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Critical Care  2009 

Bench-to-bedside review: Inhaled nitric oxide therapy in adults

DOI: 10.1186/cc7734

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Abstract:

Nitric oxide (NO) is an important determinant of local blood flow and is formed by the action of NO synthase (NOS) on the semi-essential amino acid L-arginine in the presence of molecular oxygen. Inhaled NO (iNO) results in preferential pulmonary vasodilatation and lowers pulmonary vascular resistance (PVR), augments hypoxic pulmonary vasoconstriction (HPV), and improves oxygenation. These effects are harnessed in the therapeutic applications of iNO to patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), to those with acute right ventricular failure (RVF) complicating cardiac surgery or acute pulmonary embolism, or in acute sickle chest crisis. Despite dramatic physiological improvements that are often seen during the therapeutic use of iNO, there remains a lack of evidence concerning any beneficial effect on outcomes. This 'Bench-to-bedside' review focuses on the mechanisms of action of iNO and its clinical applications, with particular attention to ALI and ARDS. Alterations in endogenous NO production and the use of exogenous intravenous NO donors in acute inflammatory conditions are beyond the scope of this review.The licensed indication of iNO is restricted to persistent pulmonary hypertension in neonates, yet most iNO is administered for unlicensed indications. Pharmaceutical iNO is available at a very high cost, and in light of this and concerns over potential adverse effects of iNO, international guidelines have been developed. An advisory board under the auspices of the European Society of Intensive Care Medicine and the European Association of Cardiothoracic Anaesthesiologists published its recommendations in 2005 [1]. Although this valuable project was sponsored by the manufacturer of iNO (INO Therapeutics, now part of Ikaria Holdings, Clinton, NJ, USA), the board stated that the sponsor had no authorship or editorial control over the content of the meetings or any subsequent publication.iNO is administered most commonly to inv

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