Inhaled Nitric Oxide for Persistent Pulmonary Hypertension Clinical Pathway — N/IICU

N/IICU Clinical Pathway for Inhaled Nitric Oxide Use in Newborns with Persistent Pulmonary Hypertension

Goal and Metrics
Persistent Pulmonary Hypertension of the Newborn (PPHN) Requiring Nitric Oxide (iNO)
Criteria for Initiating iNO
Consider starting iNO for infants with rising FiO2 requirement due to PPHN not adequately responsive to other therapies

Nitric Oxide Pearls

Methemoglobin Pearls
Initiating iNO
  • Obtain baseline ABG
  • Initiate iNO 20 ppm
  • After 30 minutes, repeat ABG
Post-ductal PaO2 increase ≥ 20 mmHg
or
Post-ductal SpO2 increased ≥ 5%
Post-ductal PaO2 increase < 20 mmHg
or
Post-ductal SpO2 increased < 5%
  • Maintaining iNO at 20 ppm, wean FiO2 as follows:
    • Titrate Fi02 to maintain post-ductal SpO2 94-98%
    • Do not wean FiO2 > 10 % per hour
    • Weaning recommendations also apply to infants who arrive to CHOP on iNO

  • Consider discontinuing iNO

  • 25-30% of neonates will be
    non-responders to iNO therapy

  • When FiO2 ≤ 60%

  • Wean iNO 20 to 10
  • While continuing to wean FiO2 as above, begin iNO weaning every 4 hours as tolerated
Definition of Tolerating a Wean
  • iNO Weaning Progression
  • 10
    5 ppm
  • 5
    3 ppm
  • 3
    2 ppm
  • 2
    1 ppm
  • Increase FiO2 by 10% and turn iNO off
  • If the infant does not tolerate wean, return to the previous iNO ppm and resume wean after 4 hours.
  • After each iNO wean, wait 30 minutes before continuing to wean FiO2.
Posted: January 2016
Revised: October 2022
Authors: D. Munson, MD; M. Padula, MD; U. Nawab, MD; K. Nilan, RN; L. Tyler, RRT; J. Stoller, MD; M. Fraga, MD; J. Chuo, MD