Inhaled Nitric Oxide for Severe Hypoxemia After CABG: A Propensity Score‒Matched Analysis.

Authors

Qiong Zhang, Tiantian Wang, Tianshu Chu, Ling Yan, Xiaochen Wang, Jianjun Ge, Sheng Li

Published in

Journal of cardiothoracic and vascular anesthesia. Aug 06, 2026. Epub Aug 06, 2026.

Abstract

To evaluate whether a stepped treatment strategy incorporating inhaled nitric oxide (iNO) is associated with more rapid improvement in oxygenation and a lower likelihood of treatment escalation compared to conventional high-flow nasal cannula (HFNC) therapy, in extubated patients with severe hypoxemia (PaO₂/FiO₂ ≤ 100 mmHg) following coronary artery bypass grafting (CABG).
A single-center, retrospective, propensity score‒matched cohort study.
A cardiac surgery intensive care unit (ICU) at a tertiary care hospital.
Adult patients (≥18 years) who developed severe hypoxemia after extubation following elective off-pump CABG via median sternotomy between January and December 2025. After 1:1 propensity score matching, 122 patients (61 per group) were included.
The iNO‑first strategy group (n = 61) received a stepwise regimen: iNO alone (20 ppm), then iNO with HFNC, then iNO with non-invasive positive pressure ventilation (NPPV) based on predefined oxygenation criteria. The HFNC‑first strategy group (n = 61) received a stepwise regimen: HFNC alone, then NPPV.
The primary outcome was the PaO₂/FiO₂ ratio at 6, 12, and 24 hours. The iNO‑first strategy group had significantly higher median PaO₂/FiO₂ at 6 hours (158 v 132 mmHg, p < .001) and 12 hours (161 v 144 mmHg, p < .001). The difference at 24 hours was not significant (199 v 187 mmHg, p = .056). In the iNO‑first strategy group, 24 patients (39.34%) required escalation to HFNC added to iNO, whereas all patients in the HFNC‑first strategy group received HFNC as initial therapy. NPPV use did not differ (16.39% v 19.67%, p = .639). Postoperative hospital stay was shorter in the iNO‑first strategy group (13 v 14 days, p = .043), though this finding should be interpreted with caution. No reintubation or mortality occurred in either group.
In this retrospective analysis, an iNO-first strategy was associated with superior early oxygenation at 6 and 12 hours compared to an HFNC-first strategy. This study compares 2 non‑randomized treatment strategies rather than the isolated pharmacological effect of iNO. The strategy demonstrated a favorable safety profile. However, the benefits were not sustained at 24 hours, and no differences were found in NPPV utilization or ICU length of stay. Given the non-randomized design, these results should be interpreted as associations, not causal effects.

PMID:
42649006
Bibliographic data and abstract were imported from PubMed on 27 Aug 2026.

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