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Combined nitric oxide inhalation, prone positioning and almitrine infusion improve oxygenation in severe ARDS

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Abstract

Purpose

To determine the efficacy and side effects of prone positioning (PP) and nitric oxide (NO) inhalation, alone, associated, or combined withiv almitrine for the treatment of hypoxaemia in severe acute respiratory distress syndrome (ARDS).

Methods

Over a period of 20 months, 27 consecutive critically ill patients with severe ARDS (Murray score > 2.5, PaO2/FiO2 < 170 after alveolar recruitment) were prospectively and randomly included. They inhaled NO for two hours at concentrations of 5 and 10 ppm for one hour each (H0–H2). One hour later, they were returned to the prone position for four hours (H3–H7). During the last two hours in this position (H5–H7), they were assigned to further inhalation of 10 ppm NO (Group B, n = 9) or to no further inhalation (Group A, n = 9). In group C (n = 9), the procedure for group B was combined with perfusion of 16 mg · kg−1 · min−1 almitrine throughout the study.

Results

Compared with control values, two hours NO inhalation improves PaO2/FiO2 and shunt effect by +28% and −9%, PP by +88% and −27%, PP + almitrine by + 132% and −28%, NO + almitrine by + 153 and −28%, PP + NO by +94% and −29%, NO + PP + almitrine by +327 and −48%. NO inhalation reduces pulmonary vascular resistance. Other haemodynamic parameters remain unchanged, whatever the treatment. NO inhalation improves PaO2/FiO2 by over 20% in 50% of the patients and PP is effective in 78% of the cases.

Conclusion

Prone Position improves PaO2/FiO2 significantly more than NO alone but less than PP+ almitrine or NO+ almitrine. The best results are obtained with the association of NO + Prone position + Almitrine.

Résumé

Objectif

Apprécier et comparer l’intérêt du décubitus ventral (DV), de l’inhalation de NO et de l’administration continue d’almitrine, seuls ou en association, dans le traitement de l’hypoxémie au cours du syndrome de détresse respiratoire aiguë (SDRA).

Méthode

Sur une période de 20 mois, 27 patients hospitalisés en réanimation avec un SDRA grave (score de Murray > 2,5, PaO2/FiO2 < 170 après recrutement alvéolaire) ont été inclus prospectivement et de manière randomisée. Ils ont bénéficié de l’inhalation de NO pendant 2 heures à la posologie de 5ppm pendant une heure puis I0ppm (H0–H2). Après une heure d’arrêt, on les a retournés 4 heures en décubitus ventral (H3–H7). De H5 à H7 un groupe A (n = 9) était traité par DV seul tandis que l’on ajoutait dans un groupe B (n = 9) l’inhalation de NO à 10 ppm. Un troisième groupe C (n = 9) bénéficiait d’une perfusion continue d’almitrine (16 mg · kg−1 · min−1) associée à cette même séquence thérapeutique.

Résultats

Par rapport à H0, 2 heures de NO améliorent le rapport PaO2/FiO2 et diminuent le shunt de +28% et −9%, le DV de +88% et −27%, les associations DV + almitrine de + 132% et −28%, NO + almitrine de +153 et −28%, DV + NO de +94% et −29%, NO + PP + almitrine de +327 et −48%. L’inhalation de NO diminue les resistances vasculaires pulmonaires. Les autres paramètres hémodynamiques restent inchangés quel que soit le traitement institué. L’inhalation de NO améliore le rapport PaO2/FiO2 de plus de 20% chez 50% des patients tandis qu’avec le même critère d’efficacité, 78% des malades sont répondeur au DV

Conclusion

Le DV s’avère plus efficace que le NO seul pour ce qui est d’améliorer le rapport PaO2/FiO2, mais moins que les associations DV + almitrine ou NO + almitrine. Les meilleurs résultats sont obtenus avec latrithérapie DV + NO + almitrine.

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Correspondence to Thierry Gillart.

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Gillart, T., Bazin, J.E., Cosserant, B. et al. Combined nitric oxide inhalation, prone positioning and almitrine infusion improve oxygenation in severe ARDS. Can J Anaesth 45, 402–409 (1998). https://doi.org/10.1007/BF03012574

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Keywords

  • Nitric Oxide
  • Mean Arterial Pressure
  • Prone Position
  • Acute Respiratory Distress Syndrome
  • Acute Respiratory Failure