Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA.
Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA.
Chest. 2022 Dec;162(6):1287-1296. doi: 10.1016/j.chest.2022.08.001. Epub 2022 Aug 8.
The inhaled vasodilators nitric oxide and epoprostenol may be initiated to improve oxygenation in mechanically ventilated patients with severe acute respiratory failure (ARF); however, practice patterns and head-to-head comparisons of effectiveness are unclear.
What are the practice patterns and comparative effectiveness for inhaled nitric oxide and epoprostenol in severe ARF?
Using a large US database (Premier Healthcare Database), we identified adult patients with ARF or ARDS who were mechanically ventilated and started on inhaled nitric oxide, epoprostenol, or both. Leveraging large hospital variation in the choice of initial inhaled vasodilator, we compared the effectiveness of inhaled nitric oxide with that of epoprostenol by limiting analysis to patients admitted to hospitals that exclusively used either inhaled nitric oxide or epoprostenol. The primary outcome of successful extubation was modeled using multivariate Fine-Grey competing risk (death or hospice discharge) time-to-event models.
Among 11,200 patients (303 hospitals), 6,366 patients (56.8%) received inhaled nitric oxide first, 4,720 patients (42.1%) received inhaled epoprostenol first, and 114 patients (1.0%) received both therapies on the same day. One hundred four hospitals (34.3%; 1,666 patients) exclusively used nitric oxide and 118 hospitals (38.9%; 1,812 patients) exclusively used epoprostenol. No differences were found in the likelihood of successful extubation between patients admitted to nitric oxide-only hospitals vs those admitted to epoprostenol-only hospitals (subdistribution hazard ratio, 0.97; 95% CI, 0.80-1.18). Also no differences were found in total hospital costs or death. Results were robust to multiple sensitivity analyses.
Large variation exists in the use of initial inhaled vasodilator for respiratory failure across US hospitals. Comparative effectiveness analyses identified no differences in outcomes based on inhaled vasodilator type.
吸入性血管扩张剂一氧化氮和依前列醇可用于改善机械通气的严重急性呼吸衰竭（ARF）患者的氧合；然而，使用情况和有效性的头对头比较尚不清楚。
吸入性一氧化氮和依前列醇在严重 ARF 中的使用情况和比较效果是什么？
利用美国大型数据库（Premier Healthcare Database），我们确定了接受机械通气且开始使用吸入性一氧化氮、依前列醇或两者的 ARF 或 ARDS 成年患者。利用大型医院在初始吸入性血管扩张剂选择方面的巨大差异，我们通过将分析仅限于仅使用吸入性一氧化氮或依前列醇的医院的患者，比较了吸入性一氧化氮和依前列醇的效果。成功拔管的主要结局通过多变量 Fine-Grey 竞争风险（死亡或临终关怀出院）时间事件模型进行建模。
在 11200 名患者（303 家医院）中，6366 名患者（56.8%）首先接受吸入性一氧化氮治疗，4720 名患者（42.1%）首先接受吸入性依前列醇治疗，114 名患者（1.0%）在同一天接受了两种治疗。104 家医院（34.3%；1666 名患者）仅使用一氧化氮，118 家医院（38.9%；1812 名患者）仅使用依前列醇。与仅接受依前列醇治疗的患者相比，仅接受一氧化氮治疗的患者成功拔管的可能性没有差异（亚分布危险比，0.97；95%CI，0.80-1.18）。总住院费用或死亡率也没有差异。多项敏感性分析结果稳健。
美国医院在呼吸衰竭初始吸入性血管扩张剂的使用方面存在很大差异。基于吸入性血管扩张剂类型的比较效果分析未发现结果存在差异。
