, Volume 184, Issue 1, pp 1–5 | Cite as

Inhaled Nitric Oxide Improves Pulmonary Functions Following Massive Pulmonary Embolism: A Report of Four Patients and Review of the Literature

  • Oded SzoldEmail author
  • Wisam Khoury
  • Philippe Biderman
  • Joseph M. Klausner
  • Pinchas Halpern
  • Avi A. Weinbroum


Acute pulmonary embolism increases pulmonary vascular resistance and may lead to acute right ventricular failure and cardiocirculatory collapse and respiratory failure, possibly resulting in substantial morbidity and mortality. Inhaled nitric oxide (NO) dilates pulmonary blood vessels and has been used to reduce pulmonary vascular resistance in patients with chronic thromboembolic pulmonary hypertension and acute respiratory distress syndrome. This case series describes our experience with inhaled NO administered to four patients suffering from acute massive pulmonary embolism following abdominal surgery. The four described patients recovering from small bowel resection, pancreatoduodenectomy, hemipelvectomy, or recent gastrointestinal bleeding had severe respiratory and hemodynamic deterioration due to pulmonary embolism. Each received inhaled NO (20–25 ppm) via the inspiratory side of the breathing circuit of the ventilator. Pulmonary and systemic blood pressures, heart rate, and lung gas exchange improved in all the patients within minutes after the initiation of NO administration. Inhaled NO may be useful in treating acute massive pulmonary embolism. This potential application warrants further investigation.


Pulmonary embolism Pulmonary hypertension Nitric oxide 



Esther Eshkol is thanked for editorial assistance.


  1. 1.
    Anggard E (1994) Nitric oxide: mediator, murderer, and medicine. Lancet 343:1199–1206PubMedGoogle Scholar
  2. 2.
    Bottiger BW, Bach A, Bohrer H, Martin E (1993) Acute thromboembolism of the lung. Clinical picture, pathophysiology, diagnosis therapy. Anaesthesist 42:55–73PubMedGoogle Scholar
  3. 3.
    Bottiger BW, Motsch J, Dorsam J, et al. (1996) Inhaled nitric oxide selectively decreases pulmonary artery pressure and pulmonary vascular resistance following acute massive pulmonary microembolism in piglets. Chest 110:1041–1047PubMedGoogle Scholar
  4. 4.
    Bylin G, Hedenstierna G, Lindvall T, Sundin B (1988) Ambient nitrogen dioxide concentrations increase bronchial responsiveness in subjects with mild asthma. Eur Respir J 1:606–612PubMedGoogle Scholar
  5. 5.
    Calvin JE, (1991) Acute right heart failure: pathophysiology, recognition, and pharmacological management. J Cardiothorac Vasc Anesth 5:507–513PubMedCrossRefGoogle Scholar
  6. 6.
    Capellier G, Jacques T, Balvay P, et al. (1997) Inhaled nitric oxide in patients with pulmonary embolism. Intensive Care Med 23:1089–1092PubMedCrossRefGoogle Scholar
  7. 7.
    Crerar –Gilbert A, Boots R (1999) Use of inhaled nitric oxide in pulmonary embolism. Anaesth Intensive Care 27:412–414PubMedGoogle Scholar
  8. 8.
    Emerson M, Momi S, Paul W, et al. (1999) Endogenous nitric oxide acts as a natural antithrombotic agent in vivo by inhibiting platelet aggregation in the pulmonary vasculature. Thromb Haemost 81:961–966PubMedGoogle Scholar
  9. 9.
    Fedullo PF, Auger WR, Kerr KM, Rubin IJ (2001) Chronic thromboembolic pulmonary hypertension. N Engl J Med 345:1465–1472PubMedCrossRefGoogle Scholar
  10. 10.
    Frostell C, Fratacci MD, Wain JC, Jones R, Zapol WM (1991) Inhaled nitric oxide: a selective pulmonary vasodilator reversing hypoxic pulmonary vasoconstriction. Circulation 83:2038–2047PubMedGoogle Scholar
  11. 11.
    Girard C, Durand PG, Vedrinne C, et al. (1993) Inhaled nitric oxide for right ventricular failure after heart transplantation. J Cardiothorac Vasc Anesth 7:481–485PubMedCrossRefGoogle Scholar
  12. 12.
    Horlander KT, Mannino DM, Leeper KV (2003) Pulmonary embolism mortality in the United States, 1979–1998: an analysis using multiple cause mortality data. Arch Intern Med 163:1711–1717PubMedCrossRefGoogle Scholar
  13. 13.
    McIntyre KM, Sasahara AA (1971) The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. Am J Cardiol 28:288–294CrossRefGoogle Scholar
  14. 14.
    Mlczoch J, Tucker A, Weir EK, Reeves JT, Grover PF (1978) Platelet-mediated pulmonary hypertension and hypoxia during pulmonary microembolism: reduction by platelet inhibition. Chest 74:648–653PubMedGoogle Scholar
  15. 15.
    Nong Z, Hoylaerts M, Van Pelt N, Collen D, Janssens S (1997) Nitric oxide inhalation inhibits platelet aggregation and platelet-mediated pulmonary thrombosis in rats. Circ Res 81:865–869PubMedGoogle Scholar
  16. 16.
    Pepke –Zaba J, Higenbottam TW, Dinh–Xuan AT, Stone D, Wallwork J (1991) Inhaled nitric oxide as a cause of selective pulmonary vasodilatation in pulmonary hypertension. Lancet 338:1173–1174PubMedGoogle Scholar
  17. 17.
    Persinger RL, Blay WM, Heintz NH, Hemenway DR, Janssen–Heininger YM (2001) Nitrogen dioxide induces death in lung epithelial cells in a density-dependent manner. Am J Respir Cell Mol Biol 24:583–590PubMedGoogle Scholar
  18. 18.
    Schenk P, Mittermayer C, Ratheiser K (1999) Inhaled nitric oxide in a patient with severe pulmonary embolism. Ann Emerg Med 33:710–714PubMedCrossRefGoogle Scholar
  19. 19.
    Sellden H, Winberg P, Gustafsson LE, et al. (1993) Inhalation of nitric oxide reduced pulmonary hypertension after cardiac surgery in a 3.2 kg infant. Anesthesiology 78:577–580PubMedGoogle Scholar
  20. 20.
    Sitbon O, Brenot F, Denjean A, et al. (1995) Inhaled nitric oxide as a screening vasodilator agent in primary pulmonary hypertension. A dose-response study and comparison with prostacyclin. Am J Respir Crit Care Med 151:384–389PubMedGoogle Scholar
  21. 21.
    Stein PD, Henry JW (1995) Prevalence of acute pulmonary embolism among patients in a general hospital at autopsy. Chest 108:978–981PubMedGoogle Scholar
  22. 22.
    Trimmer G, Berchtold–Herz M, Martin J, Beyersdoff F (2002) Successful treatment of pulmonary hypertension with inhaled nitric oxide after pulmonary embolectomy. Ann Thorac Surg 73:1299–1301Google Scholar
  23. 23.
    Wessel DL, Adatia I, Thompson JE, Hickey PR (1994) Delivery and monitoring of inhaled nitric oxide in patients with pulmonary hypertension. Crit Care Med 22:930–938PubMedGoogle Scholar
  24. 24.
    Zapol WM, Rimar S, Gillis N, Marletta M, Bosken CH (1994) Nitric oxide and the lung. Am J Respir Crit Care Med 149:1375–1380PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • Oded Szold
    • 1
    Email author
  • Wisam Khoury
    • 1
  • Philippe Biderman
    • 1
  • Joseph M. Klausner
    • 2
  • Pinchas Halpern
    • 3
  • Avi A. Weinbroum
    • 4
  1. 1.Surgical Intensive Care Unit, Tel Aviv Sourasky Medical Center and Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
  2. 2.Department of Surgery “B”, Tel Aviv Sourasky Medical Center and Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
  3. 3.Emergency Medicine, Tel Aviv Sourasky Medical Center and Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
  4. 4.Post-Anesthesia Care Unit, Tel Aviv Sourasky Medical Center and Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael

Personalised recommendations