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

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
Revised: April 2020
Authors: R. Giordano, L. Tyler, N. Craig, M. Priestley, MD, R. Lin, MD