Use of Inhaled PGE1 to Improve Diastolic Dysfunction, LVEDP, Pulmonary Hypertension and Hypoxia in ARDS—A Randomised Clinical Trial

Abstract

Introduction: We wished to see the effects of inhaled PGE1 on diastolic dysfunction, left ventricular end diastolic pressure (LVEDP), pulmonary hypertension and hypoxia in ARDS patients. Methods: This is a randomized, prospective, clinical trial conducted in the main adult intensive care unit of a tertiary care University hospital. A total of 67 patients were recruited. Inclusion criteria included all adult patients with a P/F ratio <200 and/or Pulmonary Artery systolic (Pa) pressures of >35 mmHg on Pulmonary artery catheter or suspected on clinical grounds. A transthoracic echo was performed to record the diastolic function, LVEDP and Pa pressures. Subsequently patients were randomized by a block computerized randomization to either cases (n = 34) or controls (n = 33). Cases received nebulised PGE1 over 30 minutes in the ICU and normal saline was administered to controls blindly. Following this the echo and arterial blood gases were repeated. Our primary outcomes were an improvement in diastolic function and P/F ratio of greater than 20% and a decrease in pulmonary pressure and LVEDP of >20%. Results: At baseline, mean diastolic dysfunction was grade II, with a mean LVEDP of >15 and the PaO2/FiO2 ratio was 148.38 ± 60.05 with a mean pulmonary artery pressure of 81.35 ± 16.91. Inhaled PGE1 was followed by an improvement in diastolic dysfunction (grade I, p = 0.001) with a resulting improvement in LVEDP (12 +/? 2, p = 0.001) as well as Pa pressures (97.09 ± 30.06, p = 0.04) and a non significant improvement in PaO2/FiO2 ratio (161.45 ± 77.52, p = 0.21). There were no side effects observed in any patients. Conclusion: Our study shows that there is a significant improvement in diastolic dysfunction, LVEDP and Pa pressures after administration of nebulised PGE1, and an improvement although non-significant in hypoxia in ARDS patients. The trial was registered with Clinicaltrials.gov (NCT00314548) and funded by the Pakistan medical research council.

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S. Siddiqui, N. Salahuddin, S. Zubair, M. Yousuf, I. Azam and A. Gilani, "Use of Inhaled PGE1 to Improve Diastolic Dysfunction, LVEDP, Pulmonary Hypertension and Hypoxia in ARDS—A Randomised Clinical Trial," Open Journal of Anesthesiology, Vol. 3 No. 2, 2013, pp. 109-115. doi: 10.4236/ojanes.2013.32027.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] G. Domenighetti, H. Stricker, et al., “Nebulized Prostacyclin in ARDS: Impact of Primary and Secondary Disease on Gas Exchange Response,” Critical Care Medicine, Vol. 29, No. 1, 2001, pp. 57-62.doi:10.1097/00003246-200101000-00015
[2] S. Macherndl, M. Kneussl, et al., “Long Term Treatment of Pulmonary Hypertension with Aerosolized Iloprost,” European Respiratory Journal, Vol. 17, No. 1, 2001, pp. 8-13. doi:10.1183/09031936.01.17100080
[3] M. Max and R. Rossaint, “Inhaled Prostacyclin in the Treatment of Pulmonary Hypertension,” European Respiratory Journal, Vol. 158, No. S1, 1999, pp. S23-S26. doi:10.1007/PL00014316
[4] M. Hoeper, H. Olschewski, et al., “A Comparison of the Acute Hemodynamic Effects of Inhaled Nitric Oxide and Aerosolized Iloprost in Primary Pulmonary Hypertension. German PPH Study Group,” Journal of the American College of Cardiology, Vol. 35, No. 1, 2000, pp. 176-182. doi:10.1016/S0735-1097(99)00494-5
[5] H. Olschewski, H. Ghofrani, et al., “Inhaled Iloprost to Treat Severe Pulmonary Hypertension. An Uncontrolled Trial. German PPH Study Group,” Annals of International Medicine, Vol. 132, No. 6, 2000, pp. 435-443.
[6] N. Galie and A. Manes, “Medical Therapy of Pulmonary Hypertension. The Prostacyclins,” Clinics in Chest Medicine, Vol. 22, No. 3, 2001, pp. 529-537. doi:10.1016/S0272-5231(05)70289-6
[7] G. Raimondi, “Gas Exchange in Acute Respiratory Distress Syndrome,” Medicina (Buenos Aires), 2003, pp. 157-164.
[8] K. Theodoraki, P. Rellia, et al., “Inhaled Iloprost Controls Pul Hypertension after Cardiopul Bypass,” Canadian Journal of Anesthesia, Vol. 49, No. 9, 2002, pp. 963-967.doi:10.1007/BF03016884
[9] T. J. Lasserson, et al., “Prostacyclin for Pulmonry Hypertension,” Cochrane Database Systematic Review, Vol. 2, 2003, Article ID: CD002994.
[10] R. T. Schermuly, A. Schulz, et al., “Pharmacokinetics and Metabolism of Infused Versus Inhaled Iloprost in Isolated Rabbit Lungs,” Journal of Pharmacology and Experimental Therapeutics, Vol. 303, No. 2, 2002, pp. 741-745. doi:10.1124/jpet.303.2.741
[11] T. Gessler, T. Schmehl, et al., “Aerosolized Vasodilators in Pulmonary Hypertension,” Journal of Aerosological Medicine, Vol. 15, No. 2, 2002, pp. 117-122.
[12] “ICU Quality Indicators 2002-2003,” Aga Khan University, Karachi.
[13] M. R. Zile and D. L. Brutsaert, “New Concepts in Diastolic Dysfunction and Diastolic Heart Failure. Part II: Causal Mechanisms and Treatment,” Circulation, Vol. 105, 2002, pp. 1503-1508. doi:10.1161/hc1202.105290
[14] A. Sablotzki, T. Hentschel, et al., “Hemodynamic Effects of Inhaled Effects of Inhaled Aerosolized Iloprost and Inhaled Nitric Oxide in Heart Transplant Candidates with Elevated Pulmonary Vascular Resistance,” European Journal of Cardiothoracic Surgery, Vol. 22, No. 5, 2002, pp. 746-752. doi:10.1016/S1010-7940(02)00488-8
[15] Lusardi, et al., “2001 Open Forum at International Resp Congress: The Annual Convention and Exhibition for Respiratory Care, 2001, San Antonio,” Respiratory Care, Vol. 46, No. 10, 2001, pp. 1065-1070.
[16] R. Brower, “Mechanical Ventilation in Acute Lung Injury and ARDS. Tidal volume Reduction,” Critical Care Clinics, Vol. 18, No. 1, 2002, pp. 1-13.
[17] R. G. Brower, L. B. Ware, Y. Berthiaume and M. A. Matthay, “Treatment of ARDS,” Chest, Vol. 120, No. 4, 2001, pp. 1347-1367. doi:10.1378/chest.120.4.1347
[18] E. James, II. Bartlett, J. W. Kotrlik and C. C. Higgins, “Organizational Research: Determining Appropriate Sample Size in Survey Research,” Information Technology, Learning and Performance Journal, Vol. 19, No. 1, 2001.
[19] T. Busch, S. Bercker, et al., “Inhaled Nitric Oxide for Rescue Treatment of Refractory Hypoxemia in ARDS Patients,” Anasthesiol Intensivmed Notfallmed Schmerzther, Vol. 43, No. 11-12, 2008, pp. 778-783. doi:10.1055/s-0028-1104618
[20] Z. G. Wei, B. Zhong, J. Ji and X. Yi, “Guidelines for Management of Acute Lung Injury/Acute Respiratory Distress Syndrome,” The Chinese Society of Critical Care Medicine, Vol. 218, No. 12, 2006, pp. 706-710.
[21] J. M. Camamo, R. H. McCoy, et al., “Retrospective Evaluation of Inhaled Prostaglandins in Patients with Acute Respiratory Distress Syndrome,” Pharmacotherapy, Vol. 25, No. 2, 2005, pp. 184-190. doi:10.1592/phco.25.2.184.56952
[22] J. Cranshaw, M. J. Griffiths, et al., “The Pulmonary Physician in Critical Care. Part 9: Non-Ventilatory Strategies in ARDS,” Thorax, Vol. 57, No. 9, 2002, pp. 823-829.doi:10.1136/thorax.57.9.823
[23] K. F. Schulz, D. G. Altman and D. Moher, “CONSORT 2010. Statement: Updated Guidelines for Reporting Parallel Group Randomised Trials,” Annals of International Medicine, Vol. 152, 2010.
[24] L. Fierobe, F. Brunet, J. F. Dhainut, et al., “Effect of Inhaled Nitric Oxide on Right Ventricular Function in Adult Respiratory Distress Syndrome,” American Journal of Respiratory and Critical Care Medicine, Vol. 151, No. 5, 1995, pp. 1414-1419

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