Sildenafil May Facilitate Weaning in Mechanically Ventilated COPD Patients: A Report of Three Cases

Stanopoulos, Ioannis; Manolakoglou, N.; Pitsiou, Georgia; Trigonis, Ioannis; Ea, Tsiata; Ak, Boutou; Pk, Kontou; Argyropoulou, Paraskevi

doi:10.1177/0310057x0703500425

Cited by 10 publications

(8 citation statements)

References 18 publications

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“…However, nitroglycerin has been tested previously in stable or mechanically ventilated COPD patients with chronic pulmonary hypertension [27-29]; in accordance with our findings, nitroglycerin decreased mean pulmonary arterial pressure in stable mechanically ventilated COPD patients [28] and decreased both mean pulmonary arterial pressure and right ventricular stroke work in mechanically ventilated COPD patients [29]. In a recent anecdotal report, another type of vasodilator therapy (that is, phosphodiesterase 5 inhibitors [sildenafil]) was used to facilitate weaning in three difficult-to-wean COPD patients [30]. …”

Section: Discussionsupporting

confidence: 75%

Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study

et al. 2010

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IntroductionBoth experimental and clinical data give convincing evidence to acute cardiac dysfunction as the origin or a cofactor of weaning failure in patients with chronic obstructive pulmonary disease. Therefore, treatment targeting the cardiovascular system might help the heart to tolerate more effectively the critical period of weaning. This study aims to assess the hemodynamic, respiratory and clinical effects of nitroglycerin infusion in difficult-to-wean patients with severe chronic obstructive pulmonary disease.MethodsTwelve difficult-to-wean (failed ≥ 3 consecutive trials) chronic obstructive pulmonary disease patients, who presented systemic arterial hypertension (systolic blood pressure ≥ 140mmHg) during weaning failure and had systemic and pulmonary artery catheters in place, participated in this prospective, interventional, non-randomized clinical trial. Patients were studied in two consecutive days, i.e., the first day without (Control day) and the second day with (Study day) nitroglycerin continuous intravenous infusion starting at the beginning of the spontaneous breathing trial, and titrated to maintain normal systolic blood pressure. Hemodynamic, oxygenation and respiratory measurements were performed on mechanical ventilation, and during a 2-hour T-piece spontaneous breathing trial. Primary endpoint was hemodynamic and respiratory effects of nitroglycerin infusion. Secondary endpoint was spontaneous breathing trial and extubation outcome.ResultsCompared to mechanical ventilation, mean systemic arterial pressure, rate-pressure product, mean pulmonary arterial pressure, and pulmonary artery occlusion pressure increased [from (mean ± SD) 94 ± 14, 13708 ± 3166, 29.9 ± 4.8, and 14.8 ± 3.8 to 109 ± 20mmHg, 19856 ± 4877mmHg b/min, 41.6 ± 5.8mmHg, and 23.4 ± 7.4 mmHg, respectively], and mixed venous oxygen saturation decreased (from 75.7 ± 3.5 to 69.3 ± 7.5%) during failing trials on Control day, whereas they did not change on Study day. Venous admixture increased throughout the trial on both Control day and Study day, but this increase was lower on Study day. Whereas weaning failed in all patients on Control day, nitroglycerin administration on Study day enabled a successful spontaneous breathing trial and extubation in 92% and 88% of patients, respectively.ConclusionsIn this clinical setting, nitroglycerin infusion can expedite the weaning by restoring weaning-induced cardiovascular compromise.

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Section: Discussionsupporting

confidence: 75%

Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study

et al. 2010

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“…In almost all studies of weaning failure of cardiovascular origin, systolic blood pressure increased immediately after the start of an unsuccessful SBT [6, 15, 18, 19, 44]. As it has been shown by Jubran et al this rise in systolic blood pressure during unsuccessful SBTs was associated with a lack of change in cardiac index, implying an increase in LV afterload [44].…”

Section: Treatment Strategies In Weaning Failure Of Cardiovascular Ormentioning

confidence: 99%

“…Phosphodiesterase-5 inhibitors have been used in selected mechanically ventilated patients with pulmonary hypertension and difficult weaning in order to take advantage of their short-term acute vasodilatory effects on pulmonary circulation. The first report included three COPD patients with repeated SBT failures [19]. These patients received 50 mg of sildenafil through the nasogastric tube under respiratory and hemodynamic monitoring with a pulmonary artery catheter.…”

Section: Treatment Strategies In Weaning Failure Of Cardiovascular Ormentioning

confidence: 99%

Weaning failure of cardiovascular origin: how to suspect, detect and treat—a review of the literature

Routsi¹,

Stanopoulos²,

Kokkoris³

et al. 2019

Ann. Intensive Care

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Among the multiple causes of weaning failure from mechanical ventilation, cardiovascular dysfunction is increasingly recognized as a quite frequent cause that can be treated successfully. In this review, we summarize the contemporary evidence of the most important clinical and diagnostic aspects of weaning failure of cardiovascular origin with special focus on treatment. Pathophysiological mechanisms are complex and mainly include increase in right and left ventricular preload and afterload and potentially induce myocardial ischemia. Patients at risk include those with preexisting cardiopulmonary disease either known or suspected. Clinically, cardiovascular etiology as a predominant cause or a contributor to weaning failure, though critical for early diagnosis and intervention, may be difficult to be recognized and distinguished from noncardiac causes suggesting the need of high suspicion. A cardiovascular diagnostic workup including bedside echocardiography, lung ultrasound, electrocardiogram and biomarkers of cardiovascular dysfunction or other adjunct techniques and, in selected cases, right heart catheterization and/or coronary angiography, should be obtained to confirm the diagnosis. Official clinical practice guidelines that address treatment of a confirmed weaning-induced cardiovascular dysfunction do not exist. As the etiologies of weaning-induced cardiovascular dysfunction are diverse, principles of management depend on the individual pathophysiological mechanisms, including preload optimization by fluid removal, guided by B-type natriuretic peptide measurement, nitrates administration in excessive afterload and/or myocardial ischemia, contractility improvement in severe systolic dysfunction as well as other rational treatment in specific indications in order to lead to successful weaning from mechanical ventilation.

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“…While selective pulmonary vasodilation may benefit chronic obstructive pulmonary disease patients with increased pulmonary artery pressure during stress [4], this study was not designed to prove such an effect of bosentan. The pathophysiology of exercise limitation in severe chronic obstructive pulmonary disease subjects and the ventilation/perfusion ratio mismatching, which is induced by unselective pulmonary vasodilation [5], should have been taken more seriously under consideration in the study design of STOLZ et al [1].…”

mentioning

confidence: 99%

“…Thus it was suggested that PH-specific treatment first be studied in the subgroup of patients identified by CHAOUAT et al [3], with severe disproportionate PH [4,5], arbitrarily defined by a mean pulmonary arterial pressure (P pa) of .40 mmHg [3].…”

mentioning

confidence: 99%

To the Editors

Boutou¹,

Stanopoulos²,

Pitsiou³

et al. 2009

Eur Respir J

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To the Editors:After great development in the knowledge of pulmonary arterial hypertension (PAH) during the last decades, there is now an increasing interest in the pathophysiology of other forms of pulmonary hypertension, such as chronic obstructive pulmonary disease (COPD). The results obtained in the study by STOLZ et al. [1] have shown that for an average COPD Global Initiative for Chronic Obstructive Lung Disease stage III-IV population, the use of bosentan is not related to a significant improvement in exercise capacity and is associated with worsening of ventilation-perfusion mismatch. Although it is the first randomised study to address the use of bosentan, a proven PAH specific therapy, in the setting of COPD, the study design may lead to misinterpretation of the results. The study was not designed to treat COPD associated pulmonary hypertension. Furthermore, the absence of invasive measurements did not allow a proper subgroup analysis that could provide further support for the use of specific PAH therapy in the treatment of ''disproportional'' pulmonary hypertension associated with COPD. It is well known that most patients who present with pulmonary hypertension in the setting of COPD and other diseases actually have other associated causes for pulmonary hypertension development rather than an idiopathic PAH-like disease [2, 3], for instance, frequently presenting with some degree of left ventricle dysfunction. Since the study did not perform invasive haemodynamic assessment of the COPD patients, no assumption about a possible presence of post-capillary impairment, a situation in which bosentan has shown no effect so far [4], could be made.Another matter of debate is the use of an echocardiogram to assess the presence of pulmonary hypertension in patients with severe COPD, since the technical difficulties in this specific clinical presentation have shown to impair the accuracy of this methodology.In summary, we believe the authors have addressed an important question, but due to the chosen study design we remain with more questions than answers about the use of specific pulmonary arterial hypertension therapy in the setting of chronic obstructive pulmonary disease. hemodynamic effects of bosentan dose optimization in symptomatic heart failure patients with severe systolic dysfunction, associated with secondary pulmonary hypertension-a multi-center randomized study.

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Sildenafil May Facilitate Weaning in Mechanically Ventilated COPD Patients: A Report of Three Cases

Cited by 10 publications

References 18 publications

Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study

Nitroglycerin can facilitate weaning of difficult-to-wean chronic obstructive pulmonary disease patients: a prospective interventional non-randomized study

Weaning failure of cardiovascular origin: how to suspect, detect and treat—a review of the literature

To the Editors

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