Correspondence

Continuous Intraarterial Measurement of Oxygenation during Aerosolized Prostacyclin Administration in Severe Respiratory Failure

N Engl J Med 1994; 331:335-336August 4, 1994

Article

To the Editor:

A recent report1 stimulated us to use aerosolized prostaglandin I₂ (PGI₂; also called prostacyclin or epoprostenol) to improve arterial oxygenation by producing selective pulmonary vasodilation in well-ventilated areas. PGI₂ decreases microvascular pressure in the lung and reduces pulmonary fluid filtration and right-heart afterload2.

We report here on a 65-year-old patient with severe respiratory failure due to pneumonia (Klebsiella pneumoniae infection) and pulmonary hypertension. The chest film showed extensive bilateral interstitial infiltrates, signs of a “capillary leak syndrome,” and atelectasis. Because of critically decreased oxygenation, we inserted a sensor into the left radial artery and connected it to an intravascular blood gas monitoring system (Paratrend 7, Biomedical Sensors, Pfizer, New York), which measured partial pressure of oxygen (PaO₂), partial pressure of carbon dioxide (PaCO₂), and pH continuously. We administered PGI₂ as a nebulized aerosol (Wellcome Laboratories, London) at a dose of 5 ng per kilogram of body weight per minute for 30 minutes into the afferent limb of the ventilatory system and recorded changes in blood gases, pulmonary-artery pressure, systemic arterial pressure, and heart rate.

After the administration of PGI₂ began, we registered a rapid improvement in arterial oxygenation (Figure 1Figure 1Continuous Measurements of Arterial-Blood Gas Changes during the Administration of Aerosolized PGI₂.). The pretreatment PaO₂ value (79.4 mm Hg) increased continuously for 10 minutes, until a plateau was reached (150.5 mm Hg). The PaCO₂ decreased slightly, from 43.4 mm Hg to 40.9 mm Hg. The mean pulmonary-artery pressure decreased from 49 mm Hg at the start of treatment to 38 mm Hg at the end. The heart rate (102 bpm) and mean systemic arterial pressure (100 mm Hg) remained unchanged. The effects were reversed 10 minutes after the withdrawal of PGI₂.

To our knowledge, this was the first documentation of the rapid and extensive effect of PgI₂ inhalation on arterial oxygenation by continuous blood gas measurements. Continuous intravascular blood gas monitoring is a useful tool in patients with critically decreased pulmonary function in whom the application of unconventional therapies such as the administration of PGI₂ is requested.

Thomas Bein, M.D.
Michael Pfeifer, M.D.
Gunter A.J. Riegger, M.D.
Kai Taeger, M.D.
University of Regensburg, 93042 Regensburg, Germany

2 References

1. 1

   Welte M, Zwissler B, Habazettl H, Messmer K. PGI₂ aerosol versus nitric oxide for selective pulmonary vasodilation in hypoxic pulmonary vasoconstriction. Eur Surg Res 1993;25:329-340
   CrossRef | Web of Science | Medline

2. 2

   Radermacher P, Santak B, Wust HJ, Tarnow J, Falke KJ. Prostacyclin and right ventricular functions in patients with pulmonary hypertension associated with ARDS. Intensive Care Med 1990;16:227-232
   CrossRef | Web of Science | Medline

Citing Articles (11)

Citing Articles

1. 1

   Arash Afshari, Jesper Brok, Ann Merete Møller, Jørn Wetterslev, Arash Afshari. 2010. Aerosolized prostacyclin for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). .
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2. 2

   Bala Venkatesh. 2008. In-Line Blood Gas Monitoring. , 487-499.
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3. 3

   James M. Camamo, Ruth H. McCoy, Brian L. Erstad. (2005) Retrospective Evaluation of Inhaled Prostaglandins in Patients with Acute Respiratory Distress Syndrome. Pharmacotherapy 25:2, 184-190
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4. 4

   Peter Dahlem, Wim M. C. van Aalderen, Marjorie de Neef, Marcel G. W. Dijkgraaf, Albert P. Bos. (2004) Randomized controlled trial of aerosolized prostacyclin therapy in children with acute lung injury*. Critical Care Medicine 32:4, 1055-1060
   CrossRef

5. 5

   Adam Balen. (2003) Ovulation induction — Optimizing results and minimizing risks. Human Fertility 6:2s, S42-S51
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6. 6

   J ZIMMERMAN, N HANANIA. (1998) VASODILATORS IN MECHANICAL VENTILATION. Critical Care Clinics 14:4, 611-627
   CrossRef

7. 7

   O. Habler, M. Kleen, R. Leiderer, R. Pusch, M. Welte, K. Messmer, B. Zwissler, S. Takenaka. (1996) Eight hours' inhalation of prostacyclin (PGl2) in healthy lambs: Effects on tracheal, bronchial, and alveolar morphology. Intensive Care Medicine 22:11, 1232-1238
   CrossRef

8. 8

   O. Eichelbrönner, H. Reinelt, H. Wiedeck, M. Mezödy, R. Rossaint, M. Georgieff, P. Radermacher. (1996) Aerosolized prostacyclin and inhaled nitric oxide in septic shock — different effects on splanchnic oxygenation?. Intensive Care Medicine 22:9, 880-887
   CrossRef

9. 9

   O. Habler, M. Kleen, B. Zwissler, R. Pusch, M. Welte, C. Vogelmeier, B. Kempter, F. Krombach, K. Messmer. (1996) Inhalation of prostacyclin (PGI2) for 8 hours does not produce signs of acute pulmonary toxicity in healty lambs. Intensive Care Medicine 22:5, 426-433
   CrossRef

10. 10

    Thomas Bein, Christoph Metz, Cornelius Keyl, Ernst Sendtner, Michael Pfeifer. (1996) Cardiovascular and Pulmonary Effects of Aerosolized Prostacyclin Administration in Severe Respiratory Failure Using a Ventilator Nebulization System. Journal of Cardiovascular Pharmacology 27:4, 583-586
    CrossRef

11. 11

    M. WELTE, B. ZWISSLER, O. HABLER, M. KLEEN, K. MESSMER. (1995) Prostacyclin aerosol and inhaled nitric oxide fail to reverse pulmonary vasoconstriction induced by thromboxane analogue in dogs. Acta Physiologica Scandinavica 154:3, 395-405
    CrossRef