INHALED NITRIC-OXIDE FOR SEVERE ACUTE RESPIRATORY-DISTRESS SYNDROME -A BLESSING OR A CURSE

The effects of inhaled nitric oxide (NO) in two young adults who devel oped severe acute respiratory distress syndrome are presented. Modest improvements in gas exchange and reductions in pulmonary artery pressu res occurred after the initiation of treatment with inhaled NO. Howeve r, both patients became ''dependent'' on the inhaled NO for stabilizat ion of their cardiopulmonary function. Repeated attempts to discontinu e the inhaled NO resulted in life-threatening deterioration in gas exc hange and hemodynamic instability. Prolonged family discussions were h eld regarding the withdrawal of inhaled NO and other life-sustaining t herapies, when the irreversible nature of the patients' lung disease b ecame apparent. However, both families were strong in their desire to continue all therapies-due in large part to the single organ nature of the disease process. Both patients died while receiving inhaled NO an d escalating doses of sedatives and analgesics. Based on this experien ce, it is recommend that clearly defined goals or endpoints for the di scontinuation of inhaled NO should be established before its initial a dministration. If these goals are not achieved, then the therapy shoul d be considered a failure and withdrawn. A similar strategy should be applied to all life-sustaining therapies in the intensive care unit se tting (e.g., mechanical ventilation, vasopressors, dialysis). This req uires that critical care clinicians effectively communicate the differ ence between aggressive supportive care and definitive treatment of th e underlying disease process to patients or their families, or both. F urthermore, until the results of ongoing clinical trials of inhaled NO become available, it is recommended that its administration be restri cted to medical centers examining its use in Clinical trials.