1
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Di Fenza R, Shetty NS, Gianni S, Parcha V, Giammatteo V, Safaee Fakhr B, Tornberg D, Wall O, Harbut P, Lai PS, Li JZ, Paganoni S, Cenci S, Mueller AL, Houle TT, Akeju O, Bittner EA, Bose S, Scott LK, Carroll RW, Ichinose F, Hedenstierna M, Arora P, Berra L. High-Dose Inhaled Nitric Oxide in Acute Hypoxemic Respiratory Failure Due to COVID-19: A Multicenter Phase II Trial. Am J Respir Crit Care Med 2023; 208:1293-1304. [PMID: 37774011 PMCID: PMC10765403 DOI: 10.1164/rccm.202304-0637oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/28/2023] [Indexed: 10/01/2023] Open
Abstract
Rationale: The effects of high-dose inhaled nitric oxide on hypoxemia in coronavirus disease (COVID-19) acute respiratory failure are unknown. Objectives: The primary outcome was the change in arterial oxygenation (PaO2/FiO2) at 48 hours. The secondary outcomes included: time to reach a PaO2/FiO2.300mmHg for at least 24 hours, the proportion of participants with a PaO2/FiO2.300mmHg at 28 days, and survival at 28 and at 90 days. Methods: Mechanically ventilated adults with COVID-19 pneumonia were enrolled in a phase II, multicenter, single-blind, randomized controlled parallel-arm trial. Participants in the intervention arm received inhaled nitric oxide at 80 ppm for 48 hours, compared with the control group receiving usual care (without placebo). Measurements and Main Results: A total of 193 participants were included in the modified intention-to-treat analysis. The mean change in PaO2/FiO2 ratio at 48 hours was 28.3mmHg in the intervention group and 21.4mmHg in the control group (mean difference, 39.1mmHg; 95% credible interval [CrI], 18.1 to 60.3). The mean time to reach a PaO2/FiO2.300mmHg in the interventional group was 8.7 days, compared with 8.4 days for the control group (mean difference, 0.44; 95% CrI, 23.63 to 4.53). At 28 days, the proportion of participants attaining a PaO2/FiO2.300mmHg was 27.7% in the inhaled nitric oxide group and 17.2% in the control subjects (risk ratio, 2.03; 95% CrI, 1.11 to 3.86). Duration of ventilation and mortality at 28 and 90 days did not differ. No serious adverse events were reported. Conclusions: The use of high-dose inhaled nitric oxide resulted in an improvement of PaO2/FiO2 at 48 hours compared with usual care in adults with acute hypoxemic respiratory failure due to COVID-19.
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Affiliation(s)
- Raffaele Di Fenza
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Naman S. Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stefano Gianni
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Vibhu Parcha
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Valentina Giammatteo
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Daniel Tornberg
- Department of Clinical Sciences and
- Department of Anesthesia and Intensive Care and
| | - Olof Wall
- Department of Clinical Sciences and
- Department of Clinical Science and Education, Sodersxjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Piotr Harbut
- Department of Clinical Sciences and
- Department of Anesthesia and Intensive Care and
| | - Peggy S. Lai
- Pulmonary and Critical Care Medicine, Department of Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Jonathan Z. Li
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sabrina Paganoni
- Sean M. Healey and AMG Center for ALS
- Neurological Clinical Research Institute
- Harvard Medical School, Boston, Massachusetts
| | - Stefano Cenci
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Ariel L. Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Research Center
- Harvard Medical School, Boston, Massachusetts
| | - Timothy T. Houle
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Research Center
- Harvard Medical School, Boston, Massachusetts
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine
- Harvard Medical School, Boston, Massachusetts
| | - Somnath Bose
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Louie K. Scott
- Critical Care Medicine, Department of Medicine, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Ryan W. Carroll
- Division of Pediatric Critical Care Medicine, Department of Pediatrics
- Harvard Medical School, Boston, Massachusetts
| | - Fumito Ichinose
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Harvard Medical School, Boston, Massachusetts
| | | | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care, and Pain Medicine
- Anesthesia Critical Care Center for Research, and
- Respiratory Care Services, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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2
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Morais CCA, Alcala G, De Santis Santiago RR, Valsecchi C, Diaz E, Wanderley H, Fakhr BS, Di Fenza R, Gianni S, Foote S, Chang MG, Bittner EA, Carroll RW, Costa ELV, Amato MBP, Berra L. Pronation Reveals a Heterogeneous Response of Global and Regional Respiratory Mechanics in Patients With Acute Hypoxemic Respiratory Failure. Crit Care Explor 2023; 5:e0983. [PMID: 37795456 PMCID: PMC10547249 DOI: 10.1097/cce.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVES Experimental models suggest that prone position and positive end-expiratory pressure (PEEP) homogenize ventral-dorsal ventilation distribution and regional respiratory compliance. However, this response still needs confirmation on humans. Therefore, this study aimed to assess the changes in global and regional respiratory mechanics in supine and prone positions over a range of PEEP levels in acute respiratory distress syndrome (ARDS) patients. DESIGN A prospective cohort study. PATIENTS Twenty-two intubated patients with ARDS caused by COVID-19 pneumonia. INTERVENTIONS Electrical impedance tomography and esophageal manometry were applied during PEEP titrations from 20 cm H2O to 6 cm H2O in supine and prone positions. MEASUREMENTS Global respiratory system compliance (Crs), chest wall compliance, regional lung compliance, ventilation distribution in supine and prone positions. MAIN RESULTS Compared with supine position, the maximum level of Crs changed after prone position in 59% of ARDS patients (n = 13), of which the Crs decreased in 32% (n = 7) and increased in 27% (n = 6). To reach maximum Crs after pronation, PEEP was changed in 45% of the patients by at least 4 cm H2O. After pronation, the ventilation and compliance of the dorsal region did not consistently change in the entire sample of patients, increasing specifically in a subgroup of patients who showed a positive change in Crs when transitioning from supine to prone position. These combined changes in ventilation and compliance suggest dorsal recruitment postpronation. In addition, the subgroup with increased Crs postpronation demonstrated the most pronounced difference between dorsal and ventral ventilation distribution from supine to prone position (p = 0.01), indicating heterogeneous ventilation distribution in prone position. CONCLUSIONS Prone position modifies global respiratory compliance in most patients with ARDS. Only a subgroup of patients with a positive change in Crs postpronation presented a consistent improvement in dorsal ventilation and compliance. These data suggest that the response to pronation on global and regional mechanics can vary among ARDS patients, with some patients presenting more dorsal lung recruitment than others.
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Affiliation(s)
- Caio C A Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Glasiele Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Roberta R De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Carlo Valsecchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Eduardo Diaz
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Hatus Wanderley
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Sara Foote
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ryan W Carroll
- Division of Pediatric Critical Care, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA
| | - Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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3
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Carron M, Tamburini E, Safaee Fakhr B, De Cassai A, Linassi F, Navalesi P. High-flow nasal oxygenation during gastrointestinal endoscopy. Systematic review and meta-analysis. BJA Open 2022; 4:100098. [PMID: 37588780 PMCID: PMC10430836 DOI: 10.1016/j.bjao.2022.100098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 09/14/2022] [Indexed: 08/18/2023]
Abstract
Background The use of high-flow nasal oxygen (HFNO) has the potential to improve patient safety by limiting hypoxaemia during gastrointestinal endoscopy. The degree of benefit is not adequately established. Methods English language literature searches of PubMed, Scopus, Web of Science, and Cochrane Library electronic databases were performed to identify randomised controlled trials comparing HFNO and conventional oxygen therapy (COT) for patients undergoing gastrointestinal endoscopy under deep sedation. The primary endpoint was the incidence of hypoxic events observed during endoscopic procedures. The secondary endpoints were the incidence of recourse to rescue manoeuvres, procedure interruption, and adverse events. A meta-analysis and a post hoc trial sequence analysis were performed. Results A total of 2867 patients from six randomised controlled trials were considered. Desaturation was observed in 5.2% and 27.2% of patients receiving HFNO and COT, respectively. Desaturation <90% was observed in 1.8% and 12.6% of the patients receiving HFNO and COT, respectively. In the subgroup analysis, desaturation occurrence was lower during HFNO than during COT in non-obese patients (2.2% vs 25.2%) and obese patients (22.9% vs 43.3%). Desaturation occurrence was lower during maximum (3.6% vs 26.9%) and minimum (15.9% vs 29.8%) HFNO therapy than during COT. HFNO showed a lower recurrence to rescue manoeuvres rate (4.7% vs 34.3%), a lower procedure interruption rate (0.4% vs 6.7%), and a lower adverse events rate (18.7% vs 21%) than COT. A high level of heterogeneity between the studies precluded confidence in drawing inference from the meta-analysis. Conclusions The evidence reviewed suggests that compared with COT, HFNO has fewer hypoxaemic events during gastrointestinal endoscopy, but this may not apply to all patients and clinical scenarios.
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Affiliation(s)
- Michele Carron
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - Enrico Tamburini
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - Bijan Safaee Fakhr
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - Alessandro De Cassai
- Institute of Anaesthesia and Intensive Care - Azienda Ospedale Università Padova, Padua, Italy
| | - Federico Linassi
- Department of Anaesthesia and Intensive Care, Ca’ Foncello Treviso Regional Hospital, Piazzale Ospedale 1,Treviso, Italy
| | - Paolo Navalesi
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
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Gianni S, Fenza RD, Morais CCA, Fakhr BS, Mueller AL, Yu B, Carroll RW, Ichinose F, Zapol WM, Berra L. High-Dose Nitric Oxide From Pressurized Cylinders and Nitric Oxide Produced by an Electric Generator From Air. Respir Care 2022; 67:201-208. [PMID: 34413210 PMCID: PMC9993937 DOI: 10.4187/respcare.09308] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-dose (≥ 80 ppm) inhaled nitric oxide (INO) has antimicrobial effects. We designed a trial to test the preventive effects of high-dose NO on coronavirus disease 2019 (COVID-19) in health care providers working with patients with COVID-19. The study was interrupted prematurely due to the introduction of COVID-19 vaccines for health care professionals. We thereby present data on safety and feasibility of breathing 160 ppm NO using 2 different NO sources, namely pressurized nitrogen/NO cylinders (INO) and electric NO (eNO) generators. METHODS NO gas was inhaled at 160 ppm in air for 15 min twice daily, before and after each work shift, over 14 d by health care providers (NCT04312243). During NO administration, vital signs were continuously monitored. Safety was assessed by measuring transcutaneous methemoglobinemia (SpMet) and the inhaled nitrogen dioxide (NO2) concentration. RESULTS Twelve healthy health care professionals received a collective total of 185 administrations of high-dose NO (160 ppm) for 15 min twice daily. One-hundred and seventy-one doses were delivered by INO and 14 doses by eNO. During NO administration, SpMet increased similarly in both groups (P = .82). Methemoglobin decreased in all subjects at 5 min after discontinuing NO administration. Inhaled NO2 concentrations remained between 0.70 ppm (0.63-0.79) and 0.75 ppm (0.67-0.83) in the INO group and between 0.74 ppm (0.68-0.78) and 0.88 ppm (0.70-0.93) in the eNO group. During NO administration, peripheral oxygen saturation and heart rate did not change. No adverse events occurred. CONCLUSIONS This pilot study testing high-dose INO (160 ppm) for 15 min twice daily using eNO seems feasible and similarly safe when compared with INO.
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Affiliation(s)
- Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Caio C Araujo Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Ariel L Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Binglan Yu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Ryan W Carroll
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, and Harvard Medical School, Boston, Massachusetts
| | - Fumito Ichinose
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Warren M Zapol
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts.
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5
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Pasin L, Boraso S, Golino G, Fakhr BS, Tiberio I, Trevisan C. The impact of frailty on mortality in older patients admitted to an Intensive Care Unit. Med Intensiva 2022; 46:23-30. [PMID: 34991871 DOI: 10.1016/j.medine.2020.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 05/24/2020] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Frailty is a relatively new concept for intensivists, and is defined as a status of increased vulnerability to stressors associated with reduced reserve and function of different physiological systems. Supporting the hypothesis that frailty may be an important predictor of poor prognosis among older patients admitted to Intensive Care Unit (ICU), this study seeks to evaluate the association between frailty at ICU admission and short and long-term mortality. DESIGN An unmatched case-control study was carried out. SETTING Intensive Care Unit. PATIENTS OR PARTICIPANTS Patients≥80 years of age admitted to the ICU for medical reasons. INTERVENTIONS None. MAIN VARIABLES OF INTEREST The primary outcome was 30-day mortality, while secondary outcomes were ICU mortality and mortality at one year. RESULTS Most of the patients were classified as frail at ICU admission (55.3%). The prevalence of frailty was higher among those who died than in those who were alive within 30 days from ICU admission (62.3% vs 48.3%, p=0.01). One-year mortality was higher in frail (84.4%) than in non-frail patients (65.2%, p<0.001). In the logistic regression analysis, after adjusting for potential confounders such as chronic diseases, clinical complexity, cause of ICU admission and use of advanced procedures, frailty was seen to be significantly associated to one-year mortality, but not with ICU mortality or 30-day mortality. DISCUSSION The admission of geriatric patients to the ICU is increasing. Frailty assessment may play an important role in the clinical evaluation of such individuals for triage, but should not be considered a priori as an exclusion criterion for admission.
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Affiliation(s)
- L Pasin
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy.
| | - S Boraso
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - G Golino
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - B S Fakhr
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - I Tiberio
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - C Trevisan
- Department of Medicine (DIMED), Geriatric Unit, University of Padova, Italy
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6
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Safaee Fakhr B, Di Fenza R, Gianni S, Wiegand SB, Miyazaki Y, Araujo Morais CC, Gibson LE, Chang MG, Mueller AL, Rodriguez-Lopez JM, Ackman JB, Arora P, Scott LK, Bloch DB, Zapol WM, Carroll RW, Ichinose F, Berra L. Inhaled high dose nitric oxide is a safe and effective respiratory treatment in spontaneous breathing hospitalized patients with COVID-19 pneumonia. Nitric Oxide 2021; 116:7-13. [PMID: 34400339 PMCID: PMC8361002 DOI: 10.1016/j.niox.2021.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/21/2021] [Accepted: 08/10/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Inhaled nitric oxide (NO) is a selective pulmonary vasodilator. In-vitro studies report that NO donors can inhibit replication of SARS-CoV-2. This multicenter study evaluated the feasibility and effects of high-dose inhaled NO in non-intubated spontaneously breathing patients with Coronavirus disease-2019 (COVID-19). METHODS This is an interventional study to determine whether NO at 160 parts-per-million (ppm) inhaled for 30 min twice daily might be beneficial and safe in non-intubated COVID-19 patients. RESULTS Twenty-nine COVID-19 patients received a total of 217 intermittent inhaled NO treatments for 30 min at 160 ppm between March and June 2020. Breathing NO acutely decreased the respiratory rate of tachypneic patients and improved oxygenation in hypoxemic patients. The maximum level of nitrogen dioxide delivered was 1.5 ppm. The maximum level of methemoglobin (MetHb) during the treatments was 4.7%. MetHb decreased in all patients 5 min after discontinuing NO administration. No adverse events during treatment, such as hypoxemia, hypotension, or acute kidney injury during hospitalization occurred. In our NO treated patients, one patient of 29 underwent intubation and mechanical ventilation, and none died. The median hospital length of stay was 6 days [interquartile range 4-8]. No discharged patients required hospital readmission nor developed COVID-19 related long-term sequelae within 28 days of follow-up. CONCLUSIONS In spontaneous breathing patients with COVID-19, the administration of inhaled NO at 160 ppm for 30 min twice daily promptly improved the respiratory rate of tachypneic patients and systemic oxygenation of hypoxemic patients. No adverse events were observed. None of the subjects was readmitted or had long-term COVID-19 sequelae.
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Affiliation(s)
- Bijan Safaee Fakhr
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Raffaele Di Fenza
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Stefano Gianni
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Steffen B Wiegand
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Yusuke Miyazaki
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Caio C Araujo Morais
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Lauren E Gibson
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Marvin G Chang
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Ariel L Mueller
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Josanna M Rodriguez-Lopez
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Jeanne B Ackman
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Tinsley Harrison Tower, Suite 311, 1900 University Boulevard, Birmingham, AL, 35233, USA
| | - Louie K Scott
- Critical Care Medicine, Department of Medicine, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA
| | - Donald B Bloch
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Center for Immunology and Inflammatory Diseases and Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Warren M Zapol
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Ryan W Carroll
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Fumito Ichinose
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Respiratory Care Services, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
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7
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Pinciroli R, Traeger L, Fischbach A, Gianni S, Morais CCA, Fakhr BS, Di Fenza R, Robinson D, Carroll R, Zapol WM, Berra L. A Novel Inhalation Mask System to Deliver High Concentrations of Nitric Oxide Gas in Spontaneously Breathing Subjects. J Vis Exp 2021. [PMID: 34028428 DOI: 10.3791/61769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Nitric Oxide (NO) is administered as gas for inhalation to induce selective pulmonary vasodilation. It is a safe therapy, with few potential risks even if administered at high concentration. Inhaled NO gas is routinely used to increase systemic oxygenation in different disease conditions. The administration of high concentrations of NO also exerts a virucidal effect in vitro. Owing to its favorable pharmacodynamic and safety profiles, the familiarity in its use by critical care providers, and the potential for a direct virucidal effect, NO is clinically used in patients with coronavirus disease-2019 (COVID-19). Nevertheless, no device is currently available to easily administer inhaled NO at concentrations higher than 80 parts per million (ppm) at various inspired oxygen fractions, without the need for dedicated, heavy, and costly equipment. The development of a reliable, safe, inexpensive, lightweight, and ventilator-free solution is crucial, particularly for the early treatment of non-intubated patients outside of the intensive care unit (ICU) and in a limited-resource scenario. To overcome such a barrier, a simple system for the non-invasive NO gas administration up to 250 ppm was developed using standard consumables and a scavenging chamber. The method has been proven safe and reliable in delivering a specified NO concentration while limiting nitrogen dioxide levels. This paper aims to provide clinicians and researchers with the necessary information on how to assemble or adapt such a system for research purposes or clinical use in COVID-19 or other diseases in which NO administration might be beneficial.
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Affiliation(s)
- Riccardo Pinciroli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
| | - Lisa Traeger
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
| | - Anna Fischbach
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
| | - Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
| | - Caio Cesar Araujo Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
| | | | - Ryan Carroll
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School
| | - Warren M Zapol
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School;
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8
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Morais CCA, Safaee Fakhr B, De Santis Santiago RR, Di Fenza R, Marutani E, Gianni S, Pinciroli R, Kacmarek RM, Berra L. Bedside Electrical Impedance Tomography Unveils Respiratory "Chimera" in COVID-19. Am J Respir Crit Care Med 2021; 203:120-121. [PMID: 33196303 PMCID: PMC7781126 DOI: 10.1164/rccm.202005-1801im] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Caio C A Morais
- Department of Anesthesia, Critical Care and Pain Medicine and
| | | | | | | | - Eizo Marutani
- Department of Anesthesia, Critical Care and Pain Medicine and
| | - Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine and
| | | | - Robert M Kacmarek
- Department of Anesthesia, Critical Care and Pain Medicine and.,Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine and.,Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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9
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Safaee Fakhr B, Araujo Morais CC, De Santis Santiago RR, Di Fenza R, Gibson LE, Restrepo PA, Chang MG, Bittner EA, Pinciroli R, Fintelmann FJ, Kacmarek RM, Berra L. Bedside monitoring of lung perfusion by electrical impedance tomography in the time of COVID-19. Br J Anaesth 2020; 125:e434-e436. [PMID: 32859359 PMCID: PMC7413127 DOI: 10.1016/j.bja.2020.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Bijan Safaee Fakhr
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Caio C Araujo Morais
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Roberta R De Santis Santiago
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Raffaele Di Fenza
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lauren E Gibson
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Paula A Restrepo
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Marvin G Chang
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Edward A Bittner
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Riccardo Pinciroli
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Florian J Fintelmann
- Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Robert M Kacmarek
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA.
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10
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Pasin L, Boraso S, Golino G, Fakhr BS, Tiberio I, Trevisan C. The impact of frailty on mortality in older patients admitted to an Intensive Care Unit. Med Intensiva 2020; 46:S0210-5691(20)30191-1. [PMID: 32654922 DOI: 10.1016/j.medin.2020.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/27/2020] [Accepted: 05/24/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Frailty is a relatively new concept for intensivists, and is defined as a status of increased vulnerability to stressors associated with reduced reserve and function of different physiological systems. Supporting the hypothesis that frailty may be an important predictor of poor prognosis among older patients admitted to Intensive Care Unit (ICU), this study seeks to evaluate the association between frailty at ICU admission and short and long-term mortality. DESIGN An unmatched case-control study was carried out. SETTING Intensive Care Unit. PATIENTS OR PARTICIPANTS Patients≥80 years of age admitted to the ICU for medical reasons. INTERVENTIONS None. MAIN VARIABLES OF INTEREST The primary outcome was 30-day mortality, while secondary outcomes were ICU mortality and mortality at one year. RESULTS Most of the patients were classified as frail at ICU admission (55.3%). The prevalence of frailty was higher among those who died than in those who were alive within 30 days from ICU admission (62.3% vs 48.3%, p=0.01). One-year mortality was higher in frail (84.4%) than in non-frail patients (65.2%, p<0.001). In the logistic regression analysis, after adjusting for potential confounders such as chronic diseases, clinical complexity, cause of ICU admission and use of advanced procedures, frailty was seen to be significantly associated to one-year mortality, but not with ICU mortality or 30-day mortality. DISCUSSION The admission of geriatric patients to the ICU is increasing. Frailty assessment may play an important role in the clinical evaluation of such individuals for triage, but should not be considered a priori as an exclusion criterion for admission.
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Affiliation(s)
- L Pasin
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy.
| | - S Boraso
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - G Golino
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - B S Fakhr
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - I Tiberio
- Department of anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - C Trevisan
- Department of Medicine (DIMED), Geriatric Unit, University of Padova, Italy
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11
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Lei C, Su B, Dong H, Bellavia A, Fenza RD, Fakhr BS, Gianni S, Grassi LG, Kacmarek R, Morais CCA, Pinciroli R, Vassena E, Berra L. Protocol of a randomized controlled trial testing inhaled Nitric Oxide in mechanically ventilated patients with severe acute respiratory syndrome in COVID-19 (SARS-CoV-2). medRxiv 2020:2020.03.09.20033530. [PMID: 32511534 PMCID: PMC7273302 DOI: 10.1101/2020.03.09.20033530] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction Severe acute respiratory syndrome due to novel Coronavirus (SARS-CoV-2) related infection (COVID-19) is characterized by severe ventilation perfusion mismatch leading to refractory hypoxemia. To date, there is no specific treatment available for COVID-19. Nitric oxide is a selective pulmonary vasodilator gas used as a rescue therapy in refractory hypoxemia due to acute respiratory distress syndrome (ARDS). In has also shown invitro and clinical evidence that inhaled nitric oxide gas (iNO) has antiviral activity against other strains of coronavirus. The primary aim of this study is to determine whether inhaled NO improves oxygenation in patients with hypoxic COVID-19. This is a multicenter randomized controlled trial with 1:1 individual allocation. Patients will be blinded to the treatment. Methods and analysis Intubated patients admitted to the intensive care unit with confirmed SARS-CoV-2 infection and severe hypoxemia will be randomized to receive inhalation of NO (treatment group) or not (control group). Treatment will be stopped when patients are free from hypoxemia for more than 24 hours. The primary outcome evaluates levels of oxygenation between the two groups at 48 hours. Secondary outcomes include rate of survival rate at 28 and 90 days in the two groups, time to resolution of severe hypoxemia, time to achieve negativity of SARS-CoV-2 RT-PCR tests. Ethics and dissemination The study protocol has been approved by the Investigational Review Board of Xijing Hospital (Xi'an, China) and by the Partners Human Research Committee (Boston, USA). Recruitment will start after approval of both IRBs and local IRBs at other enrolling centers. Results of this study will be published in scientific journals, presented at scientific meetings, reported through flyers and posters, and published on related website or media in combating against this widespread contagious disease. Trial registration Clinicaltrials.gov. NCT04306393.
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Affiliation(s)
- Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University. Xi’an, Shaanxi, China
| | - Binxiao Su
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University. Xi’an, Shaanxi, China
- Intensive Care Unit, Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University. Xi’an, Shaanxi, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University. Xi’an, Shaanxi, China
| | - Andrea Bellavia
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- University of Milan-Bicocca, Milan-Italy
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Luigi Giuseppe Grassi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert Kacmarek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caio Cesar Araujo Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Riccardo Pinciroli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Vassena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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12
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Lei C, Su B, Dong H, Fakhr BS, Grassi LG, Di Fenza R, Gianni S, Pinciroli R, Vassena E, Morais CCA, Bellavia A, Spina S, Kacmarek R, Berra L. Protocol for a randomized controlled trial testing inhaled nitric oxide therapy in spontaneously breathing patients with COVID-19. medRxiv 2020:2020.03.10.20033522. [PMID: 32511450 PMCID: PMC7239076 DOI: 10.1101/2020.03.10.20033522] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction the current worldwide outbreak of Coronavirus disease 2019 (COVID-19) due to a novel coronavirus (SARS-CoV-2) is seriously threatening the public health. The number of infected patients is continuously increasing and the need for Intensive Care Unit admission ranges from 5 to 26%. The mortality is reported to be around 3.4% with higher values for the elderly and in patients with comorbidities. Moreover, this condition is challenging the healthcare system where the outbreak reached its highest value. To date there is still no available treatment for SARS-CoV-2. Clinical and preclinical evidence suggests that nitric oxide (NO) has a beneficial effect on the coronavirus-mediated acute respiratory syndrome, and this can be related to its viricidal effect. The time from the symptoms' onset to the development of severe respiratory distress is relatively long. We hypothesize that high concentrations of inhaled NO administered during early phases of COVID-19 infection can prevent the progression of the disease. Methods and analysis This is a multicenter randomized controlled trial. Spontaneous breathing patients admitted to the hospital for symptomatic COVID-19 infection will be eligible to enter the study. Patients in the treatment group will receive inhaled NO at high doses (140-180 parts per million) for 30 minutes, 2 sessions every day for 14 days in addition to the hospital care. Patient in the control group will receive only hospital care. The primary outcome is the percentage of patients requiring endotracheal intubation due to the progression of the disease in the first 28 days from enrollment in the study. Secondary outcomes include mortality at 28 days, proportion of negative test for SARS-CoV-2 at 7 days and time to clinical recovery. Ethics and dissemination The trial protocol has been approved at the Investigation Review Boards of Xijing Hospital (Xi'an, China) and The Partners Human Research Committee of Massachusetts General Hospital (Boston, USA) is pending. Recruitment is expected to start in March 2020. Results of this study will be published in scientific journals, presented at scientific meetings, and on related website or media in fighting this widespread contagious disease.
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Affiliation(s)
- Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University. Xi’an, Shaanxi, China
| | - Binxiao Su
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University. Xi’an, Shaanxi, China
- Intensive Care Unit, Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University. Xi’an, Shaanxi, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, the Fourth Military Medical University. Xi’an, Shaanxi, China
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Luigi Giuseppe Grassi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Riccardo Pinciroli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Vassena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caio Cesar Araujo Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrea Bellavia
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stefano Spina
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert Kacmarek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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13
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Gotti M, Chiumello D, Cressoni M, Guanziroli M, Brioni M, Safaee Fakhr B, Chiurazzi C, Colombo A, Massari D, Algieri I, Lonati C, Cadringher P, Taccone P, Pizzocri M, Fumagalli J, Rosso L, Palleschi A, Benti R, Zito F, Valenza F, Gattinoni L. Inflammation and primary graft dysfunction after lung transplantation: CT-PET findings. Minerva Anestesiol 2018; 84:1169-1177. [DOI: 10.23736/s0375-9393.18.12651-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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