An inhaled pulmonary vasodilator that selectively dilates the pulmonary vasculature and improves ventilation and perfusion (V/Q) mismatch
Indications:
Treatment for hypoxic respiratory failure associated with clinical or echocardiographic evidence of pulmonary hypertension
Treatment of acute respiratory distress syndrome and various other lung disorders characterized by pulmonary hypertension and hypoxemia
Disease states and examples of those disease states that could potentially benefit from NO therapy
Pulmonary Hypertensive Disorders:
Congenital diaphragmatic hernia
Meconium aspiration syndrome
Neonatal respiratory distress syndrome
Idiopathic pulmonary hypertension
Sepsis
Acute Lung Injury and Respiratory Distress Syndrome
Sepsis syndrome
Gastric aspiration
Hydrocarbon aspiration
Traumatic lung contusion
Diffuse infectious pneumonias
ln these conditions hypoxic pulmonary vasoconstriction may not be functioning optimally or is defeated by vasodilatory drugs. Increasing flow to more aerated regions of lung will result in better V/Q matching and improved systemic oxygen saturations, resulting in lower levels of required supplementary oxygen and perhaps diminished oxygen toxicity.
Postoperative Cardiac surgery patients
Any condition with pulmonary hypertensive crises or right ventricular dysfunction, whether due to an increased afterload or pump failure
Atrioventricular septal defects
Tetrology of Fallot with RV dysfunction due to extensive ventriculotomy, increased afterload, etc
Univentricular repairs with cave-pulmonary shunts and resultant systemic venous perfusion pressure gradients producing blood flow to the lungs
Bidirectional Glenn procedure
Fontan procedure
Mitral valve repairs
Contraindications
Refractory hypotension despite adequate volume and vasopressor support
Lethal congenital anomaly
Life threatening bleeding including grade III IVH, active pulmonary bleed, and thrombocytopenia
Patients dependent on right to left shunting
In patients with pre-existing left ventricular dysfunction, nitric may increase pulmonary capillary wedge pressure leading to pulmonary edema
Precautions/Hazards/Side Effects of use:
Nitrogen Dioxide formation resulting in pulmonary edema associated with high doses of NO
Methemoglobinemia. Levels above 5% can result in decreased oxygen delivery and tissue hypoxia
Rebound hypoxemia and pulmonary hypertension
Production of Nitric Acid leading to severe pulmonary toxicity
Increased left ventricular filling pressure in known left ventricular failure
Sudden increase in blood flow to the lungs causes increased pulmonary venous return to left heart which may result in overload and worsen pulmonary edema
Key Points
Cylinders will be changed out at 200 psig
A high calibration should be done once a month
When using with an oscillator, place a one-way valve with 22/22 adapter between the injector and the humidifier inlet to protect the injector from potential back flow, which may result in high NO delivery
Never run medications through the injector, as deposits will cause malfunction and possible shutdown. If inhaled medications are necessary, MDI’s are recommended to reduce moisture and possibility of acid formation.
A purge and performance should be done before patient initiation
If depressurized the purge and performance should be initiated within 12 hrs
If pressurized the purge and performance should be initiated within 10 min
INO vent will perform automatic low calibrations
INO sampling should be at least 6 inches from the injector as well as at least 6 inches from the patient
All ordered doses are set per a calibrated, properly functiioning iNO analyzer. Not per the iNO wheel dial.
Orders
Ordered as “INOmax” should include ppm, continuous frequency, and the route of delivery as “inhalation”.
Documentation
Must be documented under “Specialty Gases” (Compass
Must be charged in the Omni Cell for hours in use
Delivery method
INO is delivered inline via:
Nasal Cannula-must be at least 2 lpm
High Flow Nasal Cannula-must be at least 2 lpm
Servo-I - any settings (invasive or noninvasive)
HFOV
VDR
Steps
Adapt the injector module with the flow arrow pointing down on the dry side of the heater using 22mm adapters on all devices besides Servo-I
Use a one way valve on HFOV only.
If a nebulizer is inline, place the injector module above the nebulizer (less proximal to the patient than the nebulizer)
On Servo-I place injector module on inspiratory inlet.
Place sample line on the inspiratory limb connector, above the heater on pediatric circuits
Add a sample line adapter to dry side of heater, after the inspiratory limb for adult circuits
For VDR and IPV, separate blender setup is needed for bagging and managing Nitric values
A nitric adapter kit is added to the phasitron for sample line and injector line
For initial setup:
Set the dial to 80 ppm and the flow to 2 Lpm
Adjust to deliver the ordered amount of INO
Do not go less than 2 lpm
If readout high while at 2 lpm, decrease PPM from 80
Go back up to 80 PPM before increasing flow above 2 lpm
iNO Sample line volume loss calculation
The sample line pulls at a rate of 190ml-240ml per minute
Servoi:
Targets inspiratory volumes in volume targeted modes of ventilation
To see how much volume is being pulled per breath:
Use 200ml/minute as an average
200ml / 60 seconds = 3.33ml loss every second
3.33 x inspiratory time = mL loss from target volume set on the ventilator
If Insp time is 0.6 seconds then:
3.33 x 0.6 = 1.99 mL loss from target volume set on vent
Draeger:
The ventilator measures volumes on expiration:
This is difficult to adjust for if a patient has a spontaneous respiratory rate due to the fluctuation of the patients expiratory time.
If paralyzed and there is no leak in the system, ie:uncuffed ETT, you would use expiratory time rather than inspiratory time, like with the servo, in the formula above.