Use of Inhaled Nitric Oxide During Interhospital Transport of Newborns With Hypoxemic Respiratory Failure

Inhaled nitric oxide (iNO) therapy improves oxygenation and reduces the need for extracorporeal membrane oxygenation (ECMO) in near-term and term newborns with hypoxemic respiratory failure and pulmonary hypertension.^1–4 The use of nitric oxide (NO) gas as an inhalational therapy for persistent pulmonary hypertension of the newborn (PPHN) was recently approved by the US Food and Drug Administration (FDA). Because iNO therapy has become adopted as a standard of care for PPHN, its use has increased in many centers without the capability of providing other rescue therapies, such as ECMO. Although iNO therapy is often effective, 30% to 40% of sick newborns do not have sustained improvement in oxygenation and hemodynamics after the initiation of therapy. Patients in whom iNO fails are critically ill and often require rapid transfer to an ECMO center. Abrupt discontinuation of iNO therapy before transport, even in patients who have had little apparent clinical benefit, can be dangerous because of acute deterioration with severe hypoxemia.^5–7 The use of iNO for the stabilization and transport of such neonates has been previously described⁵; however, since this report, at least 1 death has been associated with the discontinuation of iNO before transport to an ECMO center.⁸ Thus, the availability of iNO therapy during transport is vital to its safe and effective application. In this report, we describe: 1) a practical approach to stabilization and transport of critically ill newborns with iNO therapy; 2) the clinical course of newborns treated with iNO during transport; and 3) a survey of the current availability of iNO therapy for transport to ECMO centers in the United States.

Address correspondence to John P. Kinsella, MD, Division of Neonatology, Box B-070, Children’s Hospital, 1056 E 19th Ave, Denver, CO 80218-1088. E-mail: john.kinsellauchsc.edu