Inhaled Nitric Oxide for Acute Hypoxemic Respiratory Failure Clinical Pathway — PICU

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Goals and Metrics

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Related Pathway
PICU Ventilator Weaning Pathway

Patient Requiring Inhaled Nitric Oxide (iNO) for Hypoxemic Respiratory Failure

Criteria for Initiating iNO

Oxygen Index > 15 AND/OR P/F Ratio ≤ 100

RT to obtain Baseline Data

Ventilator settings
OI/PF Ratio
Pre-iNO ABG
Co-oximetry
Inotropic support

Initiate iNO at 20ppm

Obtain ABG 30 minutes after iNO initiation

PaO₂ increase ≥ 20%
OR
SpO₂ increase ≥ 5%

PaO₂ increase < 20%
OR
SpO₂ increase < 5%

Discontinue iNO

Maintain iNO at 20ppm
Wean FiO₂ to < 50% x4 hours

Begin Wean q4 Hours
(5 hours post-initiation)
RT team will discuss with medical and nursing teams readiness and subsequent steps

EPIC Order: Critical Care Inhaled Nitric Oxide Weaning Clinical Pathway Started

HFV does not preclude weaning iNO

Increase FiO₂ by 10% before discontinuing

Discontinue iNO

Start:
Wean 20ppm
to 10ppm

*Tolerated?

Return to 20ppm

YES

At 4 hours:
Wean 10ppm
to 5ppm

*Tolerated?

Return to 10ppm

YES

At 4 hours:
Wean 5ppm
to 2ppm

*Tolerated?

Return to 5ppm

YES

At 4 hours:
Increase FiO₂
by 10%
Turn iNO off

*Tolerated?

Return to 2ppm

After 24 hours, reattempt weaning

Posted: May 2015
Reviewed: October 2022
Authors: M. Priestley, MD; R. Lin, MD; C. Dominick, RRT; N. Yehya, MD

Evidence

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PICU Clinical Pathway for use of Inhaled Nitric Oxide for Management of Children with Acute Hypoxemic Respiratory Failure

Evidence