title: The effect of inhaled nitric oxide in acute respiratory distress syndrome in children and adults: a Cochrane Systematic Review with trial sequential analysis.
abstract: Acute respiratory distress syndrome is associated with high mortality and morbidity. Inhaled nitric oxide has been used to improve oxygenation but its role remains controversial. Our primary objective in this systematic review was to examine the effects of inhaled nitric oxide administration on mortality in adults and children with acute respiratory distress syndrome. We included all randomised, controlled trials, irrespective of date of publication, blinding status, outcomes reported or language. Our primary outcome measure was all-cause mortality. We performed several subgroup and sensitivity analyses to assess the effect of inhaled nitric oxide. There was no statistically significant effect of inhaled nitric oxide on longest follow-up mortality (inhaled nitric oxide group 250/654 deaths (38.2%) vs. control group 221/589 deaths (37.5%; relative risk (95% CI) 1.04 (0.9-1.19)). We found a significant improvement in PaO2/FIO2ratio at 24 h (mean difference (95% CI) 15.91 (8.25-23.56)), but not at 48 h or 72 h, while four trials indicated improved oxygenation in the inhaled nitric oxide group at 96 h (mean difference (95% CI) 14.51 (3.64-25.38)). There were no statistically significant differences in ventilator-free days, duration of mechanical ventilation, resolution of multi-organ failure, quality of life, length of stay in intensive care unit or hospital, cost-benefit analysis and methaemoglobin and nitrogen dioxide levels. There was an increased risk of renal impairment (risk ratio (95% CI) 1.59 (1.17-2.16)) with inhaled nitric oxide. In conclusion, there is insufficient evidence to support inhaled nitric oxide in any category of critically ill patients with acute respiratory distress syndrome despite a transient improvement in oxygenation, since mortality is not reduced and it may induce renal impairment.
authors.affiliation: Paediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland.
authors.forename: O
authors.identifier: 0000-0001-6606-1736
authors.initials: O
authors.lastname: Karam
authors.affiliation: Paediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland.
authors.forename: F
authors.initials: F
authors.lastname: Gebistorf
authors.affiliation: Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark.
authors.forename: J
authors.initials: J
authors.lastname: Wetterslev
authors.affiliation: The Cochrane Anaesthesia, Critical and Emergency Care Group and Copenhagen Trial Unit and Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet, Copenhagen, Denmark.
authors.forename: A
authors.initials: A
authors.lastname: Afshari
mesh_terms: D055371:Acute Lung Injury / Q000188:drug therapy / Q000401:mortality; D000280:Administration, Inhalation; D015982:Bias; D001993:Bronchodilator Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D006801:Humans; D009569:Nitric Oxide / Q000008:administration & dosage* / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012128:Respiratory Distress Syndrome / Q000188:drug therapy* / Q000401:mortality
chemical_list: D001993:Bronchodilator Agents; D009569:Nitric Oxide
keywords: acute respiratory distress syndrome; nitric oxide; systematic review