Heart & Lung xxx (2014) 1e4
Contents lists available at ScienceDirect
Heart & Lung journal homepage: www.heartandlung.org
Use of inhaled nitric oxide in preterm infants: A regional survey of practices Arun Sasi, MD, DM a, Arvind Sehgal, MD, MRCPCH, FRACP a, b, * a b
Monash Newborn, Monash Children’s Hospital, Melbourne, Australia Department of Pediatrics, Monash University, Melbourne, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 March 2014 Received in revised form 16 April 2014 Accepted 17 April 2014 Available online xxx
Objectives: To conduct a regional survey of neonatal intensive care unit (NICU) Directors in Australia and New Zealand (ANZ) to ascertain current practice. Background: Use of inhaled nitric oxide (iNO) therapy in infants < 34 weeks gestational age is not supported by current evidence. Methods: A cross-sectional electronic survey based on structured questionnaire was conducted amongst the Directors of all the tertiary neonatal intensive care units in Australia and New Zealand Neonatal Network (ANZNN). Information was collected on indications, dosage, monitoring response and weaning for iNO therapy. Results: The survey was sent to 28 units, of which 2 were quaternary units’ not routinely admitting preterm infants, hence were excluded from analysis. The response rate was 77% (20/26). Majority of units (16; 80%) did not have preterm specific protocol. In almost all units nitric was used as early rescue for hypoxemic respiratory failure (95%; 19/20). Neonatologist performed functional echocardiography (fECHO) was frequently used for prior assessment (90%) and monitoring (65%). Variations were noted regarding initiating criteria, dosage and weaning strategies. Conclusions: Wide variation in practice was noted highlighting the need for the formulation of consensus guidelines. Ó 2014 Elsevier Inc. All rights reserved.
Keywords: Inhaled nitric oxide Preterm Survey Practice Echocardiography
Introduction Persistent pulmonary hypertension of the newborn (PPHN) is an acute condition characterized by hypoxemic respiratory failure (HRF). It reflects failure of extra-uterine adaptation and continued elevation of pulmonary pressures and carries with it high risk of mortality and morbidity. The underlying etiopathogenesis could include severe hyaline membrane disease, sepsis or pulmonary hypoplasia. Inhaled nitric oxide (iNO) is efficacious in improving oxygenation in PPHN in term infants’ 34 weeks gestation at birth.
Abbreviations: (PPHN), Persistent pulmonary hypertension of the newborn; (HRF), Hypoxemic respiratory failure; (iNO), Inhaled nitric oxide; (CLD), Chronic lung disease; (ICH), Intracranial hemorrhage; (RCTs), Randomised controlled trials; (NICU), Neonatal intensive care unit; (ANZ), Australia and New Zealand; (fECHO), Functional Echocardiography; (OI), Oxygenation index; (BPD), Bronchopulmonary dysplasia; (PPROM), Preterm premature rupture of membrane; (ANZNN), Australia and New Zealand Neonatal Network. Declaration of interest or financial disclosures: none. * Corresponding author. Monash University, 246, Clayton Road, Clayton, Melbourne, VIC 3168, Australia. Tel.: þ61 3 95945197. E-mail address: [email protected] (A. Sehgal). 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2014.04.014
It has also been shown to reduce the combined outcome of death or use of extracorporeal membranous oxygenation.1 However, unlike its well-established role in late preterm and term infants, its use is highly contentious in infants born at 1000 g-birth weight and increased incidence of severe ICH in-group < 1000 g birth weight.15 Additional data needs to be compiled for its use in settings of premature infants with pulmonary hypoplasia. We feel a response rate of 20/26 (77%) is representative of the overall practice in the region. A structured question based survey might have limited the options for the respondents. Conclusion In this survey of NICU Directors in the ANZ region, we noted that in preterm infants, iNO is predominantly used as an early rescue therapy. Variability in practice of dosage and weaning was also noted. Given the high usage of pre-iNO echocardiograms, a prospective RCT in preterm infants with documented PPHN would be useful.
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References 1. Finer N, Barrington KJ. Nitric oxide for respiratory failure in infants born at or near term. Cochrane Database Syst Rev 2006;(Issue 4):CD000399. 2. Kinsella JP, Walsh WF, Bose CL. Inhaled nitric oxide in premature neonates with severe hypoxemic respiratory failure: a randomized controlled trial. Lancet. 1999;354:1061e1065. 3. Schreiber MD, Gin-Mestan K, Marks JD, Huo D, Lee G, Srisuparp P. Inhaled nitric oxide in premature infants with the respiratory distress syndrome. N Engl J Med. 2003;349:2099e2107. 4. Barrington KJ, Finer N. Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane Database Syst Rev 2010;(Issue12):CD000509. 5. Clark RH, Ursprung RK, Walker MW, et al. Changing pattern of use of inhaled nitric acid in neonatal intensive care units. J Perinatol. 2010;30:800e804. 6. Cole FS, Alleyne C, Barks JD, et al. National institute of health consensus development conference statement. Inhaled nitric oxide therapy for premature infants. NIH Consens State Sci Statements. 2010; Oct 27-29;27:1e34. 7. Schneiderman R, Kirby S, Genen L. Inhaled Nitric Oxide Utilization in Patients
Contents lists available at ScienceDirect
Heart & Lung journal homepage: www.heartandlung.org
Use of inhaled nitric oxide in preterm infants: A regional survey of practices Arun Sasi, MD, DM a, Arvind Sehgal, MD, MRCPCH, FRACP a, b, * a b
Monash Newborn, Monash Children’s Hospital, Melbourne, Australia Department of Pediatrics, Monash University, Melbourne, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 March 2014 Received in revised form 16 April 2014 Accepted 17 April 2014 Available online xxx
Objectives: To conduct a regional survey of neonatal intensive care unit (NICU) Directors in Australia and New Zealand (ANZ) to ascertain current practice. Background: Use of inhaled nitric oxide (iNO) therapy in infants < 34 weeks gestational age is not supported by current evidence. Methods: A cross-sectional electronic survey based on structured questionnaire was conducted amongst the Directors of all the tertiary neonatal intensive care units in Australia and New Zealand Neonatal Network (ANZNN). Information was collected on indications, dosage, monitoring response and weaning for iNO therapy. Results: The survey was sent to 28 units, of which 2 were quaternary units’ not routinely admitting preterm infants, hence were excluded from analysis. The response rate was 77% (20/26). Majority of units (16; 80%) did not have preterm specific protocol. In almost all units nitric was used as early rescue for hypoxemic respiratory failure (95%; 19/20). Neonatologist performed functional echocardiography (fECHO) was frequently used for prior assessment (90%) and monitoring (65%). Variations were noted regarding initiating criteria, dosage and weaning strategies. Conclusions: Wide variation in practice was noted highlighting the need for the formulation of consensus guidelines. Ó 2014 Elsevier Inc. All rights reserved.
Keywords: Inhaled nitric oxide Preterm Survey Practice Echocardiography
Introduction Persistent pulmonary hypertension of the newborn (PPHN) is an acute condition characterized by hypoxemic respiratory failure (HRF). It reflects failure of extra-uterine adaptation and continued elevation of pulmonary pressures and carries with it high risk of mortality and morbidity. The underlying etiopathogenesis could include severe hyaline membrane disease, sepsis or pulmonary hypoplasia. Inhaled nitric oxide (iNO) is efficacious in improving oxygenation in PPHN in term infants’ 34 weeks gestation at birth.
Abbreviations: (PPHN), Persistent pulmonary hypertension of the newborn; (HRF), Hypoxemic respiratory failure; (iNO), Inhaled nitric oxide; (CLD), Chronic lung disease; (ICH), Intracranial hemorrhage; (RCTs), Randomised controlled trials; (NICU), Neonatal intensive care unit; (ANZ), Australia and New Zealand; (fECHO), Functional Echocardiography; (OI), Oxygenation index; (BPD), Bronchopulmonary dysplasia; (PPROM), Preterm premature rupture of membrane; (ANZNN), Australia and New Zealand Neonatal Network. Declaration of interest or financial disclosures: none. * Corresponding author. Monash University, 246, Clayton Road, Clayton, Melbourne, VIC 3168, Australia. Tel.: þ61 3 95945197. E-mail address: [email protected] (A. Sehgal). 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2014.04.014
It has also been shown to reduce the combined outcome of death or use of extracorporeal membranous oxygenation.1 However, unlike its well-established role in late preterm and term infants, its use is highly contentious in infants born at 1000 g-birth weight and increased incidence of severe ICH in-group < 1000 g birth weight.15 Additional data needs to be compiled for its use in settings of premature infants with pulmonary hypoplasia. We feel a response rate of 20/26 (77%) is representative of the overall practice in the region. A structured question based survey might have limited the options for the respondents. Conclusion In this survey of NICU Directors in the ANZ region, we noted that in preterm infants, iNO is predominantly used as an early rescue therapy. Variability in practice of dosage and weaning was also noted. Given the high usage of pre-iNO echocardiograms, a prospective RCT in preterm infants with documented PPHN would be useful.
4
A. Sasi, A. Sehgal / Heart & Lung xxx (2014) 1e4
References 1. Finer N, Barrington KJ. Nitric oxide for respiratory failure in infants born at or near term. Cochrane Database Syst Rev 2006;(Issue 4):CD000399. 2. Kinsella JP, Walsh WF, Bose CL. Inhaled nitric oxide in premature neonates with severe hypoxemic respiratory failure: a randomized controlled trial. Lancet. 1999;354:1061e1065. 3. Schreiber MD, Gin-Mestan K, Marks JD, Huo D, Lee G, Srisuparp P. Inhaled nitric oxide in premature infants with the respiratory distress syndrome. N Engl J Med. 2003;349:2099e2107. 4. Barrington KJ, Finer N. Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane Database Syst Rev 2010;(Issue12):CD000509. 5. Clark RH, Ursprung RK, Walker MW, et al. Changing pattern of use of inhaled nitric acid in neonatal intensive care units. J Perinatol. 2010;30:800e804. 6. Cole FS, Alleyne C, Barks JD, et al. National institute of health consensus development conference statement. Inhaled nitric oxide therapy for premature infants. NIH Consens State Sci Statements. 2010; Oct 27-29;27:1e34. 7. Schneiderman R, Kirby S, Genen L. Inhaled Nitric Oxide Utilization in Patients
