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Abstract

Purpose:

Several reports have demonstrated similar effects on oxygenation between inhaled epoprostenol (iEPO) compared to inhaled nitric oxide (iNO) for acute respiratory distress syndrome (ARDS). Previous studies directly comparing oxygenation and clinical outcomes between iEPO and iNO exclusively in an adult ARDS patient population utilized a weight-based dosing strategy. The purpose of this study was to compare the clinical and economic impact between iNO and fixed-dosed iEPO for ARDS in adult intensive care unit (ICU) patients.

Methods:

This retrospective cohort study was conducted at a major academic medical center between January 1, 2014, and October 31, 2018. Patients ≥18 years of age with moderate-to-severe ARDS were included. The primary end point was to compare the mean change in partial arterial oxygen pressure to fraction of inspired oxygen (Pao ₂: Fio ₂) at 4 hours from baseline between iEPO and iNO. Other secondary aims were total acquisition drug costs, in-hospital mortality, ICU and hospital length of stay, and duration of mechanical ventilation.

Results:

A total of 239 patients were included with 139 (58.2%) and 100 (41.8%) in the iEPO and iNO groups, respectively. The mean change in Pao ₂: Fio ₂ at 4 hours from baseline in the iEPO and iNO groups were 31.4 ± 54.6 and 32.4 ± 42.7 mm Hg, respectively (P = .88). The responder rate at 4 hours was similar between iEPO and iNO groups (64.7% and 66.0%, respectively, P = .84). Clinical outcomes including mortality, overall hospital and ICU length of stay, and mechanical ventilation duration were similar between iEPO and iNO groups. Estimated annual cost-savings realized with iEPO was USD1 074 433.

Conclusion:

Fixed-dose iEPO was comparable to iNO in patients with moderate-to-severe ARDS for oxygenation and ventilation parameters as well as clinical outcomes. Significant cost-savings were realized with iEPO use.

Keywords

acute respiratory distress syndrome inhaled prostacyclin inhaled epoprostenol inhaled nitric oxide critically ill intensive care

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References

Thompson

Chambers

Liu

. Acute respiratory distress syndrome. N Engl J Med. 2017;377(19):1904–1905.

Bellani

Laffey

Pham

, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800.

Fan

Brodie

Slutsky

. Acute respiratory distress syndrome: advances in diagnosis and treatment. JAMA. 2018;319(7):698–710.

Buckley

Dzierba

Muir

Gonzales

. Moderate to severe acute respiratory distress syndrome management strategies: a narrative review. J Pharm Pract. 2019;32(3):347–360.

Griffiths

MJD

McAuley

Perkins

, et al. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res. 2019;6(1):e000420.

Papazian

Aubron

Brochard

, et al. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):69.

Duan

Adhikari

NKJ

D’Aragon

, et al. Management of acute respiratory distress syndrome and refractory hypoxemia. A multicenter observational study. Ann Am Thorac Soc. 2017;14(12):1818–1826.

Buckley

Feldman

. Inhaled epoprostenol for the treatment of pulmonary arterial hypertension in critically ill adults. Pharmacotherapy. 2010;30(7):728–740.

Dzierba

Abel

Buckley

Lat

. A review of inhaled nitric oxide and aerosolized epoprostenol in acute lung injury or acute respiratory distress syndrome. Pharmacotherapy. 2014;34(3):279–290.

10.

De Wet

Affleck

Jacobsohn

, et al. Inhaled prostacyclin is safe, effective, and affordable in patients with pulmonary hypertension, right heart dysfunction, and refractory hypoxemia after cardiothoracic surgery. J Thorac Cardiovasc Surg. 2004;127(4):1058–1067.

11.

Fattouch

Sbraga

Bianco

, et al. Inhaled prostacyclin, nitric oxide, and nitroprusside in pulmonary hypertension after mitral valve replacement. J Card Surg. 2005;20(2):171–176.

12.

Fattouch

Sbraga

Sampognaro

, et al. Treatment of pulmonary hypertension in patients undergoing cardiac surgery with cardiopulmonary bypass: a randomized, prospective, double-blind study. J Cardiovasc Med (Hagerstown). 2006;7(2):119–123.

13.

Hache

Denault

Belisle

, et al. Inhaled prostacyclin (PGI2) is an effective addition to the treatment of pulmonary hypertension and hypoxia in the operating room and intensive care unit. Can J Anaesth. 2001;48(9):924–929.

14.

Khan

Schnickel

Ross

, et al. A prospective, randomized, crossover pilot study of inhaled nitric oxide versus inhaled prostacyclin in heart transplant and lung transplant recipients. J Thorac Cardiovasc Surg. 2009;138(6):1417–1424.

15.

Ammar

Bauer

Bass

Sasidhar

Mullin

Lam

. Noninferiority of inhaled epoprostenol to inhaled nitric oxide for the treatment of ARDS. Ann Pharmacother. 2015;49(10):1105–1112.

16.

Torbic

Szumita

Anger

Nuccio

LaGambina

Weinhouse

. Inhaled epoprostenol vs inhaled nitric oxide for refractory hypoxemia in critically ill patients. J Crit Care. 2013;28(5):844–848.

17.

Walmrath

Schneider

Schermuly

Olschewski

Grimminger

Seeger

. Direct comparison of inhaled nitric oxide and aerosolized prostacyclin in acute respiratory distress syndrome. Am J Respir Crit Care Med. 1996;153(3):991–996.

18.

Hawn

Wanek

Bauer

, et al. Effectiveness, safety, and economic comparison of two inhaled epoprostentol products (Flolan and Veletri) in cardiothoracic surgery patients. Ann Pharmacother. 2018;52(10):956–964.

19.

Torbic

Szumita

Anger

Nuccio

Lagambina

Weinhouse

. Clinical and economic impact of formulary conversion from inhaled Flolan to inhaled Veletri for refractory hypoxemia in critically ill patients. Ann Pharmacother. 2016;50(2):106–112.

20.

Epoprostenol. In: Redbook Online. Greenwood village, CO: Truven Health Analytics; 2017. www.micromedexsolutions.com. Accessed October 25, 2019. Subscription required to view.

21.

Sardo

Osawa

Finco

, et al. Nitric oxide in cardiac surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2018;32(6):2512–2519.

22.

Aguilar

Kollef

. Point: does persistent or worsening ARDS refractory to optimized ventilation and proning deserve a trial of prostacyclin? Yes. Chest. 2019;155(4):662–665.

23.

Brodie

Guerin

. Rescue therapy for refractory ARDS should be offered early: No. Intensive Care Med. 2015;41(5):926–929.

24.

Dunkley

Louzon

Lee

. Efficacy, safety, and medication errors associated with the use of inhaled epoprostenol for adults with acute respiratory distress syndrome: a pilot study. Ann Pharmacother. 2013;47(6):790–796.

25.

Kallet

Burns

Zhuo

, et al. Severity of hypoxemia and other factors that influence the response to aerosolized prostacyclin in ARDS. Respir Care. 2017;62(8):1014–1022.

26.

Stapleton

Wang

Hudson

Rubenfeld

Caldwell

Steinberg

. Causes and timing of death in patients with ARDS. Chest. 2005;128(2):525–532.

27.

Villar

Blanco

Anon

, et al. The alien study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation. Intensive Care Med. 2011;37(12):1932–1941.

Comparison of Fixed-Dose Inhaled Epoprostenol and Inhaled Nitric Oxide for Acute Respiratory Distress Syndrome in Critically Ill Adults

Abstract

Purpose:

Methods:

Results:

Conclusion:

Keywords

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References