nandiran ratnavel in... · 2015-04-08 · persistent pulmonary hypertension of the newborn...
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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