Inhaled Nitric Oxide in Acute Severe Pulmonary Hypertension and Severe Acute Respiratory Distress Syndrome Secondary to COVID-19 Pneumonia: A Case Report

Abstract

Patient: Female, 36-year-old Final Diagnosis: Severe ARDS secondary to COVID-19 leading to severe PAH and RV systolic function impairment Symptoms: Hypoxemia Medication: — Clinical Procedure: — Specialty: Critical Care Medicine Objective: Rare disease Background: Inhaled nitric oxide (iNO) is used as a treatment for pulmonary arterial hypertension (PAH). Severe hypoxia with hypoxic vasoconstriction caused by severe acute respiratory distress syndrome (ARDS) can induce pulmonary hypertension with hemodynamic implications, mainly secondary to right ventricle (RV) systolic function impairment. We report the case of the use of iNO in a critically ill patient with bilateral SARS-CoV-2 pneumonia and severe ARDS and hypoxemia leading to acute severe PAH, causing a ventilation/perfusion mismatch, RV pressure overload, and RV systolic dysfunction. Case Report: A 36-year-old woman was admitted to the Intensive Care Unit with a severe ARDS associated with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. Severe hypoxia and hypoxic vasoconstriction developed, leading to an acute increase in pulmonary vascular resistance, severe to moderate tricuspid regurgitation, RV pressure overload, RV systolic function impairment, and RV dilatation. Following 24 h of treatment with iNO at 15 ppm, significant oxygenation and hemodynamic improvement were noted, allowing vasopressors to be stopped. After 24 h of iNO treatment, echocardiography showed very mild tricuspid regurgitation, a non-dilated RV, no impairment of transverse free wall contractility, and no paradoxical septal motion. iNO was maintained for 7 days. The dose of iNO was progressively decreased with no adverse effects and maintaining an improvement of oxygenation and hemodynamic status, allowing respiratory weaning. Conclusions: Sustained acute hypoxia in ARDS secondary to SARS-CoV-2 pneumonia can lead to PAH, causing a ventilation/perfusion mismatch and RV systolic impairment. iNO can be considered in patients with significant PAH causing hypoxemia and RV dysfunction.

Unraveling the impact of nitric oxide, almitrine, and their combination in COVID-19 (at the edge of sepsis) patients: a systematic review

“…After excluding duplicate articles and screening titles and abstracts, 84 articles were evaluated for full-text review. Among these, we found 35 relevant articles (2 RCTs, 19 cohort studies, 1 case-control study, 1 cross-sectional study, and 12 case reports) ( Figure 1 ) ( Abou-Arab et al, 2020 ; Bagate et al, 2020 ; Barthélémy et al, 2020 ; Cardinale et al, 2020 ; Ferrari et al, 2020 ; Huette et al, 2020 ; Losser et al, 2020 ; Safaee Fakhr et al, 2020 ; Tavazzi et al, 2020 ; Caplan et al, 2021 ; Chandel et al, 2021 ; Feng et al, 2021 ; Garfield et al, 2021 ; Giri et al, 2021 ; Herranz et al, 2021 ; Heuts et al, 2021 ; Huette et al, 2021 ; Laghlam et al, 2021 ; Longobardo et al, 2021 ; Lotz et al, 2021 ; Moni et al, 2021 ; Paramanathan et al, 2021 ; Ziehr et al, 2021 ; Al Sulaiman et al, 2022 ; Brown et al, 2022 ; Kalfon et al, 2022 ; Lubinsky et al, 2022 ; Poonam et al, 2022 ; Vives et al, 2022 ; Bicakcioglu et al, 2023 ; Blot et al, 2023 ; Di Fenza et al, 2023 ; Mekontso Dessap et al, 2023 ; Saccheri et al, 2023 ; van Zyl et al, 2023 ).…”

The Efficacy of Nitric Oxide-Generating Lozenges on Outcome in Newly Diagnosed COVID-19 Patients of African American and Hispanic Origin

“…Most report that inhaled nitric oxide improves oxygenation in critically ill patients with COVID-19, but conflicting results have been reported in terms of a mortality benefit. 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 …”