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Pellegrini M, Sousa MLA, Dubo S, Menga LS, Hsing V, Post M, Brochard LJ. Impact of airway closure and lung collapse on inhaled nitric oxide effect in acute lung injury: an experimental study. Ann Intensive Care 2024; 14:149. [PMID: 39312044 PMCID: PMC11420414 DOI: 10.1186/s13613-024-01378-z] [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: 04/18/2024] [Accepted: 09/10/2024] [Indexed: 09/26/2024] Open
Abstract
BACKGROUND Efficacy of inhaled therapy such as Nitric Oxide (iNO) during mechanical ventilation may depend on airway patency. We hypothesized that airway closure and lung collapse, countered by positive end-expiratory pressure (PEEP), influence iNO efficacy. This could support the role of an adequate PEEP titration for inhalation therapy. The main aim of this study was to assess the effect of iNO with PEEP set above or below the airway opening pressure (AOP) generated by airway closure, on hemodynamics and gas exchange in swine models of acute respiratory distress syndrome. Fourteen pigs randomly underwent either bilateral or asymmetrical two-hit model of lung injury. Airway closure and lung collapse were measured with electrical impedance tomography as well as ventilation/perfusion ratio (V/Q). After AOP detection, the effect of iNO (10ppm) was studied with PEEP set randomly above or below regional AOP. Respiratory mechanics, hemodynamics, and gas-exchange were recorded. RESULTS All pigs presented airway closure (AOP > 0.5cmH2O) after injury. In bilateral injury, iNO was associated with an improved mean pulmonary pressure from 49 ± 8 to 42 ± 7mmHg; (p = 0.003), and ventilation/perfusion matching, caused by a reduction in pixels with low V/Q and shunt from 16%[IQR:13-19] to 9%[IQR:4-12] (p = 0.03) only at PEEP set above AOP. iNO had no effect on hemodynamics or gas exchange for PEEP below AOP (low V/Q 25%[IQR:16-30] to 23%[IQR:14-27]; p = 0.68). In asymmetrical injury, iNO improved pulmonary hemodynamics and ventilation/perfusion matching independently from the PEEP set. iNO was associated with improved oxygenation in all cases. CONCLUSIONS In an animal model of bilateral lung injury, PEEP level relative to AOP markedly influences iNO efficacy on pulmonary hemodynamics and ventilation/perfusion match, independently of oxygenation.
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Affiliation(s)
- Mariangela Pellegrini
- Anesthesiology and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden.
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University Hospital, Akademiska sjukhuset, ing 40 2 tr. 751 85, Uppsala, Sweden.
| | - Mayson L A Sousa
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
| | - Sebastian Dubo
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
- Department of Physiotherapy, Universidad de Concepción, Concepción, Chile
| | - Luca S Menga
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
| | - Vanessa Hsing
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
| | - Martin Post
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
| | - Laurent J Brochard
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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2
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Kamenshchikov NO, Safaee Fakhr B, Kravchenko IV, Dish AY, Podoksenov YK, Kozlov BN, Kalashnikova TP, Tyo MA, Anfinogenova ND, Boshchenko AA, Berra L. Assessment of continuous low-dose and high-dose burst of inhaled nitric oxide in spontaneously breathing COVID-19 patients: A randomized controlled trial. Nitric Oxide 2024; 149:41-48. [PMID: 38880198 DOI: 10.1016/j.niox.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/23/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) showed to improve oxygenation at low doses by reducing intrapulmonary shunt and to display antiviral properties at high doses. To assess the safety and potential benefits, we designed an exploratory clinical trial comparing low-dose with intermittent high-dose iNO to only intermittent high-dose iNO in hypoxemic COVID-19 patients. METHODS In this single-center interventional non-inferiority randomized trial (ClinicalTrials.gov, NCT04476992), twenty oxygen-dependent COVID-19 patients were randomly assigned to the high-dose (200 ppm for 30 min) + continuous low-dose (20 ppm) iNO group (iNO200/20) or the high-dose iNO group (iNO200). Methemoglobinemia (MetHb) assessed 48 h after iNO initiation was the primary endpoint. Reverse-transcription polymerase chain reaction for SARS-CoV-2, inflammatory markers during hospitalization, and heart ultrasounds during the iNO200 treatments were evaluated. RESULTS MetHb difference between iNO groups remained within the non-inferiority limit of 3 %, indicating comparable treatments despite being statistically different (p-value<0.01). Both groups presented similar SpO2/FiO2 ratio at 48 h (iNO200 vs. iNO200/20 341[334-356] vs. 359 [331-380], respectively, p-value = 0.436). Both groups showed the same time to SARS-CoV-2 negativization, hospital length of stay, and recovery time. iNO-treated patients showed quicker SARS-CoV-2 negativization compared to a similar group of non-iNO patients (HR 2.57, 95%CI 1.04-6.33). During the 228 treatments, iNO200 and iNO200/20 groups were comparable for safety, hemodynamic stability, and respiratory function improvement. CONCLUSIONS iNO200/20 and iNO200 are equally safe in non-intubated patients with COVID-19-induced respiratory failure with regards to MetHb and NO2. Larger studies should investigate whether iNO200/20 leads to better outcomes compared to non-iNO treated patients.
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Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Bijan Safaee Fakhr
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
| | - Igor V Kravchenko
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | | | - Yuri K Podoksenov
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Boris N Kozlov
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Tatiana P Kalashnikova
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Mark A Tyo
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Nina D Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Alla A Boshchenko
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences", 634012, Tomsk, Russia
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA; Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA.
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3
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Wolak T, Dicker D, Shifer Y, Grossman A, Rokach A, Shitrit M, Tal A. A safety evaluation of intermittent high-dose inhaled nitric oxide in viral pneumonia due to COVID-19: a randomised clinical study. Sci Rep 2024; 14:17201. [PMID: 39060420 PMCID: PMC11282178 DOI: 10.1038/s41598-024-68055-w] [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: 03/07/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024] Open
Abstract
High-dose inhaled Nitric Oxide (iNO) has been shown to have anti-inflammatory, vasodilator, and antimicrobial properties, resulting in improved arterial oxygenation as well as a beneficial therapeutic effect on lower respiratory tract infections. This study evaluated the safety and efficacy of 150-ppm intermittent iNO administered with a novel iNO-generator, for treating adults hospitalised for viral pneumonia. In this prospective, open-label, multicenter study, subjects aged 18-80, diagnosed with viral pneumonia received either standard supportive treatment alone (Control-Group) or combined with iNO for 40 min, 4 times per day up to 7 days (Treatment-Group). Out of 40 recruited subjects, 35 were included in the intention-to-treat population (34 with COVID-19). Adverse Events rate was similar between the groups (56.3% vs. 42.1%; respectively). No treatment-related adverse events were reported, while 2 serious adverse events were accounted for by underlying pre-existing conditions. Among the Treatment-Group, oxygen support duration was reduced by 2.7 days (Hazard Ratio = 2.8; p = 0.0339), a greater number of subjects reached oxygen saturation ≥ 93% within hospitalisation period (Hazard Ratio = 5.4; p = 0.049), and a trend for earlier discharge was demonstrated. Intermittent 150-ppm iNO-treatment is well-tolerated, safe, and beneficial compared to usual care for spontaneously breathing hospitalised adults diagnosed with COVID-19 viral pneumonia.
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Affiliation(s)
- Talya Wolak
- Department of Internal Medicine D, Shaare Zedek Medical Center, 12 Bait Shmuel St, P.O. Box 3235, 9103102, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - D Dicker
- Internal Medicine D, Hasharon Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
| | - Y Shifer
- Internal Medicine D, Hasharon Hospital, Rabin Medical Center, Petah-Tikva, Israel
| | - A Grossman
- Internal Medicine B, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
| | - A Rokach
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Pulmonary Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - M Shitrit
- Respiratory Therapy Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - A Tal
- Beyond Air, Ltd, Rehovot, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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Larsson AO, Eriksson MB. Role of NO in Disease: Good, Bad or Ugly. Biomedicines 2024; 12:1343. [PMID: 38927550 PMCID: PMC11201552 DOI: 10.3390/biomedicines12061343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
This Special Issue of Biomedicines (https://www [...].
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Affiliation(s)
- Anders O. Larsson
- Department of Medical Sciences, Section of Clinical Chemistry, Uppsala University, 751 85 Uppsala, Sweden;
| | - Mats B. Eriksson
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, 751 85 Uppsala, Sweden
- NOVA Medical School, New University of Lisbon, 1099-085 Lisbon, Portugal
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5
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Gaulton TG, Xin Y, Victor M, Nova A, Cereda M. Imaging the pulmonary vasculature in acute respiratory distress syndrome. Nitric Oxide 2024; 147:6-12. [PMID: 38588918 PMCID: PMC11253040 DOI: 10.1016/j.niox.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/21/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by a redistribution of regional lung perfusion that impairs gas exchange. While speculative, experimental evidence suggests that perfusion redistribution may contribute to regional inflammation and modify disease progression. Unfortunately, tools to visualize and quantify lung perfusion in patients with ARDS are lacking. This review explores recent advances in perfusion imaging techniques that aim to understand the pulmonary circulation in ARDS. Dynamic contrast-enhanced computed tomography captures first-pass kinetics of intravenously injected dye during continuous scan acquisitions. Different contrast characteristics and kinetic modeling have improved its topographic measurement of pulmonary perfusion with high spatial and temporal resolution. Dual-energy computed tomography can map the pulmonary blood volume of the whole lung with limited radiation exposure, enabling its application in clinical research. Electrical impedance tomography can obtain serial topographic assessments of perfusion at the bedside in response to treatments such as inhaled nitric oxide and prone position. Ongoing technological improvements and emerging techniques will enhance lung perfusion imaging and aid its incorporation into the care of patients with ARDS.
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Affiliation(s)
- Timothy G Gaulton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Yi Xin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Marcus Victor
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Electronics Engineering Division, Aeronautics Institute of Technology, Sao Paulo, Brazil
| | - Alice Nova
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Maurizio Cereda
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
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6
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Shetty NS, Giammatteo V, Gaonkar M, Li P, Akeju O, Arora G, Berra L, Arora P. Reply to D'Couto and Celi: Racial Physiology: A Dangerous Precedent. Am J Respir Crit Care Med 2024; 209:1284-1285. [PMID: 38452370 PMCID: PMC11146535 DOI: 10.1164/rccm.202402-0333le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 03/09/2024] Open
Affiliation(s)
| | - Valentina Giammatteo
- Department of Anesthesia, Critical Care and Pain Medicine
- Harvard Medical School, Boston, Massachusetts; and
| | | | - Peng Li
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine
- Harvard Medical School, Boston, Massachusetts; and
| | | | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Respiratory Care Services, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Pankaj Arora
- Division of Cardiovascular Disease and
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
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7
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Wu X, Zheng R, Zhao Z. Case report: Inhaled nitric oxide rescued a hypoxemia patient caused by dermatomyositis complicated with interstitial pneumonia. Front Med (Lausanne) 2024; 11:1371183. [PMID: 38765258 PMCID: PMC11100410 DOI: 10.3389/fmed.2024.1371183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 05/21/2024] Open
Abstract
Interstitial pneumonia is the most common and serious secondary lesion of dermatomyositis. In some cases, patients may develop severe acute pneumonia that can quickly progress to respiratory failure, resulting in high mortality rates. A 57-year-old woman with dermatomyositis and interstitial pulmonary fibrosis experienced severe hypoxemia due to pulmonary infection. Despite receiving various treatments after entering the intensive care unit (ICU), such as anti-infection therapy, lung recruitment, prone position ventilation, sedative and muscle relaxation, the patient's oxygen saturation continued to decline. Electrical impedance tomography (EIT) monitoring revealed that prone position could not improve ventilation homogeneity. However, the patient's ventilation/perfusion (V/Q) matching significantly improved 10 min after initiation of supine position ventilation combined with inhalation of nitric oxide (iNO). The patient's PaO2/FiO2 (P/F) ratio increased from 86 mmHg to 150 mmHg at 30 min post-treatment. iNO treatment continued for 2 days. Then the patient's condition improved and she was successfully weaned off the ventilator with rigorous monitoring and symptomatic care. The implementation of mechanical ventilation combined with iNO therapy rapidly improved V/Q matching and oxygenation in a patient with hypoxemia caused by dermatomyositis complicated with interstitial pneumonia. This approach successfully avoided the need for invasive extracorporeal membrane oxygenation (ECMO) support.
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Affiliation(s)
- Xiaoyan Wu
- Medical College of Yangzhou University, Department of Critical Care Medicine, Northern Jiangsu People’s Hospital, Yangzhou, China
| | - Ruiqiang Zheng
- Medical College of Yangzhou University, Department of Critical Care Medicine, Northern Jiangsu People’s Hospital, Yangzhou, China
| | - Zhanqi Zhao
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, China
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
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8
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Shetty NS, Giammatteo V, Gaonkar M, Li P, Akeju O, Arora G, Berra L, Arora P. Differences in the Response to High-Dose Inhaled Nitric Oxide in Self-identified Black and White Individuals: A Post Hoc Analysis of the NOSARSCOVID Randomized Clinical Trial. Am J Respir Crit Care Med 2024; 209:887-890. [PMID: 38190705 PMCID: PMC10995561 DOI: 10.1164/rccm.202310-1852le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/03/2024] [Indexed: 01/10/2024] Open
Affiliation(s)
| | - Valentina Giammatteo
- Department of Anesthesia, Critical Care and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | | | - Peng Li
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | | | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Respiratory Care Services, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Pankaj Arora
- Division of Cardiovascular Disease, and
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
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9
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Schmedtje JF, Ciske F, Muzzarelli KM, Assar Z. Novel nitric oxide donors are coronary vasodilators that also bind to the papain-like protease of SARS-CoV-2. Biomed Pharmacother 2024; 173:116378. [PMID: 38492437 DOI: 10.1016/j.biopha.2024.116378] [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: 12/10/2023] [Revised: 02/24/2024] [Accepted: 02/29/2024] [Indexed: 03/18/2024] Open
Abstract
Several investigational nitric oxide donors were originally created to correct vascular endothelial dysfunction in cardiovascular diseases. These 48 compounds contain an urea-like moiety attached to the well-known NO donors isosorbide 2- and 5-mononitrate. CR-0305 and CR-0202 were synthesized and found to be nontoxic in the cell lines HMEC-1, A549/hACE2 and VeroE6. CR-0305 induced vasodilation in human coronary arteries ex vivo. Since NO can also have antiviral properties, a study of drug-protein interactions with SARS-CoV-2 was undertaken using in silico modeling. CR-0305 experimentally outperformed the other compounds, including CR-0202, in binding the catalytic site of SARS-CoV-2 papain-like protease (PLpro). PLpro is a primary target for therapeutic inhibition of SARS-CoV-2 as it mediates viral replication and modulates host innate immune responses. CR-0305 is predicted to sit firmly in the PLpro catalytic pocket as confirmed by molecular dynamics simulations, wherein stability of binding to the catalytic site of PLpro induces a conformational change in the BL2 loop to a more closed conformation as observed previously with GRL0617. Surface plasmon resonance was performed with CR-0305 and CR-0202 to characterize binding affinity to purified SARS-CoV-2 PLpro protein. CR-0305 and CR-0202 also inhibited SARS-CoV-2 infection compared to vehicle as measured by virus N protein staining with a specific antibody in A549-ACE2 and VeroE6 cells at 20 µM. CR-0305 is a coronary vasodilator that appears to bind to the catalytic site of the PLpro of SARS-CoV-2 while targeting delivery of antiviral NO to cells infected by SARS-CoV-2, suggesting multiple indications for future development.
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Affiliation(s)
- John F Schmedtje
- Coeurative, Inc., 201 McClanahan St. SW, Roanoke, VA 24014, USA.
| | - Fred Ciske
- Cayman Chemical Co., 1180 East Ellsworth Road, Ann Arbor, MI 48108, USA
| | | | - Zahra Assar
- Cayman Chemical Co., 1180 East Ellsworth Road, Ann Arbor, MI 48108, USA
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10
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Zheng Z, Wang L, Wang S, Fan Q, Zhang H, Luo G, Gao B, Yang X, Zhao B, Wang X, Dong H, Nie H, Lei C. Inhaled Nitric Oxide ReDuce postoperatIve pulmoNAry complicaTions in patiEnts with recent COVID-19 infection (INORDINATE): protocol for a randomised controlled trial. BMJ Open 2024; 14:e077572. [PMID: 38485487 PMCID: PMC10941156 DOI: 10.1136/bmjopen-2023-077572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 02/29/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND A history of SARS-CoV-2 infection has been reported to be associated with an increased risk of postoperative pulmonary complications (PPCs). Even mild PPCs can elevate the rates of early postoperative mortality, intensive care unit (ICU) admission and prolong the length of ICU and/or hospital stays. Consequently, it is crucial to develop perioperative management strategies that can mitigate these increased risks in surgical patients who have recently been infected with SARS-CoV-2. Accumulating evidence suggests that nitric oxide (NO) inhalation might be effective in treating COVID-19. NO functions in COVID-19 by promoting vasodilation, anticoagulation, anti-inflammatory and antiviral effects. Therefore, our study hypothesises that the perioperative use of NO can effectively reduce PPCs in patients with recent SARS-CoV-2 infection. METHOD AND ANALYSIS A prospective, double-blind, single-centre, randomised controlled trial is proposed. The trial aims to include participants who are planning to undergo surgery with general anaesthesia and have been recently infected with SARS-CoV-2 (within 7 weeks). Stratified allocation of eligible patients will be performed at a 1:1 ratio based on the predicted risk of PPCs using the Assess Respiratory Risk in Surgical Patients in Catalonia risk index and the time interval between infection and surgery.The primary outcome of the study will be the presence of PPCs within the first 7 days following surgery, including respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm and aspiration pneumonitis. The primary outcome will be reported as counts (percentage) and will be compared using a two-proportion χ2 test. The common effect across all primary components will be estimated using a multiple generalised linear model. ETHICS AND DISSEMINATION The trial is approved by the Institutional Review Board of Xijing Hospital (KY20232058-F1). The findings, including positive, negative and inconclusive results, will be published in scientific journals with peer-review processes. TRIAL REGISTRATION NUMBER NCT05721144.
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Affiliation(s)
- Ziyu Zheng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
- Anesthesia Clinical Research Center, Xijing Hospital, Xian, Shaanxi, China
| | - Lini Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
- Anesthesia Clinical Research Center, Xijing Hospital, Xian, Shaanxi, China
| | - Shuxiu Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
| | - Qianqian Fan
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
| | - Gang Luo
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
| | - Baobao Gao
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
| | - Xue Yang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
| | - Bingqing Zhao
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
| | - Xiaomei Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
| | - Hailong Dong
- Department of Anesthesiology and Perioprative Medicine, Fourth Military Medical University, Xijing Hospital, Xi'an, Shaanxi, China
| | - Huang Nie
- Department of Anesthesiology, Xijing Hospital, The fourth Military Medical University, Xi'an, China
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xian, Shaanxi, China
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11
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Shetty NS, Gaonkar M, Giammatteo V, Arora P, Berra L. Reply to Eleuteri et al.: High-Dose Inhaled Nitric Oxide in Acute Hypoxemic Respiratory Failure: Need for Patient Phenotyping? Am J Respir Crit Care Med 2024; 209:460-462. [PMID: 38128097 PMCID: PMC10878377 DOI: 10.1164/rccm.202311-2112le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
- Naman S. Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mokshad Gaonkar
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Valentina Giammatteo
- Department of Anesthesia, Critical Care and Pain Medicine
- Harvard Medical School, Boston, Massachusetts; and
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Respiratory Care Services, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
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Eleuteri D, Montini L, Antonelli M, Grieco DL. High-Dose Inhaled Nitric Oxide in Acute Hypoxemic Respiratory Failure: Need for Patient Phenotyping? Am J Respir Crit Care Med 2024; 209:459-460. [PMID: 38128106 PMCID: PMC10878385 DOI: 10.1164/rccm.202310-1909le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
- Davide Eleuteri
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; and
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Montini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; and
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; and
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico L. Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy; and
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
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Wang Y, Yu Q, Tian Y, Ren S, Liu L, Wei C, Liu R, Wang J, Li D, Zhu K. Unraveling the impact of nitric oxide, almitrine, and their combination in COVID-19 (at the edge of sepsis) patients: a systematic review. Front Pharmacol 2024; 14:1172447. [PMID: 38318311 PMCID: PMC10839063 DOI: 10.3389/fphar.2023.1172447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 12/27/2023] [Indexed: 02/07/2024] Open
Abstract
Introduction: During the coronavirus disease 2019 (COVID-19) pandemic, a large number of critically ill and severe COVID-19 patients meet the diagnostic criteria for sepsis and even septic shock. The treatments for COVID-19 patients with sepsis are still very limited. For sepsis, improving ventilation is one of the main treatments. Nitric oxide (NO) and almitrine have been reported to improve oxygenation in patients with "classical" sepsis. Here, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of NO, almitrine, and the combination of both for COVID-19 (at the edge of sepsis) patients. Method: A systematic search was performed on Embase, PubMed, the Cochrane Library, the Web of Science, Wanfang Data, and China National Knowledge Infrastructure. Randomized clinical trials, cohort studies, cross-sectional studies, case-control studies, case series, and case reports in COVID-19 patients with suspected or confirmed sepsis were performed. Study characteristics, patient demographics, interventions, and outcomes were extracted from eligible articles. Results: A total of 35 studies representing 1,701 patients met eligibility criteria. Inhaled NO did not affect the mortality (OR 0.96, 95% CI 0.33-2.8, I2 = 81%, very low certainty), hospital length of stay (SMD 0.62, 95% CI 0.04-1.17, I2 = 83%, very low certainty), and intubation needs (OR 0.82, 95% CI 0.34-1.93, I2 = 56%, very low certainty) of patients with COVID-19 (at the edge of sepsis). Meanwhile, almitrine did not affect the mortality (OR 0.44, 95% CI 0.17-1.13, low certainty), hospital length of stay (SMD 0.00, 95% CI -0.29-0.29, low certainty), intubation needs (OR 0.94, 95% CI 0.5-1.79, low certainty), and SAEs (OR 1.16, 95% CI 0.63-2.15, low certainty). Compared with pre-administration, the PaO2/FiO2 of patients with NO (SMD-0.87, 95% CI -1.08-0.66, I2 = 0%, very low certainty), almitrine (SMD-0.73, 95% CI-1.06-0.4, I2 = 1%, very low certainty), and the combination of both (SMD-0.94, 95% CI-1.71-0.16, I2 = 47%, very low certainty) increased significantly. Conclusion: Inhaled NO, almitrine, and the combination of the two drugs improved oxygenation significantly, but did not affect the patients' mortality, hospitalization duration, and intubation needs. Almitrine did not significantly increase the patients' SAEs. Well-designed high-quality studies are needed for establishing a stronger quality of evidence. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=367667, identifier CRD42022367667.
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Affiliation(s)
- Ying Wang
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Qian Yu
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
| | - Yuan Tian
- Department of Nutrition and Food Hygiene, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Shiying Ren
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Liping Liu
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Chaojie Wei
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Renli Liu
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Jing Wang
- Department of Pharmacy, Siping Tumor Hospital, Siping, Jilin, China
| | - Dong Li
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Kun Zhu
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
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Lal A, Gladwin MT, Gajic O. Inhaled NO in COVID-19 Acute Respiratory Distress Syndrome: Yes or No? Am J Respir Crit Care Med 2023; 208:1259-1261. [PMID: 37934465 PMCID: PMC10765394 DOI: 10.1164/rccm.202310-1823ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/06/2023] [Indexed: 11/08/2023] Open
Affiliation(s)
- Amos Lal
- Division of Pulmonary and Critical Care Medicine Mayo Clinic Rochester, Minnesota
| | - Mark T Gladwin
- University of Maryland School of Medicine Baltimore, Maryland
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine Mayo Clinic Rochester, Minnesota
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