1. 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

2. 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 1997 2.Finner NN,Barrington KJ.Cochrane Database Syst Rev 2009 3.Askie LM.2011,iNO in preterm infants RCT.Pediatrics 2011 4.Mercier et al 2010, EUNO RCT.Lancet 2010 5.Finner NN,Barrington KJ.Cochrane Database Syst Rev 2010

3. 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.

4. Methods January 2009 to December 2011 Badger database Standard proforma

5. Results 3934 Total no admitted on badger 46( other causes) Included 16 < 27+6 weeks 14 28 to 36+6 weeks 16 > 37 weeks 31(CDH) Excluded 77 Treated with iNO

6. Gestational age

7. Birth weight

8. Trend in iNO use 7 677 67 2011 n=20 67 567 5 2010 n=18 3 1 43 1 4 2009 n=8 <27+6 weeks 28 – 36+6 weeks >37 weeks Gestation

9. Evidence of pulmonary hypertension

10. Early vs. Late iNO

11. Referral for ECMO

12. Chronic lung disease and Home oxygen

13. Death

14. 4/7 3/6 1/7 2011 3/6 3/7 1/5 2010 (Died/total n) 2/3 0/1 0/4 2009 <27+6 weeks 28 – 36+6 weeks >37 weeks Gestation

15. 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

16. 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.

17. Thank you!!

18. 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;336:597-604 2.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):729- 239 3.Mercier J et al.iNO for prevention of bronchopulmonary dysplasia in premature babies(EUNO) a RCT. Lancet 2010 Jul;376(9738):346-54 4.Finner NN, Barrington KJ. Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane Database Syst Rev 2007;(3):CD000509