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nashwa

iNO in preterm

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Can anyone share his experience in using iNO in PT with Pulmonary hypertension in BPD

 

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I have no personal experience. In very severe cases of BPD we sometimes try sildenafil and/or inhal iloprost, assessing pulm pressure before/after with echo. 

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We used it in crisis during my fellowship with the goal, obviously, of transitioning to some combination of sildenafil, trepostinil, bosentan etc. Was there a specific aspect of therapy you had questions on?  My experience with using iNO in this circumstance is that many, if not most of the 'bad BPD' we saw, the clinical manifestations of pulmonary hypertension were more helped by aggressive respiratory support as opposed to pulmonary vasodilator therapy.  We would get many patients as transfers from level IIIs to our BPD program at the level IV ICU and these babies would be been on non-invasive support for very long periods of time and, in retrospect they had been retaining CO2 and were on far too much FiO2.  These babies ended up in pulmonary hypertensive crisis around transport and needed iNO for a period, but it wasn't the iNO that 'fixed' things, it was choosing an appropriate ventilatory strategy with things like much higher PEEP, including possible use of peep titration during bronchoscopy, transitioning to a higher tidal volume and lower rate strategy (very different strategies designed to prevent BPD and much more like what our colleagues in PICU are used to doing).  Steve Atman gave an excellent talk on this point at PAS a couple of years ago and has published quite a bit in this area.

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We used it in crisis during my fellowship with the goal, obviously, of transitioning to some combination of sildenafil, trepostinil, bosentan etc. Was there a specific aspect of therapy you had questions on?  My experience with using iNO in this circumstance is that many, if not most of the 'bad BPD' we saw, the clinical manifestations of pulmonary hypertension were more helped by aggressive respiratory support as opposed to pulmonary vasodilator therapy.  We would get many patients as transfers from level IIIs to our BPD program at the level IV ICU and these babies would be been on non-invasive support for very long periods of time and, in retrospect they had been retaining CO2 and were on far too much FiO2.  These babies ended up in pulmonary hypertensive crisis around transport and needed iNO for a period, but it wasn't the iNO that 'fixed' things, it was choosing an appropriate ventilatory strategy with things like much higher PEEP, including possible use of peep titration during bronchoscopy, transitioning to a higher tidal volume and lower rate strategy (very different strategies designed to prevent BPD and much more like what our colleagues in PICU are used to doing).  Steve Atman gave an excellent talk on this point at PAS a couple of years ago and has published quite a bit in this area.
Bimalc, if you use iNO in PT, can you tell me how in detail, because we have baby 24 weeks, 3 weeks ventilatory dependant and then now he need fio2 100% to spo2 reach 90%, we have iNO in our unite, we tried dexamethasone, but stopped because of hypertension.

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On ‎12‎/‎2‎/‎2018 at 11:23 PM, nashwa said:

Bimalc, if you use iNO in PT, can you tell me how in detail, because we have baby 24 weeks, 3 weeks ventilatory dependant and then now he need fio2 100% to spo2 reach 90%, we have iNO in our unite, we tried dexamethasone, but stopped because of hypertension. 

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I'm not sure we did anything particularly involved, iNO at 20ppm and assess if responder or not based on FiO2 requirement (although, in practice, I feel like no one ever turned the iNO off in non-responders, the kids just died eventually).  We would try to get ECHO for indirect estimation of PH before starting (and to make sure this wasn't anomalous veins).  My original comment still stands though: as this patient sounds like they have evolving CLD, I'd invest more of my time and effort in reviewing XRays and optimizing the vent for CLD.  Also, if you haven't started, I'd have a very frank discussion about morbidity and mortality with the family.

 

Have you considered re-posting/cross-posting to the virtual NICU if you are interested in discussing a specific patient?

 

Bimal

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In the experience, I remember that the NICU above the transport team I worked for used iNO with ventilation during a 'crisis' with pulmonary hypertension with the goal of stabilizing.  It was always available for use during transport.

         One occasion I was able to observe some bed teaching. In this case there was a neonate who was on iNO and oscillating ventilation for some time before being transferred to another unit for ECMO.

 

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Just remember that premature neonates born after very early rupture of membranes, especially before 20 weeks, may have a dramatic response to iNO. Usually a dose of 10 ppm will be sufficient. 

We had a poster on our results some years ago in Granada

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