• Abdelaal Ahmed MahmoudAhmedADepartment of Anaesthesia, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt; Department of Anaesthesia, Pain Medicine and Critical Care, Tallaght University Hospital, Dublin, Ireland. Electronic address: carnitin7@ya, Hatem Elmoutaz Mahmoud, Mohamed Ali Mahran, and Marwa Khaled.
• Department of Anaesthesia, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt; Department of Anaesthesia, Pain Medicine and Critical Care, Tallaght University Hospital, Dublin, Ireland. Electronic address: carnitin7@yahoo.com.
• J. Cardiothorac. Vasc. Anesth. 2020 Feb 1; 34 (2): 436-443.

ObjectiveTo examine and compare nebulizing heparin versus streptokinase for reversing alveolar collapse nonresponsive to recruitment.DesignA clinical trial at a tertiary intensive care unit (ICU). Sixty patients with severe acute respiratory distress syndrome (ARDS) (PaO2/FIO2 <100) nonresponsive to recruitment maneuver (RM), prone position, and neuromuscular block (NMB) were randomized into intervention arms or the standard-of-care arm.SettingThe ICU at Beni-Suef University Hospital.ParticipantsSixty patients with severe ARDS (PaO2/FIO2 <100) nonresponsive to RM, PP, and NMB.InterventionsNebulized heparin (10,000 IU/4 h), nebulized streptokinase (250,000 IU/4 h), and conservative management.Measurements And Main ResultsThe primary outcome was the change in PaO2/FIO2; the secondary outcomes included the change in compliance, plateau pressure, coagulation, and ICU mortality. The PaO2/FIO2 was significantly higher in the streptokinase group from day 1 to day 8 compared to the heparin and standard-of-care groups. Streptokinase produced PaO2/FIO2>100 at day 1, >200 at day 5, and >300 at day 7. The heparin group achieved a PaO2/FIO2 >100 at day 5 but remained <200 until day 8. The standard-of-care group did not achieve a PaO2/FIO2>100 after 8 days. Streptokinase significantly reduced plateau pressure and improved compliance at day 8. Only streptokinase decreased PaCO2 (p < 0.0001). Moreover, ICU mortality was significantly lower in streptokinase patients compared to other groups. Additionally, no heparin-induced thrombocytopenia was observed in all groups.ConclusionInhaled streptokinase serves as rescue therapy in patients with severe ARDS with improving oxygenation and lung mechanics more quickly than heparin or conventional management.Copyright © 2019 Elsevier Inc. All rights reserved.

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