Nandiran Ratnavel

Inhaled Nitric Oxide Therapy in Neonates

March 2015

Pragmatic approaches to the use of iNO in Neonatal Transport

Objectives

• Context of use in neonatal transportation

• Clinical conditions in which therapy considered during transport

• Data

• Delivery systems

• Air retrieval considerations

Context of use in neonatal transportation

• Escalation package of care in hypoxic respiratory failure

• Continuation of inhaled NO delivery

• Assessment of response in potential ECLS cases

Petros A, Lutman D. Early Human Development 2008

Neonatal Transport Group NO Missions: NTG Dataset

Clinical conditions

Persistent pulmonary hypertension of the newborn

Persistent foetal circulation

• Meconium aspiration syndrome

• Congenital lung lesion eg CDH, CCAML, CLE

• Sepsis, congenital pneumonia

• Chronic lung disease + acute exacerbation

• Perinatal asphyxia + acidosis

• Preterm infant with surfactant deficiency disease

• Planned reventilation of baby with chronic lung disease

European Journal of Pediatrics 2007: Lowe & Trautwein

Inhaled NO during transport of neonates with PPHN or severe HRF

Onset of therapy at referring vs receiving unit

Outcome measures

1. Survival

2. Need for ECLS

3. Hospital days 22 vs 38 p=0.018 (18 vs 29 p=0.006 at receiving)

Single centre. Retrospective review of 88 patients

London NTS 2011

Inhaled nitric oxide therapy during transport of neonates – experience of CENTRE transport service

• 25 missions on inhaled NO

• Mec asp, resp failure, HIE, sepsis, CDH

• Mean OI 44 33

• p=0.008

Bhoomia, Chandra, Leslie ADC F&N 2014

Delivery Systems

2L cylinder contains 307L gas at

400ppm mol/mol

Regulator connects

either to flowmeter

or Inovent delivery

system. Carry spare

‘o’ rings!

Rear of flowmeter

NO inlet on insp line

Fresh NO gas

to insp port

NO monitoring line on insp limb

NO monitoring line to printernox box

Flowmeter System

Advantages

• Simple to use

• Relatively inexpensive

• Lightweight

• Can replace single parts

• Not dependent on electricity

• Battery changes to analyser

needed infrequently

• Resistant to extremes of temp,

humidity, vibration & electrical

interference

Disadvantages

• Intermittent gas flow from

vent may lead to peaks &

troughs in NO delivery

• Overall consumption higher

• Closer monitoring needed by

transfer team

• Dose adjustments harder to

make

• Flowmeter knob can be

accidentally knocked

• Diluted Fi02 not measured

• Under reads at altitude

INOmax DS transport system

Back up system

£400 per 2 litre cylinder (307L)

£4800 per year for head unit

Nitric oxide therapy during air retrieval

• European Aviation Safety Agency (EASA)

• Classed as ‘dangerous goods’ under convention class 2

• Clearance reqd from flight ops inspector for the aviation operator

• Procedures specific to operator and aircraft

• Ventilation positioning, air change frequency, vol of dispersant gas

and containment area

• Cylinder/regulator assembly most subject to damage. Will need

EASA clearance

• Environment monitoring + checks of cylinder contents

Skeoch, Jackson, Wilson, Booth ADC F&N 2005

Summary

• NO availability in neonatal retrieval improves oxygenation

• Outcome data is lacking but associated with reduced hospital stay

• ECMO treatment rates & survival are unaffected

• Delivery systems are not standardised in the UK

• Air transport poses additional considerations