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Short-term effect of inhaled nitric oxide and prone positioning on gas exchange in patients with severe acute respiratory distress syndrome

Dupont, Hervé MD; Mentec, Hervé MD; Cheval, Christine MD; Moine, Pierre MD; Fierobe, Lisiane MD; Timsit, Jean-François MD

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Objective: To compare the short-term effects of inhaled nitric oxide (NO) and prone positioning in improving oxygenation in acute respiratory distress syndrome (ARDS).

Methods: Charts of consecutive ARDS patients (lung injury score >2) during a 2-yr period, tested for both inhaled NO and prone positioning efficacy were retrospectively reviewed. Variations in the PaO2/FIO2 ratio induced by inhaled NO and prone positioning were evaluated.

Measurements and Main Results: Twenty-seven patients (age, 42 ± 17 yrs) were included. Simplified Acute Physiology Score II was 45 ± 14. Mortality rate in the intensive care unit was 63%. The causes of ARDS were pneumonia (n = 14), extra-lung infection (n = 5), and noninfectious systemic inflammatory response syndrome (n = 8). Lung injury score was 2.7 ± 0.3. At baseline, before the initiation of inhaled NO, the PaO2/FIO2 ratio was 97 ± 46 torr and before prone positioning, 92 ± 26 torr. Variations in the PaO2/FIO2 ratio were lower at start of NO therapy (11 ± 4 ppm) than that observed at prone positioning initiation (23 ± 31 vs. 62 ± 78 torr, p < .05). An increase in variations in the PaO2/FIO2 ratio of > 15 torr was associated with prone positioning in 16 patients (59%) and with NO inhalation in 13 patients (48%) (not significant). An increase in variations in the PaO2/FIO2 ratio of > 15 torr was associated with both techniques in only six patients (22%). There was no correlation between the response to prone positioning and the response to inhaled NO (r2 = .005;p= .73).

Conclusions: Prone positioning improves hypoxemia significantly better than does inhaled NO. The response to one technique is not predictive of the response to the other technique.

From the Department of Réanimation des Maladies Infectieuses (Drs. Dupont and Timsit), Hôpital Bichat-Claude Bernard, Paris; Réanimation Polyvalente (Dr. Mentec), Hôpital Victor Dupouy, Argenteuil; Réanimation Polyvalente (Dr. Cheval), Hôpital Saint-Joseph, Paris; Réanimation Chirurgicale (Dr. Moine), Hôpital de Bicêtre, Le Kremlin-Bicêtre; Réanimation Chirurgicale (Dr. Fierobe), Hôpital Bichat-Claude Bernard, Paris, France.

Presented, in part, at the American Thoracic Society international Conference, May 1997, San Francisco, CA.

Address requests for reprints to: Jean-François Timsit, MD, Réanimation Polyvalente, Hôpital Saint Joseph, 156 rue Raymond Losserand, 75014 Paris, France. E-mail:

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