ICU Management of Pulmonary Hypertension
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ICU Management of Pulmonary Hypertension

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Brief literature review for the use of inhaled Nitric Oxide (iNO) to treat pulmonary hypertension in the critical care setting

Brief literature review for the use of inhaled Nitric Oxide (iNO) to treat pulmonary hypertension in the critical care setting

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  • Nitroprussidecaused a similar degree of pulmonary vasodilation. In contrast to inhaled NO, nitroprusside caused systemic hypotension associated with an increase in RV contractility. Acute administration of nifedipine did not cause pulmonary vasodilation, but RVEDP increased and RV contractility decreased.
  • characterized by a marked maldistribution of pulmonary perfusion in favor of nonventilated, atelectatic areas of the lungs, and it is the main cause of pulmonary right-to-left shunting and hypoxemia

ICU Management of Pulmonary Hypertension ICU Management of Pulmonary Hypertension Presentation Transcript

  • ICU management of Pulmonary Hypertension Literature review for the use of inhaled Nitric Oxide (iNO) Farooq Khan MDCM PGY2 FRCP-EM McGill University Dec 3rd 2010
  • Mechanism of action of nitric oxide • Potent inhaled vasodilator • Dilates pulmonary vasculature in ventilated lung units – improves oxygenation – reverses hypoxic pulmonary vasoconstriction – reduces PAP • Quickly inactivated by reaction with hemoglobin in the pulmonary capillaries – no significant systemic vasodilatory effects
  • Current WHO indications for therapy • Group 1 – Stabilization of PAH crisis – Hemodynamic support in OB patients – Treatment of porto-pulmonary hypertension • Groups 2-5 – PVH post cardiac surgery – Rescue from refractory hypoxemia in acute lung disease – Hemodynamic support in acute thromboembolic disease
  • Human physiological study • Pepke-Zaba J, Higenbottam TW, Dinh-Xuan AT, et al: Inhaled nitric oxide as a cause of selective pulmonary vasodilatation in pulmonary hypertension. Lancet 1991; 338: 1173–1174 – Inhaled NO vs prostacyclin in severe PAH patients and control patients – Predictable drop in PAP without concomitant drop in SVR in both groups compared to placebo and compared to prostacyclin
  • Clinical studies of effect on chronic PAH • Cockrill BA, Kacmarek RM, Fifer MA, et al: Comparison of the effects of nitric oxide, nitroprusside, and nifedipine on hemodynamics and right ventricular contractility in patients with chronic pulmonary hypertension. Chest 2001; 119:128–136 – Decreased PAP, PVR and RVEDP – MAP unchanged, RV contractility unchanged – SVI increased
  • Effect of iNO in RH syndrome • Bhorade S, Christenson J, O’Connor M, et al: Response to inhaled nitric oxide in patients with acute right heart syndrome. Am J Respir Crit Care Med 1999; 159: 571–579 – Increase in CO (36%), SV and MVO2 sat – 38% decrease in PVR – 28% increase in PaO2/FiO2 – Not designed to study mortality
  • iNO in other disease states • iNO as treatment for severe ARDS – Kaisers U, Busch T, Deja M, et al: Selective pulmonary vasodilation in acute respiratory distress syndrome. Crit Care Med 2003; 31: S337–S342 • reduce pulmonary hypertension • improve matching of ventilation to perfusion and thus, hypoxemia – Taylor RW, Zimmerman JL, Dellinger RP, et al: Low- dose inhaled nitric oxide in patients with acute lung injury: A randomized controlled trial. JAMA 2004; 291:1603–1609 • Short term effect on increasing PaO2 • No effect on mortality or days spent off vent
  • iNO in other disease states • iNO in severe heart failure – Semigran MJ, Cockrill BA, Kacmarek R, et al: Hemodynamic effects of inhaled nitric oxide in heart failure. J Am Coll Cardiol 1994; 24:982–988 • Decrease in PAH caused by LV failure • Identify patients with reversible pulmonary vasocontriction where nipride can cause systemic hypotension
  • iNO in other disease states • iNO post MVR in chronic PAH patients – Girard C, Lehot JJ, Pannetier JC, et al: Inhaled nitric oxide after mitral valve replacementin patients with chronic pulmonary artery hypertension. Anesthesiology 1992;77:880–883 • Decrease in PAP, PVR • Increase in MVO2 Sat, no change in MAP or PCWP
  • Adverse effects • Methemoglobinemia – Weinberger B, Laskin DL, Heck DE, et al: The toxicology of inhaled nitric oxide. Toxicol Sci 2001; 59:5–16 • Oxidative stress due to combination with O2 creating NO2 – Wang T, El Kebir D, Blaise G: Inhaled nitric oxide in 2003: A review of its mechanisms of action. Can J Anaesth 2003; 50:839–846 • Abrupt withdrawal can cause rebound Pah and cardiovascular collapse – Christenson J, Lavoie A, O’Connor M, et al: The incidence and pathogenesis of cardiopulmonary deterioration after abrupt withdrawal of inhaled nitric oxide. Am J Respir Crit Care Med 2000; 161:1443–1449