Nitric Oxide Therapy for COVID-19 Patients With Oxygen Requirement
الكلمات الدالة
نبذة مختصرة
وصف
Coronavirus disease 2019 (COVID-19) consists mainly of a respiratory infection that spans from a mild involvement of the upper respiratory tract to severe pneumonia leading to respiratory distress, shock, and death. Fever, cough, and dyspnea/tachypnea, together with myalgia and fatigue, have been identified as the most common presenting symptoms. Most of the patients remain in a state of mild upper respiratory tract disease for a relatively long period (a median of 8-10 days), after which a proportion of up to 25% may develop severe hypoxemia and ARDS with the necessity of mechanical ventilation. Deterioration with ICU admission (most likely in older patients with comorbidities) raises the incidence of mortality in a range that goes from 3.4 up to 61%. Moreover, ICU admission poses a significant strain in terms of healthcare resources. Thus, a treatment able to avoid the progression of the disease from the mild to the severe phases would have a substantial benefit both in terms of lives saved and hospital resources spared. However, at the time, only Remdesivir and Dexamethasone have shown some benefits in robust clinical trials.
Nitric Oxide gas is a therapy currently approved for the treatment of pulmonary hypertension in newborns and is also used as rescue therapy in patients with acute respiratory distress syndrome (ARDS). The clinical role of NO gas in COVID-19 patients could be of particular relevance since there is in-vitro evidence of NO antiviral activity specifically against SARS coronavirus. At the time of the SARS pandemic, a small rescue trial on intubated patients with SARS showed that NO was effective in improving the oxygenation, fasten the resolution of chest X-ray abnormalities, and improve the clinical outcomes. Moreover, in vitro studies demonstrated that the NO-donor compound S-nitroso-N-acetylpenicillamine was able to increase the survival rate of in vitro mammalian cells infected with SARS-CoV. SARS-CoV and SARS-CoV-2 share the same subgenus inside the family Coronaviridae. The literature seems to point towards an a-specific rather than pathogen-specific antimicrobial effect of NO. Thus, the role of exogenous inhaled NO as a viricidal agent during COVID-19 infection could be hypothesized.
Nitric Oxide at high concentration has been found to be microbicidal but still safe in spontaneously breathing subjects in a phase I trial. There are several trials testing the efficacy of NO therapy in improving the outcome of COVID-19 patients. So far, only a retrospective observational study showed that NO gas is useful in improving the oxygenation in spontaneously breathing patients. However, the optimal therapeutic regimens and the efficacy of NO gas in improving the oxygenation in hypoxemic COVID-19 patients haven't been tested.
تواريخ
| آخر التحقق: | 06/30/2020 |
| تم الإرسال لأول مرة: | 07/15/2020 |
| تم إرسال التسجيل المقدر: | 07/15/2020 |
| أول نشر: | 07/19/2020 |
| تم إرسال آخر تحديث: | 07/15/2020 |
| آخر تحديث تم نشره: | 07/19/2020 |
| تاريخ بدء الدراسة الفعلي: | 07/16/2020 |
| تاريخ الإنجاز الأساسي المقدر: | 07/16/2021 |
| التاريخ المتوقع لانتهاء الدراسة: | 09/16/2021 |
حالة أو مرض
التدخل / العلاج
Drug: NO High Concentration
Drug: NO High Concentration + Continuous Low Concentration
مرحلة
مجموعات الذراع
| ذراع | التدخل / العلاج |
|---|---|
| Active Comparator: NO High Concentration Nitric oxide will be delivered twice a day with a non-rebreathing system that allows a safe administration of Nitric Oxide gas at high concentrations limiting the amount of NO2 delivered to the patient. | Drug: NO High Concentration Nitric Oxide will be delivered at 200 ppm in 2 daily sessions (morning, evening; 9-12 hours apart) for 14 days. Each session will last 30 minutes, for a total of 60 minutes/day for each patient. A tank of NO gas will be connected to the inspiratory limb of the circuit, and the flow will be adjusted to deliver a target concentration of 200 ppm NO. Commercially available tanks will be used to provide the gas. The desired mixture of air, oxygen (O2), and NO will be titrated with the respective flowmeter to reach a concentration of 200 ppm at the inspiratory limb with the desired Fraction of inspired oxygen (FiO2). |
| Experimental: NO High Concentration + Continuous Low Concentration Nitric oxide will be delivered twice a day with a non-rebreathing system that allows a safe administration of Nitric Oxide gas at high concentrations limiting the amount of NO2 delivered to the patient.
This arm will receive in addition a continuous low flow of Nitric Oxide at 20 ppm among the high concentration treatments. | Drug: NO High Concentration + Continuous Low Concentration Nitric Oxide will be delivered at 200 ppm in 2 daily sessions (morning, evening; 9-12 hours apart) for 14 days. Each session will last 30 minutes, for a total of 60 minutes/day for each patient. A tank of NO gas will be connected to the inspiratory limb of the circuit, and the flow will be adjusted to deliver a target concentration of 200 ppm NO. Commercially available tanks will be used to provide the gas. The desired mixture of air, oxygen (O2), and NO will be titrated with the respective flowmeter to reach a concentration of 200 ppm at the inspiratory limb with the desired Fraction of inspired oxygen (FiO2).
The subjects assigned to the group "NO High Concentration + Continuous Low Concentration" will receive in adjunction a continuous dose of NO at 20 ppm. |
معايير الأهلية
| الأعمار المؤهلة للدراسة | 18 Years إلى 18 Years |
| الأجناس المؤهلة للدراسة | All |
| يقبل المتطوعين الأصحاء | نعم |
| المعايير | Inclusion Criteria: 1. COVID-19 confirmed by a positive RT-PCR test 2. Hospital admission within 11 days from the onset of symptoms 3. Spontaneous breathing with oxygen requirement ≥1 L/min 4. Expected discharge > 96 hours at randomization Exclusion Criteria: 1. Pregnancy 2. Presence of a tracheostomy 3. Assistance by any non-invasive CPAP or NIV at the screening 4. Treatment with high flow nasal cannula at the screening 5. Clinical contraindication to the use of NO 6. Patients enrolled in another interventional trial 7. Hospitalized and confirmed diagnosis of COVID-19 for more than 7 days 8. Previous intubation for COVID-19 9. Subject not committed to full support (DNR, DNI or CMO) 10. Subject requiring oxygen at home for lung comorbidities 11. The primary cause of hospitalization not due to COVID-19 12. Subject receiving vasopressor at the time of screening 13. History of malignancy or other irreversible disease/conditions with 6-month mortality >50% 14. Oxygen saturation of 100% at screening, despite oxygen requirement 15. Patients on dialysis at the time of enrollment |
النتيجة
مقاييس النتائج الأولية
1. Change in Methemoglobin level at 48 hours [48 hours]
مقاييس النتائج الثانوية
1. Change in Methemoglobin level at 96 hours [96 hours]
2. Improvement in oxygenation between the groups at 48 hours or at discharge if before 48 hours [48 hours]
3. Improvement in oxygenation between the groups at 96 hours or at discharge if before 96 hours [96 hours]
4. Rate of positive RT-PCR for SARS-CoV-2 between groups in 5 days, discharge, and 28 days [28 days]
5. Time to clinical recovery among groups, defined as time to interruption of oxygen administration for 24 hours or discharge [28 days]
6. Reduction in the inflammatory markers among groups [7 days]
7. Rate of Acute Kidney Disease (AKI) between groups during hospitalization [28 days]
8. Difference in Katz score between groups [28 days]
تدابير النتائج الأخرى
1. Effect of NO gas treatment on cardiovascular hemodynamics assessed using cardiac ultrasound in COVID-19 hypoxemic patients [96 hours]
2. Effect of NO gas treatment on lung function evaluated with serial spirometry in COVID-19 hypoxemic patients [96 hours]
