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Found 3 results

  1. If you work in Neonatology you no doubt have listened to people talk in rounds or at other educational sessions about the importance of opening the lung. Many units in the past were what you might call “peepaphobic” but over time and with improvements in technology many centers are adopting an attitude that you use enough PEEP to open the lung. There are some caveats to this of course such as there being upper limits to what units are comfortable and not just relying on PEEP but adding in surfactant when necessary to improve pulmonary compliance. When we think about giving nitric oxide the importance of opening the lung can’t be stressed enough. I have heard it said many times when a baby has been found to be a “non responder” to inhaled nitric oxide that they may have been so because the lung wasn’t open. What we mean by this is that the distal alveoli are open. One can administer all the iNO in the world but if the majority of alveoli are collapsed the drug can’t get to the pulmonary vasculature and cause the pulmonary vasodilation that is so sorely needed in the presence of hypoxemic respiratory failure. Surfactant and inhaled nitric oxide in the presence of hypoxemic respiratory failure could be a great combo as one would help open the alveoli and then the iNO could address any pulmonary vasoconstriction which might be exacerbating the hypoxemic state. Study Tests This Theory Researchers in Chile led by Gonzalez A published Early use of combined exogenous surfactant and inhaled nitric oxide reduces treatment failure in persistent pulmonary hypertension of the newborn: a randomized controlled trial in the Journal of Perinatology. The concept of this study was to compare in a double blind RCT for 100 patients (based on a power calculation looking for a 25% reduction in treatment failure) whether provision of surfactant as up to 2 doses and iNO would be better than just iNO alone. Included infants needed an oxygenation index (OI = MAPXFiO2/pO2) of 20 or more to qualify and treatment failure was an OI of 40 or more. The patients recruited were similar in common characteristics including types of conditions that would benefit from iNO. RDS, meconium aspiration syndrome and pneumonia certainly have been shown to benefit from surfactant before while in the PPHN category that is questionable. In order to ensure that it was not just the primary disease but pulmonary hypertension that was present as well, all patients required confirmation of pulmonary hypertension prior to enrollment via ECHO with either a TR jet indicating a pulmonary pressure at least 2/3 of systemic or right to left shunting at the ductal or atrial level. The results of the study demonstrated a clear difference in the primary outcome. Patients receiving the combination of surfactant prior to starting iNO showed a faster reduction in OI than those receiving iNO alone. In fact the reduction in primary outcome of treatment failure was over 50% different while the power calculation had been based on only a 25% difference. That’s ok as this means there were more than enough patients to demonstrate a difference. As a secondary outcome the rate of ECMO or death was also different between the groups favouring use of surfactant. It works so now what? Who doesn’t like seeing a study that confirms what you have long believed. I feel that this study validates the teaching I received throughout the years about ensuring the lung is open before giving iNO. There are some caveats to this however. About 90% of the patients studied had conditions present (RDS, MAS, pneumonia) for which surfactant would have been indicated anyway. If this study had been done let’s say in patients with asphyxia induced pulmonary hypertension and clear lungs the surfactant may have made no difference as the lungs were already open. I mention this as I don’t think readers of this analysis need to jump to the conclusion that every time there is a patient with PPHN that you MUST give surfactant. What I think this illustrates though is the importance of first asking the question if iNO is being considered “Have I opened the lungs?”. The next time you encounter such a patient consider whether you are using enough PEEP and whether surfactant is indicated. The bottom line is if the lung isn’t open then all the iNO in the world isn’t going to make much difference!
  2. I am currently writing my dissertation on the use of non-invasive ventilation to deliver nitric oxide in neonates and I was wondering: What are people‘s experiences of using non-invasive iNO with CPAP, Nasal cannula, oxygen hood etc? Which gestational have you primarily used it with? What were the indications/ underlying pathologies? Have you found this has reduced the need for mechanical ventilation or ECMO? Have you needed to deliver higher doses to achieve the same effect seen on mechanical ventilation? Which countries have you seen this being practiced? Any other insights or information would be greatly appreciated
  3. Just wanted to share a recent and good experience with inhalation of epoprostenol in PPHN. I currently work in a large level2-unit (≈8000 inborn/y) with no access to NO-inhalation. Infants born in our delivery ward with PPHN and needing level-3-care (i.e. NO/mechanical ventilation) needs to be transferred. We recently had a baby with echo-verified PPHN, on CPAP and with saturations around 88-90% on 100% oxygen. While preparing for premed/relaxation and intubation we connected our CPAP inhalation device and inhaled epoprostenol with surprisingly good response! We avoided intubation and transfer. We gave two inhalations about 30 min apart initially, and shortly our saturations were >95% and could start to decrease FiO2. Doses were repeated every 2nd hour until we reached FiO2 <0.5, in total the baby recieved five inhalations. Before/during and after - the baby was cardiovascular stable (stable normal BP and pulse) and the 2nd echo at about 4h of age showed balanced shunt over the open duct (as opposed to right-left shunting at 1.5h after birth). We used the dose suggested in this article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342750/
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