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2022, Number 4

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Med Crit 2022; 36 (4)

Effect of inhaled nitric oxide on ventilatory mechanics and oxygenation of patients with severe hypoxemia refractory to prolonged prone and neuromuscular blockade secondary to SARS-CoV-2

Castro SA, Sánchez CA, Aguirre SJS, Chaires GR, Hernández SN

Language: Spanish
References: 52
Page: 202-209
PDF size: 250.47 Kb.


ABSTRACT

Introduction: Among the patients infected with SARS-CoV-2, 14.6% were admitted to intensive care unit. this 29 to 75% required invasive mechanical ventilation with an associated mortality of 12 to 81%. Acute respiratory distress syndrome (ARDS) is the most serious form of presentation. The pathophysiology of ARDS secondary to SARS-CoV-2 differs from conventional causes. It presents dysregulation in hypoxic pulmonary vasoconstriction, secondary acute pulmonary hypertension and microthrombotic phenomena. The development of refractory severe hypoxemia (PaO2 < 60 mmHg or PaO2/FiO2 < 100 mmHg, with FiO2 80 to 100%, with PEEP > 10 to 20 cmH2O for at least 10 to 12 hours) constitutes the scenario of maximum severity with an associated mortality of 71 to 94%. The use of rescue strategies that impact on the specific pathophysiology of this entity such as the use of inhaled nitric oxide, neuromuscular blockade and prone ventilation have emerged as therapeutic targets of interest. Protective mechanical ventilation (plateau pressure [Pplat] < 27 cmH2O and driving pressure [DP] < 15 cmH2O) continues to be the cornerstone of the management. Objectives: To determine whether there is an association between the use of inhaled nitric oxide and prone ventilation with ventilatory mechanics in patients with severe refractory hypoxemia secondary to SARS-CoV-2 infection. Material and methods: A historical, retrospective, descriptive, comparative and retrolective cohort study was carried out. Data from the records of patients admitted to the Respiratory ICU of the ABC Medical Center with a diagnosis of ARDS secondary to SARS-CoV-2 infection who required iNO and mechanical ventilation in prone from April 1 to December 31, 2020 were analyzed. A univariate analysis was performed, the statistical analysis was performed in SPSS v 21, measures of trend, dispersion were analyzed as well as the analysis of risk factors with Student's t test and χ2. Results: A total of 108 patients were analyzed, of which 54 received iNO, neuromuscular blockade and prone and 54 only neuromuscular blockade and prone ventilation. 81.5% (n = 88) were men. The most common comorbidity was diabetes mellitus in 51.9% (n = 56). The increase in oxygenation (delta PaO2/FiO2) was with a median of 31.9 ± 15.2 mmHg in the iNO group and 52.9 ± 16.74 mmHg in the control group (p = 0.001). The postintervention Pplat in the iNO group was 26.3 ± 3 and 34.5 ± 1.9 cmH2O in the control group (p = 0.792). The preintervention DP in the iNO group was 17.2 ± 3.9 and 13.4 ± 2.8 cmH2O in control group vs 13.1 ± 1.29 and 12 ± 1.92 cmH2O after the intervention (p = 0.001). Conclusions: The use of iNO in patients with severe hypoxemia refractory to prone ventilation and neuromuscular blockade did not produce a statistically significant improvement in oxygenation, however it allowed to reprogram the ventilatory support to keep the patient in goals of alveolar protection.


REFERENCES

  1. Li J, Huang DQ, Zou B, Yang H, Hui WZ, Rui F, et al. Epidemiology of COVID-19: a systematic review and meta-analysis of clinical characteristics, risk factors, and outcomes. J Med Virol. 2021;93(3):1449-1458.

  2. WHO. Coronavirus disease [Internet]. Geneva: World Heal Organization; 2020. p. 2633.

  3. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York city area. JAMA. 2020;323(20):2098.

  4. Ioannidis JPA. Global perspective of COVID-19 epidemiology for a full-cycle pandemic. Eur J Clin Invest. 2020;50(12):e13423.

  5. Parra-Bracamonte GM, Lopez-Villalobos N, Parra-Bracamonte FE. Clinical characteristics and risk factors for mortality of patients with COVID-19 in a large data set from Mexico. Ann Epidemiol. 2020;52:93-98.e2.

  6. Ramírez P, Gordón M, Martín-Cerezuela M, Villarreal E, Sancho E, Padrós M, et al. Acute respiratory distress syndrome due to COVID-19. Clinical and prognostic features from a medical Critical Care Unit in Valencia, Spain. Med Intensiva (Engl Ed). 2021;45(1):27-34.

  7. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet. 1967;2(7511):319-323.

  8. Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis. 1988;138(3):720-723.

  9. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;149(3 Pt 1):818-824.

  10. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526-2533.

  11. Thompson BT, Chambers RC, Liu KD. Acute respiratory distress syndrome. N Engl J Med. 2017;377(19):1904-1905.

  12. Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020;46(6):1099-1102.

  13. Thille AW, Esteban A, Fernández-Segoviano P, Rodriguez JM, Aramburu JA, Vargas-Errázuriz P, et al. Chronology of histological lesions in acute respiratory distress syndrome with diffuse alveolar damage: a prospective cohort study of clinical autopsies. Lancet Respir Med. 2013;1(5):395-401.

  14. Sweeney RM, McAuley DF. Acute respiratory distress syndrome. Lancet. 2016;388(10058):2416-2430.

  15. Frank JA, Wray CM, McAuley DF, Schwendener R, Matthay MA. Alveolar macrophages contribute to alveolar barrier dysfunction in ventilator-induced lung injury. Am J Physiol Lung Cell Mol Physiol. 2006;291(6):L1191-L1198.

  16. Dunham-Snary KJ, Wu D, Sykes EA, Thakrar A, Parlow LRG, Mewburn JD, et al. Hypoxic pulmonary vasoconstriction: from molecular mechanisms to medicine. Chest. 2017;151(1):181-192.

  17. Derwall M, Martin L, Rossaint R. The acute respiratory distress syndrome: pathophysiology, current clinical practice, and emerging therapies. Expert Rev Respir Med. 2018;12(12):1021-1029.

  18. Rocco PR, Dos Santos C, Pelosi P. Lung parenchyma remodeling in acute respiratory distress syndrome. Minerva Anestesiol. 2009;75(12):730-740.

  19. Lamm WJ, Starr IR, Neradilek B, Polissar NL, Glenny RW, Hlastala MP. Hypoxic pulmonary vasoconstriction is heterogeneously distributed in the prone dog. Respir Physiol Neurobiol. 2004;144(2-3):281-294.

  20. Karmouty-Quintana H, Thandavarayan RA, Keller SP, Sahay S, Pandit LM, Akkanti B. Emerging mechanisms of pulmonary vasoconstriction in sars-cov-2-induced acute respiratory distress syndrome (ARDS) and potential therapeutic targets. Int J Mol Sci. 2020;21(21):8081.

  21. Talbot NP, Balanos GM, Dorrington KL, Robbins PA. Two temporal components within the human pulmonary vascular response to approximately 2 h of isocapnic hypoxia. J Appl Physiol (1985). 2005;98(3):1125-1139.

  22. Vieillard-Baron A, Schmitt JM, Augarde R, Fellahi JL, Prin S, Page B, et al. Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis. Crit Care Med. 2001;29(8):1551-1555.

  23. Amato MBP, Barbas CSV, Medeiros DM, Magaldi RB, Schettino GDP, Filho GL, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347-354.

  24. Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):69.

  25. Jardin F, Dubourg O, Bourdarias JP. Echocardiographic pattern of acute cor pulmonale. Chest. 1997;111(1):209-217.

  26. Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865-873.

  27. Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-2168.

  28. Lim CM, Kim EK, Lee JS, Shim TS, Lee SD, Koh Y, et al. Comparison of the response to the prone position between pulmonary and extrapulmonary acute respiratory distress syndrome. Intensive Care Med. 2001;27(3):477-485.

  29. Pelosi P, Croci M, Calappi E, Mulazzi D, Cerisara M, Vercesi P, et al. Prone positioning improves pulmonary function in obese patients during general anesthesia. Anesth Analg. 1996;83(3):578-583.

  30. Kaneko K, Milic-Emili J, Dolovich MB, Dawson A, Bates DV. Regional distribution of ventilation and perfusion as a function of body position. J Appl Physiol. 1966;21(3):767-777.

  31. Moerer O, Tonetti T, Quintel M. Rescue therapies for acute respiratory distress syndrome: what to try first? Curr Opin Crit Care. 2017;23(1):52-59.

  32. Piehl MA, Brown RS. Use of extreme position changes in acute respiratory failure. Crit Care Med. 1976;4(1):13-14.

  33. Dellinger RP, Zimmerman JL, Taylor RW, Straube RC, Hauser DL, Criner GJ, et al. Effects of inhaled nitric oxide in patients with acute respiratory distress syndrome: results of a randomized phase II trial. Inhaled Nitric Oxide in ARDS Study Group. Crit Care Med. 1998;26(1):15-23.

  34. Froese AB. Gravity, the belly, and the diaphragm: you can't ignore physics. Anesthesiology. 2006;104(1):193-196.

  35. Glenny RW, Robertson HT. Spatial distribution of ventilation and perfusion: mechanisms and regulation. Compr Physiol. 2011;1(1):375-395.

  36. Johannigman JA, Davis K Jr, Miller SL, Campbell RS, Luchette FA, Frame SB, et al. Prone positioning for acute respiratory distress syndrome in the surgical intensive care unit: who, when, and how long? Surgery. 2000;128(4):708-716.

  37. Papazian L, Paladini MH, Bregeon F, Huiart L, Thirion X, Saux P, et al. Is a short trial of prone positioning sufficient to predict the improvement in oxygenation in patients with acute respiratory distress syndrome? Intensive Care Med. 2001;27(6):1044-1049.

  38. Moncada S, Higgs A. The L-arginine-nitric oxide pathway. N Engl J Med. 1993;329(27):2002-2012.

  39. Griffiths MJ, Evans TW. Inhaled nitric oxide therapy in adults. N Engl J Med. 2005;353(25):2683-2695.

  40. Wang X, Tanus Santos JE, Reiter CD, Dejam A, Shiva S, Smith RD, et al. Biological activity of nitric oxide in the plasmatic compartment. Proc Natl Acad Sci U S A. 2004;101(31):11477-11482.

  41. Gebistorf F, Karam O, Wetterslev J, Afshari A. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database Syst Rev. 2016;(6):CD002787.

  42. Gerlach H, Keh D, Semmerow A, Busch T, Lewandowski K, Pappert DM, et al. Dose response characteristics during long term inhalation of nitric oxide in patients with severe acute respiratory distress syndrome: a prospective, randomized, controlled study. Am J Respir Crit Care Med. 2003;167(7):1008-1015.

  43. Cuthbertson BH, Dellinger P, Dyar OJ, et al. UK guidelines for the use of inhaled nitric oxide therapy in adult ICUs: Ameri- can-European Consensus Conference on ALI/ARDS. Intensive Care Med. 1997;23:1212-1218.

  44. Gerlach H, Rossaint R, Pappert D, Falke KJ. Time-course and dose-response of nitric oxide inhalation for systemic oxygenation and pulmonary hypertension in patients with adult respiratory distress syndrome. Eur J Clin Invest. 1993;23:499-502.

  45. Feng WX, Yang Y, Wen J, Liu YX, Liu L, Feng C. Implication of inhaled nitric oxide for the treatment of critically ill COVID-19 patients with pulmonary hypertension. ESC Heart Fail. 2021;8(1):714-718.

  46. Taylor MB, Christian KG, Patel N, Churchwell KB. Methemoglobinemia: toxicity of inhaled nitric oxide therapy. Pediatr Crit Care Med. 2001;2:99-101.

  47. Lundin S, Mang H, Smithies M, Stenqvist O, Frostell C. Inhalation of nitric oxide in acute lung injury: results of a European multicentre study. The European Study Group of Inhaled Nitric Oxide. Intensive Care Med. 1999;25(9):911-919.

  48. Michael JR, Barton RG, Saffle JR, Mone M, Markewitz BA, Hillier K, et al. Inhaled nitric oxide versus conventional therapy: effect on oxygenation in ARDS. Am J Respir Crit Care Med. 1998;157(5 Pt 1):1372-1380.

  49. Park KJ, Lee YJ, Oh YJ, Lee KS, Sheen SS, Hwang SC. Combined effects of inhaled nitric oxide and a recruitment maneuver in patients with acute respiratory distress syndrome. Yonsei Med J. 2003;44(2):219-226.

  50. Taylor RW, Zimmerman JL, Dellinger RP, Straube RC, Criner GJ, Davis K Jr, et al. Low dose inhaled nitric oxide in patients with acute lung injury: a randomized controlled trial. JAMA. 2004;291(13):1603-1609.

  51. Lotz C, Muellenbach RM, Meybohm P, Mutlak H, Lepper PM, Rolfes CB, et al. Effects of inhaled nitric oxide in COVID-19-induced ARDS - Is it worthwhile? Acta Anaesthesiol Scand. 2021;65(5):629-632.

  52. Weinberger B, Heck DE, Laskin DL, Laskin JD. Nitric oxide in the lung: therapeutic and cellular mechanisms of action. Pharmacol Ther. 1999;84(3):401-411.




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