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inhaled nitric oxideindication,, contraindication,,and stuff
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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
^_^