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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
Abhijit S Nair, Sai Kaushik Pulipaka, Poornachand Anne, Basanth Kumar Rayani
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
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sja.SJA_782_20
| Date of Submission | 20-Jul-2020 |
| Date of Decision | 21-Jul-2020 |
| Date of Acceptance | 21-Jul-2020 |
| Date of Web Publication | 5-Jan-2021 |
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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 2022 Jan 19];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 | |  |
| 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].  |
| 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. |
| 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]. |
| 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]. |
| 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. |
| 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]. |
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