Dear Mariam. I am not sure that I will be able to answer your questions fully. Many years ago when our NICU decided to start using inhaled NO therapy we were concerned about the safety aspects associated with NO therapy. I contacted other iNO users and was told of similar stories to what you have described. I was also told of staff complaining of headaches, blurred vision and pregnant staff refusing to work with iNO therapy. We could not find any corroborating evidence to these anecdotes. We were concerned about environmental NO in our NICU as at that time were contemplating using it up to 80 ppm! Further investigations showed that the environmental NO levels would be higher in busy inner-city streets and smoky bars. I recall that a study was published (from France I think) which showed that the environmental NO level was higher in the outside air sample than in the NICU with iNO therapy running. However, we decided to do two things before we introduced iNO therapy into our unit. We installed an Active/Passive scavenger to our ventilator exhaust port to remove NO product out of our NICU. We also included in the NO therapy training a session on the health and safety aspects of NO and demonstrated the low risk of exposure to environmental NO product within our NICU. We have not had a documented case of dizziness, nausea etc or refusal of staff to work, associated with our iNO therapy. I recall a visit to our NICU by a couple of German doctors. They were quite surprised to see us using a iNO scavenger system as they said that it was not necessary. When I explained that the benefit was to ensure the safety of our staff and that we had not had any issues regarding illness or staffing iNO therapy, they agreed that it was for the best. Some year later we purchased an INOvent that when set up, includes a test for checking for NO leaks during the “Purge and Performance” test. As for your situation I would suggest the following. Check all of your iNO delivery and monitoring system for leaks. If not in use already, install an Active/Passive scavenger system to your ventilator exhaust port. I have heard that an active charcoal filter can be used instead. Monitor your environmental NO and NO 2 levels during iNO therapy, especially if it is in a small room. Environmental monitors are available from mining and engineering suppliers, you don’t have to get a medical monitor to do that. Also calculate a theoretical environmental NO level. Measure the volume of the room and then find out the efficiency of that rooms air duct/air conditioner. That should tell you how often the air in the room is “refreshed”. Determine the maximum NO input into that room by using the maximum delivered NO and ventilator flow rate (eg 40 ppm at 10 L/min). Using these measurements you should be able to approximate the maximum theoretical environmental NO in that room. You have described an association between iNO therapy and staff illness. If iNO therapy turns out to have caused the problem, then you will have to do everything to ensure your staffs safety. If iNO therapy did not cause your staff’s illness, then you will have to everything to restore your staff’s confidence that iNO therapy is not a risk to their health and safety. I hope this has helped and wish you all the best. I would be interested in hearing of the outcome.
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