Meta Analysis Effect of nitric oxide on oxygenation and mortality in acute lung injury: systematic review and meta-analysis
This review may be edited
Summary
Posted By:	Ken Havill
E-Mail:	khavill@hnehealth.nsw.gov.au
Posted Date:	26/10/07
Title:	Effect of nitric oxide on oxygenation and mortality in acute lung injury: systematic review and meta-analysis
Authors:	Adhikari, Neill K J. Burns, Karen E A. Friedrich, Jan O. Granton, John T. Cook, Deborah J. Meade, Maureen O.
Reference:	BMJ. 334(7597):779, 2007 Apr 14.
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Abstract:	To review the literature on the use of inhaled nitric oxide to treat acute lung injury/acute respiratory distress syndrome (ALI/ARDS) and to summarise the effects of nitric oxide, compared with placebo or usual care without nitric oxide, in adults and children with ALI or ARDS. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, CINAHL, Embase, and CENTRAL (to October 2006), proceedings from four conferences, and additional information from authors of 10 trials. REVIEW METHODS: Two reviewers independently selected parallel group randomised controlled trials comparing nitric oxide with control and extracted data related to study methods, clinical and physiological outcomes, and adverse events. MAIN OUTCOME MEASURES: Mortality, duration of ventilation, oxygenation, pulmonary arterial pressure, adverse events. RESULTS: 12 trials randomly assigning 1237 patients met inclusion criteria. Overall methodological quality was good. Using random effects models, we found no significant effect of nitric oxide on hospital mortality (risk ratio 1.10, 95% confidence interval 0.94 to 1.30), duration of ventilation, or ventilator-free days. On day one of treatment, nitric oxide increased the ratio of partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2 ratio) (13%, 4% to 23%) and decreased the oxygenation index (14%, 2% to 25%). Some evidence suggested that improvements in oxygenation persisted until day four. There was no effect on mean pulmonary arterial pressure. Patients receiving nitric oxide had an increased risk of developing renal dysfunction (1.50, 1.11 to 2.02). CONCLUSIONS: Nitric oxide is associated with limited improvement in oxygenation in patients with ALI or ARDS but confers no mortality benefit and may cause harm. We do not recommend its routine use in these severely ill patients.
Are the Results Valid?
1. Did the overview address a focused clinical question?
	Yes. Effect of NO on mortality in Adults or Children with establishes ALI or ARDS.
2. Were the criteria used to select articles for inclusion appropriate?
	Yes. Parallel group trials that enrolled adults or children(excluding neonated), with >80% of patients or a separtely reported subgroup having ALI or ARDS Included trials compared NO with placebo or usual treatment for ALI or ARDS and reported mortality. Cointerventions applied equally in both groups
3. Is it unlikely that important, relevant studies were missed?
	No. Only searched however english literature.Funnel plot(fig 3) not suggestive of publication bias
4. Was the validity of the included studies appraised?
	Yes. Table 2; The 12 trials had good scientific quality. Ten concealed randomisation, 5 blinded clinicians. Allhad complete followup ,analysed patients in assigned group.
5. Were assessments of studies reproducible?
	Yes> the author's use Cohen's K
6. Were the results similar from study to study?
	Yes. Used Cochran Q statistic and I2. and fig 2 for mortality. suggest minimal heterogeneity.
What are the Results?
1. What are the overall results of the overview?
	11 trials patients met criteria for ARDS , one trial included some patients with ALI.
2. How precise were the results?
	Risk ratio from in hospital mortality was 1.09 CI 0.94 t0 1.27
Will the Results Help Me In Caring For My Patients?
1. Can the results be applied to my patient care
	Adults and children with standard definition of ARDS. However does not differentiate between aetiologies of ARDS. The included trial did not specifically study the issue of NO as rescue therapy for patients with critically low oxygenation
2. Were all clinically important outcomes considered?
	yes.
3. Are the benefits worth the harms and costs?
	No
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