Inhaled Nitric Oxide for Persistent Pulmonary Hypertension Clinical Pathway — N/IICU

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goal and Metrics

Persistent Pulmonary Hypertension of the Newborn (PPHN) Requiring Nitric Oxide (iNO)

Criteria for Initiating iNO

Consider starting iNO for infants with rising FiO₂ requirement due to PPHN not adequately responsive to other therapies

Nitric Oxide Pearls

Methemoglobin Pearls

Initiating iNO

Obtain baseline ABG
Initiate iNO 20 ppm
After 30 minutes, repeat ABG

Post-ductal PaO₂ increase ≥ 20 mmHg
or
Post-ductal SpO₂ increased ≥ 5%

Post-ductal PaO₂ increase < 20 mmHg
or
Post-ductal SpO₂ increased < 5%

Maintaining iNO at 20 ppm, wean FiO₂ as follows:
- Titrate Fi0₂ to maintain post-ductal SpO₂ 94-98%
- Do not wean FiO₂ > 10 % per hour
- Weaning recommendations also apply to infants who arrive to CHOP on iNO

Consider discontinuing iNO
25-30% of neonates will be
non-responders to iNO therapy

When FiO₂ ≤ 60%
Wean iNO 20 to 10
While continuing to wean FiO₂ as above, begin iNO weaning every 4 hours as tolerated

Definition of Tolerating a Wean

iNO Weaning Progression
10

5 ppm
5

3 ppm
3

2 ppm
2

1 ppm
Increase FiO₂ by 10% and turn iNO off
If the infant does not tolerate wean, return to the previous iNO ppm and resume wean after 4 hours.
After each iNO wean, wait 30 minutes before continuing to wean FiO₂.

Posted: January 2016
Revised: October 2022
Authors: D. Munson, MD; M. Padula, MD; U. Nawab, MD; K. Nilan, RN; L. Tyler, RRT; J. Stoller, MD; M. Fraga, MD; J. Chuo, MD

Evidence

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact us.

©2024 by Children's Hospital of Philadelphia, all rights reserved.
Use of this site is subject to the Terms of Use.

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.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

N/IICU Clinical Pathway for Inhaled Nitric Oxide Use in Newborns with Persistent Pulmonary Hypertension

Evidence