Inhaled Nitric Oxide for Preventing Progression in COVID-19 (NO-COVID-19)

This is a pilot randomized-controlled (2:1) open label investigation of inhaled NO to prevent progression to more advanced disease in 42 hospitalized patients with COVID-19, at risk for worsening, based on baseline systemic oxygenation and 2 or more of the major risk factors of age > 60 years, type II DM, hypertension, and obesity.

Primary Objective: • To investigate the hypothesis that inhaled NO will reduce clinical worsening of hospitalized, high-risk patients with early COVID-19 to progressive systemic de-oxygenation, intubation, or death. Secondary Objectives: • To investigate the hypothesis that the beneficial effects of inhaled NO occur coincident with a decrease in systemic inflammation in COVID-19. This is a pilot randomized-controlled (2:1) open label investigation of inhaled NO to prevent progression to more advanced disease in 42 hospitalized patients with COVID-19, at risk for worsening, based on baseline systemic oxygenation and 2 or more of the major risk factors of age > 60 years, type II DM, hypertension, and obesity. We will perform computerized block randomization (on day zero) with a 2:1 study drug-to-control ratio to receive either open label pulsed inhaled nitric oxide, in addition to standard of care, or standard of care alone. Randomization will be stratified by being in clinical severity stage 1 or stage 2. Randomization will occur in blocks of 6 subjects: 4 iNO and 2 standard of care. Subjects will receive iNO using the INO pulse device at a dose of 125 mcg/kg IBW/hr (equivalent to approximately 20 ppm) The clinical disease severity will be assessed pre-randomization as the worse of 2 scores measured 2 hours apart. Patients eligible for randomization will be those with scores of 1 or 2 (below), and randomization will be stratified according to score (1 or 2). Study drug will begin within 1 hour of randomization. Beginning on the day following randomization ("day 1"), we will be calculate clinical score, daily, as the average of 3 assessments made within 2 hour windows. The patient will be followed, and clinical stage determined daily, through discharge, death or 28 days post-randomization. Treatment will be given for up to 2 weeks unless patient deteriorates and requires escalation to high flow or intubation or improves and is no longer deemed to need therapy. The following severity score 3 times daily, based on the level of oxygenation / ventilation support, where the treatment target is 92% <= O2 saturation < 96% : Scale Title:7-Point Respiratory Severity Scale Scale Range: 0-6 Higher values = worse Stage Oxygen support 0. Not receiving O2 supplementation; AND room air O2 saturation ≥95% Supplemental O2 ≤ 2 liters/min; OR room air O2 saturation ≤ 94% Supplemental nasal O2 >2 and <= 5 liters/min Supplemental nasal O2 >5 liters/min HFNC or NIV with FiO2 > 50% Intubation, ECMO, or need to intubate with "Do not intubate" order Death Treatment effect will also be assessed, as a secondary endpoint, via an alternate severity scale, assigned daily from the data accrued, as above, through 14 days post-randomization or discharge. Data from this pilot study will be used to plan future a larger randomized controlled outcome trial.

Subjects will receive iNO using the INO pulse device at a dose of 125 mcg/kg IBW/hr (equivalent to approximately 20 ppm). The clinical disease severity will be assessed pre-randomization as the worse of 2 scores measured 2 hours apart. Patients eligible for randomization will be those with scores of 1 or 2 (below), and randomization will be stratified according to score (1 or 2). Study drug will begin within 1 hour of randomization. Beginning on the day following randomization ("day 1"), we will be calculate clinical score, daily, as the average of 3 measurements taken within 2 hour windows centered at 6AM, 2PM, and 10PM.

The clinical disease severity was assessed pre-randomization as the worse of 2 scores measured 2 hours apart. Patients eligible for randomization were those with scores of 1 or 2 (below), and randomization was stratified according to score (1 or 2). Study drug began within 1 hour of randomization. Beginning on the day following randomization ("day 1"), we calculated clinical score, daily, as the average of 3 measurements taken within 2 hour windows centered at 6AM, 2PM, and 10PM.

The number of days for participants to reach their maximum clinical disease severity score. Severity score assessed by the following table Stage Oxygen support 0 Not receiving O2 supplementation; AND room air O2 saturation ≥95% Supplemental O2 ≤ 2 liters/min; OR room air O2 saturation ≤ 94% Supplemental nasal O2 >2 and ≤ 5 liters/min Supplemental nasal O2 >5 liters/min HFNC or NIV with FiO2 > 50% Intubation, ECMO, or need to intubate with "Do not intubate" order Death

The number of days for patients to reach maximum severity score from randomization. clinical score, daily, as the average of 3 measurements taken within 2 hour windows centered at 6AM, 2PM, and 10PM according to the following table: The following severity score 3 times daily, based on the level of oxygenation / ventilation support, where the treatment target is 92% ≤ O2 saturation < 96%: Stage Oxygen support 0 Not receiving O2 supplementation; AND room air O2 saturation ≥95% Supplemental O2 ≤ 2 liters/min; OR room air O2 saturation ≤ 94% Supplemental nasal O2 >2 and ≤ 5 liters/min Supplemental nasal O2 >5 liters/min HFNC or NIV with FiO2 > 50% Intubation, ECMO, or need to intubate with "Do not intubate" order Death HFNC = high-flow nasal cannula; NIV = non-invasive ventilation

Inclusion Criteria: Age 18-85 years. Admitted to the hospital (med-surg or critical care) with dyspnea Diagnosis of COVID-19 based on either positive nasal or oral pharyngeal swab by PCR, or highly probable clinical picture based on clinical and CXR/CT scan Requiring oxygen supplementation OR O2 saturation on room air of ≤ 94% At least 2 of the following 4 risk factors for clinical worsening: Age >= 60 years T2DM or pre-diabetes as evidenced by either treatment with a hypoglycemic agent or any documented HgA1c >= 5.6 Obesity, based on BMI >= 30 kg/m2 Hypertension, based on treatment with an antihypertensive medication or systolic or diastolic blood pressure measurement >= 140 or >= 90 mmHg, documented at enrollment or at any time within the prior 6 months. Exclusion Criteria: Intubated or prior intubation (during present hospitalization) or anticipated intubation within the subsequent 2 hours. Receiving > 5L/min flow nasal O2 to maintain O2sat greater than or equal to 92% Using high-flow nasal cannula (HFNC) or non-invasive ventilation (NIV) Receiving iNO, a PDE5 inhibitor, oral or intravenous nitrates, nitroprusside, prilocaine, sulfonamides, or riociguat. Other major pulmonary, cardiac, such as chronic obstructive lung disease or heart failure, or systemic illness or disease involvement with potential to represent the primary driver for clinical deterioration within the next 3 days. History of group 1 pulmonary hypertension. Pregnancy Active breast feeding Severe chronic kidney disease, either receiving renal replacement therapy or eGFR < 15 ml/min/m2 Acute kidney injury (AKI), evidenced by acute doubling of serum creatinine within previous 48 hours. Clinically relevant spontaneous alteration of mental state Inability to provide written informed consent.