B106-22 Divergent Hemodynamic and Oxygenation Outcomes of Vasodilators for Pulmonary Hypertension in ARDS: A Network Meta-Analysis

Purpose Acute respiratory distress syndrome (ARDS) complicated by pulmonary hypertension is associated with high mortality. Optimal vasodilator selection remains controversial due to heterogeneous hemodynamic and oxygenation effects. This study evaluates the comparative efficacy of six vasodilators across critical outcomes. Methods We systematically searched PubMed, Cochrane, Scopus, Google Scholar, and ClinicalTrials.gov up to February 3rd, 2025, identifying 9 RCTs (n = 521 patients). We compared inhaled nitric oxide (NO), prostacyclin (PGI2), levosimendan, nitroglycerin (NTG), prostaglandin E1 (PGE1), liposomal PGE1, and placebo/control. Primary outcomes included mean pulmonary artery pressure (mPAP; mm Hg), pulmonary vascular resistance (PVR; dyn·sec·cm−-5), and cardiac index (CI; L/min/m²), with PaO2:FiO2 ratio (oxygenation) as a secondary outcome. Surface Under the Cumulative Ranking (SUCRA) values were computed using R, with effects reported as mean differences (MD) and 95% credible intervals (CrI). Results The cohort included 266 intervention patients (mean age: 42.6 ± 2.7 years, 84% male) and 255 controls (mean age: 51.0± 4.6 years, 58% male). Hemodynamics: NO and PGI2 demonstrated superior mPAP reduction (SUCRA: 78.5%, MD: −7.27 [95% CrI: −9.62, −4.75]; SUCRA: 78.2%, MD: −7.41 [CrI: −10.89, −3.63]; I²=12.7%). Levosimendan ranked highestfor PVR reduction (SUCRA: 76.0%, MD: −81.31[CrI: −142.94, −20.14]), followed by PGI2 (SUCRA: 73.6%, MD: −72.76 [CrI: −138.16, −4.01]). PGI2 led in CI improvement (SUCRA: 88.5%, MD: +0.83 [CrI: −0.19, 1.81]), though no agent achieved statistical significance (I²=65.2%). Oxygenation: Liposomal PGE1 achieved the greatest PaO2:FiO2 enhancement (SUCRA: 97.9%, MD: +32.04 [CrI: 19.30, 44.74]), whereas PGI2 worsened oxygenation (MD: −15.58 [CrI:−28.55, −2.56]; I²=81.6%). Clinical Dichotomies: NO uniquely balanced mPAP reduction with moderate oxygenation benefits (MD: +20.63 [CrI: 11.09, 30.14]). Levosimendan’s PVR efficacy contrasted with neutral CI/oxygenation effects. Conclusions No vasodilator demonstrated universal superiority. Clinicians must prioritize outcome-specific therapy: NO/PGI2 for hemodynamic stabilization, levosimendan for isolated PVR reduction, and liposomal PGE1 for refractory hypoxemia. Critical efficacy dichotomies exist—PGI2 improves cardiac output but impairs oxygenation, necessitating personalizedtreatment. Clinical Implications These findings guide individualized vasodilator selection in ARDS-associated pulmonary hypertension, emphasizing the need to balance hemodynamic stabilization against oxygenation tradeoffs. Future trials should prioritize combinationregimens to optimize dual outcomes.