The Off-Label Use of Inhaled Nitric Oxide as a Rescue Therapy in Neonates with Refractory Hypoxemic Respiratory Failure: Therapeutic Response and Risk Factors for Mortality
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design, Setting and Data Source
2.2. Study Outcomes
2.3. Statistical Analyses
3. Results
4. Discussion
Author Contributions
Acknowledgments
Conflicts of Interest
References
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Baseline Demographics | Neonates with iNO Use | The Control Group (All Neonates with Respiratory Failure Requiring HFOV) | ||
---|---|---|---|---|
Standard Rescue (for PPHN) | Off-Label Use of iNO as a Rescue Therapy | |||
iNO Within First 7 Days | iNO after 7 Days | |||
Case Number (n) | 122 | 57 | 27 | 636 |
Gestational age (week), median (IQR) | 34.6 (27.0–37.6) | 28.4 (25.0–35.3) | 30.5 (26.0–36.5) | 27.6 (25.3–31.6) |
Birth body weight (g), median (IQR) | 2057 (845–2945) | 1150 (714.5–2462.5) | 1305 (788.5–2532) | 940.0 (721–1545) |
Gender (male/female), n (%) | 79 (64.8)/43 (35.2) | 30 (52.6)/27 (47.4) | 21 (77.8)/6(22.2) | 384 (60.4)/252 (39.6) |
Apgar score 5 min ≦ 7, n (%) | 63 (51.6) | 27 (47.4) | 15 (55.6) | 360 (56.6) |
Primary pulmonary diagnosis *, n (%) | ||||
PPHN | 122 (100) | 0 (0) | 0 (0) | 84 (13.2) |
Respiratory distress syndrome | 54 (44.3) | 38 (66.7) | 5 (18.5) | 411 (64.6) |
Congenital diaphragmatic hernia | 8 (6.6) | 1 (1.8) | 0 (0) | 9 (1.4) |
Meconium aspiration syndrome | 13 (10.7) | 0 (0) | 0 (0) | 21 (3.3) |
Sepsis | 17 (13.9) | 15 (26.3) | 13 (48.1) | 120 (18.9) |
Pneumonia | 4 (3.3) | 0 (0) | 1 (3.7) | 22 (3.5) |
Pneumonthorax | 17 (13.9) | 6 (10.5) | 0 (0) | 77 (12.1) |
Pulmonary hemorrhage | 15 (12.3) | 5 (8.8) | 0 (0) | 65 (10.2) |
Hydrops fetalis | 5 (4.1) | 0 (0) | 0 (0) | 20 (3.1) |
Bronchopulmonary dysplasia | 0 (0) | 0 (0) | 19 (70.4) | 28 (4.4) |
Secondary pulmonary hypertension | 0 (0) | 0 (0) | 14 (51.9) | 5 (0.8) |
Other concurrent comorbidities * | ||||
Congenital heart disease & | 2 (1.6) | 6 (10.5) | 2 (7.4) | 15 (2.4) |
Intraventricular hemorrhage ≧ grade III | 10 (8.2) | 8 (14.0) | 1 (3.7) | 51 (8.0) |
Congenital gastrointestinal obstruction | 1 (0.8) | 0 (0) | 3 (11.1) | 20 (3.1) |
Ventilation Setting When on iNO or When on HFOV | Neonates with iNO Use | The Control Group (All Neonates with Respiratory Failure Requiring HFOV) | ||
---|---|---|---|---|
Standard Rescue (for PPHN) | Off-Label Use of iNO as a Rescue Therapy | |||
iNO Within First 7 Days | iNO After 7 Days | |||
DeltaP, cm H2O | 33.5 (24.8–100.0) | 38.0 (30.0–100.0) | 75.0 (35.0–100.0) | 100.0 (32.0–100.0) |
Frequency, Hz | 12.0 (11.0–13.0) | 12.0 (11.0–13.0) | 11.0 (11.0–13.0) | 12.0 (11.0–13.0) |
FiO2 | 100 (80.0–100.0) | 100 (80.0–100.0) | 90.0 (70.0–100.0) | 80.0 (60.0–100.0) |
Oxygenation index | 21.0 (11.0–40.5) | 26.0 (13.5–40.0) | 28.0 (14.0–44.0) * | 18.0 (10.0–34.0) |
AaDO2 | 553.5 (385.5–593.0) | 544.0 (392.5–608.0) | 463.0 (290.0–596.0) | 390.0 (243.5–567.8) |
Mean airway pressure (cm H2O) | 14.0 (12.0–15.3) | 13.0 (11.0–15.5) | 14.0 (11.0–18.0) | 11.0 (10.0–14.0) |
PH * | 7.22 (7.09–7.29) | 7.22 (7.02–7.34) | 7.37 (7.34–7.43) | 7.25 (7.14–7.36) |
PaO2 | 47.6 (32.8–66.8) | 42.0 (28.0–70.5) | 47.6 (32.8–66.8) | 54.7 (39.3–82.0) |
PaCO2 | 54.2 (44.0–68.3) | 54.0 (40.5–73.5) | 48.0 (40.3–60.5) | 52.0 (42.0–65.9) |
Other treatment modalities | ||||
Surfactant use | 79 (64.8) | 37 (64.9) | 1 (3.7) | 389 (61.2) |
Dopamine | 115 (94.3) ** | 42 (73.7) | 10 (37.0) | 459 (72.2) |
Dobutamine | 81 (66.4) ** | 23 (40.4) | 6 (22.2) | 222 (34.9) |
Epinephrine | 22 (18.0) | 12 (21.1) | 3 (11.1) | 48 (7.5) |
Milrinone | 26 (21.3) | 7 (12.3) | 6 (22.2) | 32 (5.0) |
NTISS score | 21.0 (18.0–24.0) | 21.0 (17.5–24.0) | 21.5 (18.0–24.0) | 19.5 (16.0–22.0) * |
Oxygenation Index after Initiation of iNO or HFOV (the Control Group) | Neonates with iNO Use (the Study Group) | The Control Group (All Neonates with Respiratory Failure Requiring HFOV) | ||
---|---|---|---|---|
Standard Rescue (for PPHN) | Off-Label Use of iNO as a Rescue Therapy | |||
iNO Within First 7 Days | iNO After 7 Days | |||
Oxygenation index, median (IQR) | ||||
Within the first 2 h | 25.0 (13.0–39.3) | 30.0 (13.0–48.5) | 28.0 (15.0–44.0) | 14.0 (8.0–28.0) |
6 h later | 17.5 (10.0–24.3) | 19.0 (9.5–30.0) | 18.0 (8.0–43.0) | 10.0 (6.0–17.0) |
12–24 h later & | 15.0 (8.0–22.5) | 15.0 (6.0–30.5) | 18.0 (9.0–44.0) ** | 8.0 (5.0–15.0) |
2 days later & | 11.0 (5.0–27.0) | 18.0 (7.0–33.5) | 20.0 (6.0–47.0) ** | 8.0 (4.0–19.0) |
Treatment response, n (%) | ||||
Good response | 50 (41.0) | 22 (38.6) | 4 (14.8) ** | 419 (65.9) |
Partial response | 33 (27.0) | 11 (19.3) | 10 (37.0) | 76 (11.9) |
Partial response and then failure | 7 (5.7) | 3 (5.3) | 3 (11.1) | 45 (7.1) |
Failure | 32 (26.2) | 21 (36.8) | 10 (37.0) | 96 (15.1) |
Final outcomes, n (%) | ||||
Progress to BPD | 37 (30.3) | 21 (36.8) | 24 (88.9) ** | 343 (53.9) |
Survival without BPD | 58/80 (72.5) ** | 16/32 (50.0) | 0/8 (0) ** | 183/435 (42.1) |
In-hospital mortality | 42 (34.4) | 25 (43.9) | 19 (70.4) ** | 200 (31.4) |
Variables | Univariate Logistic Regression | Multivariate Logistic Regression | ||
---|---|---|---|---|
OR (95% CI) | p Value | OR (95% CI) | p Value | |
Gestational age (GA) | ||||
≧37 weeks | 1 (Reference) | - | 1 (Reference) | - |
30–36 weeks | 3.02 (1.21–7.57) | 0.018 | 3.16 (1.35–7.42) | 0.008 |
<30 weeks | 5.16 (2.33–11.43) | <0.001 | 5.51 (2.54–11.93) | <0.001 |
Low apgar score at 5 min (<7) | 1.88 (1.18–3.02) | 0.009 | 1.22 (0.70–2.11) | 0.485 |
Initial oxygenation index | ||||
0–10 | 1 (Reference) | - | ||
11–20 | 0.65 (0.25–1.69) | 0.379 | ||
21–30 | 1.17 (0.49–2.81) | 0.726 | ||
31–40 | 1.08 (0.40–2.83) | 0.897 | ||
>40 | 1.86 (0.80–4.29) | 0.148 | ||
Pulmonary hemorrhage | 2.72 (1.09–6.81) | 0.032 | 2.51 (1.06–5.92) | 0.036 |
Sepsis | 1.81 (0.94–3.55) | 0.077 | 1.32 (0.66–2.65) | 0.439 |
Severe hypotension * | 2.41 (1.16–4.97) | 0.018 | 2.78 (1.31–5.94) | 0.008 |
Secondary pulmonary hypertension | 5.21 (1.50–16.56) | 0.019 | 6.79 (0.81–15.05) | 0.078 |
Diagnosis other than PPHN (off-label use) | 2.02 (1.14–3.56) | 0.015 | 1.60 (0.80–3.20) | 0.184 |
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Hsiao, H.-F.; Yang, M.-C.; Lai, M.-Y.; Chu, S.-M.; Huang, H.-R.; Chiang, M.-C.; Fu, R.-H.; Hsu, J.-F.; Tsai, M.-H. The Off-Label Use of Inhaled Nitric Oxide as a Rescue Therapy in Neonates with Refractory Hypoxemic Respiratory Failure: Therapeutic Response and Risk Factors for Mortality. J. Clin. Med. 2019, 8, 1113. https://doi.org/10.3390/jcm8081113
Hsiao H-F, Yang M-C, Lai M-Y, Chu S-M, Huang H-R, Chiang M-C, Fu R-H, Hsu J-F, Tsai M-H. The Off-Label Use of Inhaled Nitric Oxide as a Rescue Therapy in Neonates with Refractory Hypoxemic Respiratory Failure: Therapeutic Response and Risk Factors for Mortality. Journal of Clinical Medicine. 2019; 8(8):1113. https://doi.org/10.3390/jcm8081113
Chicago/Turabian StyleHsiao, Hsiu-Feng, Mei-Chin Yang, Mei-Yin Lai, Shih-Ming Chu, Hsuan-Rong Huang, Ming-Chou Chiang, Ren-Huei Fu, Jen-Fu Hsu, and Ming-Horng Tsai. 2019. "The Off-Label Use of Inhaled Nitric Oxide as a Rescue Therapy in Neonates with Refractory Hypoxemic Respiratory Failure: Therapeutic Response and Risk Factors for Mortality" Journal of Clinical Medicine 8, no. 8: 1113. https://doi.org/10.3390/jcm8081113