A retrospective evaluation of clinical outcomes in the use of inhaled nitric oxide in acute respiratory distress syndrome caused by COVID-19: The NITRICOVID study.
Mohamed Zuhail Kizhakka Peediyakkal, Muna A Rahman Al Maslamani, Nevin Kannappilly, Saifil Sidhique, Mohamed Aboukamar, Sreekanth Komath Mohan, Jintu Iype, Virendra Pratap Chaudhary, Ashib Thurakkal, Karimulla Shakeer Shaik, Solaiman Allafi, Abdulqadir Nashwan, Nabeel F Suleiman Al LObaney
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Abstract
Background: Acute respiratory distress syndrome (ARDS) remains a leading cause of mortality among critically ill patients with COVID-19. Inhaled nitric oxide (iNO), a selective pulmonary vasodilator, is often used as rescue therapy to improve oxygenation; however, its impact on survival remains uncertain.
Objective: To evaluate the clinical outcomes of iNO therapy in patients with COVID-19-related ARDS and to stratify patients into Early, Delayed, and Non-Responder groups based on the timing of their oxygenation response.
Methods: A retrospective cohort study of 99 patients with COVID-19-related ARDS who received iNO was conducted. Patients were categorized as.
Early responders: ≥20% improvement in the PaO2/FiO2 ratio within 8 h.
Delayed responders: ≥20% improvement in the PaO2/FiO2 ratio between 8 and 24 h.
Non-responders no improvement: <20% improvement in the PaO2/FiO2 ratio within 24 h, including those who showed in their PaO2/FiO2 ratio within 24 h of iNO initiation.Baseline demographics, comorbidities, and outcomes, including duration of mechanical ventilation, ICU and hospital length of stay, and mortality, were compared.
Results: Early and Delayed Responders showed significant improvement in oxygenation (mean PaO2/FiO2: 137.3 vs. 126.9 vs. 106.4; p = 0.004), with mean percentage increases of 65.3%, 56.6%, and 8.2%, respectively (p < 0.001). However, this did not translate into differences in ICU mortality (64.8%, 62.5%, and 71.4%, respectively; p = 0.81) or other hospital outcomes. Rates of acute kidney injury (AKI), methemoglobinemia, and other complications were comparable among the groups.
Conclusion: iNO improved oxygenation in a subset of patients with COVID-19-related ARDS but did not reduce mortality. Stratification by timing of response highlights patient heterogeneity and supports response-guided, time-limited use of iNO in critical care.
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