Inhaled nitric oxide use in newborns

Question 1

How does iNO work?

Answer 1

Selective pulmonary vasodilator

Question 2

Who should be treated with iNO?

Answer 2

1. Infants >35wks GA w/ hypoxemic respiratory failure who fail to respond to appropriate respiratory management
2. Recommend urgent echo to r/o cyanotic CHD and assess for pulmonary hypertension
3. iNO start in infants w/ OI > 20-25 or PaO2 <100 despite optimal ventilation w/ 100% O2

Question 3

What are the recommendations for the use of iNO in premature infants?

Answer 3

Overall, iNO does not appear to be effective as a rescue treatment or as a routine treatment for preterm infants who require assisted ventilation. It may be beneficial for a small number of critically ill infants in defined clinical situations, such as respiratory failure associated with oligohydramnios.

Question 4

What is the recommended administration of iNO?

Answer 4

Start at 20ppm, increase to 40ppm if PaO2 increases by <20mmHg

Question 5

How should iNO be weaned?

Answer 5

After 4-6h of stability if O2 decreased to 60-80% or OI <10 can wean
Decrease dose by 50% q4-6h as long as OI remains <10
Once dose 5ppm wean by 1ppm q4h
d/c at 1ppm if <60% O2 and PaO2 >50mmHg

Question 6

What is the safe duration of use of iNO?

Answer 6

Unknown, mean duration 48-96h

If cannot be weaned by 7d should look carefully for other lung pathology and cardiac disease

Question 7

What is the toxicity of iNO?

Answer 7

1. Production NO2 = cytotoxic and causes pulmonary injury (minimum production usu.)
2. Methehemoglobin, measure freq. and keep <2.5%
3. Decreased platelet aggregation
4. Increased risk of bleeding
5. Surfactant dysfunction

Question 8

What can iNO prevent?

Answer 8

1. Mortality

2. Need for ECMO