Inhaled Prostacyclins for Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis

Efficacy and safety of several common drugs in the treatment of acute respiratory distress syndrome: A systematic review and network meta-analysis

BACKGROUND

This study aimed to compare the effectiveness and safety of neuromuscular blockers, mesenchymal stem cells (MSC), and inhaled pulmonary vasodilators (IV) for acute respiratory distress syndrome through a network meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched Chinese and English databases, including China National Knowledge Infrastructure, The Cochrane Library, PubMed, and EMbase, with no time restrictions. We conducted a network meta-analysis and reported the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We included 27 clinical RCTs, all of which were two-arm trials, totaling 3492 patients. We selected 28-day mortality as the primary outcome measure, whereas 90-day mortality, ventilator-free days, and oxygenation served as secondary outcome measures for analysis and comparison.

RESULTS

We selected 3 treatment modalities and evaluated their clinical trials in comparison with the standard control group. For the 28-day in-hospital mortality, we included 21 RCTs, involving 2789 patients. Compared to standard treatment, neuromuscular blockers were associated with reduced 28-day hospital mortality (odds ratios [OR] 0.52, 95% confidence intervals [CI] (0.31, 0.88)), while IV and MSC were not associated with reduced hospital mortality (OR 0.89, 95% CI (0.50, 1.55); OR 0.90, 95% CI (0.49, 1.66)). In terms of 90-day mortality, days free of mechanical ventilation, and improvement in oxygenation, there were no significant differences compared to standard treatment with neuromuscular blockers, MSC, and IV.

CONCLUSION

Neuromuscular blockers significantly reduced the 28-day mortality rate in acute respiratory distress syndrome patients. However, in terms of 90-day mortality, ventilator-free days, oxygenation improvement, IV, MSC, and neuromuscular blockers did not significantly improve.

A Narrative Review on the Administration of Inhaled Prostaglandins in Critically Ill Adult Patients With Acute Respiratory Distress Syndrome

OBJECTIVE

To describe the effect of inhaled prostaglandins on both oxygenation and mortality in critically ill patients with acute respiratory distress syndrome (ARDS), with a focus on safety and efficacy in coronavirus disease 2019 (COVID-19)-associated ARDS and non-COVID-19 ARDS.

DATA SOURCES

A literature search of MEDLINE was performed using the following search terms: inhaled prostaglandins, inhaled epoprostenol, inhaled nitric oxide, ARDS, critically ill. All abstracts were reviewed.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language reports and studies conducted in humans between 1980 and June 2023 were considered.

DATA SYNTHESIS

Data regarding inhaled prostaglandins and their effect on oxygenation are limited but show a benefit in patients who respond to therapy, and data pertaining to their effect on mortality is scarce. Concerns exist regarding the formulation of inhaled epoprostenol (iEPO) utilized in addition to modes of medication delivery; however, the limited data surrounding their use have shown a reasonable safety profile. Other avenues and beneficial effects may exist with inhaled prostaglandins, such as use in COVID-19-associated ARDS or non-COVID-19 ARDS patients undergoing noninvasive mechanical ventilation or during patient transport.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

The use of inhaled prostaglandins can be considered in critically ill patients with COVID-19-associated ARDS or non-COVID-19 ARDS who are experiencing difficulties with oxygenation refractory to nonpharmacologic strategies.

CONCLUSIONS

The use of iEPO and other inhaled prostaglandins requires further investigation to fully elucidate their effects on clinical outcomes, but it appears these medications may have a potential benefit in COVID-19-associated ARDS and non-COVID-19 ARDS patients with refractory hypoxemia but with little effect on mortality.