Abstract
Inhaled nitric oxide (NO) is thought to provide a noninvasive therapeutic alternative to extracorporeal membrane oxygenation (ECMO) in the treatment of persistent pulmonary hypertension of the newborn (PPHN).
Objective
Since January 1993, we have studied inhalation of NO in PPHN patients meeting the ECMO criteria of our institution. We focused on the questions of whether or not the need for ECMO could be obviated and whether differences could be found between NO responders and nonresponders.
Design
NO gas was delivered via conventional IPPV ventilation in incrementally increasing concentrations from 20 to 80 ppm.
Patients
NO therapy was attempted in ten ECMO candidates with clinical and echocardiographical evidence of PPHN (mean OI 51.9, SD 10.4).
Results
At various NO levels (30–60 ppm), five patients showed a significant increase in meanPaO2 (range 32.9–85.9 mmHg). Improvement was transient in three patients (6–10 h) and prolonged in two others (54–80 h); in the latter cases, ECMO was avoided. Five patients did not respond at all to treatment. Responders and nonresponders differed in their mean respiratory tidal volume (8.9 vs 4.18 ml/kg,P<0.05).
Conclusions
In our study, inhalation of NO obviated the necessity of ECMO therapy in only two out of ten PPHN patients. Thus, we would discourage any overoptimistic expectations about the effectiveness of NO therapy in PPHN until larger clinical trials have been performed.
Article PDF
Similar content being viewed by others
References
Fox WW, Duara S (1983) Persistent pulmonary hypertension in the neonate: diagnosis and management. J Pediatr 103: 505–511
Wung J-T, James LS, Kilchevsky E, James E (1985) Management of infants with severe respiratory failure and persistence of the fetal circulation, without hyperventilation. Pediatrics 76: 488–494
Stevenson DK, Kasting DS, Darnall RA (1979) Refractory hypoxemia associated with neonatal pulmonary disease: the use and limitations of tolazoline. J Pediatr 95: 595–599
Carter JM, Gerstmann DR, Clark RH, Snyder G, Cornish JD, Null DM, deLemos RA (1990) High-frequency oscillatory ventilation and extracorporeal membrane oxygenation for the treatment of neonatal respiratory failure. Pediatrics 85: 159–164
Andrews AF, Roloff DW, Bartlett RH (1984) Use of extracorporeal membrane oxygenators in persistent pulmonary hypertension of the newborn. Clin Perinatol 2: 729–735
Stolar CJH, Snedecor SM, Bartlett RH (1991) Extracorporeal membrane oxygenation and neonatal respiratory failure: experience from the Extracorporeal Life Support Organization. J Pediatr Surg 26: 563–571
Frostell C, Fractacci M, Wain JC, Jones R, Zapol WM (1991) Inhaled nitric oxide: a selective pulmonary vasodilator reversing hypoxic pulmonary vasoconstriction. Circulation 83: 2038–2047
Fratacci MD, Frostell CG, Chen TY, Wain JC, Robinson DR, Zapol WM (1991) Inhaled nitric oxide: a selective pulmonary vasodilator of heparinprotamine vasoconstriction in sheep. Anesthesiology 75: 990–999
Archer SL, Rist K, Nelson DP, DeMaster EG, Cowan N, Weir EK (1990) Comparison of the hemodynamic effects of nitric oxide and endothelium-dependent vasodilators in intact lungs. J Appl Physiol 68: 735–747
Geggel RL (1993) Inhalational nitric oxide: a selective pulmonary vasolidator for treatment of persistent pulmonary hypertension of the newborn. J Pediatr 123: 76–79
Roberts JD, Polander DM, Lang P, Zapol WM (1992) Inhaled nitric oxide in persistent pulmonary hypertension of the newborn. Lancet 340: 818–819
Kinsella JP, Neish SR, Shaffer E, Abman SH (1992) Low-dose inhalational nitric oxide in persistent pulmonary hyper-tension of the newborn. Lancet 340: 819–820
Kinsella JP, Neish SR, Dunbar Ivy D, Shaffer E, Abman SH (1993) Clinical responses to prolonged treatment of persistent pulmonary hypertension of the newborn with low doses of nitric oxide. J Pediatr 123: 103–108
Abman SH, Kinsella JP, Schaffer MS, Wilkening RB (1993) Inhaled nitric oxide in the management of a premature newborn with severe respiratory distress and pulmonary hypertension. Pediatrics 92: 606–609
Finer NN, Etches PC, Kamstra B, Tierney AJ, Peliowski A, Ryan CA (1994) Inhaled nitric oxide in infants referred for extracorporeal membrane oxygenation: dose response. J Pediatr 124: 302–308
Skinner JR, Boys RJ, Hunter S, Hey EN (1991) Non-invasive assessment of pulmonary arterial pressure in healthy neonates. Arch Dis Child 66: 386–390
Evans NJ, Archer LNJ (1991) Doppler assessment of pulmonary artery pressure and extrapulmonary shunting in the acute phase of hyaline membrane disease. Arch Dis Child 66: 6–11
Rozé J-C, Storme L, Zupan V, Morville P, Dinh-Xuan AT, Mercier J-C (1994) Echocardiographic investigation of inhaled nitric oxide in newborn babies with severe hypoxaemia. Lancet 344: 303–305
Antunes MJ, Greenspan JS, Holt WI, Vallieu DS, Spitzer AR (1994) Assessment of lung function pre-nitric oxide therapy: a predictor of response? Pediatr Res 35: 212A
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Müller, W., Kachel, W., Lasch, P. et al. Inhaled nitric oxide for avoidance of extracorporeal membrane oxygenation in the treatment of severe persistent pulmonary hypertension of the newborn. Intensive Care Med 22, 71–76 (1996). https://doi.org/10.1007/BF01728335
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF01728335