PICU Clinical Pathway for use of Inhaled Nitric Oxide for Management of Children with Acute Hypoxemic Respiratory Failure
Related Pathway
PICU Ventilator Weaning Pathway
PICU Ventilator Weaning Pathway
Oxygen Index > 15 AND/OR P/F Ratio ≤ 100
RT to obtain Baseline Data
- Ventilator settings
- OI/PF Ratio
- Pre-iNO ABG
- Co-oximetry
- Inotropic support
Initiate iNO at 20ppm
Obtain ABG 30 minutes after iNO initiation
PaO2 increase ≥ 20%
OR
SpO2 increase ≥ 5%
OR
SpO2 increase ≥ 5%
PaO2 increase < 20%
OR
SpO2 increase < 5%
OR
SpO2 increase < 5%
Discontinue iNO
Maintain iNO at 20ppm
Wean FiO2 to < 50% x4 hours
Wean FiO2 to < 50% x4 hours
Begin Wean q4 Hours
(5 hours post-initiation)
RT team will discuss with medical and nursing teams readiness and subsequent steps
(5 hours post-initiation)
RT team will discuss with medical and nursing teams readiness and subsequent steps
EPIC Order: Critical Care Inhaled Nitric Oxide Weaning Clinical Pathway Started
HFV does not preclude weaning iNO
Increase FiO2 by 10% before discontinuing
Discontinue iNO
Start:
Wean 20ppm
to 10ppm
Wean 20ppm
to 10ppm
*Tolerated?
Return to 20ppm
NO
YES
At 4 hours:
Wean 10ppm
to 5ppm
Wean 10ppm
to 5ppm
*Tolerated?
Return to 10ppm
NO
YES
At 4 hours:
Wean 5ppm
to 2ppm
Wean 5ppm
to 2ppm
*Tolerated?
Return to 5ppm
NO
YES
At 4 hours:
Increase FiO2
by 10%
Turn iNO off
Increase FiO2
by 10%
Turn iNO off
*Tolerated?
Return to 2ppm
NO
After 24 hours, reattempt weaning
Posted: May 2015
Reviewed: October 2022
Authors: M. Priestley, MD; R. Lin, MD; C. Dominick, RRT; N. Yehya, MD
Reviewed: October 2022
Authors: M. Priestley, MD; R. Lin, MD; C. Dominick, RRT; N. Yehya, MD
Evidence
- Inhaled Nitric Oxide Does Not Reduce Mortality in Patients With Acute Respiratory Distress Syndrome Regardless of Severity
- Inhaled Nitric Oxide for Acute Respiratory Distress Syndrome (ARDS) in Children and Adults
- Weaning of Inhaled Nitric Oxide: Is There a Best Strategy?
- A Quality Improvement Initiative to Standardize Use of Inhaled Nitric Oxide in the PICU
- Inhaled Epoprostenol vs. Inhaled Nitric Oxide for Refractory Hypoxemia in Critically Ill Patients
- The Effect of Inhaled Nitric Oxide in Acute Respiratory Distress Syndrome in Children and Adults
- Pediatric Acute Respiratory Distress Syndrome