TY - JOUR
T1 - Inhaled Nitric Oxide Use in Pediatric Hypoxemic Respiratory Failure∗
AU - Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network
AU - Berger, John T.
AU - Maddux, Aline B.
AU - Reeder, Ron W.
AU - Banks, Russell
AU - Mourani, Peter M.
AU - Berg, Robert A.
AU - Carcillo, Joseph A.
AU - Carpenter, Todd
AU - Hall, Mark W.
AU - Meert, Kathleen L.
AU - McQuillen, Patrick S.
AU - Pollack, Murray M.
AU - Sapru, Anil
AU - Yates, Andrew R.
AU - Notterman, Daniel A.
AU - Holubkov, Richard
AU - Dean, J. Michael
AU - Wessel, David L.
N1 - Funding Information:
lion. Drs. Reeder’s, Banks’s, Mourani’s, Carcillo’s, Hall’s, Meert’s, Pollack’s, Sapru’s, Yates’s, Holubkov’s, Dean’s, and Wessel’s institutions received funding from the NIH. Dr. Holubkov received funding from Pfizer (data safety monitoring board [DSMB] member), Medimmune (DSMB member), DURECT Corporation (biostatistical consulting), and St. Jude Medical (biostatistical consulting for Physicians Committee for Responsible Medicine). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jberger@childrensnational. org
Funding Information:
Supported, in part, by grant from the following cooperative agreements from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services: UG1HD050096, UG1HD049981, UG1HD049983, UG1HD063108, UG1HD083171, UG1HD083166, UG1HD083170, and U01HD049934.
Funding Information:
Drs. Berger’s, Mourani’s, Berg’s, and Pollack’s institution received funding from the National Institute of Child Health and Human Development. Drs. Berger, Reeder, Banks, Mourani, Berg, Carcillo, Carpenter, Meert, McQuil-len, Pollack, Sapru, Yates, Holubkov, Dean, and Wessel received support for article research from the National Institutes of Health (NIH). Drs. Berger, Mourani, Hall, and Pollack disclosed off-label product use of inhaled nitric oxide for acute respiratory failure. Dr. Berger’s institution also received funding from Association for Pediatric Pulmonary Hypertension and Acte-
Publisher Copyright:
© 2020 Lippincott Williams and Wilkins. All rights reserved.
PY - 2020/8/1
Y1 - 2020/8/1
N2 - Objectives: To characterize contemporary use of inhaled nitric oxide in pediatric acute respiratory failure and to assess relationships between clinical variables and outcomes. We sought to study the relationship of inhaled nitric oxide response to patient characteristics including right ventricular dysfunction and clinician responsiveness to improved oxygenation. We hypothesize that prompt clinician responsiveness to minimize hyperoxia would be associated with improved outcomes. Design: An observational cohort study. Setting: Eight sites of the Collaborative Pediatric Critical Care Research Network. Patients: One hundred fifty-one patients who received inhaled nitric oxide for a primary respiratory indication. Measurements and Main Results: Clinical data were abstracted from the medical record beginning at inhaled nitric oxide initiation and continuing until the earliest of 28 days, ICU discharge, or death. Ventilator-free days, oxygenation index, and Functional Status Scale were calculated. Echocardiographic reports were abstracted assessing for pulmonary hypertension, right ventricular dysfunction, and other cardiovascular parameters. Clinician responsiveness to improved oxygenation was determined. One hundred thirty patients (86%) who received inhaled nitric oxide had improved oxygenation by 24 hours. PICU mortality was 29.8%, while a new morbidity was identified in 19.8% of survivors. Among patients who had echocardiograms, 27.9% had evidence of pulmonary hypertension, 23.1% had right ventricular systolic dysfunction, and 22.1% had an atrial communication. Moderate or severe right ventricular dysfunction was associated with higher mortality. Clinicians responded to an improvement in oxygenation by decreasing Fio2to less than 0.6 within 24 hours in 71% of patients. Timely clinician responsiveness to improved oxygenation with inhaled nitric oxide was associated with more ventilator-free days but not less cardiac arrests, mortality, or additional morbidity. Conclusions: Clinician responsiveness to improved oxygenation was associated with less ventilator days. Algorithms to standardize ventilator management may improve signal to noise ratios in future trials enabling better assessment of the effect of inhaled nitric oxide on patient outcomes. Additionally, confining studies to more selective patient populations such as those with right ventricular dysfunction may be required.
AB - Objectives: To characterize contemporary use of inhaled nitric oxide in pediatric acute respiratory failure and to assess relationships between clinical variables and outcomes. We sought to study the relationship of inhaled nitric oxide response to patient characteristics including right ventricular dysfunction and clinician responsiveness to improved oxygenation. We hypothesize that prompt clinician responsiveness to minimize hyperoxia would be associated with improved outcomes. Design: An observational cohort study. Setting: Eight sites of the Collaborative Pediatric Critical Care Research Network. Patients: One hundred fifty-one patients who received inhaled nitric oxide for a primary respiratory indication. Measurements and Main Results: Clinical data were abstracted from the medical record beginning at inhaled nitric oxide initiation and continuing until the earliest of 28 days, ICU discharge, or death. Ventilator-free days, oxygenation index, and Functional Status Scale were calculated. Echocardiographic reports were abstracted assessing for pulmonary hypertension, right ventricular dysfunction, and other cardiovascular parameters. Clinician responsiveness to improved oxygenation was determined. One hundred thirty patients (86%) who received inhaled nitric oxide had improved oxygenation by 24 hours. PICU mortality was 29.8%, while a new morbidity was identified in 19.8% of survivors. Among patients who had echocardiograms, 27.9% had evidence of pulmonary hypertension, 23.1% had right ventricular systolic dysfunction, and 22.1% had an atrial communication. Moderate or severe right ventricular dysfunction was associated with higher mortality. Clinicians responded to an improvement in oxygenation by decreasing Fio2to less than 0.6 within 24 hours in 71% of patients. Timely clinician responsiveness to improved oxygenation with inhaled nitric oxide was associated with more ventilator-free days but not less cardiac arrests, mortality, or additional morbidity. Conclusions: Clinician responsiveness to improved oxygenation was associated with less ventilator days. Algorithms to standardize ventilator management may improve signal to noise ratios in future trials enabling better assessment of the effect of inhaled nitric oxide on patient outcomes. Additionally, confining studies to more selective patient populations such as those with right ventricular dysfunction may be required.
KW - acute respiratory syndrome
KW - morbidity
KW - nitric oxide
KW - pediatrics
KW - pulmonary hypertension
KW - right ventricular failure
UR - http://www.scopus.com/inward/record.url?scp=85089302012&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85089302012&partnerID=8YFLogxK
U2 - 10.1097/PCC.0000000000002310
DO - 10.1097/PCC.0000000000002310
M3 - Article
C2 - 32195895
AN - SCOPUS:85089302012
SN - 1529-7535
VL - 21
SP - 708
EP - 719
JO - Pediatric Critical Care Medicine
JF - Pediatric Critical Care Medicine
IS - 8
ER -