Inhaled Nitric Oxide as Salvage Therapy in Massive Pulmonary Embolism: A Case Series

Abstract

Inhaled nitric oxide (INO) has been shown to preferentially lower resistance in the pulmonary vasculature. The relative selectiveness of INO in accomplishing this effect makes it an attractive drug to administer as salvage therapy in patients with acute right ventricular failure secondary to pulmonary embolism. We describe 4 cases in which INO was used as a temporizing agent to decrease right ventricular after-load following massive near-fatal pulmonary embolism. All 4 patients survived to hospital discharge. Key words: massive pulmonary embolism; acute cor pulmonale; right heart failure; inhaled nitric oxide. [Respir Care 2012;57(3):444 -448. © 2012 Daedalus Enterprises]

Beneficial effects of inhaled NO on apoptotic pneumocytes in pulmonary thromboembolism model

“…The treatment with inhaled nitric oxide(NO) has been advocated to improve RPE after pulmonary suction thrombectomy and pulmonary thromboendarterectomy for chronic PTE [13-15]. However, this treatment does not work in all patients.…”

Pilot study of a protocol to administer inhaled nitric oxide to treat severe acute submassive pulmonary embolism

“…In view of the fact that the corpus of published literature on the use of inhaled NO is restricted to case reports comprising fewer than 14 patients, this protocol was constructed with very little firm basis to protocolise its delivery, including the type of mask, how rapidly to titrate it upward, and the maximal dose 10–16. Summerfield et al described the largest previous case series of inhaled nitric oxide to treat acute PE described in four patients 10. The Summerfield case series studied patients with massive PE, and all four had either respiratory failure or cardiogenic shock, but all four had improvements in oxygenation and mean arterial pressure after starting inhaled nitric oxide in doses from 10 to 20 ppm.…”

“…Despite a strong pathophysiological basis for its potential to improve lung function, meta-analyses controlled trials of inhaled nitric oxide for the treatment of acute lung injury found no benefit on mortality or ventilator dependence 9. To date, published literature describing the use of iNO in humans with acute PE is limited to case reports and case series which did not use a prescribed protocol 10 11–15. Not all have been favourable 16.…”

Anticoagulant treatment for acute pulmonary embolism: a pathophysiology-based clinical approach

“…Thromboxane A 2 and serotonin have been reported to be among the principal mediators of pulmonary artery vasoconstriction [16]. Limited data on the role of neurohumorally mediated vasoconstriction and on the clinical benefit of its reversal are available in humans [17][18][19][20].…”