PICU Clinical Pathway for use of Inhaled Nitric Oxide for Management of Children with Acute Hypoxemic Respiratory Failure
Related Pathway
PICU Ventilator Weaning Pathway
PICU Ventilator Weaning Pathway
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%
OR
SpO2 increase ≥ 5%
PaO2 increase < 20%
OR
SpO2 increase < 5%
OR
SpO2 increase < 5%
Discontinue iNO
Maintain iNO at 20ppm
Wean FiO2 to < 50% x4 hours
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
(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
Wean 20ppm
to 10ppm
*Tolerated?
Return to 20ppm
NO
YES
At 4 hours:
Wean 10ppm
to 5ppm
Wean 10ppm
to 5ppm
*Tolerated?
Return to 10ppm
NO
YES
At 4 hours:
Wean 5ppm
to 2ppm
Wean 5ppm
to 2ppm
*Tolerated?
Return to 5ppm
NO
YES
At 4 hours:
Increase FiO2
by 10%
Turn iNO off
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
Revised: April 2020
Authors: R. Giordano, L. Tyler, N. Craig, M. Priestley, MD, R. Lin, MD
Resources
- Inhaled Nitric Oxide Does Not Reduce Mortality in Patients With Acute Respiratory Distress Syndrome Regardless of Severity
- Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults
- Weaning of inhaled nitric oxide: is there a best strategy?
- A Quality Improvement Initiative to Standardize Use of Inhaled Nitric Oxide in the PICU
- Inhaled epoprostenol vs inhaled nitric oxide for refractory hypoxemia in critically ill patients
- The effect of inhaled nitric oxide in acute respiratory distress syndrome in children and adults
- Pediatric Acute Respiratory Distress Syndrome