Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
Department of Pulmonary and Critical Care, Mayo Clinic, Jacksonville, FL, USA.
Crit Care. 2024 Oct 25;28(1):344. doi: 10.1186/s13054-024-05093-w.
The benefit of Inhaled nitric oxide (iNO) therapy in the setting of COVID-19-related ARDS is obscure. We performed a multicenter retrospective study to evaluate the impact of iNO on patients with COVID-19 who require respiratory support.
This retrospective multicenter study included COVID-19 patients enrolled in the SCCM VIRUS COVID-19 registry who were admitted to different Mayo Clinic sites between March 2020 and June 2022 and required high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), or invasive mechanical ventilation (IMV). Patients were included in the 'spontaneously breathing' group if they remained non-intubated or were initiated on an HFNC (± NIV) before intubation. Patients who got intubated without prior use of an HFNC (± NIV) were included in the 'intubated group.' They were further divided into categories based on their iNO usage. Propensity score matching (PSM) and inverse propensity of treatment weighting (IPTW) were performed to examine outcomes.
Among 2767 patients included in our analysis, 1879 belonged to spontaneously breathing (153 received iNO), and 888 belonged to the intubated group (193 received iNO). There was a consistent improvement in FiO2 requirement, P/F ratio, and respiratory rate within 48 h of iNO use among both spontaneously breathing and intubated groups. However, there was no significant difference in intubation risk with iNO use among spontaneously breathing patients (PSM OR 1.08, CI 0.71-1.65; IPTW OR 1.10, CI 0.90-1.33). In a time-to-event analysis using Cox proportional hazard model, spontaneously breathing patients initiated on iNO had a lower hazard ratio of in-hospital mortality (PSM HR 0.49, CI 0.32-0.75, IPTW HR 0.40, 95% CI 0.26-0.62) but intubated patients did not (PSM HR: 0.90; CI 0.66-1.24, IPTW HR 0.98, 95% CI 0.73-1.31). iNO use was associated with longer in-hospital stays, ICU stays, ventilation duration, and a higher incidence of creatinine rise.
This retrospective propensity-score matched study showed that spontaneously breathing COVID-19 patients on HFNC/ NIV support had a decreased in-hospital mortality risk with iNO use in a time-to-event analysis. Both intubated and spontaneously breathing patients had improvement in oxygenation parameters with iNO therapy but were associated with longer in-hospital stays, ICU stays, ventilation duration, and higher incidence of creatinine rise.
吸入一氧化氮（iNO）治疗在 COVID-19 相关 ARDS 中的益处尚不清楚。我们进行了一项多中心回顾性研究，以评估 iNO 对需要呼吸支持的 COVID-19 患者的影响。
这项多中心回顾性研究纳入了 2020 年 3 月至 2022 年 6 月期间在 SCCM VIRUS COVID-19 注册中心登记、并在不同梅奥诊所院区入院且需要高流量鼻导管（HFNC）、无创通气（NIV）或有创机械通气（IMV）的 COVID-19 患者。如果患者仍未插管或在插管前开始使用 HFNC（±NIV），则将其纳入“自主呼吸”组。如果患者在未使用 HFNC（±NIV）前插管，则将其纳入“插管”组。他们根据 iNO 使用情况进一步分为不同类别。采用倾向评分匹配（PSM）和治疗逆概率加权（IPTW）来检查结局。
在我们的分析中，共纳入 2767 例患者，其中 1879 例属于自主呼吸（153 例接受 iNO 治疗），888 例属于插管组（193 例接受 iNO 治疗）。在接受 iNO 治疗后的 48 小时内，自主呼吸和插管组的 FiO2 需求、P/F 比值和呼吸频率均有一致改善。然而，在自主呼吸患者中，iNO 治疗并未降低插管风险（PSM OR 1.08，95%CI 0.71-1.65；IPTW OR 1.10，95%CI 0.90-1.33）。使用 Cox 比例风险模型进行的时间事件分析表明，开始接受 iNO 治疗的自主呼吸患者的院内死亡率风险较低（PSM HR 0.49，95%CI 0.32-0.75，IPTW HR 0.40，95%CI 0.26-0.62），但插管患者则不然（PSM HR：0.90；95%CI 0.66-1.24，IPTW HR 0.98，95%CI 0.73-1.31）。iNO 治疗与住院时间延长、ICU 住院时间延长、通气时间延长和肌酐升高发生率增加有关。
这项回顾性倾向评分匹配研究表明，在时间事件分析中，HFNC/NIV 支持的自主呼吸 COVID-19 患者使用 iNO 治疗可降低院内死亡率风险。插管和自主呼吸患者的氧合参数均有改善，但与住院时间延长、ICU 住院时间延长、通气时间延长和肌酐升高发生率增加有关。
