Treatment of COVID-19 by Inhaled NO to Reduce Shunt?

Hedenstierna, Göran; Chen, Luni; Hedenstierna, Magnus; Scaramuzzo, Gaetano

doi:10.1164/rccm.202004-0940le

Cited by 10 publications

(9 citation statements)

References 6 publications

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“…The potential benefit of iNO in reducing pulmonary shunt in COVID-19 related ARDS has been postulated. 5 However, we found that the increase in PaO 2 :FiO 2 ratio in COVID-19 ARDS patients in response to iNO was significantly lower compared to ARDS patients without ARDS, consistent with another published series. 6 Pulmonary vascular endothelial dysfunction and microthrombi are hallmarks of COVID-19 induced lung damage, and this may impair iNO-induced pulmonary vasodilation.…”

supporting

confidence: 92%

Inhaled nitric oxide minimally improves oxygenation in COVID-19 related acute respiratory distress syndrome

Longobardo

Montanari

Shulman

et al. 2021

British Journal of Anaesthesia

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Advance Access published on July 17 8. No clinical benefit from use of hydroxychloroquine in hospitalised patients with COVID-19 2020. Available from: https:// www.recoverytrial.net/news/statement-from-the-chiefinvestigators-of-the-randomised-evaluation-of-covid-19therapy-recovery-trial-on-hydroxychloroquine-5-june-2020-no-clinical-benefit-from-use-of-hydroxychloroquine-in-hospitalised-patients-with-covid-19. [Accessed 17 May 2020] 9. Baum A, Schwartz MD. Admissions to Veterans Affairs hospitals for emergency conditions during the COVID-19 pandemic. JAMA 2020; 324: 96e9 10. Quilter-Pinner H. The hidden cost of Covid-19 on the NHSand how to 'build back better' 2020.

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supporting

confidence: 92%

Inhaled nitric oxide minimally improves oxygenation in COVID-19 related acute respiratory distress syndrome

Longobardo

Montanari

Shulman

et al. 2021

British Journal of Anaesthesia

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“…Since the oxygenation response to the first PP can highlight patients at major risk of death, it may be used to inform who may benefit from a further level of assistance. Beside PP, indeed, other interventions can be used to increase oxygenation in COVID-19, like inhaled nitric oxide [ 5 , 28 ], intravenous Almitrine [ 29 ], ECMO [ 30 ]. The reduced oxygenation response to PP may be, therefore, helpful to select patients needing alternative ventilatory treatment.…”

Section: Discussionmentioning

confidence: 99%

“…The pneumonia caused by SARS-CoV-2 (COVID-19), indeed, can lead to severe Acute Respiratory Distress Syndrome (ARDS) requiring invasive mechanical ventilation. COVID-19-related ARDS is associated to a severe impairment of lung ventilation/perfusion matching, resulting from a defect of hypoxic pulmonary vasoconstriction and presence of thrombi in the pulmonary microcirculation, leading to high intra-pulmonary shunt and dead space, respectively [ 4 , 5 ]. Early prone positioning (PP) has been used in critically ill patients affected by the COVID-19, both in patients receiving invasive mechanical ventilation [ 6 ] and in those spontaneously breathing [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

Scaramuzzo

Gamberini

Tonetti

et al. 2021

Ann. Intensive Care

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Background Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. Results The median PaO2/FiO2 variation after the first PP cycle was 49 [19–100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. Conclusions Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.

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“…In a scenario of extensive vasoconstriction in well-ventilated areas, possible treatment strategies could be aimed at improving perfusion. Luni Chen et al treated patients with severe SARS in 2003 with inhaled nitric oxide, with significant improvement in arterial oxygenation [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

COVID-19: What Iodine Maps From Perfusion CT can reveal—A Prospective Cohort Study

et al. 2020

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Background Subtraction CT angiography (sCTA) is a technique used to evaluate pulmonary perfusion based on iodine distribution maps. The aim of this study is to assess lung perfusion changes with sCTA seen in patients with COVID-19 pneumonia and correlate them with clinical outcomes. Material and methods A prospective cohort study was carried out with 45 RT-PCR-confirmed COVID-19 patients that required hospitalization at three different hospitals, between April and May 2020. In all cases, a basic clinical and demographic profile was obtained. Lung perfusion was assessed using sCTA. Evaluated imaging features included: Pattern predominance of injured lung parenchyma in both lungs (ground-glass opacities, consolidation and mixed pattern) and anatomical extension; predominant type of perfusion abnormality (increased perfusion or hypoperfusion), perfusion abnormality distribution (focal or diffuse), extension of perfusion abnormalities (mild, moderate and severe involvement); presence of vascular dilatation and vascular tortuosity. All participants were followed-up until hospital discharge searching for the development of any of the study endpoints. These endpoints included intensive-care unit (ICU) admission, initiation of invasive mechanical ventilation (IMV) and death. Results Forty-one patients (55.2 ± 16.5 years, 22 men) with RT-PCR-confirmed SARS-CoV-2 infection and an interpretable iodine map were included. Patients with perfusion anomalies on sCTA in morphologically normal lung parenchyma showed lower Pa/Fi values (294 ± 111.3 vs. 397 ± 37.7, p = 0.035), and higher D-dimer levels (1156 ± 1018 vs. 378 ± 60.2, p < 0.01). The main common patterns seen in lung CT scans were ground-glass opacities, mixed pattern with predominant ground-glass opacities and mixed pattern with predominant consolidation in 56.1%, 24.4% and 19.5% respectively. Perfusion abnormalities were common (36 patients, 87.8%), mainly hypoperfusion in areas of apparently healthy lung. Patients with severe hypoperfusion in areas of apparently healthy lung parenchyma had an increased probability of being admitted to ICU and to initiate IMV (HR of 11.9 (95% CI 1.55–91.9) and HR 7.8 (95% CI 1.05–61.1), respectively). Conclusion Perfusion abnormalities evidenced in iodine maps obtained by sCTA are associated with increased admission to ICU and initiation of IMV in COVID-19 patients.

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Treatment of COVID-19 by Inhaled NO to Reduce Shunt?

Cited by 10 publications

References 6 publications

Inhaled nitric oxide minimally improves oxygenation in COVID-19 related acute respiratory distress syndrome

Inhaled nitric oxide minimally improves oxygenation in COVID-19 related acute respiratory distress syndrome

Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

COVID-19: What Iodine Maps From Perfusion CT can reveal—A Prospective Cohort Study

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