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Life-threatening effects of discontinuing inhaled nitric oxide in children
E Cueto1, J López-Herce, A Sánchez
1Paediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Madrid, Spain.
Insights
Sudden withdrawal of inhaled nitric oxide in children can cause dangerous drops in oxygen and increases in pulmonary artery pressure. Progressive withdrawal is recommended to prevent these adverse effects.
Area of Science:
- Pediatric Critical Care
- Neonatology
- Pulmonology
Background:
- Acute Respiratory Distress Syndrome (ARDS) and pulmonary hypertension are serious conditions in children.
- Inhaled nitric oxide (iNO) is used to treat these conditions.
- The effects of discontinuing iNO in pediatric patients are not fully understood.
Purpose of the Study:
- To evaluate the effects of sudden discontinuation of inhaled nitric oxide in pediatric patients with ARDS and/or pulmonary hypertension.
- To identify potential adverse events associated with iNO withdrawal.
- To provide recommendations for safe iNO discontinuation in this population.
Main Methods:
- A cohort of 40 children (15 days to 17 years) with ARDS and/or pulmonary hypertension were treated with inhaled nitric oxide.
- The study observed patients during and after iNO treatment, specifically noting effects of discontinuation.
- Underlying diagnoses and specific adverse events were recorded.
Main Results:
- Sudden discontinuation of iNO led to decreased oxygenation in 11 patients, with some experiencing increased pulmonary artery pressure.
- Two patients developed severe pulmonary hypertension, bradycardia, and hypoxemia requiring cardiopulmonary resuscitation upon iNO withdrawal.
- Underlying conditions included bronchopneumonia, sepsis, and postsurgical cardiac defects.
Conclusions:
- Abrupt interruption of inhaled nitric oxide can cause hypoxemia and pulmonary hypertension in pediatric patients.
- This may be due to a decrease in pulmonary nitric oxide concentration, potentially from inhibited endogenous production.
- A gradual withdrawal of inhaled nitric oxide is recommended to mitigate adverse effects.
Abstract:
We treated 40 children, aged between 15 d and 17 y, diagnosed with acute respiratory distress syndrome and/or pulmonary hypertension, with inhaled nitric oxide. The most frequent underlying diagnosis associated with ARDS were bronchopneumonia (eight), cardiac surgery (five), and sepsis (three). Pulmonary hypertension was secondary to cardiomyopathy in 2 patients and occurred in the postoperative period of cardiac surgery in 17 patients--the most frequent were ventricular septal defect (5), transposition of great arteries (4), and atrioventricular septal defect (3). In 11 patients, sudden discontinuation of nitric oxide induced a decrease in oxygenation associated in some of the patients with an increase in pulmonary artery pressure. In two patients discontinuation of nitric oxide induced severe pulmonary hypertension, extreme bradycardia and hypoxaemia, which required cardiopulmonary resuscitation. When exogenous nitric oxide is abruptly interrupted, hypoxaemia and pulmonary hypertension are found in some patients, due to a decrease in the nitric oxide concentration in the pulmonary circulation. This may be caused by the exogenous nitric oxide administration that may have inhibited endogenous production. We recommend making a progressive withdrawal of inhaled nitric oxide to avoid the side effects observed in the sudden discontinuation.