THERAPEUTIC OPTIMIZATION INCLUDING INHALED NITRIC-OXIDE IN ADULT-RESPIRATORY-DISTRESS-SYNDROME IN A POLYVALENT INTENSIVE-CARE UNIT

Objective: To investigate the effects of inhaled nitric oxide (NO) in adult respiratory distress syndrome (ARDS) associated with a therapeut ic optimization strategy on oxygen parameters, barotrauma, and evoluti on in a medical and surgical intensive care unit. Design: Prospective study. Materials and Methods: Twenty consecutive patients with ARDS we re studied (Murray score 3.6 +/- 0.2). Eleven were surgical patients a nd nine were medical patients. All fulfilled the extracorporeal membra ne oxygenation entry criteria. The APACHE II score predicted mortality was 39%. All were ventilated with FiO(2) 1 with positive end-expirato ry pressure (PEEP) of 11 +/- 1 cm H2O. Therapeutic optimization includ ed permissive hypercapnia, tracheal gas insufflation, prone position, continuous hemofiltration, treatment of infection, and pleural drainag e. We used NO continuously inhaled at a concentration ranging from 5 t o 10 ppm. Measurements and Main Results: After 1 hour, inhaled NO impr oved PaO2 in all patients except one (78 +/- 11 to 130 +/- 25 mm Hg)(p < 0.05), allowing a reduction of FiO(2) and PEEP. After 24 hours, mea n pulmonary arterial pressure decreased from 31 +/- 3 to 25 +/- 2 mm H g (p < 0.05). Systemic hemodynamics were unaffected. Oxygen delivery i ncreased from 531 +/- 135 to 603 +/- 125 mL/minute/m(-2) (p < 0.05). B arotraumatic lesions were present in only one patient. Reversal of ARD S was obtained in 16 patients, of whom 14 (70%) were discharged. Concl usions: This study was shorter to demonstrate an improvement in the su rvival rate. Nevertheless, these preliminary results are encouraging. Because of its safety, effectiveness, and easy use, inhaled NO should be used as a part of a therapeutic optimization protocol before consid ering more invasive and expensive procedures, such as extracorporeal r espiratory support or intravascular oxygenation.