Inhaled nitric oxide in infants referred for extracorporeal membrane oxygenation: Dose response (original) (raw)
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Low-dose inhaled nitric oxide for neonates with pulmonary hypertension
Journal of Paediatrics and Child Health, 1996
Objective: Inhaled nitric oxide (iNO) has been shown to cause selective pulmonary vasodilatation and improve ventilationperfusion matching and may be an important therapeutic option for the treatment of persistent pulmonary hypertension of the newborn (PPHN). We report our experience on the use of iNO in neonates with severe PPHN. Methodology: Inhaled NO was administered to 10 infants with PPHN and persistent hypoxaemia (meconium aspiration syndrome, n = 9; pneumonia, n = 1) after failure of conventional therapy to improve oxygenation. With the exception of one infant, iNO was commenced at 10 ppm. Results: After 30 min exposure to iNO, the arterial oxygen tension (PaO,) rose from a median of 49 mmHg (6.5 kPa) [range 12-82mmHg (1.6-10.9 kPa)] to 75mmHg (10 kPa) [range 17-450mmHg (2.3-60 kPa)] (P = 0.005), while the median oxygenation index fell (pre-iNO of 37 vs post-iN0 20) (P = 0.005) and median systemic arterial pressure rose (pre-iNO 46.5 mmHg (6.2 kPa) [range 32-63 mmHg (4.3 to 8.4 kPa vs post-iN0 54.5 mmHg (7.3 kPa) [range 36-74 kPa]) P = 0.005). All infants subsequently continued to receive iNO with the duration of exposure to iNO ranging from 12 to 168 h (median duration 100 h). Three infants died despite showing an initial beneficial response to iNO. The mean duration of intubation for survivors was 11.9k2.6 days. Methaemoglobinaemia and toxic levels of nitrogen dioxide were not seen during iNO administration. Of the seven survivors, 12 month follow up in two infants and 4 month follow up in four infants showed age-appropriate neurodevelopmental skills, with one infant having very mild hearing loss. Conclusions: Inhaled NO reduces the oxygenation index by improving the PaO, and decreasing ventilation pressures, and appears to be clinically useful in severely hypoxaemic infants with PPHN refractory to conventional treatment.
Critical care …, 1997
Effectiveness data were derived from a single study. Link between effectiveness and cost data Although no details were reported, the costing was presumably undertaken on the same patient sample as that used in the effectiveness study. Study sample No power calculations were reported. A total of 50 patients out of 103 neonates referred for rescue therapy during the study period were included in the study. Of these, 29 were admitted when inhaled nitric oxide was unavailable (due either to its permanent unavailability or to the concurrent use by other patients of the single delivery system at the institution), while the remainder (21 patients), were admitted when this delivery system was available. The final number of patients who met ECMO criteria was 21 and 16 for the control and intervention groups, respectively.
Inhaled nitric oxide in persistent pulmonary hypertension of the newborn
The Lancet, 1992
Background: This study was designed to evaluate the effect of nitric oxide (NO) on the management of neonates with severe persistent pulmonary hypertension refractory to high-frequency oscillatory ventilation. Methods: The birth weight and the gestational age of infants were 3125.5 ± 794 g (mean ± SD) and 39 ± 2.4 weeks, respectively. All neonates were ventilated for an average of 137.5 min (range 90-180 min) prior to NO therapy. The mean oxygenation index (OI) of all neonates prior to NO was 46.3 ± 5 (mean ± SEM). NO was initially administered at 20 parts per million (ppm) for at least 2 h and increased gradually by 2 ppm to a maximum of 80 ppm. Results: Eighteen infants (75%) responded and six (25%) did not respond to the treatment. Three neonates died in the responding group, while all the nonresponders died (P = 0.0001). The survival rate was 62.5% among all neonates. NO significantly decreased OI (P < 0.0001) and improved the arterial/alveolar (a/A) oxygen ratio (P < 0.0001) within the first 2 h of NO therapy in 61.1% of the responders. However, the OI and the a/A oxygen ratio remained almost the same throughout the treatment in the non-responders and the non-survivors. Conclusion: Inhaled NO at 20 ppm, following adequate ventilation for 2 h without significant response, could be used to identify the majority of the nonresponders in order to seek other alternatives.
Inhaled nitric oxide in hypoxaemic newborns who are candidates for extracorporeal life support
European Respiratory Journal, 1998
Term and preterm newborns suffering from severe hypoxaemic respiratory failure, either due to persistent pulmonary hypertension (PPHN) or respiratory distress syndrome (RDS), still account for a relatively high morbidity and mortality . Several treatments have been attempted in these patients, such as exogenous surfactant replacement, i.v. vasodilators such as tolazoline and prostacyclins, inhaled prostacyclins, magnesium sulphate, highfrequency ventilation and liquid ventilation, although rarely has their efficacy been confirmed by controlled studies . Extracorporeal membrane oxygenation (ECMO) constitutes a valid therapeutic option in neonates with refractory hypoxaemia , as recently confirmed by the UK ECMO collaborative trial . However, ECMO remains a complex and expensive technique that requires systemic anticoagulation and cannulation of major vessels. Inhaled nitric oxide (NO) has been shown to be a promising novel treatment in hypoxaemic newborns with severe PPHN, either idiopathic or secondary to various cardiopulmonary diseases. In using this therapy several authors have observed a marked improvement of oxygenation in most patients and a decline of ECMO cases . It is still unclear, however, why in some patients gas exchange during NO therapy is not improved and whether, in cases of positive response, a rapid improvement of oxygenation is necessarily associated with a favourable outcome. The objectives of this study were: 1) to assess the acute physiological effect of inhaled NO on systemic oxygenation in newborns with acute respiratory failure approaching ECMO criteria; and 2) to evaluate whether survival without ECMO support was correlated to an acute and sustained response to inhaled NO and, conversely, whether death or need for ECMO could be anticipated by a poor or absent response.
Journal of Perinatal Medicine, 2006
Aim: To determine whether inhaled nitric oxide might reduce the need for excessive respiratory alkalosis to maintain systemic oxygenation in infants with persistent pulmonary hypertension of the newborn (PPHN). Materials and methods: A retrospective historical cohort study of 34 infants with PPHN with oxygenation index (OI) of 25 or more, including 19 infants without inhaled nitric oxide (i-NO) therapy (control group) and 15 infants with inhaled nitric oxide therapy (i-NO group) was performed. The initial dose of 10 ppm of i-NO was administered and no responders received the maximum dose of 25 ppm. We evaluated the mortality rate and the change of OI index and PaCO 2 during the first 6 days. Results: There were no significant differences in characteristics between groups. Two of 15 in the i-NO group and 6 of 19 infants in the control group died during the first 48 h. Baseline OI, PaCO 2 and arterial pH were similar in the two groups. OI in the i-NO group was significantly higher than in the control group between 12 and 96 h. PaCO 2 in the i-NO group was higher than in the control group between 24 and 144 h. Conclusion: i-NO therapy for PPHN might improve systemic oxygenation without excessive hypocapnia. However there was no reduction in duration of ventilation support or oxygen supply.