Evidence-Based Guidelines for Acute Stabilization and Management of Neonates with Persistent Pulmonary Hypertension of the Newborn

Abstract

Persistent pulmonary hypertension of the newborn, or PPHN, represents a challenging condition associated with high morbidity and mortality. Management is complicated by complex pathophysiology and limited neonatal specific evidence-based literature, leading to a lack of universal contemporary clinical guidelines for the care of these patients. To address this need and to provide consistent high-quality clinical care for this challenging population in our neonatal intensive care unit, we sought to develop a comprehensive clinical guideline for the acute stabilization and management of neonates with PPHN. Utilizing cross-disciplinary expertise and incorporating an extensive literature search to guide best practice, we present an approachable, pragmatic, and clinically relevant guide for the bedside management of acute PPHN. KEY POINTS: · PPHN is associated with several unique diagnoses; the associated pathophysiology is different for each unique diagnosis.. · PPHN is a challenging, dynamic, and labile process for which optimal care requires frequent reassessment.. · Key management goals are adequate tissue oxygen delivery, avoiding harm..

Figure 1:. Comprehensive clinical care guideline for acute stabilization PPHN not associated with CDH

*** Relative contra-indications to pulmonary vasodilator therapies: severe left ventricular dysfunction, obstructed total anomalous pulmonary venous return, critical congenital heart disease with systemic perfusion dependent upon right-to-left shunting across the ductus arteriosus. Abbreviations: PPHN=persistent pulmonary hypertension of the newborn, CDH=congenital diaphragmatic hernia, UAC=umbilical arterial line, BP=blood pressure, UOP=urine output, MAS=meconium aspiration syndrome, $\mathsf{OI}$=oxygenation index, MAP=mean airway pressure, HFOV=high frequency oscillatory ventilation, CCHD=critical congenital heart disease, PFO=patent foramen ovale, PDA=patent ductus arteriosus, PA=pulmonary artery, RV=right ventricle, LV=left ventricle, TAPVR=total anomalous pulmonary venous return, R=right, L=left, PVR=pulmonary vascular resistance, SVR=systemic vascular resistance, IV=intravenous, IH=inhaled, HR=heart rate, bpm=beats per minute