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The Use of Inhaled Nitric Oxide During Gas EmbolismThe Use of Inhaled Nitric Oxide During Gas Embolism FREE TO VIEW

Jose Eduardo Tanus-Santos, MD, PhD; Heitor Moreno, Jr., MD, PhD
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Affiliations: Department of Pharmacology State University of Campinas Campinas, São Paulo, Brazil ,  Medical Director, Hyperbaric Medicine LDS Hospital Associate Professor of Medicine University of Utah Medical Center Director of Research Pulmonary Division LDS Hospital Professor of Medicine University of Utah Medical Center Salt Lake City, UT



Chest. 1999;115(4):1220-1221. doi:10.1378/chest.115.4.1220-a
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We read with interest the article entitled, “Venous and Arterial Gas Embolism Associated with Positive Pressure Ventilation,” by Weaver and Morris (April 1998).1 They elegantly reported a case of massive gas embolism in a patient who died after becoming hemodynamically unstable and sustaining a right ventricular infarction. The development of right-heart failure and circulatory shock secondary to a massive increase in pulmonary vascular resistance requires prompt management, and any therapeutic attempt to improve hemodynamics is of utmost importance.

Some recent experimental data consistently support the hypothesis that inhaled nitric oxide might be a therapeutic option in the acute management of pulmonary gas embolism.2,,3 For example, 3 ppm of inhaled nitric oxide attenuated the increase in pulmonary vascular resistance and blunted the decrease of cardiac output after a massive air embolism in dogs.2Similar effects were observed when nitric oxide (3 or 40 ppm) was administered during a venous air infusion in dogs.3In addition, although controlled trials are needed to confirm the beneficial effects of nitric oxide inhalation in patients with pulmonary embolism,4some authors described significantly lower pulmonary artery pressures and increases in cardiac output after nitric oxide therapy during this critical condition.5 Even though the relevance of these findings remains to be elucidated, we believe that nitric oxide therapy could partially reverse the circulatory collapse caused by a massive gas embolism.

Correspondence to: Jose Eduardo Tanus-Santos, MD, PhD, Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas, 13081-970 Campinas, São Paulo, Brazil, e-mail: tanus@turing.unicamp.br

Weaver, LK, Morris, A (1998) Venous and arterial gas embolism associated with positive pressure ventilation.Chest113,1132-1134. [CrossRef]
 
Tanus-Santos, JE, de Nucci, G Low-dose inhaled nitric oxide attenuates hemodynamic changes following pulmonary air embolism in dogs [abstract]. Anesth Analg. 1998;;86(25) ,.:S155
 
Tanus-Santos, JE, Moreno, H, Jr, Moreno, RA, et al Inhaled nitric oxide (NO) improves hemodynamics during a venous air infusion (VAI) in dogs. Anesthesiology. 1998;;89 ,.:A452. [CrossRef]
 
Tanus-Santos, JE Inhaled nitric oxide and pulmonary embolism.Intensive Care Med1998;24,747-748. [CrossRef]
 
Capellier, G, Jacques, T, Balvay, P, et al Inhaled nitric oxide in patients with pulmonary embolism.Intensive Care Med1997;23,1089-1092. [CrossRef]
 

The Use of Inhaled Nitric Oxide During Gas Embolism

To the Editor:

We agree with Drs. Tanus-Santos and Moreno that the clinical relevance of these findings remains to be elucidated. The experimental observations in dogs cannot be extrapolated to the sick human. As Drs. Tanus-Santos and Moreno indicate, controlled trials are needed. Such trials will likely depend upon the development of methodology for early detection (eg, esophageal echo) and its widespread dissemination in a large consortium of investigative centers. The infrequent clinical recognition of massive air embolism requires that a large number of investigative centers participate. One would probably design an explicit, exportable method to assure investigative uniformity among participants. Some would, we suspect, rank this clinical problem below many others to which priority might be given if the investment in an adequate multicenter consortium were made.

Correspondence to: Lindell K. Weaver, MD, FCCP, Medical Director, Hyperbaric Medicine, LDS Hospital, Eighth Avenue and C Street, Salt Lake City, Utah 84143; e-mail: lweaver@ihc.com


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References

Weaver, LK, Morris, A (1998) Venous and arterial gas embolism associated with positive pressure ventilation.Chest113,1132-1134. [CrossRef]
 
Tanus-Santos, JE, de Nucci, G Low-dose inhaled nitric oxide attenuates hemodynamic changes following pulmonary air embolism in dogs [abstract]. Anesth Analg. 1998;;86(25) ,.:S155
 
Tanus-Santos, JE, Moreno, H, Jr, Moreno, RA, et al Inhaled nitric oxide (NO) improves hemodynamics during a venous air infusion (VAI) in dogs. Anesthesiology. 1998;;89 ,.:A452. [CrossRef]
 
Tanus-Santos, JE Inhaled nitric oxide and pulmonary embolism.Intensive Care Med1998;24,747-748. [CrossRef]
 
Capellier, G, Jacques, T, Balvay, P, et al Inhaled nitric oxide in patients with pulmonary embolism.Intensive Care Med1997;23,1089-1092. [CrossRef]
 
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