key: cord-0876697-put9r0zy
authors: Ferrari, Michele; Santini, Alessandro; Protti, Alessandro; Andreis, Davide T.; Iapichino, Giacomo; Castellani, Gianluca; Rendiniello, Valerio; Costantini, Elena; Cecconi, Maurizio
title: Inhaled nitric oxide in mechanically ventilated patients with COVID-19
date: 2020-08-11
journal: J Crit Care
DOI: 10.1016/j.jcrc.2020.08.007
sha: 03b9da4139ed803ce0190a44b5210957f57a2f6c
doc_id: 876697
cord_uid: put9r0zy

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line with this model, a recent series has revealed the presence of diffuse pulmonary endothelial injury and microthrombosis in COVID-19 lung pathology [4] . Given the novelty of COVID-19, its treatment is currently grounded on our knowledge of ARDS. Modern supportive therapy of ARDS generally consists of endotracheal intubation and mechanical ventilation with supplemental oxygen and Positive End Expiratory Pressure (PEEP), along with muscle paralysis, prone positioning, and ExtraCorporeal Membrane Oxygenation (ECMO) for the most severe cases [5, 6] . Inhaled nitric oxide (iNO) can be considered as rescue therapy for hypoxemia due to its potent vasodilator effect on the pulmonary circulation [7] . International guidelines [5] , and experts in the field [6, [8] [9] [10] , all suggest considering iNO even for refractory hypoxemia due to COVID-19. However, there are no strong clinical data to support this indication.

Herein we describe the response to iNO in a small group of mechanically ventilated patients with severe COVID admitted to our Intensive Care Unit.

As part of our routine clinical practice for ARDS, we administered a 30-minute test dose of 20 ppm to ten adults with COVID-19 treated with invasive mechanical ventilation and with a partial pressure of arterial oxygen (PaO 2 ) to the fraction of inspired oxygen ratio (FiO 2 ) around or below 100 mmHg. All patients had been previously ventilated in prone position for 12 to 16 hours (one session) with only a minor, if any, improvement in arterial oxygenation. By the time iNO was tested, they were already sedated and ventilated in a controlled mode in the supine position. A tank with 450 ppm NO in nitrogen was connected to the inspiratory limb of the ventilatory circuit; NO was delivered during the inspiratory phase using a digital system (Optikonox, Air Liquide, Milan,

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