Is there a role for inhaled epoprostenol, inhaled nitric oxide or sildenafil to treat secondary pulmonary hypertension and hypoxaemia in ICU patients with acute respiratory distress syndrome?

  • An analysis of pooled randomised controlled trials of the use of inhaled nitric oxide in patients with acute respiratory distress syndrome (ARDS) found no mortality benefit; however renal dysfunction was increased. The recommendation in the resulting guidelines was weakly against using inhaled nitric oxide in patients with ARDS. However, it may be useful as a short term adjunct to cardiorespiratory support in those with acute hypoxemia, life-threatening pulmonary hypertension or both.
  • Meta-analysis of 16 trials of patients with ARDS showed inhaled prostaglandins (including epoprostenol) improved oxygenation and decreased pulmonary pressure but caused hypotension.
  • Trials of inhaled prostaglandins have not shown improvements in patient-oriented outcomes e.g. mortality. Inhaled prostaglandins should not be routinely used to treat ARDS but may be offered to patients with severe ARDS in critical care, prior to extra corporeal membrane oxygenation.
  • A small study of the use of sildenafil in patients with ARDS found a reduction in pulmonary arterial pressure but a decrease in arterial oxygen. The results make sildenafil unsuitable for routine use; however it may be beneficial for ARDS patients with severe pulmonary arterial hypertension who do not have systemic arterial hypotension.
  • Reviews of the use of inhaled prostaglandins, inhaled nitric oxide and sildenafil have been based on limited, low-quality evidence. Some authors have expressed the need for larger, appropriately powered studies which assess patient mortality for inhaled prostaglandins and sildenafil.