Brigham & Women's Hospital, Boston, MA
Inhaled Nitric Oxide (INO)
Protocol for Newborns with Hypoxemic Respiratory Failure
1. infant requiring assisted ventilation for hypoxic
2. Indwelling arterial line
3. GA >= 34 weeks
4. diagnosis of one of the following:
c. Aspiration syndrome (meconium,
blood or amnionic fluid)
f. suspected pulmonary hypoplasia
5. An OI >25 on two ABGs at least 30 minutes apart.
6. Lung recruitment and other PPHN therapy optimized
prior to initiating iNO (e.g.. surfactant therapy, alkalosis, hemodynamic
1. Decision not to provide full treatment
2. Known structural heart disease (excluding PDA
and atrial level shunts)
4. Jet ventilation (any other HiFi is acceptable
Process for Obtaining
Nitric & InoVent
To figure O.I., enter data in the
boxes above, & then click "calculate". Note: your
O.I. = (MAP X FiO2 X 100)/PaO2
For instance, if your MAP is 11, FiO2
is 1.00 and PaO2 is 44, your O.I. is 25 and you must call the Medical Director.
Start INO at 20 ppm* A 20% improvement in PaO2 with SpO2 >90% should
occur within 15-30 min., or SpO2 lability should decrease in that time.
RARELY , a dose of 40 ppm may be needed if no improvement in oxygenation
is seen at 20 ppm.
Decrease INO to 10 ppm if PaO2 >60 mmHg on FiO2 < 60 and SpO2 >90%;
If SpO2 decreases by >5% and SpO2 <90%, return to 20 ppm.
Decrease INO in 10-15 min intervals from 10 to 5 to 1 ppm if PaO2 > 60
mmHg on FiO2 <60 and SpO2 >90%; If SpO2 decreases by >5% and SpO2 <90%,
stop weaning and maintain on previous INO dose.
If PaO2 > 60 mm Hg on FiO2 <40 and SpO2 > 90; increase FiO2 to 60 and
Wean FiO2 over 1 hour
Restarting INO at 1 ppm may be considered if FiO2 > 60, SpO2 is labile
and ventilator settings increase after 1 hour off INO.
Attempt to discontinue INO 4-8 hours later
Obtain MetHb the morning after INO was started. If MetHb >1% obtain
MetHb QD otherwise, MetHb does not need to be obtained unless clinical
circumstances change. Treat with Vitamin C if MetHb >5%
The course of INO therapy for newborns with hypoxemic respiratory failure
is generally 3 to 4 days.