CAPHC Guidelines for Inhaled Nitric Oxide in Neonates:  Dosing, Administration and Weaning

Last modified by Ann Watkins on 2016/04/01 17:03

This guideline represents the views of the CAPHC Inhaled Nitric Oxide Collaborative and was arrived at after careful consideration of the available evidence as well as a consensus building process.  The guideline does not override the responsibility of individual clinicians and organizations to make decisions and provide the most appropriate care to infants, children and youth in consultation with the patient and family/guardian.

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Despite generally good quality evidence to guide the use of inhaled nitric oxide (iNO) in term and near-term newborns, a recent survey conducted by CAPHC demonstrated considerable variation in practice across NICUs in Canada.  Moreover, the high cost of iNO and recent trends toward increasing off-label use (1) necessitates a critical re-examination of the role of iNO in neonatal intensive care.  The Canadian consensus guidelines contained herein were therefore developed with the goal of promoting safe, rational and cost-effective use of iNO therapy in newborns. more...

Guideline Recommendations

  1. Conditions
  2. Inclusion Criteria
  3. Policy
  4. Contraindications/Cautions
  5. Equipment and Procedure
  6. Monitoring and Documentation 
  7. Prior to Administration of iNO
  8. Starting Dose
  9. Assessment of Response
  10. Weaning
  11. Monitoring for Complications

Guideline Development Process

Guideline Review

A review of hospital guidelines for administration of inhaled Nitric Oxide (iNO) was completed. Eighteen documents from eleven hospitals across Canada and a systematic review of the literature, the American Association for Respiratory Care: Evidence-Based Clinical Practice Guideline: Inhaled Nitric Oxide for Neonates With Acute Hypoxic Respiratory Failure, were analyzed. There are two documents from IWK Health Centre. The first document is a literature review and guideline from 2006 and the second is a guideline with some content based upon the first document. Two of the documents from London Health Science Centre consisted of tables used to document monitoring levels. more...


ABG                   Arterial Blood Gas

ARDS                 Acute Respiratory Distress Syndrome

CCM                  Critical Care Medicine

CCU                  Critical Care Unit

CDH                  Congenital Diaphragmatic Hernia

ECMO               Extracorporeal membrane oxygenation

FiO2                  Fraction of Inspired Oxygen

iNO                    Inhaled Nitrogen Oxide

MPAW               Mean Airway Pressure

MRSP                Medical Readiness Strategic Plan

NICU                 Neonatal intensive Care Unit

NO                    Nitric Oxide

OI                      Oxygenation index (OI)  = Mean airway pressure (MPAW) × FiO2 × 100

OR                    Operating Room

PaO2                 Partial Pressure of Oxygen in Arterial Blood

PICU                  Pediatric Intensive Care Unit

ppm                   Parts per million

PPROM             Preterm Premature Rupture of Membranes

PPHN                Persistent pulmonary hypertension of newborn

PVR                   Pulmonary Vascular Resistance

RDS                   Respiratory Distress Syndrome 

RRT                   Registered Respiratory Therapist

SaO2                 Arterial Oxygen Saturation

SpO2                 Saturation of Peripheral Oxygen

SvO2                 Venous Oxygen Saturation

Download Full Guideline PDF


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