Elsevier

The Journal of Pediatrics

Volume 124, Issue 2, February 1994, Pages 302-308
The Journal of Pediatrics

Inhaled nitric oxide in infants referred for extracorporeal membrane oxygenation: Dose response,☆☆,

https://doi.org/10.1016/S0022-3476(94)70324-8Get rights and content

Abstract

To determine the role of inhaled nitric oxide (NO) in a population of critically ill hypoxic near-term infants and to determine the dose response to inhaled NO, we examined a consecutive group of 23 infants referred for neonatal extracorporeal membrane oxygenation (ECMO) who had an oxygen index of 20 or greater after treatment with bovine surfactant. Inhaled NO was administered in concentrations from 5 to 80 ppm in random order to 23 infants. Overall, 13 infants had a significant response (an improvement in arterial oxygen pressure > 10 mm Hg or arterial oxygen saturation > 10%) to the first administration of inhaled NO, and one infant had a late response. There was no significant difference in the response to inhaled NO as measured by changes in arterial oxygen pressure or in the alveolar-arterial difference in partial pressure of oxygen, for any of the doses from 5 to 80 ppm. Thirteen infants had echocardiographic evidence of persistent pulmonary hypertension; 11 of these infants responded, compared with 3 responders among the 10 infants without persistent pulmonary hypertension of the newborn (p < 0.01). Overall, 11 infants required ECMO; there were two deaths in this group. Seven infants had congenital diaphragmatic hernia; five of those had a response to NO inhalation and four required ECMO. Our study demonstrates that there is no significant difference in response between low and high doses of inhaled NO and that this treatment may prevent the need for ECMO in some infants referred for this therapy, especially in infants with pulmonary hypertension. Prospective, controlled, randomized, and blinded trials of low doses of inhaled NO are needed to determine the clinical role of this potentially useful therapy. (J PEDIATR 1994;124:302-8)

Section snippets

Patient population

All infants referred to the Royal Alexandra Hospital for ECMO therapy after Jan. 1, 1993, were considered as potential subjects for this trial. Qualifying criteria for ECMO were that the infant was at least 35 weeks of gestational age and had reversible cardiopulmonary disease and no lethal malformations or evidence of intraventricular or intracranial hemorrhage of grade II or greater severity, plus the presence of an oxygen index (MAP × FIO2 × 100 ÷ PaO2, where MAP is the mean airway pressure)

RESULTS

During the period from Jan. 1 to May 1, 1993, a total of 23 infants were referred for consideration of ECMO therapy because of an OI of 20 or greater (Table). Surfactant was given to 22 infants before NO inhalation. Of the 23 infants, 8 had an OI of less than 25; 4 of these 8 responded to inhaled NO, and 2 infants (one of whom was a responder initially) required ECMO; both died of severe group B streptococcal sepsis. These two infants had severe lactic acidosis (pH < 7.00) and hypotension and

DISCUSSION

This study confirms the observations of Roberts et al.15 and Kinsella et al.16, 17 that some near-term critically ill infants with severe hypoxemia and evidence of pulmonary hypertension may respond to inhaled NO with significant improvement in oxygenation. Our study differs from previ ous trials in human neonates in that we studied a consecutive series of infants referred for possible ECMO whose initial OI was 20 or greater after treatment with a bovine surfactant, whereas the previous studies

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    From the Department of Newborn Medicine, Royal Alexandra Hospital, and the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada

    ☆☆

    Reprint requests: Neil N. Finer, MD, Royal Alexandra Hospital, 10240 Kingsway, Edmonton, Alberta, T5H 3V9, Canada.

    0022-3476/94 $3.00 + 0 9/23/51589

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