INHALED NITRIC-OXIDE REDUCES THE UTILIZATION OF EXTRACORPOREAL MEMBRANE-OXYGENATION IN PERSISTENT PULMONARY-HYPERTENSION OF THE NEWBORN

Objective: To determine if the use of inhaled nitric oxide therapy red uces the need for extracorporeal membrane oxygenation (ECMO) in persis tent pulmonary hypertension of the newborn. Design: A matched cohort s tudy with retrospective data extraction. Setting: Pediatric and neonat al intensive care units at a medical school-affiliated children's hosp ital serving as a regional referral center for respiratory failure. Pa tients: Records of all neonates transferred for rescue therapy for per sistent pulmonary hypertension during the study period were analyzed, with inclusion in the study based on defined gas exchange parameters, and with exclusion from the study based on the presence of congenital heart disease, diaphragmatic hernia, or lethal chromosomal abnormality . Assignment to cohorts was based on availability of inhaled nitric ox ide therapy: group 1 patients were admitted when inhaled nitric oxide was unavailable; group 2 patients were admitted when inhaled nitric ox ide was available. Interventions: Standard criteria (alveolar-arterial oxygen tension gradient of >600 torr [>80 kPa], or oxygenation index of >40) were used to trigger initial evaluation for ECMO when these cr iteria were met for 2 hrs, and ECMO was initiated if these criteria co ntinued to be met for 12 hrs, or if cardiovascular instability occurre d. Ventilator management in all patients was directed to improve arter ial oxygenation, such that ECMO criteria were no longer met. Patients in group 2 only were treated with inhaled nitric oxide after meeting E CMO evaluation criteria, and they continued to receive inhaled nitric oxide if a quantifiable improvement in gas exchange occurred. Measurem ents and Main Results: Fifty patients qualified for inclusion in the a nalysis (29 patients in group 1, and 21 patients in group 2). In group 1, 21 (72%) patients met ECMO criteria, and 16 (76%) patients require d ECMO therapy. Tn group 2, 16 (76%) patients met ECMO criteria, 15 pa tients received inhaled nitric oxide therapy, and only four (25%) pati ents required ECMO therapy (p = .003 compared with group 1). Treatment with inhaled nitric oxide resulted in an initial increase in Pao(2), without adverse effects, in all of the treated patients. The reduction in ECMO utilization in group 2 was achieved with a higher rate of com plication-free survival (survival without oxygen requirement at 28 day s, p =.018; survival without intracranial hemorrhage, p =.048), and a fewer hospital cost per survivor (p =.021), compared with group 1 pati ents. Conclusion: In neonates with persistent pulmonary hypertension, therapy with inhaled nitric oxide reliably and safely improves oxygena tion, thereby resulting in a decreased need for ECMO therapy, improved patient outcome, and lower hospital costs.