Q: A 54-year-old female is in the ICU due to Pulmonary Arterial Hypertension (PAH) and has been dependent on inhaled Nitric Oxide (iNO) for the last few days. Every time there is an attempt to wean and discontinue iNO, the patient becomes hemodynamically unstable. Which one trick may help to wean and discontinue iNO relatively easily?
Answer: Addition of sildenafil
It is well known that abrupt discontinuation of inhaled NO, particularly in patients who are dependent on it for many days, can precipitate rapid rebound of pulmonary hypertension and worsening of ventilation/perfusion (V/Q) mismatch, resulting in hypoxemia and/or hemodynamic instability. Risks continue to rise after the first 10-12 hours of dependence, particularly in older patients.
One marker for weaning-related hemodynamic instability is a patient whose blood pressure and hemodynamics respond well at initiation. Responders are at higher risk of instability on discontinuation!
Overlapping weaning with coadministration of sildenafil may transit weaning smoothly, along with slow weaning, may be over the days. Also, keeping FiO2 higher during weaning may help.
#pulmonary
#pharmacology
References:
1. Atz AM, Wessel DL. Sildenafil ameliorates effects of inhaled nitric oxide withdrawal. Anesthesiology 1999; 91:307.
2. Khawaja H, Sanders TA, Schreiber M, Bondi D, Shah P, Brennan G. Sildenafil as Bridge Therapy for Inhaled Nitric Oxide in Preterm Neonates. J Pediatr Pharmacol Ther. 2024 Oct;29(5):525-529. doi: 10.5863/1551-6776-29.5.525. Epub 2024 Oct 14. PMID: 39411417; PMCID: PMC11472410.
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