Nitric oxide for respiratory failure in infants born at or near term

Abstract

Background: This section is under preparation and will be included in the next issue.

Objectives: To determine whether treatment of hypoxemic newborn infants with inhaled nitric oxide (INO) improves oxygenation and reduces the rates of death, or the requirement for ECMO.

Search strategy: Electronic and hand searching of pediatric/neonatal literature and personal data files. In addition we contacted the principal investigators of articles which have been published as abstracts to ascertain the necessary information.

Selection criteria: Randomized and quasi randomized studies in term and near term infants. Administration of inhaled nitric oxide. Clinically relevant outcomes, including death, requirement for ECMO, and oxygenation.

Data collection and analysis: Eight randomized controlled studies were found in term and near term infants with hypoxia. Entry criteria were reasonably consistent except for the one trial that studied only infants with congenital diaphragmatic hernia (Ninos 1997).

Main results: Inhaled nitric oxide appears to improve outcome in hypoxemic term and near term infants by reducing the incidence of the combined endpoint of death or need for ECMO. The reduction seems to be entirely a reduction in need for ECMO; mortality is not reduced. Oxygenation improves in approximately 50% of infants receiving nitric oxide. The Oxygenation Index decreases by a (weighted) mean of 15.1 within 30 to 60 minutes after commencing therapy and PaO2 increases by a mean of 53 mmHg. It does not appear to affect outcome whether infants have clear echocardiographic evidence of PPHN or not. The outcome of infants with diaphragmatic hernia was not improved; indeed there is a suggestion that outcome was slightly worsened.

Reviewer's conclusions: On the evidence presently available, it appears reasonable to use inhaled nitric oxide in a concentration of 20 ppm for term and near term infants with hypoxic respiratory failure who do not have a diaphragmatic hernia. Longterm neurodevelopmental and pulmonary followup of surviving infants enrolled in randomized trials of INO are required to establish more firmly the role of INO in the treatment of neonatal respiratory failure.