POINT: Does Persistent or Worsening ARDS Refractory to Optimized Ventilation and Proning Deserve a Trial of Prostacyclin? Yes

Comparison of Fixed-Dose Inhaled Epoprostenol and Inhaled Nitric Oxide for Acute Respiratory Distress Syndrome in Critically Ill Adults

“…Stabilizing or improving refractory hypoxemia in ARDS patients with the use of inhaled pulmonary vasodilating therapies resulting in either lower oxygen requirements (F io 2 ) or avoiding the use of more invasive and costly therapies such as ECMO could be deemed as clinical success. 22 We found most patients responded to inhaled therapy, which is consistent with another report using weight-based dosing. A descriptive report using weight-based iEPO in ARDS with a “response” definition a priori of an absolute increase in Pa o 2 : F io 2 from baseline by ≥10 mm Hg also showed an overall response rate of 62%.…”

“…4 Currently, inhaled pulmonary vasodilators are mostly considered a temporizing agent for more established or invasive therapeutic options in refractory ARDS such as prone positioning, NMBAs, and ECMO. 6,22,23 However, others suggest inhaled pulmonary vasodilating agents should not be considered at all or at least not within the early course of ARDS. 5 Despite discordant expert opinions, over 40% of patients with refractory hypoxemia are administered inhaled vasodilators in contemporary clinical practice.…”

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists—Part II, Intraoperative Management and Troubleshooting

“…37,70,86 Other rescue measures that can be considered in the operating room include deep sedation, neuromuscular blockade, institution of mild hypothermia to reduce metabolic demand, and use of inhaled pulmonary vasodilators such as nitric oxide or epoprostenol, which improve ventilation-perfusion matching and reduce recirculation in patients with tricuspid regurgitation. [87][88][89][90][91][92][93][94][95] Prone positioning is usually not feasible intraoperatively but can be used in the immediate postoperative period if the patient has refractory hypoxemia. Liberal allogeneic red blood cell (RBC) transfusion (up to a hemoglobin of 10 g/dL) has been suggested as a potential strategy to improve oxygen delivery in patients with hypoxemia.…”

Rebuttal From Drs Viau-Lapointe and Fan

“…We read with great interest the editorial written by Drs Aguilar and Kollef. 1 Although we agree that ARDS is a highly lethal and morbid disease in need of novel interventions, we argue inhaled prostacyclins should not be a routine part of the intensivist's ARDS armamentarium.…”