Q: 52 year old male is in refractory hypoxemia due to ARDS. Patient is not an ECMO candidate due to very recent neuro bleed. Pt. didn't respond to prone positioning either. In last 24 hours pulmonary artery catheter reading is showing progressive increase in pulmonary pressure. you requested iNO (inhaled nitric oxide). RT (Respiratory Therapy) service informed you that no iNO machine is available. What could be your alternative?
Answer: Inhaled aerosolized prostacyclin
Inhaled aerosolized prostacyclin (iAP), is an effective alternative to inhaled nitric oxide (iNO) for refractory hypoxemia and severe pulmonary hypertension. Tradiotionally, iNO is used in patients with pulmonary hypertension and acute respiratory distress syndrome (ARDS), but both iNO and iAP have been shown to reduce pulmonary vascular pressure and improve oxygenation in patients with ARDS. Moreover, it is more cost-effective also.
Walmrath D, Schneider T, Schermuly R, Olschewski H, Grimminger F, Seeger W. - Direct comparison of inhaled nitric oxide and aerosolized prostacyclin in acute respiratory distress syndrome. - Am J Respir Crit Care Med. 1996 Mar;153(3):991-6.