iNOBy;

Saja A. AL-marshad

Senior RT student

Dammam university

Saudi arabia

What is iNO??

• Nitric oxide (NO) is a colorless, highly diffusible, and very toxic gas.

• iNO is a selective pulmonary vasodilator

• The therapeutic goal of using [NO] is to improve pulmonary blood flow and enhance arterial oxygenation.

Research Discovery

• Three American researchers recently won the Nobel Prize for their work in the 1970s and 80s in characterizing nitric oxide’s role in the relaxation of blood vessels.

Nitric Oxide Approved for Use

• In December 1999 the U.S. Food and Drug Administration approved the use of inhaled NO as a pulmonary vasodilator for the treatment of hypoxic respiratory failure (HRF) in full- and near-term infants (greater than 34 weeks gestation).

• This gas is administered by special instruments developed using different techniques.

• For precise and safe delivery, the monitoring of the levels of nitric oxide and nitrogen dioxide is essential

Review of clinical studies :

Indications of Nitric Oxide and Various

Clinical

Applications

Pulmonary Indications of Inhaled Nitric

Oxide

Sickle Cell Disease

One-lung Ventilation

Heart and Lung Surgery

Pulmonary Indications of Inhaled :Nitric Oxide

1)Pulmonary hypertensionInhaled nitric oxide therapy shows beneficial or no or

worsen results in various clinical situations where pulmonary hypertension is pertinent. The following are the diseases that causes PHN that iNO was investigated with;

hypoxemia COPD IPF

IRDS PPHN PHN

CABG

Hypoxemia due to pulmonary disease states causes a

low ventilation/perfusion ratio, and right-to-left shunting

of blood through pulmonary routes. Inhaled nitric oxide

dilates only the vessels adjacent to the alveolar units being

ventilated. Therefore, in patients with intrapulmonary

shunt, inhaled nitric oxide can increase oxygenation by improving V/Q (ventilation/perfusion) matching

hypoxemia

In COPD patients, reports of worsening oxygenation with inhaled nitric oxide shows broad V/Q heterogeneity and the presence of low V/Q areas.

COPD

IRDS

Nitric oxide is supposed to work by

improving gas exchange through ventilation-perfusion

matching and reducing pulmonary vascular resistance. Its

exact mechanism of action in RDS is not completely

understood.

documented improved oxygenation in 23 premature neonates at doses of 5-20

ppm. This effect was dose-independent

CABG

“ all absorbed in studies”

Inhaled nitric oxide isthe medication of choice for treatment of pulmonary hypertension and hypoxemia following cardiopulmonary bypass or the use of a ventricular assist device for mitral valve replacement .coronary artery bypass graft , heart or lung transplantation, and pulmonary embolism.

Asthma and Bronchospastic Diseases:

• Expired nitric oxide has been suggested as a marker of severity and therapeutic response in asthmatics.

• Exhaled nitric oxide has been shown to increase proportionally to airway inflammation in several studies .

• The data on inhaled nitric oxide therapy in asthma patients are contradictory.

Inhaled nitric oxide provides selective pulmonary vasodilatation with maintenance of systemic blood pressure and coronary perfusion pressure

inhaled nitric oxide in the range of 2-40 ppm is effective in reducing elevated pulmonary vascular resistance and does not increase cardiac work.

Why do u think iNO is important

in the transition from fetal to post

fetal circulation

?

PVR

vasodilatationhypoxemia

Contraindications:

• Refractory hypotension despite adequate volume and vasopressor support

• Life-threatening bleeding diathesis such as:

• Intraventricular hemorrhage. • Active pulmonary or

gastrointestinal hemorrhage

Diffusion:

•iNO

• Binds

with

hemoglobin

• ) metHg

b,(

methemoglobin

WEANING of iNO:

when oxygenation improve

decrease FIO2 to ≤0.50

weaned from 20 to 5 ppm in

decrements of 5 ppm every 1 to 2

hours

Monitor

&

monitor

REBOUND PULMONARY HYPERTENSION :

• This probably results from suppression by iNO of endogenous NO production.

• Rebound pulmonary hypertension is a risk with cessation of iNO from even low doses (i.e., <5 ppm), after only a few hours of iNO therapy, and regardless of whether the infant initially responded to iNO

What do u think may cuz the discunnection of the iNO therapy ??“related to RTz work”

1. during suctioning

2. malfunction of the ventilator.

So what would u do as therapist?• be certain that the bag system

• (for manual ventilation) is set up to deliver iNO at the time of the onset of iNO therapy.

Device component:

•INOvent Bedside Delivery System•http://inomax.com/assets/pdf/INOvent-Ope

ration-Manual.pdf

•INOmax DS: The latest advance in INOMAX delivery systems

•http://inomax.com/assets/pdf/INOblender-Operation-Manual.pdf

Thanxx

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