four patients (26.7%) were extubated after an average of 9.9 days post-initiation. Conclusions The findings demonstrated a trend towards improvement in oxygenation in critically ill COVID-19 patients. Although limited by the small sample size, the results of this case series portend further investigation into the role of iEpo for severe respiratory failure associated with COVID-19.
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Affiliation(s)
- Komal Imtiaz
- University of Texas at Houston, Houston, TX, USA
| | - Wade Jodeh
- St Joseph Mercy Ann Arbor. Ann Arbor, MI, USA
| | | | | | - Jason Hecht
- St Joseph Mercy Ann Arbor. Ann Arbor, MI, USA
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24
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Ghadimi K, Cappiello J, Cooter-Wright M, Haney JC, Reynolds JM, Bottiger BA, Klapper JA, Levy JH, Hartwig MG. Inhaled Pulmonary Vasodilator Therapy in Adult Lung Transplant: A Randomized Clinical Trial. JAMA Surg 2021; 157:e215856. [PMID: 34787647 DOI: 10.1001/jamasurg.2021.5856] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Inhaled nitric oxide (iNO) is commonly administered for selectively inhaled pulmonary vasodilation and prevention of oxidative injury after lung transplant (LT). Inhaled epoprostenol (iEPO) has been introduced worldwide as a cost-saving alternative to iNO without high-grade evidence for this indication. Objective To investigate whether the use of iEPO will lead to similar rates of severe/grade 3 primary graft dysfunction (PGD-3) after adult LT when compared with use of iNO. Design, Setting, and Participants This health system-funded, randomized, blinded (to participants, clinicians, data managers, and the statistician), parallel-designed, equivalence clinical trial included 201 adult patients who underwent single or bilateral LT between May 30, 2017, and March 21, 2020. Patients were grouped into 5 strata according to key prognostic clinical features and randomized per stratum to receive either iNO or iEPO at the time of LT via 1:1 treatment allocation. Interventions Treatment with iNO or iEPO initiated in the operating room before lung allograft reperfusion and administered continously until cessation criteria met in the intensive care unit (ICU). Main Outcomes and Measures The primary outcome was PGD-3 development at 24, 48, or 72 hours after LT. The primary analysis was for equivalence using a two one-sided test (TOST) procedure (90% CI) with a margin of 19% for between-group PGD-3 risk difference. Secondary outcomes included duration of mechanical ventilation, hospital and ICU lengths of stay, incidence and severity of acute kidney injury, postoperative tracheostomy placement, and in-hospital, 30-day, and 90-day mortality rates. An intention-to-treat analysis was performed for the primary and secondary outcomes, supplemented by per-protocol analysis for the primary outcome. Results A total of 201 randomized patients met eligibility criteria at the time of LT (129 men [64.2%]). In the intention-to-treat population, 103 patients received iEPO and 98 received iNO. The primary outcome occurred in 46 of 103 patients (44.7%) in the iEPO group and 39 of 98 (39.8%) in the iNO group, leading to a risk difference of 4.9% (TOST 90% CI, -6.4% to 16.2%; P = .02 for equivalence). There were no significant between-group differences for secondary outcomes. Conclusions and Relevance Among patients undergoing LT, use of iEPO was associated with similar risks for PGD-3 development and other postoperative outcomes compared with the use of iNO. Trial Registration ClinicalTrials.gov identifier: NCT03081052.
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Affiliation(s)
- Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Jhaymie Cappiello
- Department of Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter-Wright
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - John C Haney
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John M Reynolds
- Department of Medicine, Transplant Pulmonology, Duke University School of Medicine, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Jacob A Klapper
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Jerrold H Levy
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Matthew G Hartwig
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
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25
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Gierhardt M, Pak O, Walmrath D, Seeger W, Grimminger F, Ghofrani HA, Weissmann N, Hecker M, Sommer N. Impairment of hypoxic pulmonary vasoconstriction in acute respiratory distress syndrome. Eur Respir Rev 2021; 30:30/161/210059. [PMID: 34526314 DOI: 10.1183/16000617.0059-2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/05/2021] [Indexed: 12/29/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a serious complication of severe systemic or local pulmonary inflammation, such as caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. ARDS is characterised by diffuse alveolar damage that leads to protein-rich pulmonary oedema, local alveolar hypoventilation and atelectasis. Inadequate perfusion of these areas is the main cause of hypoxaemia in ARDS. High perfusion in relation to ventilation (V/Q<1) and shunting (V/Q=0) is not only caused by impaired hypoxic pulmonary vasoconstriction but also redistribution of perfusion from obstructed lung vessels. Rebalancing the pulmonary vascular tone is a therapeutic challenge. Previous clinical trials on inhaled vasodilators (nitric oxide and prostacyclin) to enhance perfusion to high V/Q areas showed beneficial effects on hypoxaemia but not on mortality. However, specific patient populations with pulmonary hypertension may profit from treatment with inhaled vasodilators. Novel treatment targets to decrease perfusion in low V/Q areas include epoxyeicosatrienoic acids and specific leukotriene receptors. Still, lung protective ventilation and prone positioning are the best available standard of care. This review focuses on disturbed perfusion in ARDS and aims to provide basic scientists and clinicians with an overview of the vascular alterations and mechanisms of V/Q mismatch, current therapeutic strategies, and experimental approaches.
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Affiliation(s)
- Mareike Gierhardt
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) - CONICET - Partner Institute of the Max Planck Society, Buenos Aires, Argentina.,Department of Lung Development and Remodeling, Max Planck Institute for Heart and Lung Research, Member of the German Center for Lung Research (DZL), Member of the Cardio-Pulmonary Institute (CPI) Bad Nauheim, Germany
| | - Oleg Pak
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Dieter Walmrath
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany
| | - Werner Seeger
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) - CONICET - Partner Institute of the Max Planck Society, Buenos Aires, Argentina.,Institute for Lung Health (ILH), Giessen, Germany
| | - Friedrich Grimminger
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Hossein A Ghofrani
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - Norbert Weissmann
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Matthias Hecker
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Both authors contributed equally
| | - Natascha Sommer
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Both authors contributed equally
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26
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Mulia EPB, Luke K. Inhaled prostacyclin analogues in COVID-19 associated acute respiratory distress syndrome: scientific rationale. Egypt Heart J 2021; 73:82. [PMID: 34529182 PMCID: PMC8443914 DOI: 10.1186/s43044-021-00208-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/06/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND COVID-19 associated acute respiratory distress syndrome (CARDS) is a severe form of SARS CoV-2 infection and affects about 15-30% of hospitalized patients with a high mortality rate. Growing research and data suggest several available drugs with appropriate pharmacological effects to treat COVID-19. MAIN BODY Prostacyclin analogues are regiments for pulmonary artery hypertension. Prostacyclin analogues are expected to be beneficial in treating CARDS based on at least four rationales: (1) inhaled prostacyclin analogues improve oxygenation, V/Q mismatch, and act as an ARDS therapy alternative; (2) it alleviates direct SARS-CoV-2-related coagulopathy; (3) increases nitric oxide production; and (4) possible anti-inflammatory effect. Prostacyclin analogues are available in oral, intravenous, and inhaled forms. The inhaled form has the advantage over other forms, such as parenteral administration risks. Previously, a meta-analysis demonstrated the beneficial effects of inhaled prostaglandins for ARDS treatment, such as improved PaO2/FiO2 and PaO2 along with reduced pulmonary artery pressure. Currently, two ongoing randomized controlled trials are evaluating inhaled epoprostenol (VPCOVID [NCT04452669]) and iloprost (ILOCOVID [NCT04445246]) for severe COVID-19 patients. CONCLUSIONS Inhaled prostacyclin could be considered in patients with refractory, life-threatening hypoxia despite standard management.
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Affiliation(s)
- Eka Prasetya Budi Mulia
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga – Dr. Soetomo General Hospital, Jl. Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, 60286 Indonesia
| | - Kevin Luke
- Faculty of Medicine, Universitas Airlangga, Jl. Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, 60286 Indonesia
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27
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Ricciotti E, Laudanski K, FitzGerald GA. Nonsteroidal anti-inflammatory drugs and glucocorticoids in COVID-19. Adv Biol Regul 2021; 81:100818. [PMID: 34303107 PMCID: PMC8280659 DOI: 10.1016/j.jbior.2021.100818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is characterized by a wide spectrum of symptom severity, which is manifested at different phases of infection and demands different levels of care. Viral load, host innate-immune response to SARS-CoV-2, and comorbidities have a direct impact on the clinical outcomes of COVID-19 patients and determine the diverse disease trajectories. The initial SARS-CoV-2 penetrance and replication in the host causes death of infected cells, determining the viral response. SARS-CoV-2 replication in the host triggers the activation of host antiviral immune mechanisms, determining the inflammatory response. While a healthy immune response is essential to eliminate infected cells and prevent spread of the virus, a dysfunctional immune response can result in a cytokine storm and hyperinflammation, contributing to disease progression. Current therapies for COVID-19 target the virus and/or the host immune system and may be complicated in their efficacy by comorbidities. Here we review the evidence for use of two classes of anti-inflammatory drugs, glucocorticoids and nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of COVID-19. We consider the clinical evidence regarding the timing and efficacy of their use, their potential limitations, current recommendations and the prospect of future studies by these and related therapies.
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Affiliation(s)
- Emanuela Ricciotti
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Krzysztof Laudanski
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Healthcare Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Garret A FitzGerald
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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28
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Elekhnawy E, Kamar AA, Sonbol F. Present and future treatment strategies for coronavirus disease 2019. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2021; 7:84. [PMID: 33850936 PMCID: PMC8033289 DOI: 10.1186/s43094-021-00238-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/29/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The recent pandemic of coronavirus disease 2019 (COVID-19) has resulted in many challenges to the healthcare organizations around the world. Unfortunately, until now, there are no proven effective therapeutic agents against this virus. MAIN BODY Several evolving studies suggest repurposing a potential list of drugs which have appropriate pharmacological and therapeutic effects to be used in treating COVID-19 cases. In the present review, we will summarize the potential drugs suggested to be repurposed to be utilized in the treatment of COVID-19 patients like lopinavir-ritonavir, ribavirin, baloxavir marboxil, favipiravir, remdesvir, umifenovir, chloroquine, hydroxychloroquine, azithromycin, corticosteroids, losartan, statins, interferons, nitric oxide, epoprostenol, tocilizumab, siltuximab, sarilumab anakinra, and ruxolitinib. In addition, we discussed the possible future therapeutic regimens based on the recent molecular and genomic discoveries. CONCLUSION This review could provide beneficial information about the potential current and future treatment strategies to treat the pandemic COVID-19 disease.
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Affiliation(s)
- Engy Elekhnawy
- grid.412258.80000 0000 9477 7793Pharmaceutical Microbiology, Faculty of Pharmacy, Tanta University, Tanta, El Gharbia Governorate Egypt
| | - Amal Abo Kamar
- grid.412258.80000 0000 9477 7793Pharmaceutical Microbiology, Faculty of Pharmacy, Tanta University, Tanta, El Gharbia Governorate Egypt
| | - Fatma Sonbol
- grid.412258.80000 0000 9477 7793Pharmaceutical Microbiology, Faculty of Pharmacy, Tanta University, Tanta, El Gharbia Governorate Egypt
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