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Reinert JP, Reinert NJ. The Role of Phosphodiesterase-5 Inhibitors in COVID-19: An Exploration of Literature From Similar Pathologies. J Intensive Care Med 2020; 36:3-8. [PMID: 32909898 DOI: 10.1177/0885066620957951] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Coronavirus Disease 2019 (COVID-19) has had a devastating impact on the ability of highly trained healthcare providers to render sufficient care, due to both the significant demand on resources and the unique nature of this disease that make it resistant to traditional therapies. This review sought to determine the potential role of phosphodiesterase-5 inhibitors (PDE-5) in the management of COVID-19 by extrapolating relevant data and clinical studies from other related disease states, including acute respiratory distress syndrome, acute lung injury, and high altitude pulmonary edema. Following a literature search, 4 reports were analyzed and included in this review. While the heterogenicity of data and the small number of trials included limit the interpretation and applicability, it was consistently demonstrated that PDE-5 inhibitors lowered pulmonary arterial pressures. The overall benefit of these agents is seemingly dependent upon the etiology of the respiratory failure, which warrants expanded clinical investigation for COVID-19.
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Affiliation(s)
- Justin P Reinert
- Fisch College of Pharmacy, The University of Texas at Tyler, TX, USA
| | - Nathan J Reinert
- The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Henrohn D, Sandqvist A, Egeröd H, Hedeland M, Wernroth L, Bondesson U, Wikström G. Changes in plasma levels of asymmetric dimethylarginine, symmetric dimethylarginine, and arginine after a single dose of vardenafil in patients with pulmonary hypertension. Vascul Pharmacol 2015; 73:71-7. [PMID: 25934511 DOI: 10.1016/j.vph.2015.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 03/31/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We investigated whether vardenafil, a phosphodiesterase-5 inhibitor, alters plasma levels of asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), and arginine. PATIENTS AND METHODS ADMA, SDMA, and arginine were measured (0-540 min) in 12 patients with pulmonary hypertension after a single oral dose of vardenafil. Invasive hemodynamic data were collected at baseline and after 60 min. RESULTS A reduction in ADMA was observed at 30 and 45 min with a median change of -11.1% (P=0.021) and -12.5% (P=0.002). SDMA decreased with a median -5.3% change (P=0.032) at 45 min. An increase in arginine, median 40.3% (P=0.002), 45.0% (P=0.010), and 77.1% (P=0.008) was observed at 120, 300, and 540 min respectively. An increase in the arginine/ADMA ratio, median 11.7% (P=0.012), 32.5% (P=0.003), 26.5% (P=0.021), 33% (P=0.007), 48.5% (P=0.007), and 63.1% (P=0.008) was observed at 15, 45, 60, 120, 300, and 540 min respectively. There was a positive correlation between vardenafil exposure and the percent change in the arginine/ADMA ratio from baseline to 540 min (r=0.80; P=0.01). A correlation between baseline mean right atrial pressure (mRAP) and baseline ADMA (r=0.65; P=0.023), and baseline SDMA (r=0.61; P=0.035) was observed. A correlation between the baseline arginine/ADMA ratio and baseline cardiac output (CO) (r=0.59; P=0.045) and baseline cardiac index (CI) (r=0.61; P=0.036) was observed. Baseline arginine/ADMA ratio correlated with baseline mRAP (r=-0.79; P=0.002). A correlation between change (0-60 min) in CI and change in arginine (r=0.77; P=0.003) as well as change in the arginine/ADMA ratio (r=0.61; P=0.037) was observed. CONCLUSIONS Vardenafil induced changes in ADMA, SDMA, arginine, and the arginine/ADMA ratio in patients with PH. An increase in arginine and the arginine/ADMA ratio was associated with improvement in CI.
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Affiliation(s)
- Dan Henrohn
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden.
| | - Anna Sandqvist
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå University Hospital, Umeå, Sweden
| | - Hanna Egeröd
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Mikael Hedeland
- Department of Chemistry, Environment and Feed Hygiene, National Veterinary Institute, (SVA), Uppsala, Sweden; Division of Analytical Pharmaceutical Chemistry, Department of Medicinal Chemistry, Uppsala University, Uppsala, Sweden
| | | | - Ulf Bondesson
- Department of Chemistry, Environment and Feed Hygiene, National Veterinary Institute, (SVA), Uppsala, Sweden; Division of Analytical Pharmaceutical Chemistry, Department of Medicinal Chemistry, Uppsala University, Uppsala, Sweden
| | - Gerhard Wikström
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
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Mok YH, Lee JH, Rehder KJ, Turner DA. Adjunctive treatments in pediatric acute respiratory distress syndrome. Expert Rev Respir Med 2014; 8:703-16. [PMID: 25119574 DOI: 10.1586/17476348.2014.948854] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a devastating process that involves pulmonary inflammation, alveolar damage and hypoxemic respiratory failure. Although advances in management approaches over the past two decades have resulted in significantly improved outcomes, death from pediatric ARDS may still occur in up to 35% of patients. While invasive mechanical ventilation is an essential component of ARDS management, various adjuncts have been utilized as treatment for these patients. However, evidence-based data in infants and children in this area are lacking. In this article, the authors review the available evidence supporting (or not supporting) the use of non-ventilatory adjunctive strategies in the management of pediatric ARDS, including prone positioning, pulmonary vasodilators, β-agonists, steroids and surfactant.
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Affiliation(s)
- Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore
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Henrohn D, Sandqvist A, Hedeland M, Egeröd H, Bondesson U, Wikström G. Acute haemodynamic response in relation to plasma vardenafil concentrations in patients with pulmonary hypertension. Br J Clin Pharmacol 2013; 74:990-8. [PMID: 22515706 DOI: 10.1111/j.1365-2125.2012.04303.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
AIMS To evaluate the acute haemodynamic effects of a single oral dose of vardenafil and to study the drug concentration in relation to haemodynamic effects in patients with pulmonary hypertension (PH). METHODS Sixteen patients with PH (aged 29-85\ years), received one single oral dose of vardenafil (5, 10 or 20 mg). The haemodynamic effect was assessed over a 60 min period. Vardenafil plasma concentrations were measured after 15, 30, 45 and 60 min using liquid chromatography-tandem mass spectrometry. RESULTS At 60 min a reduction in mPAP with a median % decrease of -20.3% (range -48.3 to 3.0; P < 0.001) and an increase in cardiac output and the cardiac index with a median % change of 10.6% (range -25.0 to 88.1; P = 0.015) and 12.1% (range -24.0 to 94.4; P = 0.01) respectively was observed. The pulmonary vascular resistance (PVR) was reduced with a median % decrease of -28.9% (range -61.5 to -5.9; P < 0.001), and pulmonary selectivity was reflected by a median percent reduction of -16.9% (range -49.0 to 16.5; P = 0.002; n = 14) in the PVR/systemic vascular resistance ratio. There was a correlation between the plasma concentrations of vardenafil and change in mPAP (r = -0.579, P = 0.019) and between vardenafil concentrations and change in PVR (r = -0.662, P = 0.005). CONCLUSIONS Vardenafil causes rapid changes in cardiopulmonary haemodynamics and there is a correlation between plasma vardenafil drug concentration and the acute changes in mPAP as well as PVR in patients with PH.
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Affiliation(s)
- Dan Henrohn
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden.
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Sandqvist AM, Henrohn D, Schneede J, Hedeland M, Egeröd HC, Bondesson UG, Wikström BG. High inter-individual variability of vardenafil pharmacokinetics in patients with pulmonary hypertension. Eur J Clin Pharmacol 2012; 69:197-207. [PMID: 22732766 DOI: 10.1007/s00228-012-1323-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 05/24/2012] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the pharmacokinetic parameters of a single oral dose of vardenafil in patients with pulmonary hypertension (PH). METHODS Sixteen patients with PH received vardenafil in single oral doses (20, 10 or 5 mg), and repeated blood sampling for up to 9 h was performed. Vardenafil plasma concentration was determined using liquid chromatography tandem mass spectrometry. Pharmacokinetic parameters were calculated using model-independent analysis. RESULTS The plasma vardenafil concentration increased rapidly and exhibited a median time to maximum plasma concentration (t(max)) of 1 h and a mean elimination half-life (t(1/2)) of 3.4 h. The geometric mean and standard deviation of (1) the peak plasma concentration (C(max)) was 21.4 ± 1.7 μg/L, (2) the normalized C(max) (C(max, norm)) 79.1 ± 1.6 g/L, (3) the area under the time-concentration curve (AUC) 71.5 ± 1.6 μg · h/L and (4) the normalized AUC (AUC(norm)) 261.6 ± 1.7 g · h/L. Patients co-medicated with bosentan reached t(max) later and had a 90% reduction of C(max), C(max, norm), AUC and AUC(norm). CONCLUSION The pharmacokinetic profile of vardenafil overall revealed considerable inter-individual variability in patients with PH. Co-medication with bosentan resulted in a pharmacokinetic drug interaction, leading to significantly decreased plasma concentrations of vardenafil. Therapeutic drug monitoring for individual dose optimization may be warranted.
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Affiliation(s)
- A M Sandqvist
- Division of Clinical Pharmacology, Department of Pharmacology and Clinical Neuroscience, Umeå University and Umeå University Hospital, 901 85 Umeå, Sweden.
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Price LC, McAuley DF, Marino PS, Finney SJ, Griffiths MJ, Wort SJ. Pathophysiology of pulmonary hypertension in acute lung injury. Am J Physiol Lung Cell Mol Physiol 2012; 302:L803-15. [PMID: 22246001 PMCID: PMC3362157 DOI: 10.1152/ajplung.00355.2011] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome are characterized by protein rich alveolar edema, reduced lung compliance, and acute severe hypoxemia. A degree of pulmonary hypertension (PH) is also characteristic, higher levels of which are associated with increased morbidity and mortality. The increase in right ventricular (RV) afterload causes RV dysfunction and failure in some patients, with associated adverse effects on oxygen delivery. Although the introduction of lung protective ventilation strategies has probably reduced the severity of PH in ALI, a recent invasive hemodynamic analysis suggests that even in the modern era, its presence remains clinically important. We therefore sought to summarize current knowledge of the pathophysiology of PH in ALI.
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Affiliation(s)
- Laura C Price
- Dept. of Critical Care, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Price LC, Wort SJ, Finney SJ, Marino PS, Brett SJ. Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review. Crit Care 2010; 14:R169. [PMID: 20858239 PMCID: PMC3219266 DOI: 10.1186/cc9264] [Citation(s) in RCA: 206] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 05/30/2010] [Accepted: 09/21/2010] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Pulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update on the management of PH and RV failure in adult critical care. METHODS A systematic review was performed, based on a search of the literature from 1980 to 2010, by using prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method. RESULTS Clinical studies of intensive care management of pulmonary vascular dysfunction were identified, describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators, and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (low-quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation (low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy. CONCLUSIONS This systematic review highlights that although some recommendations can be made to guide the critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality research is needed.
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Affiliation(s)
- Laura C Price
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Stephen J Wort
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Simon J Finney
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Philip S Marino
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Stephen J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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Mulhall JP, Bella AJ, Briganti A, McCullough A, Brock G. Erectile Function Rehabilitation in the Radical Prostatectomy Patient. J Sex Med 2010; 7:1687-98. [PMID: 20388165 DOI: 10.1111/j.1743-6109.2010.01804.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- John P Mulhall
- Memorial Sloan-Kettering Cancer Center, Sexual and Reproductive Medicine, New York, NY, USA
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Abstract
INTRODUCTION Phosphodiesterase type 5 (PDE5) hydrolyses cyclic guanylate monophosphate (cGMP) specifically to 5' GMP. PDE5 inhibitors were a breakthrough medication that addressed a previously unfulfilled medical need. They promoted vascular relaxation in the corpora cavernosa and penile erection during sexual stimulation. Sildenafil, vardenafil, and tadalafil were approved then introduced as effective treatments for male erectile dysfunction. This impact has stimulated academic, clinical, and industrial research. AIM To highlight the nonerectogenic beneficial uses of oral PDE5 inhibitors. METHOD A systematic review of published studies in this affair based on a Pubmed and medical subject heading databases search of all concerned articles. MAIN OUTCOME MEASURES Demonstrated beneficial as well as applicable uses of oral PDE5 inhibitors. RESULTS As chemical molecules, these drugs were shown to exert potential nonerectogenic beneficial effects. They showed efficacy as a useful adjunct in the management of pulmonary hypertension. Additional uses were extended to different utilities: essential hypertension, benign prostatic hyperplasia, gastrointestinal disorders, endothelial dysfunction, female sexual dysfunction, genital blood flow, exercise capacity, Raynaud's phenomenon, sperm motility, etc. CONCLUSION Exploring PDE5 inhibitors for their possible medical applications in diverse specialties seems to be beneficial in making use of these molecules for the welfare of humanity.
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Affiliation(s)
- Taymour Mostafa
- Andrology & Sexology Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
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Cai J, Su Z, Shi Z, Zhou Y, Xu Z, Liu J, Chen L, Xu Z, Yu X, Ding W, Yang Y. Nitric Oxide in Conjunction With Milrinone Better Stabilized Pulmonary Hemodynamics After Fontan Procedure. Artif Organs 2008; 32:864-9. [PMID: 18959679 DOI: 10.1111/j.1525-1594.2008.00643.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jiming Cai
- Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Iapichino G, Callegari ML, Marzorati S, Cigada M, Corbella D, Ferrari S, Morelli L. Impact of antibiotics on the gut microbiota of critically ill patients. J Med Microbiol 2008; 57:1007-1014. [PMID: 18628503 DOI: 10.1099/jmm.0.47387-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
We evaluated the relationship between the intestinal microbiota composition and clinical outcome in a group of 15 high-risk patients admitted for acute infection and/or surgical/accidental trauma who were treated with systemic antibiotics according to standard intensive care unit (ICU) protocols. There was a high mortality rate amongst these patients, each of whom had a considerable organ failure score at admission, respiratory assistance during the most of their ICU stay and a long length of stay. All of these individuals received sedation and enteral nutrition, and the majority also received insulin, vasoactive drugs and some stress-ulcer prophylaxis agents. The intestinal microbiota composition was assessed using denaturing gradient gel electrophoresis (DGGE), a molecular biology tool used to characterize bacterial ecosystems. As all of the patient subjects were in good health prior to their acute illness and admission to the ICU, the first faecal samples obtained from this group showed a DGGE banding pattern that was similar to that of healthy subjects. After 1 week of critical illness, coupled with intensive care treatment, including antibiotics, a very definite alteration in the overall microbiota composition was evident, as revealed by a reduction in the number of DGGE bands. Further pronounced changes to the DGGE banding profiles could be observed in patients remaining in the ICU for 2 weeks. Moreover, a dominant band, identified by sequencing as highly related to Enterococcus, was detected in the DGGE profile of some of our patient subjects. We also performed real-time PCR and obtained results that were in agreement with our qualitative evaluations using DGGE. The degree of organ failure and ICU mortality was significantly higher in patients for whom a high reduction in microbiota biodiversity was coupled with a massive presence of enterococci. A statistically significant link between these two ecological traits and the use of clindamycin was also found.
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Affiliation(s)
- Gaetano Iapichino
- Istituto di Anestesiologia e Rianimazione, Università degli Studi, Polo San Paolo, via Di Rudinì 8, I-20142 Milano, Italy
| | - Maria Luisa Callegari
- Centro Ricerche Biotecnologiche, Università Cattolica del Sacro Cuore, Via Milano 24, 26100 Cremona, Italy
| | - Silvia Marzorati
- Istituto di Anestesiologia e Rianimazione, Università degli Studi, Polo San Paolo, via Di Rudinì 8, I-20142 Milano, Italy
| | - Marco Cigada
- Istituto di Anestesiologia e Rianimazione, Università degli Studi, Polo San Paolo, via Di Rudinì 8, I-20142 Milano, Italy
| | - Davide Corbella
- Istituto di Anestesiologia e Rianimazione, Università degli Studi, Polo San Paolo, via Di Rudinì 8, I-20142 Milano, Italy
| | - Susanna Ferrari
- Centro Ricerche Biotecnologiche, Università Cattolica del Sacro Cuore, Via Milano 24, 26100 Cremona, Italy
| | - Lorenzo Morelli
- Istituto di Microbiologia, Università Cattolica del Sacro Cuore, Via E. Parmense 84, 29100 Piacenza, Italy
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Abstract
Pulmonary hypertension remains a significant complication of several systemic and cardiothoracic diseases. It is important to emphasize that the hemodynamic relevance relates to the effect of pulmonary hypertension on right ventricular function and right-left ventricular interaction. The goal of pulmonary vasodilation should focus on optimizing right ventricular function and improving systemic perfusion. The properties of an optimum vasodilator include selective pulmonary vasodilation (avoiding systemic vasodilation), rapid onset of action, short half-life, and ease of administration. Inhaled nitric oxide or nebulization of traditional systemically administered agents offers the greatest clinical promise. An additional merit of selective pulmonary vasodilation consists of augmenting oxygenation by improving ventilation perfusion matching.
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Affiliation(s)
- John Granton
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada.
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Stanopoulos I, Manolakoglou N, Pitsiou G, Trigonis I, Tsiata EA, Boutou AK, Kontou PK, Argyropoulou P. Sildenafil may facilitate weaning in mechanically ventilated COPD patients: a report of three cases. Anaesth Intensive Care 2008; 35:610-3. [PMID: 18020085 DOI: 10.1177/0310057x0703500425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report three cases of mechanically ventilated chronic obstructive pulmonary disease patients who were intubated due to an exacerbation of their disease and who presented with repeated spontaneous breathing trial failures. Patients were given 50 mg of sildenafil through the nasogastric tube, under close monitoring of haemodynamic and ventilatory parameters. After sildenafil, pulmonary artery pressure, pulmonary artery occlusion pressure, the respiratory frequency to tidal volume ratio and the P(a)CO2-P(ET)CO2 (arterial minus end-tidal carbon dioxide pressure) decreased. Cardiac output increased in two of the patients, while all of them were successfully extubated. This is the first report of successful extubation after sildenafil use.
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Affiliation(s)
- I Stanopoulos
- Respiratory Failure Unit, Aristotle University, G. Papanikolaou Hospital, Thessaloniki, Greece
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