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

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

Goals and Metrics
Provider Resources
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
NO
YES
At 4 hours:
Wean 10ppm
to 5ppm
*Tolerated?
Return to 10ppm
NO
YES
At 4 hours:
Wean 5ppm
to 2ppm
*Tolerated?
Return to 5ppm
NO
YES
At 4 hours:
Increase FiO2
by 10%
Turn iNO off
*Tolerated?
Return to 2ppm
NO
After 24 hours, reattempt weaning
Posted: May 2015
Reviewed: October 2022
Authors: M. Priestley, MD; R. Lin, MD; C. Dominick, RRT; N. Yehya, MD