Inhaled Nitric Oxide for Acute Hypoxemic Respiratory Failure Clinical Pathway — PICU

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Goals and Metrics

Provider Resources

Related Pathway
PICU Ventilator Weaning Pathway

Patient Requiring Inhaled Nitric Oxide (iNO) for Hypoxemic Respiratory Failure

Criteria for Initiating iNO

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%

PaO₂ increase < 20%
OR
SpO₂ increase < 5%

Discontinue iNO

Maintain iNO at 20ppm
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

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

*Tolerated?

Return to 20ppm

YES

At 4 hours:
Wean 10ppm
to 5ppm

*Tolerated?

Return to 10ppm

YES

At 4 hours:
Wean 5ppm
to 2ppm

*Tolerated?

Return to 5ppm

YES

At 4 hours:
Increase FiO₂
by 10%
Turn iNO off

*Tolerated?

Return to 2ppm

After 24 hours, reattempt weaning

Posted: May 2015
Reviewed: October 2022
Authors: M. Priestley, MD; R. Lin, MD; C. Dominick, RRT; N. Yehya, MD

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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PICU Clinical Pathway for use of Inhaled Nitric Oxide for Management of Children with Acute Hypoxemic Respiratory Failure

Evidence