Abstract
Objective
To assess the additive effect of inhaled nitric oxide (NO) and intravenous almitrine bismesylate (ALM) on gas exchange.
Design
Prospective self-controlled study.
Setting
3 medico-surgical intensive care units.
Patients
17 patients with severe hypoxemia (PaO2/FIO2 ratio: 88±30mmHg, venous admixture: 47±7%) and elevated mean pulmonary artery pressure (MPAP: 30±5mmHg) due to adult respiratory distress syndrome (ARDS).
Interventions
5 conditions were studied: 1) baseline, 2) 5 to 10ppm of NO during 30min, 3) discontinuation of NO during 30min, 4) ALM infusion (0.5mg/kg) during 30min, 5) ALM infusion (0.5mg/kg) during 30min in combination with 5 to 10ppm of NO.
Measurement and results
The PaO2/FIO2 ratio rose from 88±30 to 98±37mmHg (NS) with NO alone, and from 92±25 to 130±56mmHg (p<0.01) with NO+ALM (p<0.05 vs NO alone). Seven patients were considered as “NO-responders” (rise in PaO2/FIO2 ratio of 10mmHg or more with NO); in this subgroup the PaO2/FIO2 ratio rose from 87±30 to 128±39mmHg (p<0.05) with NO alone, and from 93±20 to 169±51mmHg (p<0.01) with NO+ALM (p<0.05 versus NO alone). MPAP decreased from 30±5 to 26±5mmHg (p<0.01) with NO alone, increased slightly from 28±5 to 31±5mmHg (NS) with ALM alone and decreased to 27±5mmHg (p<0.05) with NO+ALM.
Conclusions
NO+ALM had additive effects on gas exchange while decreasing MPAP in patients with ARDS. The effects of NO alone were small and non significant, except in a subgroup of 7 patients in whom the combination of both therapies had the more pronounced results.
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References
Schuster DP (1990) A physiologic approach to initiating, maintaining, and withdrawing mechanical ventilatory support during acute respiratory failure. Am J Med 88:268–278
Rossaint R, Falke KJ, Lopez F, Slama K, Pison U, Zapol WM (1993) Inhaled nitric oxide for the adult respiratory distress syndrome. N Engl J Med 328:399–405
Reyes A, Roca J, Rodriguez-Roisin R, Torres A, Ussetti P, Wagner P (1988) Effect of almitrine on ventilation-perfusion distribution in adult respiratory distress syndrome. Am Rev Respir Dis 137: 1062–1067
Marini JJ (1992) New approaches to the ventilatory management of the adult respiratory distress syndrome. J Crit Care 7:256–267
Murray JF, Matthay MA, Luce JM, Flick MR (1988) An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 138:720–723
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) Prognosis in acute organ system failure. Ann Surg 202:685–692
Le Gall Jr, Loirat P, Alperovitch A, Glaser P, Granthil C, Mathieu D, Mercier P, Thomas R, Villers D (1984) A simplified acute physiologic score for ICU patients. Crit Care Med 12:975–977
Adnot S, Kouyoumdjian C, Defouilloy C, Andrivet P, Said S, Herigault R, Fratacci MD (1993) Hemodynamic and gas exchange responses to infusion of acetylcholine and inhalation of nitric oxide in patients with chronic obstructive lung disease and pulmonary hypertension. Am Rev Respir Dis 148:310–316
Rouby JJ, Puybasset L, Mourgeon E, Segal E, Poete P, Viars P (1993) Respiratory effects of increasing concentrations of inhaled nitric oxide in patients with ARDS. Anesthesiology 79:A226 (abstract)
Godfrey K (1992) Comparing the means of several groups. In: Bailar III JC, Mosteller F (eds) Medical uses of statistics. NEJM Books, Boston, pp 233–257
Palmer RMJ, Ferrige AG, Moncada S (1987) Nitric oxide release accounts for the biological activity of endothelium-derived relaxing factor. Nature 327:524–526
Frostell CG (1992) Effects of inhaled nitric oxide in volunteers. In: Vincent JL (ed) Update in intensive care and emergency medicine. Springer, Berlin, pp 233–237
Frostell CG, Blomqvist H, Hedenstierna G, Lundberg J, Zapol WM (1993) Inhaled nitric oxide selectively by reverses human hypoxic pulmonary vasoconstriction without causing systemic vasodilation. Anesthesiology 78:427–435
Roberts JD, Polaner DM, Lang P, Zapol WM (1992) Inhaled nitric oxide in persistent pulmonary hypertension of the newborn. Lancet 340:818–819
Frostell CG, Fratacci MD, Wain JC, Jones R, Zapol WM (1991) Inhaled nitric oxide: a selective pulmonary vasodilator reversing hypoxic pulmonary vasoconstriction. Circulation 83:2038–2047
Pepke-Zaba J, Higenbottam TW, Dinh-Xuan AT, Stone D, Wallwork J (1991) Inhaled nitric oxide as a cause of selective pulmonary vasodilation in pulmonary hypertension. Lancet 338:1173–1174
Gerlach H, Pappert D, Lewandowski K, Rossaint R, Falke KJ (1993) Long-term inhalation with evaluated low doses of nitric oxide for selective improvement of oxygenation in patients with adult respiratory distress syndrome. Intensive Care Med 19:443–449
Wonnacott TH, Wonnacott RJ (1991) Statistique, 4nd revised edn. Economica, Paris
Naeije R, Lejeune P, Vachiery JL, Leeman M, Melot C, Hallemans R, Delcroix M, Brimioulle S (1990) Restored hypoxic pulmonary vasoconstriction by peripheral chemoreceptor agonists in dogs. Am Rev Respir Dis 142:789–795
Leeman M, Lejeune P, Hallemans R, Melot C, Naeije R (1988) Effects of increased pulmonary vascular tone on gas exchange in canine oleic acid pulmonary edema. J Appl Physiol 65:662–668
Dreyfuss D, Djedaini K, Lanore JJ, Mier L, Froidevaux R, Coste F (1992) A comparative study of the effect of almitrine bismesylate and lateral position during unilateral bacterial pneumonia with severe hypoxemia, Am Rev Respir Dis 146:295–299
Wagner PD, Saltzman HA, West JB (1974) Measurement of continuous distribution of ventilation-perfusion ratios: theory. J Appl Physiol 36:588–599
Putensen C, Smith R, Rasanen J, Lopez F (1993) Simultaneous systemic administration of N-monomethyl-L-arginin and inhalation of low nitric oxide concentrations and improved ventilation: perfusion distribution in canine acute lung injury. Anesthesiology 79:A230 (abstract)
Leeman M, Delcroix M, Vachiery JL, Melot C, Naeije R (1992) Almitrine and doxapram in experimental lung injury. Am Rev Respir Dis 145:1042–1046
Howard P (1989) Hypoxia, almitrine and peripheral neuropathy. Thorax 44:247–250
Rekik N, Plaisance P, Brun-Buisson C, Lemaire F (1990) Almitrine infusion improves PaO2 without deleterious effects on right ventricular function in ARDS patients. Am Rev Respir Dis 141:A487 (abstract)
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Wysocki, M., Delclaux, C., Roupie, E. et al. Additive effect on gas exchange of inhaled nitric oxide and intravenous almitrine bismesylate in the adult respiratory distress syndrome. Intensive Care Med 20, 254–259 (1994). https://doi.org/10.1007/BF01708960
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DOI: https://doi.org/10.1007/BF01708960