Inhaled Nitric Oxide Surveillance: Effect on Cost and Length of Use in Adult Critical Care

Abstract

Background: Inhaled Nitric Oxide (INO) is an effective pulmonary vasodilator in improving systemic oxygenation (PaO₂/FIO₂) in adult patients with ARDS. The Food and Drug Administration (FDA) has solely approved INO for the treatment of neonatal hypoxemic respiratory failure associated with pulmonary hypertension. INO is also used off-label in adult critical care to treat ARDS and postoperative pulmonary hypertension but also costly and non-reimbursable. In view of reported clinical benefit but high cost of using INO, a surveillance program was designed to monitor INO usage and effectiveness daily for either refractory hypoxemia or pulmonary hypertension to minimize costs.

Methods: We evaluated INO usage, length use, and cost for mechanically ventilated adult patients for a period of 12 months without surveillance (wo/SUV) and for 12 subsequent-additional months with surveillance (SUV). The surveillance program included a pulmonary physician and nurse to review the indications and contraindications, optimization of ventilator settings, use of other potential therapies (diuresis, bronchoscopy) and monitor effectiveness and weaning if initiated

Results: For the wo/SUV and SUV periods, mean patient age ± SD was 59 ± 15 vs 56.3 ± 15. Comparing the wo/SUV and SUV periods, there was a reduction in total use (n = 104 vs 89, average patient daily use (4.12 vs 2.79), range (1-19 days vs 0.17 to 17.2 days) and total ($86,187 cost ($593,964). During the SUV year 11 of 100 requests for INO therapy did not meet protocol inclusion criteria and were denied. Clinical surveillance of INO use reduced total cost by $192,223 and average length of use y 1.3 days.

Conclusions: We conclude that a well-defined INO surveillance program can provide cost effective treatment.