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Dead space ratio as a tool in nitric oxide weaning: a study in pulmonary hypertensive disease

Published online by Cambridge University Press:  09 December 2021

Alvaro D. Garcia ,
Wei Liu ,
Hemant Agarwal Open the ORCID record for Hemant Agarwal [Opens in a new window]  and
William J. Hanna Open the ORCID record for William J. Hanna [Opens in a new window]
Alvaro D. Garcia
Affiliation:
Pediatric Critical Care Department, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
Wei Liu
Affiliation:
Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
Hemant Agarwal
Affiliation:
Pediatric Critical Care Department, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
William J. Hanna*
Affiliation:
Pediatric Critical Care Department, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
*
Author for correspondence: W. J. Hanna, Pediatric Critical Care Department, Pediatric Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, M14, Cleveland, OH 44121, USA. Tel: 2162134513. E-mail: hannaw@ccf.org
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Abstract

Objectives:

To describe the association between successful weaning of inhaled nitric oxide and trends in dead space ratio during such weans in patients empirically initiated on nitric oxide therapy out of concern of pulmonary hypertensive crisis.

Patients:

Children in a cardiac intensive care unit initiated on inhaled nitric oxide out of clinical concern for pulmonary hypertensive crisis retrospectively over 2 years.

Measurements and Main Results:

Twenty-seven patients were included, and nitric oxide was successfully discontinued in 23/27. These patients exhibited decreases in dead space ratio (0.18 versus 0.11, p = 0.047) during nitric oxide weaning, and with no changes in dead space ratio between pre- and post-nitric oxide initiation (p = 0.88) and discontinuation (p = 0.63) phases. These successful patients had a median age of 10 months [4.0, 57.0] and had a pre-existent diagnosis of CHD in 6/23 and pulmonary hypertension in 2/23. Those who failed nitric oxide discontinuation trended with a higher dead space ratio at presentation (0.24 versus 0.10), were more likely to carry a prior diagnosis of pulmonary hypertension (50% versus 8.7%), and had longer mechanical ventilation days (5 versus 12).

Conclusions:

Patients empirically placed on nitric oxide out of concern of pulmonary hypertensive crisis and successfully weaned off showed unchanged or decreased dead space ratio throughout the initiation to discontinuation phases of nitric oxide therapy. Trends in dead space ratio may aid in determining true need for nitric oxide and facilitate effective weaning. Further studies are needed to directly compare trends between success and failure groups.

Keywords

Pulmonary hypertensiondead space fractioninhaled nitric oxide
Type
Original Article
Information
Cardiology in the Young , Volume 32 , Issue 10 , October 2022 , pp. 1603 - 1607
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Copyright
© The Author(s), 2021. Published by Cambridge University Press

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References

Hopkins, RA, Bull, C, Haworth, SG, de Leval, MR, Stark, J. Pulmonary hypertensive crises following surgery for congenital heart defects in young children. Eur J Cardiothorac Surg 1991; 5: 628–634.CrossRefGoogle ScholarPubMed
Abman, SH, Hansmann, G, Archer, SL, et al. Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society. Circulation 2015; 132: 2037–2099.CrossRefGoogle ScholarPubMed
Oishi, P, Fineman, JR. Pulmonary hypertension. Pediatr Crit Care Med 2016; 17: S140–S145.CrossRefGoogle ScholarPubMed
Pepke-Zaba, J, Higenbottam, TW, Dinh-Xuan, AT, Stone, D, Wallwork, J. Inhaled nitric oxide as a cause of selective pulmonary vasodilatation in pulmonary hypertension. Lancet 1991; 338: 1173–1174.CrossRefGoogle ScholarPubMed
Frostell, C, Fratacci, MD, Wain, JC, Jones, R, Zapol, WM. Inhaled nitric oxide. A selective pulmonary vasodilator reversing hypoxic pulmonary vasoconstriction. Circulation 1991; 83: 2038–2047.CrossRefGoogle ScholarPubMed
Journois, D, Pouard, P, Mauriat, P, Malhère, T, Vouhé, P, Safran, D. Inhaled nitric oxide as a therapy for pulmonary hypertension after operations for congenital heart defects. J Thorac Cardiovasc Surg 1994; 107: 1129–1135.CrossRefGoogle ScholarPubMed
Miller, OI, Tang, SF, Keech, A, Pigott, NB, Beller, E, Celermajer, DS. Inhaled nitric oxide and prevention of pulmonary hypertension after congenital heart surgery: a randomised double-blind study. Lancet 2000; 356: 1464–1469.CrossRefGoogle ScholarPubMed
Barr, FE, Macrae, D. Inhaled nitric oxide and related therapies. Pediatr Crit Care Med 2010; 11: S30–S36.CrossRefGoogle ScholarPubMed
Morris, K, Beghetti, M, Petros, A, Adatia, I, Bohn, D. Comparison of hyperventilation and inhaled nitric oxide for pulmonary hypertension after repair of congenital heart disease. Crit Care Med 2000; 28: 2974–2978.CrossRefGoogle ScholarPubMed
Rimensberger, PC, Spahr-Schopfer, I, Berner, M, et al. Inhaled nitric oxide versus aerosolized iloprost in secondary pulmonary hypertension in children with congenital heart disease: vasodilator capacity and cellular mechanisms. Circulation 2001; 103: 544–548.CrossRefGoogle ScholarPubMed
Di Genova, T, Sperling, C, Gionfriddo, A, et al. A stewardship program to optimize the use of inhaled nitric oxide in pediatric critical care. Qual Manag Health Care 2018; 27: 74–80.CrossRefGoogle ScholarPubMed
Schindler, MB, Bohn, DJ, Bryan, AC, Cutz, E, Rabinovitch, M. Increased respiratory system resistance and bronchial smooth muscle hypertrophy in children with acute postoperative pulmonary hypertension. Am J Respir Crit Care Med 1995; 152: 1347–1352.CrossRefGoogle ScholarPubMed
Arnold, JH, Thompson, JE, Arnold, LW. Single breath CO2 analysis: description and validation of a method. Crit Care Med 1996; 24: 96–102.CrossRefGoogle ScholarPubMed
Arnold, JH, Thompson, JE, Benjamin, PK. Respiratory deadspace measurements in neonates during extracorporeal membrane oxygenation. Crit Care Med 1993; 21: 1895–1900.CrossRefGoogle ScholarPubMed
Arnold, JH, Bower, LK, Thompson, JE. Respiratory deadspace measurements in neonates with congenital diaphragmatic hernia. Crit Care Med 1995; 23: 371–375.CrossRefGoogle ScholarPubMed
Bhalla, AK, Belani, S, Leung, D, Newth, CJ, Khemani, RG. Higher dead space is associated with increased mortality in critically ill children. Crit Care Med 2015; 43: 2439–2445.CrossRefGoogle ScholarPubMed
Devor, RL, Kang, P, Wellnitz, C, Nigro, JJ, Velez, DA, Willis, BC. Pulmonary dead space fraction and extubation success in children after cardiac surgery. Pediatr Crit Care Med 2018; 19: 301–309.CrossRefGoogle ScholarPubMed
Naruke, T, Inomata, T, Imai, H, et al. End-tidal carbon dioxide concentration can estimate the appropriate timing for weaning off from extracorporeal membrane oxygenation for refractory circulatory failure. Int Heart J 2010; 51: 116–120.CrossRefGoogle ScholarPubMed
Young, A, Marik, PE, Sibole, S, Grooms, D, Levitov, A. Changes in end-tidal carbon dioxide and volumetric carbon dioxide as predictors of volume responsiveness in hemodynamically unstable patients. J Cardiothorac Vasc Anesth 2013; 27: 681–684.CrossRefGoogle ScholarPubMed
Pokorná, M, Necas, E, Kratochvíl, J, Skripský, R, Andrlík, M, Franek, O. A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med 2010; 38: 614–621.CrossRefGoogle ScholarPubMed
Levine, RL, Wayne, MA, Miller, CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med 1997; 337: 301–306.CrossRefGoogle ScholarPubMed
Panchal, AR, Berg, KM, Hirsch, KG, et al. 2019 American Heart Association focused update on advanced cardiovascular life support: use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: an update to the American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2019; 140: e881–e894.Google Scholar
Davis, JS, Johns, JA, Olvera, DJ, et al. Vital sign patterns before shock-related cardiopulmonary arrest. Resuscitation 2019; 139: 337–342.CrossRefGoogle ScholarPubMed
Askrog, V. Changes in (a-A)CO2 difference and pulmonary artery pressure in anesthetized man. J Appl Physiol 1966; 21: 1299–1305.CrossRefGoogle Scholar
Chauhan, JC, Deb, R. Relationship between pulmonary-to-systemic-blood-flow ratio (Qp:Qs) based on cardiac catheterization and indices derived from simultaneously measured end tidal CO. Pediatr Cardiol 2019; 40: 182–187.CrossRefGoogle Scholar
Kallet, RH, Zhuo, H, Ho, K, Lipnick, MS, Gomez, A, Matthay, MA. Lung injury etiology and other factors influencing the relationship between dead-space fraction and mortality in ARDS. Respir Care 2017; 62: 1241–1248.CrossRefGoogle ScholarPubMed
Shostak, E, Schiller, O, Merzbach, A, et al. Alveolar dead-space fraction and arterial saturation predict postoperative course in Fontan patients. Pediatr Crit Care Med 2020; 21: e200–e206.CrossRefGoogle ScholarPubMed
Cigarroa, CL, van den Bosch, SJ, Tang, X, et al. Measurement of dead space fraction upon ICU admission predicts length of stay and clinical outcomes following bidirectional cavopulmonary anastomosis. Pediatr Crit Care Med 2018; 19: 23–31.CrossRefGoogle ScholarPubMed
Todd Tzanetos, DR, Housley, JJ, Barr, FE, May, WL, Landers, CD. Implementation of an inhaled nitric oxide protocol decreases direct cost associated with its use. Respir Care 2015; 60: 644–650.CrossRefGoogle ScholarPubMed
Aly, H, Sahni, R, Wung, J-T. Weaning strategy with inhaled nitric oxide treatment in persistent pulmonary hypertension of the newborn. Arch Dis Child Fetal Neonatal Ed 1997; 76: F118–F122.CrossRefGoogle ScholarPubMed
Cigarroa, RG, Lange, RA, Williams, RH, Bedotto, JB, Hillis, LD. Underestimation of cardiac output by thermodilution in patients with tricuspid regurgitation. Am J Med 1989; 86: 417–420.CrossRefGoogle ScholarPubMed
Perkin, RM, Anas, N. Pulmonary artery catheters. Pediatr Crit Care Med 2011; 12: S12–S20.CrossRefGoogle ScholarPubMed
Flori, HR, Johnson, LD, Hanley, FL, Fineman, JR. Transthoracic intracardiac catheters in pediatric patients recovering from congenital heart defect surgery: associated complications and outcomes. Crit Care Med 2000; 28: 2997–3001.CrossRefGoogle ScholarPubMed
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