Mekontso Dessap Armand, Papazian Laurent, Schaller Manuella, Nseir Saad, Megarbane Bruno, Haudebourg Luc, Timsit Jean-François, Teboul Jean-Louis, Kuteifan Khaldoun, Gainnier Marc, Slama Michel, Houeto Patrick, Lecourt Laurent, Mercat Alain, Vieillard-Baron Antoine
Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri-Mondor, AP-HP, 94010, Créteil, France.
CARMAS research group, Univ Paris Est Créteil, Faculté de Santé, 94010, Créteil, France.
Ann Intensive Care. 2023 Jun 27;13(1):57. doi: 10.1186/s13613-023-01150-9.
Inhaled nitric oxide (iNO) has been widely used in patients with COVID-19-related acute respiratory distress syndrome (C-ARDS), though its physiological effects and outcome are debated in this setting. The objective of this cohort study was to describe the modalities of iNO use, clinical response, and outcomes in a large cohort of C-ARDS patients.
Multicentre, retrospective cohort study conducted in France.
From end February to December 2020, 300 patients (22.3% female) were included, 84.5% were overweight and 69.0% had at least one comorbidity. At ICU admission, their median (IQR) age, SAPS II, and SOFA score were 66 (57-72) years, 37 (29-48), and 5 (3-8), respectively. Patients were all ventilated according to a protective ventilation strategy, and 68% were prone positioned before iNO initiation. At iNO initiation, 2%, 37%, and 61% of patients had mild, moderate, and severe ARDS, respectively. The median duration of iNO treatment was 2.8 (1.1-5.5) days with a median dosage of 10 (7-13) ppm at initiation. Responders (PaO/FiO ratio improving by 20% or more) represented 45.7% of patients at 6 h from iNO initiation. The severity of ARDS was the only predictive factor associated with iNO response. Among all evaluable patients, the crude mortality was not significantly different between responders at 6 h and their counterparts. Of the 62 patients with refractory ARDS (who fulfilled extracorporeal membrane oxygenation criteria before iNO initiation), 32 (51.6%) no longer fulfilled these criteria after 6 h of iNO. The latter showed significantly lower mortality than the other half (who remained ECMO eligible), including after confounder adjustment (adjusted OR: 0.23, 95% CI 0.06, 0.89, p = 0.03).
Our study reports the benefits of iNO in improving arterial oxygenation in C-ARDS patients. This improvement seems more relevant in the most severe cases. In patients with ECMO criteria, an iNO-driven improvement in gas exchange was associated with better survival. These results must be confirmed in well-designed prospective studies.
吸入一氧化氮（iNO）已广泛应用于新型冠状病毒肺炎相关急性呼吸窘迫综合征（C-ARDS）患者，但其在此情况下的生理效应和预后仍存在争议。本队列研究的目的是描述一大群C-ARDS患者使用iNO的方式、临床反应和预后。
在法国进行的多中心回顾性队列研究。
从2020年2月底至12月，纳入300例患者（22.3%为女性），84.5%超重，69.0%至少有一种合并症。入住重症监护病房（ICU）时，他们的年龄中位数（四分位间距）、简化急性生理学评分（SAPS）II和序贯器官衰竭评估（SOFA）评分分别为66（57 - 72）岁、37（29 - 48）和5（3 - 8）。所有患者均按照保护性通气策略进行通气，68%在开始使用iNO前采用俯卧位。开始使用iNO时，2%、37%和61%的患者分别患有轻度、中度和重度ARDS。iNO治疗的中位持续时间为2.8（1.1 - 5.5）天，开始时的中位剂量为10（7 - 13）ppm。在开始使用iNO后6小时，反应者（动脉血氧分压/吸入氧分数值改善20%或更多）占患者的45.7%。ARDS的严重程度是与iNO反应相关的唯一预测因素。在所有可评估的患者中，6小时时反应者与非反应者的粗死亡率无显著差异。在62例难治性ARDS患者（在开始使用iNO前符合体外膜肺氧合标准）中，32例（51.6%）在使用iNO 6小时后不再符合这些标准。后者的死亡率显著低于另一半（仍符合体外膜肺氧合标准者），包括在进行混杂因素调整后（调整后的比值比：0.23，95%置信区间0.06，0.89，p = 0.03）。
我们的研究报告了iNO在改善C-ARDS患者动脉氧合方面的益处。这种改善在最严重的病例中似乎更显著。在符合体外膜肺氧合标准的患者中，iNO驱动的气体交换改善与更好的生存率相关。这些结果必须在设计良好的前瞻性研究中得到证实。
