Previous article Table of Contents  Next article

LETTERS TO EDITOR
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 76-77

Role of almitrine bismesylate in managing refractory hypoxemia in COVID19 acute respiratory distress syndrome


Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

Correspondence Address:
Dr. Abhijit S Nair
Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad - 500034, Telangana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_782_20

Rights and Permissions
Date of Submission20-Jul-2020
Date of Decision21-Jul-2020
Date of Acceptance21-Jul-2020
Date of Web Publication5-Jan-2021
 


How to cite this article:
Nair AS, Pulipaka SK, Anne P, Rayani BK. Role of almitrine bismesylate in managing refractory hypoxemia in COVID19 acute respiratory distress syndrome. Saudi J Anaesth 2021;15:76-7

How to cite this URL:
Nair AS, Pulipaka SK, Anne P, Rayani BK. Role of almitrine bismesylate in managing refractory hypoxemia in COVID19 acute respiratory distress syndrome. Saudi J Anaesth [serial online] 2021 [cited 2021 Jan 27];15:76-7. Available from: https://www.saudija.org/text.asp?2021/15/1/76/306161



To the Editor,

In the ongoing COVID19 pandemic due to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), clinicians have been using several permutations and combinations to deal with COVID19 Acute Respiratory Distress Syndrome (ARDS). As there is no evidence based anti-viral or a vaccine available at this moment, management is purely supportive based on existing evidence. Clinicians all over the world have used non-invasive/invasive ventilation with lung protective strategies using high FiO2 and positive end expiratory pressure (PEEP), corticosteroids, inhaled nitric oxide (NO), extra-corporeal membrane oxygenation (ECMO), anticoagulants, antivirals, hydroxy-chloroquine sulphate, inflammatory inhibitors, serotherapy with variable results.[1] Researchers are still searching and experimenting various pharmacological agents in variety of doses which could improve intrapulmonary shunting leading to refractory hypoxia in COVID19 ARDS. One such drug is almitrine bismesylate.

Almitrine is a respiratory stimulant and acts as an agonist of peripheral chemoreceptors situated on the carotid bodies. It is a selective pulmonary vasoconstrictor which is mediated by calcium and in various doses has been shown to facilitate pulmonary vasoconstriction which eventually diverts increased pulmonary blood flow from areas of lung which are diseased or injured and thus cannot contribute to oxygenation. Roch et al. had demonstrated in a small cohort that a dose of 4-16 μg/kg/min infusion has shown to improve PaO2/FiO2 (P/F) ratio which is used to assess improvement in oxygenation.[2]

Almitrine has seen resurgence in clinical use during the recent COVID19 pandemic owing to its unique mechanism of action on pulmonary vasculature. Losser et al. recruited 17 intubated COVID19 ARDS patients who were administered 4–12 μg/kg/min infusion and found that there was statistically significant improvement in oxygenation from baseline in patients after almitrine infusion.[3] Barthélémy et al. analyzed the data from 19 mechanically ventilated patients with advanced settings, paralyzed with prone ventilation in almost all patients. Almitrine infusion was administered at 2 μg/kg/min which showed improvement in P/F ratio but did not improve overall patient outcomes.[4] Huette et al. managed a 57-year-old female who developed acute cor pulmonale secondary to COVID19 ARDS, diagnosed by transesophageal echocardiography.[5] She was ventilated as per ARDS protocol but hypoxemia was refractory. Almitrine infusion at 4 μg/kg/min was initiated which improved oxygenation and also right ventricular function.

Contrary to this, the findings of Cardinale et al. were contradictory. The authors used almitrine along with inhaled NO in 20 COVID19 ARDS patients with P/F ratio of less than 120 and were sedated, paralyzed, and mechanically ventilated.[6] They found that almitrine alone or with NO could not improve oxygenation in moderate to severe ARDS. They also mentioned that loss of HPV could not be the only mechanism of intrapulmonary shunting. In all above-mentioned scenarios, the sample size was small, patient characteristics and ICU management was not standardized and there was no control group. The timing of starting almitrine infusion was not uniform. Well-designed, adequately powered studies with a control arm would be necessary to know the dose, timing of starting and duration of infusion in critically ill COVID19 ARDS patients. Till then, almitrine bismesylate can be used as a rescue drug and titrated to manage refractory hypoxemia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Napoli RD. Features, evaluation and treatment Coronavirus (COVID-19). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.?gov/books/NBK554776/. [Last accessed on 2020 Jul 2020].  Back to cited text no. 1
    
2.
Roch A, Papazian L, Bregeon F, Gainnier M, Michelet P, Thirion X, et al. High or low doses of almitrine bismesylate in ARDS patients responding to inhaled NO and receiving norepinephrine? Intensive Care Med 2001;27:1737-43.  Back to cited text no. 2
    
3.
Losser MR, Lapoix C, Delannoy M, Champigneulle B, Payen D. Almitrine as a non-ventilatory strategy to improve intrapulmonary shunt in COVID-19 patients. Anaesth Crit Care Pain Med 2020. doi: 10.1016/j.accpm. 2020.05.013 [Epub ahead of print].  Back to cited text no. 3
    
4.
Barthélémy R, Blot PL, Tiepolo A, Mayeur C, Gaugain S, Morisson L, et al. Efficacy of almitrine in the treatment of hypoxemia in Sars-Cov-2 acute respiratory distress syndrome. Chest 2020. doi: 10.1016/j.chest. 2020.05.573 [Epub ahead of print].  Back to cited text no. 4
    
5.
Huette P, Beyls C, Guilbart M, Haye G, Najid F-Z, Mestan B, et al. Acute Cor pulmonale in COVID-19-Related ARDS: Improvement with almitrine infusion. JACC Case Rep 2020;2:1311-4.  Back to cited text no. 5
    
6.
Cardinale M, Esnault P, Cotte J, Cungi PJ, Goutorbe P. Effect of almitrine bismesylate and inhaled nitric oxide on oxygenation in COVID-19 acute respiratory distress syndrome. Anaesth Crit Care Pain Med 2020. doi: 10.1016/j.accpm. 2020.05.014 [Epub ahead of print].  Back to cited text no. 6
    




 

Top
 
Previous article    Next article
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  IN THIS Article
   References

 Article Access Statistics
    Viewed140    
    Printed2    
    Emailed0    
    PDF Downloaded14    
    Comments [Add]    

Recommend this journal