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

Goal and Metrics
Persistent Pulmonary Hypertension of the Newborn Requiring Nitric Oxide (iNO)
Nitric Oxide Pearls
Criteria for Initiating iNO
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

  • 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 patient does not tolerate wean, return to previous iNO ppm, resume wean after 4 hrs. After each iNO wean, wait 30 minutes before continuing to wean FiO2

*Weaning recommendations also apply to babies who arrive to CHOP on iNO
Posted: January 2016
Reviewed: April 2020
Authors: D. Munson, MD, M. Padula, MD, U. Nawab, MD, K. Nilan, RN, P. Clifford, RN, L. Tyler, RRT, J. Stoller, MD, K. Dysart, MD, L. Soorikan, MD, J. Carroll, M. Fraga, MD, E. Tkach, MD, J. Chuo J, MD