Hemodynamic and gas exchange response to inhaled nitric oxide and prone positioning in acute respiratory distress syndrome patients

Borelli, Massimo; Lampati, L.; Vascotto, E; Fumagalli, Roberto; Pesenti, Antonio

doi:10.1097/00003246-200008000-00004

Cited by 42 publications

(14 citation statements)

References 20 publications

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“…Six observational studies involving 85 subjects examined the combined effects of INO and PP on gas exchange and hemodynamics in ARDS. [178][179][180][181][182] In 5 of these studies, the combined therapies had an additive effect in improving oxygenation in subjects with early, severe ARDS of various etiologies. For example, mean P aO 2 or P aO 2 /F IO 2 increased an average of 29% with INO and 47% with PP alone, but when used together, oxygenation improved by an average of 88%.…”

Section: Inhaled Vasodilatorsmentioning

confidence: 99%

“…For example, mean P aO 2 or P aO 2 /F IO 2 increased an average of 29% with INO and 47% with PP alone, but when used together, oxygenation improved by an average of 88%. 25,[179][180][181][182] Furthermore, combining these therapies substantially increased the prevalence of responders over either therapy alone from 54% (INO) and 76% (PP) to 92% for both. 25,179,180,182 Some studies found that PP modestly enhanced the effects of INO in reducing pulmonary vascular resistance 25 or mean pulmonary arterial pressure, 182 whereas others did not.…”

Section: Inhaled Vasodilatorsmentioning

confidence: 99%

“…25,179,180,182 Some studies found that PP modestly enhanced the effects of INO in reducing pulmonary vascular resistance 25 or mean pulmonary arterial pressure, 182 whereas others did not. [179][180][181] An important caveat in interpreting these studies is not only the small number of subjects enrolled (n ϭ 14) but also the fact that both the INO dosage tested (1-13 ppm) and PP time (30 min to 6 h) varied considerably. Although combining these therapies further enhances oxygenation and responder rate, the optimal combination of dose and timing remains unknown.…”

Section: Inhaled Vasodilatorsmentioning

confidence: 99%

See 2 more Smart Citations

A Comprehensive Review of Prone Position in ARDS

2015

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Prone position (PP) has been used since the 1970s to treat severe hypoxemia in patients with ARDS because of its effectiveness at improving gas exchange. Compared with the supine position (SP), placing patients in PP effects a more even tidal volume distribution, in part, by reversing the vertical pleural pressure gradient, which becomes more negative in the dorsal regions. PP also improves resting lung volume in the dorsocaudal regions by reducing the superimposed pressure of both the heart and the abdomen. In contrast, pulmonary perfusion remains preferentially distributed to the dorsal lung regions, thus improving overall alveolar ventilation/perfusion relationships. 1660RESPIRATORY CARE • NOVEMBER 2015 VOL 60 NO 11Moreover, the larger tissue mass suspended from a wider dorsal chest wall effects a more homogeneous distribution of pleural pressures throughout the lung that reduces abnormal strain and stress development. This is believed to ameliorate the severity or development of ventilator-induced lung injury and may partly explain why PP reduces mortality in severe ARDS. Over 40 years of clinical trials have consistently reported improved oxygenation in approximately 70% of subjects with ARDS. Early initiation of PP is more likely to improve oxygenation than initiation during the subacute phase. Maximal oxygenation improvement occurs over a wide time frame ranging from several hours to several days. Meta-analyses of randomized controlled trials suggest that PP provides a survival advantage only in patients with relatively severe ARDS (P aO 2 /F IO 2 <150 mm Hg). Moreover, survival is enhanced when patients are managed with a smaller tidal volume (<8 mL/kg), higher PEEP (10 -13 cm H 2 O), and longer duration of PP sessions (>10 -12 h/session). Combining adjunctive therapies (high PEEP, recruitment maneuvers, and inhaled vasodilators) with PP has an additive effect in improving oxygenation and may be particularly helpful in stabilizing gas exchange in very severe ARDS.

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Section: Inhaled Vasodilatorsmentioning

confidence: 99%

Section: Inhaled Vasodilatorsmentioning

confidence: 99%

Section: Inhaled Vasodilatorsmentioning

confidence: 99%

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A Comprehensive Review of Prone Position in ARDS

2015

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“…Clinical studies have shown that INO improves arterial oxygenation and reduces pulmonary artery pressure in adults with ARDS [81][82][83][84][85][86][87][88][89] and in infants or children with acute respiratory failure [90][91][92][93][94][95][96]. The efficacy of INO has also been reported to be additive with those of PEEP [97] and patient prone positioning [98].…”

Section: Inhaled Nitric Oxide (Ino)-nitricmentioning

confidence: 99%

Pharmacotherapy of Acute Lung Injury and Acute Respiratory Distress Syndrome

Raghavendran¹,

Pryhuber²,

Chess³

et al. 2008

CMC

111

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Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) are characterized by rapid-onset respiratory failure following a variety of direct and indirect insults to the parenchyma or vasculature of the lungs. Mortality from ALI/ARDS is substantial, and current therapy primarily emphasizes mechanical ventilation and judicial fluid management plus standard treatment of the initiating insult and any known underlying disease. Current pharmacotherapy for ALI/ARDS is not optimal, and there is a significant need for more effective medicinal chemical agents for use in these severe and lethal lung injury syndromes. To facilitate future chemical-based drug discovery research on new agent development, this paper reviews present pharmacotherapy for ALI/ARDS in the context of biological and biochemical drug activities. The complex lung injury pathophysiology of ALI/ ARDS offers an array of possible targets for drug therapy, including inflammation, cell and tissue injury, vascular dysfunction, surfactant dysfunction, and oxidant injury. Added targets for pharmacotherapy outside the lungs may also be present, since multiorgan or systemic pathology is common in ALI/ARDS. The biological and physiological complexity of ALI/ARDS requires the consideration of combined-agent treatments in addition to single-agent therapies. A number of pharmacologic agents have been studied individually in ALI/ARDS, with limited or minimal success in improving survival. However, many of these agents have complementary biological/biochemical activities with the potential for synergy or additivity in combination therapy as discussed in this article.

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“…Different attempts were made to classify patients early as responders or non-responders [5,38]. Vollman and Bander [39] found responders to have lower airway pressures and a lower partial pressure of arterial CO 2 (Paco 2 ) than non-responders.…”

Section: Responders/non-respondersmentioning

confidence: 99%

Non-invasive measurement of pulmonary blood flow during prone positioning in patients with early acute respiratory distress syndrome

et al. 2004

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In the daily clinical routine at the bedside, information on effective pulmonary blood flow (PBF) is limited and requires invasive monitoring, including a pulmonary artery catheter, to determine both cardiac output and intrapulmonary shunt. Therefore we evaluated a non-invasive method for the measurement of PBF in a clinical setting, including 12 patients with acute respiratory failure (acute respiratory distress syndrome) undergoing prone positioning. PBF was determined before (baseline), during and after prone positioning, by using a foreign gas rebreathing method with a new photoacoustic gas analyser. Values were compared with the cardiac output corrected for intrapulmonary shunt (COeff). Responders to prone positioning were defined according to the improvement of arterial oxygenation. A total of 84 measurements were performed. PBF values correlated well with COeff (R2=0.96; P<0.0001). Bias and limits of agreement (+/- 2 S.D.) for all measurements were -0.11 +/- 0.76 litre/min. At baseline, responders showed significantly lower PBF levels than non-responders (4.8 +/- 1.0 compared with. 6.4 +/- 1.2 litre/min; P=0.03). During prone positioning, PBF increased continuously in responders and remained high after patients had been returned to the supine position. PBF was unaffected in non-responders. Mean total increase in PBF was 1.2 +/- 0.2 litre/min in responders compared with -0.4 +/- 0.2 litre/min in non-responders (P<0.0001). In conclusion, the investigated rebreathing system allows for a non-invasive determination of PBF at the bedside. The accuracy of the measurements is comparable with the thermodilution method. It is able to reliably reflect changes in PBF induced by prone positioning. Moreover, measuring PBF might be a promising tool to identify responders to prone therapy.

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Hemodynamic and gas exchange response to inhaled nitric oxide and prone positioning in acute respiratory distress syndrome patients

Cited by 42 publications

References 20 publications

A Comprehensive Review of Prone Position in ARDS

A Comprehensive Review of Prone Position in ARDS

Pharmacotherapy of Acute Lung Injury and Acute Respiratory Distress Syndrome

Non-invasive measurement of pulmonary blood flow during prone positioning in patients with early acute respiratory distress syndrome

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