Inhaled NO has shown benefits as long term therapy for pulmonary arterial hypertension and other types of pulmonary hypertension. But the therapy also comes with some adverse effects (e.g., inflammation and oxidative damage to the lung) when used for a prolonged period of time. What recommendations would you make for weaning to ensure that the inhaled NO therapy is terminated safely?
Can only address its use in PPHN. I will start NO at 20 PPM with 100% O2 then decrease FiO2 first as tolerated until 60%. After that I will decrease it down to 10 PPM if SpO2 is acceptable a few hours later down to 5 PPM. From 5PPM I will decrease by 1 PPM until NO is off then come back to wean FiO2. That is how I do it. To treat cor pulmonale in brochopulmonary dysplasia is different which is coordinate by our cardiologist.
Aside from it's use in neonate for PPHN and to test patients for reversible PAH, pretty similar answer here in (off-label) treatment for refractory hypoxemia. I titrate every 2 hours as tolerated and typically go from 5ppm to off. If not tolerated, return to 5ppm and titrate down by 1ppm to 0. We only continue use if we see a 20% increase in PO2 when initiating therapy. Inhaled NO is something we use sparingly due to it's side effect profile.
My experience is limited to pulmonary hypertension following pediatric cardiac surgery.
Most-often 5 to 10 PPM are efficient doses. Pulmonary artery pressure is continuously monitored via a catheter inserted during surgery and we observed frequently that initial weaning, from 5 to 1 PPM, is easy without significant modification of pulmonary artery pressure or of pulse oxymetry but weaning from 1 to zero PPM must be done very slowly in small steps during 4 to 6 hours.
We can speculate that exogenous NO decrease endogenous synthesis and that it takes some time to normalize endothelial synthesis.
In some patients we try to decrease time to extubation and 12 to 24 hours before NO weaning we started Sildenafil p.o.(we do not use NO during spontaneous breathing). It seems that this technique helps in quick weaning of inhaled NO.
I can only comment on adult patients: Treatment should be started with 20ppm, consider an increase to 40ppm after 10-20min. and stop without weaning if you cannot Observe an effect after 30min.
For weaning, we - unfortunately - do not follow a fixed protocol. However, -5ppm every 2h and smaller steps once you reached 5ppm is what many practice. consider beginning oral Treatment (Dilators) before NO-weaning.
hope That helps...
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