NeoNotes
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Andrew B. Kairalla MD, Editor
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Nitric Oxide in Preterm Infants
Methods: Infants of <34 weeks' gestation, <28 days old, and with severe respiratory failure requiring ventilatory support were randomized to receive or not receive iNO.
Findings: Recruited were 108 infants (55 allocated to receive iNO and 53 not allocated to receive iNO) from 15 neonatal units in the United Kingdom and Republic of Ireland. Fifty-nine percent (64 of 108) died, and 84% of the survivors (37 of 44) had signs of some impairment or disability, 9 (20%) of them classified as severely disabled. There was no evidence of an effect of iNO on the primary outcomes: death or severe disability at 1 year corrected age (relative risk [RR]: 0.99; 95% confidence interval [CI]: 0.76 to 1.29); death or supplemental oxygen on expected date of delivery (RR: 0.84; 95% CI: 0.68 to 1.02); or death or supplemental oxygen at 36 weeks' postmenstrual age (RR: 0.98; 95% CI: 0.87 to 1.12). There was a trend for infants allocated to the iNO group to spend more time on the ventilator (log rank: 3.6), on supplemental oxygen (log rank: 1.4), and in hospital (log rank: 3.5) than those allocated to receive no iNO. This pattern predominantly reflected the infants who died. Mean total costs at 1 year corrected age were significantly higher in the iNO group, partly because of the costs of the gas but mainly because of the difference in initial hospitalization costs.
Interpretation: Evidence of prolongation of intensive care and increased costs of such care, without clear beneficial effects, implies that iNO cannot be recommended for preterm infants with severe hypoxic respiratory failure.
Comment: This is now at least the third study that does not support the use of iNO for preterm infants with severe respiratory disease. With this study suggesting a potential harmful effect, I am skeptical about “compassionate” use of this therapy in the premature population. Perhaps in the future investigators will be able to define a subpopulation in which this therapy has a positive impact. MLH.
Date: 19 May 2005
Time: 04:01:23
Naoki Uga et al published an article in Pediatrics International (2004; 46:
10-14) on 18 VLBW-baby's with hypolastic lungs due to oligohydramnios in whom
surfactant had no effect. They experienced a beneficial effect (improved
oxygenation and improved survival) from iNO. We had the same experience in 2
VLBW-baby's with clinical picture of lunghypoplasia due to PROM (at least 3
weeks), who did not react upon surfactant instillation but dramatically improved
with iNO and survived. All our other preterm baby's treated with iNO indeed had
a bad outcome. Those lunghypoplasia-baby's may represent a subgroup that perhaps
might benefit from iNO.
UserName: Smets Koenraad
Institution: Ghent University Hospital
telephone: ++32 9 240 35 35
email: koenraad.smets@UGent.be
Date: 19 Jun 2005
Time: 09:46:22
I am wondering if we could use the criteria for using iNO in persistent
pulmonary hypertension as basis in using it for prematures.
UserName: Cesar Jeffrey Masilungan
Institution: Zamboanga Medical Center
Date: 25 Jun 2005
Time: 05:42:35
Low dose iNO may be effective as a lung-specific anti-inflammatory therapy to
diminish lung neutrophil accumulation and attendant inflammatory injury that
contribute to the evolution of CLD .
Kinsella et al. Lancet 354:10611065,1999
Inhaled nitric oxide for respiratory failure in preterm infants.
Barrington KJ, Finer NN
Cochrane Library, Issue 2, 2005
No support to the use of inhaled nitric oxide in preterm infants with hypoxic
respiratory failure.
Further studies should be performed.
I strogly believe that:
Clinical applications in premature newborn should be limited to control trials
that outcomes of both safety & efficacy.....
UserName: Dr.Hesham Al-Girim
Institution: KAAH,National Guard,KSA
telephone: 009665544552112
email: hgirim@health.net.sa
Date: 09 Jul 2005
Time: 09:32:27
My hospital MUSC was part of a double blind study using iNO . We used it on PPHN
babies and believe some preterm infants also. we were part of a study group
including Johns Hopkins. This was several years ago, but I believe our outcome
was good. I believe in this as a way to help our special patients. I hope it
will continue to be evaluated for its potenetial benefits.
UserName: Erin Sewell RRT
email: erinsewell71@yahoo.com
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