Comparison of Acute Hemodynamic Effects of Inhaled Nitric Oxide and Inhaled Epoprostenol in Patients with Pulmonary Hypertension

Preston, Ioana R.; Sagliani, Kristen D.; Roberts, Kari E.; Shah, Amish P.; DeSouza, Shilpa A.; Howard, William R; Brennan, John; Hill, Nicholas S.

doi:10.4103/2045-8932.109916

Cited by 26 publications

(25 citation statements)

References 17 publications

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“…PDNO, in contrast to iNO, caused systemic effects, but the systemic pressure remained at an acceptable clinical level and the systemic resistance did not decrease significantly. The PVR:SVR ratio, used as a measurement of pulmonary selectivity in prior studies, 43,50 decreased to baseline values, thus supporting that the main vasodilatory effect of PDNO in the present models was in the pulmonary circulation. This pilot study has limitations.…”

Section: Discussionsupporting

confidence: 80%

<p>A Comparative Study of Inhaled Nitric Oxide and an Intravenously Administered Nitric Oxide Donor in Acute Pulmonary Hypertension</p>

Hurtsén

Nilsson

Dogan

et al. 2020

DDDT

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Purpose: Inhaled nitric oxide (iNO) selectively vasodilates the pulmonary circulation but the effects are sometimes insufficient. Available intravenous (iv) substances are non-selective and cause systemic side effects. The pulmonary and systemic effects of iNO and an iv mono-organic nitrite (PDNO) were compared in porcine models of acute pulmonary hypertension. Methods: In anesthetized piglets, dose-response experiments of iv PDNO at normal pulmonary arterial pressure (n=10) were executed. Dose-response experiments of iv PDNO (n=6) and iNO (n=7) were performed during pharmacologically induced pulmonary hypertension (U46619 iv). The effects of iv PDNO and iNO were also explored in 5 mins of hypoxia-induced increase in pulmonary pressure (n=2-4). Results: PDNO (15, 30, 45 and 60 nmol NO kg −1 min −1 iv) and iNO (5, 10, 20 and 40 ppm which corresponded to 56, 112, 227, 449 nmol NO kg −1 min −1 , respectively) significantly decreased the U46619-increased mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance (PVR) to a similar degree without significant decreases in mean arterial pressure (MAP) or systemic vascular resistance (SVR). iNO caused increased levels of methemoglobin. At an equivalent delivered NO quantity (iNO 5 ppm and PDNO 45 nmol kg −1 min −1 iv), PDNO decreased PVR and SVR significantly more than iNO. Both drugs counteracted hypoxia-induced pulmonary vasoconstriction and they decreased the ratio of PVR and SVR in both settings. Conclusion: Intravenous PDNO was a more potent pulmonary vasodilator than iNO in pulmonary hypertension, with no severe side effects. Hence, this study supports the potential of iv PDNO in the treatment of acute pulmonary hypertension.

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Section: Discussionsupporting

confidence: 80%

<p>A Comparative Study of Inhaled Nitric Oxide and an Intravenously Administered Nitric Oxide Donor in Acute Pulmonary Hypertension</p>

Hurtsén

Nilsson

Dogan

et al. 2020

DDDT

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“…Inhaled nitric oxide (iNO) (Ikaria, Hampton, New Jersey) was administered via an inline system at 20 parts per million for 10 min as previously described (17,18). Measurements of PAP, PAWP, and CO were performed after 10 min on iNO.…”

Section: Methodsmentioning

confidence: 99%

Pulmonary Arterial Capacitance Is an Important Predictor of Mortality in Heart Failure With a Preserved Ejection Fraction

Al‐Naamani

Preston

Paulus

et al. 2015

JACC: Heart Failure

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145

129

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OBJECTIVES The purpose of this study was to determine the predictors of mortality in patients with pulmonary hypertension (PH) associated with heart failure with preserved ejection fraction (HFpEF). BACKGROUND PH is commonly associated with HFpEF. The predictors of mortality for patients with these conditions are not well characterized. METHODS In a prospective cohort of patients with right heart catheterization, we identified 73 adult patients who had pulmonary hypertension due to left heart disease (PH-LHD) associated with HFpEF (left ventricular ejection fraction ≥50% by echocardiography); hemodynamically defined as a mean pulmonary artery pressure ≥25 mm Hg and pulmonary artery wedge pressure >15 mm Hg. PH severity was classified according to the diastolic pressure gradient (DPG). Cox proportional hazards ratios were used to estimate the associations between clinical variables and mortality. Receiver-operating characteristic curves were used to evaluate the ability of hemodynamic measurements to predict mortality. RESULTS The mean age for study subjects was 69 ± 12 years and 74% were female. Patients classified as having combined post-capillary PH and pre-capillary PH (DPG ≥7) were not at increased risk of death as compared to patients with isolated post-capillary PH (DPG <7). A baseline pulmonary arterial capacitance (PAC) of <1.1 ml/mm Hg was 91% sensitive in predicting mortality, with better discriminatory ability than DPG, transpulmonary gradient, or pulmonary vascular resistance (area under the curve of 0.73, 0.50, 0.45, and 0.37, respectively). Fifty-seven subjects underwent acute vasoreactivity testing with inhaled nitric oxide. Acute vasodilator response by the Rich or Sitbon criteria was not associated with improved survival. CONCLUSIONS PAC is the best predictor of mortality in our cohort and may be useful in describing phenotypic subgroups among those with PH-LHD associated with HFpEF. Acute vasodilator testing did not predict outcome in our cohort but needs to be further investigated.

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“…Inhaled epoprostenol (iEPO) is a pulmonary vasodilator which has been used off-label to treat pulmonary hypertension in the United States for over 15 years [1]. Inhaled epoprostenol has shown similar effectiveness in reducing pulmonary arterial pressure and improving oxygenation as inhaled nitric oxide (iNO) among mechanically ventilated patients [2][3][4][5][6][7]. Compared to iNO, iEPO is cost-saving and has become a common treatment in clinical practice.…”

Section: Introductionmentioning

confidence: 99%

“…Compared to iNO, iEPO is cost-saving and has become a common treatment in clinical practice. Due to its short half-life, iEPO is continuously delivered for extended periods of time (usually > 24 h), which becomes a challenge for spontaneous breathing patients, as conventional aerosol therapy via mouthpiece or mask for a long duration is uncomfortable and impossible to maintain [4]. Transnasal pulmonary delivery of iEPO via high-flow nasal cannula (HFNC) provides a feasible route, which has been shown to deliver sufficient dose to elicit a clinical response [8,9].…”

Section: Introductionmentioning

confidence: 99%

The Clinical Impact of Flow Titration on Epoprostenol Delivery via High Flow Nasal Cannula for ICU Patients with Pulmonary Hypertension or Right Ventricular Dysfunction: A Retrospective Cohort Comparison Study

Gurnani

Roberts

et al. 2020

JCM

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1) Background: inhaled epoprostenol (iEPO) delivered via high-flow nasal cannula (HFNC) has been reported to be effective for pulmonary hypertension and right ventricular dysfunction. In vitro studies have identified HFNC gas flow as a key factor in trans-nasal aerosol delivery efficiency; however, little evidence is available on the clinical impact of flow titration on trans-nasal aerosol delivery. At our institution, iEPO via HFNC was initiated in 2015 and the concept of flow titration during iEPO via HFNC has been gradually accepted and carried out by clinicians in the recent years.(2) Methods: a retrospective review of the electronic medical records for all adult patients who received iEPO via HFNC in a tertiary teaching hospital. Pre-and post-iEPO responses were reported for patients whose HFNC flow was titrated or maintained constant during iEPO delivery. Positive response to iEPO was defined as the reduction of mean pulmonary arterial pressure (mPAP) > 10% for pulmonary hypertension patients or the improvement of oxygenation [pulse oximetry (SpO 2 )/fraction of inhaled oxygen (F I O 2 )] > 20%. The number of responders to iEPO was compared between groups with titrated vs constant flow. (3) Results: 51 patients who used iEPO to treat pulmonary hypertension and/or right ventricular dysfunction were reviewed. Following iEPO administration via HFNC, mPAP decreased (43.6 ± 11.7 vs. 36.3 ± 9.7 mmHg, p < 0.001). Among the 51 patients, 24 had concomitant refractory hypoxemia, their oxygenation (SpO 2 /F I O 2 ) improved after iEPO delivery (127.8 ± 45.7 vs. 157.6 ± 62.2, p < 0.001). During iEPO initiation, gas flow was titrated in 25 patients and the remaining 26 patients used constant flow. The percentage of patients in the flow titration group who met the criteria for a positive response was higher compared to the group with constant flow (85.7% vs. 50%, p = 0.035). Pre-vs post-iEPO responses were significant in the flow titration group included improvement in cardiac output (p = 0.050), cardiac index (p = 0.021) and F I O 2 reduction (p = 0.016). These improvements in hemodynamics and F I O 2 were not observed in the constant flow group. (4) Conclusion: in patients with pulmonary hypertension and/or right ventricular dysfunction, trans-nasal iEPO decreased pulmonary arterial pressure. It also improved oxygenation in patients with combined refractory hypoxemia. These improvements were more evident in patients whose gas flow was titrated during iEPO initiation than those patients using constant flow.

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Comparison of Acute Hemodynamic Effects of Inhaled Nitric Oxide and Inhaled Epoprostenol in Patients with Pulmonary Hypertension

Cited by 26 publications

References 17 publications

<p>A Comparative Study of Inhaled Nitric Oxide and an Intravenously Administered Nitric Oxide Donor in Acute Pulmonary Hypertension</p>

<p>A Comparative Study of Inhaled Nitric Oxide and an Intravenously Administered Nitric Oxide Donor in Acute Pulmonary Hypertension</p>

Pulmonary Arterial Capacitance Is an Important Predictor of Mortality in Heart Failure With a Preserved Ejection Fraction

The Clinical Impact of Flow Titration on Epoprostenol Delivery via High Flow Nasal Cannula for ICU Patients with Pulmonary Hypertension or Right Ventricular Dysfunction: A Retrospective Cohort Comparison Study

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