Rachel Tendler, BCPS, PharmD
Clinical Pharmacy Specialist, Critical Care
Emory Saint Josephs Hospital of Atlanta, United States
Disclosure information not submitted.
Nicholas Barker, BCCCP, PharmD, RPh
Clinical Pharmacy Coordinator - Critical Care
Emory Saint Joseph's Hospital
Atlanta, Georgia
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Colin Swenson, MD
Assistant Professor of Medicine
Emory University School of Medicine, United States
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William Bender, MD, MPH
Assistant Professor of Medicine
Emory University School of Medicine, United States
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Michael Baker, BS
Doctor of Pharmacy Student
Mercer University College of Pharmacy, United States
Disclosure information not submitted.
Title: Evaluation of Inhaled Vasodilators In Acute Respiratory Distress Syndrome Due to COVID-19
Introduction: According to the Society of Critical Care Medicine guidelines for the treatment of acute respiratory distress syndrome (ARDS) due to COVID-19 for rescue or adjunctive therapy, a trial of inhaled nitric oxide (iNO) or epoprostenol (iEPO) can be considered in addition to prone ventilation, neuromuscular blocking agent infusions (NMBA), and extracorporeal membrane oxygenation (ECMO). Patients who met indication for the use of inhaled vasodilators such as iNO and iEpo due to hypoxemia may see some improvement in their PaO2/FiO2 (P/F) ratios. Previous studies evaluating these agents in ARDS, outside of COVID-19, have shown variable response and are confounded by patient dependent factors as well as administration of NMBAs or prone positioning. The aim of this trial is to evaluate the efficacy outcomes of iEPO verses iNO in patients diagnosed with ARDS secondary to COVID-19.
Methods: A single-center, retrospective chart review using the electronic medical record system at a 410-bed community tertiary care hospital was performed. Patients admitted to the ICU from 3-1-20 through 2-28-21 undergoing treatment for ARDS due to COVID-19 with iEPO and/or iNO were included. Pregnant patients and/or prisoners were excluded. The primary outcome was response in P/F ratio, defined as > 20% improvement at 1 hour from inhaled vasodilator initiation. Secondary outcomes included degree of change in P/F ratio, days of mechanical ventilation, prone positioning, use of paralytic agents, mortality, and ICU and hospital length of stay.
Results: There were 38 patients evaluated in the iEPO group and 18 patients in the iNO group (n= 56). The iEPO group had a 63% response compared to 61% in the iNO group (p = 0.88). The median change in P/F ratio was 31% in the iEPO group verse 38% in the iNO group. Median number of days on the ventilator after initiation was 13.5 in the iEPO group verses 5 in the iNO group (p = 0.015).
Conclusion: Overall, the majority of patients had improvement in P/F ratio when an inhaled vasodilator was utilized. The change in P/F ratio was similar between iEPO and iNO. Patients in the iNO group had shorter ventilator days after initiation. Other factors such as filter clotting and cost may be taken into account when choosing between agents.