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

Criteria for Initiating iNO

Consider starting iNO for infants with rising FiO₂ requirement due to PPHN not adequately responsive to other therapies (lung recruitment, blood pressure management)

Infant in N/IICU with Persistent Pulmonary Hypertension of the Newborn (PPHN) Requiring Nitric Oxide (iNO)

Initiating iNO

Obtain baseline ABG
Initiate iNO 20 ppm
After 30 mins, repeat ABG

Responsive to iNO

Post-ductal PaO₂ increase ≥ 20 mmHg if available
or
Post-ductal SpO₂ increase ≥ 5%

Not Responsive to iNO

Post-ductal PaO₂ increase < 20 mmHg if available
and
Post-ductal SpO₂ increase < 5%

Maintain iNO 20 ppm
Wean FiO₂
- Titrate to maintain post-ductal SpO₂ 94–98%
- Do not wean > 10% per hour

Persistent Non-Responder to iNO

Consider discontinuing iNO
25–30% of neonates will be non-responders to iNO therapy

FiO₂ < 50% for 3 hours

Wean iNO 20 ppm to 10 ppm

Tolerating Wean

≤ 20 mmHg decrease in PaO₂ if available
or
≤ 10 % increase in FiO₂ to maintain goal post-ductal SpO₂

Not Tolerating Wean

> 20 mmHg decrease in PaO₂ if available
and
> 10% increase FiO₂ to maintain goal post-ductal SpO₂

iNO Weaning Progression
Wean q4hr as tolerated
10 ppm

5 ppm
5 ppm

3 ppm
3 ppm

2 ppm
2 ppm

1 ppm
Increase FiO₂ by 10%

Turn iNO off

Return to previous iNO level

Resume wean after 4 hrs

Posted: January 2016
Last Revised: December 2025
Authors:
- D. Munson, MD
- M. Padula, MD
- K. Nilan, RN
- L. Tyler, RRT
- J. Stoller, MD
- J. Chuo, MD
- F. Simmons, RRT
Editors: Clinical Pathways Team

Evidence

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

Evidence