Vardenafil and weaning from inhaled nitric oxide: effect on pulmonary hypertension in ARDS.

We report a 66-year-old patient with refractory pulmonary hypertension secondary to ARDS who was being treated with inhaled nitric oxide. Enteral vardenafil (phosphodiesterase-5 inhibitor) was tried at two different doses (10 mg and 5 mg), in order to wean the patient from nitric oxide. The higher dose decreased pulmonary pressure but caused systemic hypotension and the drug was discontinued. Subsequently, a 5 mg dose of vardenafil decreased pulmonary pressure without hypotension. Pulmonary hypertension was controlled using vardenafil 10-15 mg divided in 2-3 daily doses. This therapy allowed nitric oxide withdrawal, weaning from mechanical ventilation and discharge from ICU Vardenafil acted in synergy with inhaled nitric oxide, permitted nitric oxide reduction and discontinuation and proved to be effective as a single, long-term treatment for pulmonary hypertension.

Non-invasive mechanical ventilation in patients with acute cardiogenic pulmonary edema.

AIM: To evaluate the use of noninvasive mechanical ventilation (NIMV) in patients with acute cardiogenic pulmonary edema. DESIGN: prospective study. SETTING: Emergency Department at a University hospital. PATIENTS: 84 patients with acute respiratory distress due to pulmonary edema. Interven-tions: NIMV, using a pressure support mode and positive end-expiratory pressure (PEEP). A "weaning test" to evaluate clinical stability. MEASUREMENTS: heart rate, arterial blood pressure, respiratory rate, arterial blood gases, electrocardiogram and incidence of myocardial infarction before and after NIMV. Mortality and duration of hospital stay were also considered. RESULTS: A total of 84 patients received NIMV with 14+/-3.6 cm H2O pressure support over PEEP of 8.3+/-2.1 cm H2O and FiO2 1. At the end of the study period, 16 patients (19%) were considered "non responders" and required invasive ventilation; 62 patients (74%) were considered "responders" and subsequently transferred to the medical ward. The hospital mortality was 14% and 25% in the "responder" and "non responder" groups, respectively; the length of stay was 15.7+/-10.1 days in the "responder" group vs 16+/-10.6 days in the "non responder" group. We never found new episodes of myocardial infarction related to NIMV. The only significant difference between "responder" and "non responder" patients was arterial blood pressure. CONCLUSIONS: We hypothesize that "non responder" patients, characterized by blood pressure values lower than "responders", are less "cardiocompetent" and thus unable to cope with the increased work of breathing. NIMV avoided Intensive Care Unit admission for 74% of the observed patients.

Effects of continuous negative extrathoracic pressure versus positive end-expiratory pressure in acute lung injury patients.

OBJECTIVE: To compare the effects of continuous negative extrathoracic pressure (CNEP) and positive end-expiratory pressure (PEEP) at the same level of transpulmonary pressure. DESIGN: Prospective analysis. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Nine consecutive acute lung injury patients. Patients with cardiac failure and patients with chronic lung disease were excluded from the investigation. INTERVENTIONS: The patients were sedated and paralyzed while receiving mechanical ventilation and were studied in three different conditions: a) using a PEEP of 0 cm H2O (zero end-expiratory pressure); b) using a PEEP of 15 cm H2O; c) using CNEP. CNEP was applied to the thorax and the upper abdomen and its level was chosen to obtain a transpulmonary pressure similar to the one observed at a PEEP of 15 cm H2O. All patients had an arterial catheter, a pulmonary artery catheter, and a thermistor-tip fiberoptic catheter for thermo-dye-dilution in the femoral artery. These catheters were connected to an integrated monitoring system. We also placed an esophageal catheter in each patient to detect esophageal pressure. MEASUREMENTS AND MAIN RESULTS: For each step, we assessed the hemodynamic variations by measuring intravascular pressures (via a pulmonary artery catheter), transmural pressures (computed by subtracting esophageal pressure from intravascular pressure), and blood volumes (derived from the technique of double indicator). The application of CNEP of -20+/-0.7 cm H2O produced a venous admixture and PaO2/FO2 improvement similar to that obtained with a PEEP of 15 cm H2O. This procedure is associated with a higher cardiac index (5.5+/-1.5 vs. 4.6+/-1.2 L/min/m2; p < .05) coupled with lower central venous pressure, pulmonary artery occlusion pressure, and higher transmural pressures and blood volume parameters. CONCLUSIONS: In acute lung injury patients, a CNEP of -20 cm H2O has the capability to obtain transpulmonary pressure and lung function improvement similar to a PEEP of 15 cm H2O. CNEP differs from the positive pressure by increasing the venous return and the preload of the heart, and has no negative effects on cardiac performance.