Experience of inhaled nitric oxide in babies with pulmonary hypertension in a tertiary neonatal unit Supriya Bhoomaiah Vishna Rasiah Birmingham Womens Hospital QUAD Network Research study day 10/01/13

Inhaled Nitric oxide Selective pulmonary vasodilator Improves oxygenation and decreases the combined outcome of death or need for ECMO in infants >34 weeks gestation 1,2 Does not improve survival or bronchopulmonary dysplasia in preterm babies 3,4,5 1.Stork E,Verter J et al(NINOS).NEJM Finner NN,Barrington KJ.Cochrane Database Syst Rev Askie LM.2011,iNO in preterm infants RCT.Pediatrics Mercier et al 2010, EUNO RCT.Lancet Finner NN,Barrington KJ.Cochrane Database Syst Rev 2010

Aims To review the outcomes of neonates with pulmonary hypertension due to causes other than congenital diaphragmatic hernia treated with inhaled nitric oxide in a tertiary neonatal unit.

Methods January 2009 to December 2011 Badger database Standard proforma

Results 3934 Total no admitted on badger 46( other causes) Included 16 < 27+6 weeks to 36+6 weeks 16 > 37 weeks 31(CDH) Excluded 77 Treated with iNO

Gestational age

Birth weight

Trend in iNO use n= n= n=8 <27+6 weeks 28 – 36+6 weeks >37 weeks Gestation

Evidence of pulmonary hypertension

Early vs. Late iNO

Referral for ECMO

Chronic lung disease and Home oxygen

Death

4/7 3/6 1/ /6 3/7 1/ (Died/total n) 2/3 0/1 0/ <27+6 weeks 28 – 36+6 weeks >37 weeks Gestation

Summary 65% preterm vs 34% term babies Increasing trend and late use in preterm babies Only 1 term baby referred for ECMO 50% mortality in preterm vs 12.5% term babies

Conclusions Inhaled nitric oxide is the current mainstay therapy in term neonates with pulmonary hypertension with excellent outcomes. Preterm babies especially those less than 28 weeks gestation treated with iNO have a poor outcome. Cautious approach warranted in the absence of robust evidence to support routine use of iNO as early rescue and late treatment.

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References 1.Stork E, Verter J et al(NINOS).Inhaled nitric oxide in full term and nearly full term infants with hypoxic respiratory failure. NEJM 1997;336: Askie LM, Ballard RA, Subhedar V et al. Inhaled Nitric oxide in preterm infants: An individual patient data meta- analysis of randomized trials. Pediatrics 2011;128(4): Mercier J et al.iNO for prevention of bronchopulmonary dysplasia in premature babies(EUNO) a RCT. Lancet 2010 Jul;376(9738): Finner NN, Barrington KJ. Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane Database Syst Rev 2007;(3):CD000509