Inhaled Nitric Oxide Guideline

Abstract

Background: Inhaled nitric oxide (iNO) is a selective, but potent pulmonary vasodilator. At present, the only FDA approved indication for iNO is treatment of persistent pulmonary hypertension of the newborn. Use in other patient populations, namely adults, is common, however. Given high cost of this medication, coupled with lack of reimbursement, we hoped to refine the usage of iNO. In addition, safety reports citing technical problems with aerosolized epoprostenol, another pulmonary vasodilator, were rising, causing us to question this method of administration.

Methods: Leaders of respiratory care department and physician chiefs of adult ICUs met to develop a standardized guideline for iNO initiation and usage. The guideline is based upon diagnosis, (hypoxemia, right ventricular failure, or pulmonary hypertension) with monitoring of clinical vital signs for positive response to therapy and trigger for weaning iNO. Education was delivered at respiratory care staff meetings, unit faculty meetings, as well as institution critical care operations meeting. A tool was also developed to be posted at the patients’ bedside and a smartphrase created for progress note documentation, both to increase situational awareness for all the heathcare team. Local IRB approval obtained.

Results: The guideline has been active for 3 months (Mar-May 2024). Compared to the 3 months prior, the total number of patients receiving iNO was 134 vs 82 and the total h were 7,655 vs 4,801. This results in a reduction in average hours per patient of 1.42 (57.13 vs 58.55) Prior to implementation, weaning occurred when the clinical team felt the patient was stable. The guideline prompts weaning when specific clinical parameters are met. This has prompted a decrease in time to documented first wean 29.33 prior vs 22.67 after (22.7%). Despite an increase in iNO hours, inhaled epoprostenol decreased during this time period (79 to 53 syringes/week, 30% decrease) with zero safety concerns reported around delivery performance and patient risk.

Conclusions: We were able to successfully implement an iNO guideline based on clinical need and objective vital sign monitoring. Financial consideration for using more iNO exists but is offset by decrease in aerosolized epoprostenol use and decrease in the unquantifiable safety risk to patients. Despite an increase in iNO hours, we were able to treat more patients with increased appropriateness and safety.