3.53 Nitric Oxide
Category: UWHC Patient Care Policy
Effective Date: September 7, 2016
Ve rs ion: Revision
Section: Respiratory Care Services
N itr ic oxide (NO ) is a potent pulmonary vasodilator. NO decreases intrapulmonary shunting and improves arterial
oxygenation while reducing the pulmonary artery pressure. This improved arterial oxygenation is due to a
redistribution of pulmonary blood flow away from non-ventilated regions of the lungs and toward ventilated regions,
thus reducing ventila tion-perfusion mismatching.
Significant reductions in pulmonary artery pressure, pulmonary vascular resistance and improved oxygenation have
been reported within 3 minutes o f init ia tion of NO inha la tion.
A. Pa tients c rit ica lly dependent on right-to-left shunting of blood.
B. Progressive atelectasis. Progressive atelectasis inhibits effective delivery of NO to the site of action.
C. Patients who are candidates for other conventional, less expensive managements.
D. Patients with an elevated methemoglobin
1. Adults > 5%
2. Pediatric > 3%
B. Pulmonary toxicity secondary to the formation of nitric dioxide and its conversion to nitric acid.
1. pulmonary edema
2. acid pneumonitis
3. c ilia ry deple tion
4. ciliary hypertrophy
5. epithelial hyperplasia of the terminal bronchioles
C. Acute hypoxemia
D. Acute pulmonary infections
E. Inhibition of platelet aggregation
A. Nitric oxide may be administered at UWHC for the following conditions:
1. Pulmonary hypertension in the newborn.
2. Peri-operative care of patients with congenital cardiac defects.
3. Prevention of greaft failure secondary to reperfusion pulmonary dysfuction following
4. Severe right heart dysfunction.
5. Short-term diagnostic use to establish vascular reactivity.
B. Nitr ic Oxide that is ordered for the following conditions required the approval of the ICU Director or their
1. Acute respiratory distress syndrome.
2. Intractable hypoxemia.
3. Treatment of elevated pulmonary artery pressure.
C An order for Nitric Oxide must be placed in Health Link that reflects the ordered dose and indication.
D. The available doses of nitric oxide range from 1-80 ppm.
E. The duration of therapy is dependent upon the clinical response observed. If there is no response noted within
four hours of treatment, weaning should be initated.
F. A response to nitric oxide as indicated by an increase in PaO2 or a decrease in pulmonary artery pressure.
Therapy should not be abruptly discontinued. Abrupt discontinuation may result in a rebound increase in
pulmonary artery pressure and worsening oxygenation. Nitr ic oxide should be weaned as tolerated. Patients
who do not demonstrate an initial response to nitric oxide are unlikely to develop rebound pulmonary
hypertension and may have the gas abruptly discontinued when it is determined that no therapeutic benefit will
be derived from nitric oxide therapy.
G. The NO dose will be titra ted down if the patient has a methemoglobin level >3% in children or >5%
H. The NO dose will be decreased if the NO2 level is >3PPM in children or >5PPM in adults.
I. Nitric Oxide therapy is the only acceptable form of inhaled pulmonary vasodilation if a patient is receiving high
frequency oscillatory ventilation.
J. Nitric Oxide may not be used inline with BiPAP or Continuous CPAP. A nasal cannula may be placed on the
patient to deliver the Nitric Oxide and a CPAP mask placed over top. See related Link.
V. Proce dure
A. Acknowledge the physician’s order.
B. Review the patient’s chart for contraindications.
C. Assemble the INOVent and complete the Pre -Use Procedures. These are located both on the side of the
INOMax and on uconnect in the INOMax DSIR 3.53 Manual that’s a related link to this policy.
1. Circuit leak test.
2. Low range calibration.
3. Injector module purge and performance.
4. INOblender test.
D. Place a petient sticker on the Nitric Oxide Tracking Form tha t is on the s ide of the INOmax. Place the form
in the RCS Report areas where the patient is located. Document the following:
1. Patient name
2. Doctor’s name
3. Start date and time
4. Indication for NO
5. Serial number of the Nitric Oxide tank used, including any transport tanks.
E. Adapt the INOVent to any of the following delivery methods utilizing the attached directions.
1. Servo i or GE Carestation
2. High Frequency Oscillator
3. Circle Anesthesia System
4. Manual Resuscitator (0-80PPM).
5. Nasal cannula
6. High flow nasal cannula
7. Airlife Infant nCPAP
F. Initiate NO therapy at the prescribed PPM.
1. NO levels will be ordered and/or titrated per MD order. The maximum limit is 80 PPM.
2. NO should be titrated up in increments of 5 PPM for children and 20 PPM for adults.
If the patient does not respond, the NO may be increased every 5 minutes.
G. Methemoglobin levels must be checked every 4 to 6 hours for adults, every 12 hours in pediatrics.
** The NO levels must be titrated down if at any time the NO2 leve l in the c ircuit is >3PPM in pedica tr ic
patients or >5PPM in adults.
H. The NO, NO2 and O2 levels are continuously monitored by the INOmax.
**The NO dose must be titrated down if at any time the NO2 level in the circuit is >5 PPM for adult
patients or >3 PPM in pediatric patients.
I. Nitric Oxide will be charted by the Respiratory Therapist every 4 hours.
J. Suctioning of patients on NO should be done through an in-line suction cathetor.
K. Patients being transported in or out of the hospital must be transported on NO.
L. Discontinuance of NO will be based on patient response. NO should be titrated off slowly.
Increments of 2 PPM every 20 minutes should be used for children and 5 PPM every 10 to 20 minutes
should be used for adults.
. A. Respiratory Care Policy 3.51 Inhaled Epoprostenol (Flolan).
B. Wessel, D.L., etal., "Delivery and monitoring of inlhaled nitric oxide in patients with pulmonary hypertension",
Critical Care Medicine June 1994. vol 22 no 6, p930-938.
Approved by Director and Medical Director of Respiratory Care.
Origina l copy of this Policy & Procedure is available in the Respiratory Care Office [E5/489].