Nitric oxide therapy is an effective, FDA-approved method to treat conditions like hypoxic respiratory failure with pulmonary hypertension in newborns ages 34 weeks and older.

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Newborns with respiratory conditions like hypoxic respiratory failure with pulmonary hypertension are often given nitric oxide therapy. The newborn inhales the treatment through a ventilator, a machine that helps the baby breathe.

Nitric oxide therapy is an effective and low risk way to open up the blood vessels in the lungs and improve oxygen levels.

In this article, we look closely at nitric oxide therapy, why a newborn might need it, how the treatment is given, its benefits, possible risks, and when nitric oxide therapy should be avoided.

Nitric oxide therapy is used to help full-term (or almost full-term) newborns with specific respiratory conditions breathe more easily. The treatment consists of giving newborns an inhaled form of nitric oxide (NO), a substance often used to open or dilate blood vessels in the lungs (pulmonary vasodilator).

Inhaled pulmonary vasodilators are primarily used to treat pulmonary hypertension and have been shown to improve oxygenation, decrease inflammation, and protect cells from damage. They open up the blood vessels in the lungs so oxygen can flow more easily.

In 1999 and again in 2019, the Food and Drug Administration (FDA) approved nitric oxide therapy for use in newborns ages 34 weeks or older with hypoxic respiratory failure linked to pulmonary hypertension.

This treatment is meant to improve oxygen levels in infants experiencing these conditions and reduce extracorporeal membrane oxygenation (ECMO) therapy.

Here’s what to know about the two conditions that nitric oxide therapy in newborns is used to treat:

Persistent pulmonary hypertension

Persistent pulmonary hypertension is a life threatening condition in which a newborn’s lungs aren’t working correctly. As a result, the infant does not get enough oxygen.

Hypoxic respiratory failure

Hypoxic respiratory failure (HRF) in newborns is a serious respiratory illness characterized by not having enough oxygen in the blood due to problems with the respiratory system.

Before receiving nitric oxide therapy, your newborn’s healthcare team will make sure your baby is a good candidate. This may involve giving your baby various tests, such as an echocardiogram, to rule out specific heart conditions.

Nitric oxide is delivered to a newborn through a ventilator system. The ventilator is attached to a tank of nitric oxide. A small tube is gently placed in the infant’s trachea, which delivers the nitric oxide to the lungs.

The recommended dosage for nitric oxide therapy is 20 ppm. The treatment is continued for a maximum of 2 weeks until the newborn’s condition has improved.

At that time, a weaning period begins, in which the dose of nitric oxide is gradually decreased. As the newborn is weaned from nitric oxide, their condition is continually monitored to ensure that they are getting enough oxygen.

Nitric oxide therapy for newborns has shown to be an effective and quick way to treat pulmonary hypertension and hypoxic respiratory failure.

The treatment is relatively easy to administer, and its effects and duration of use are generally predictable. Most importantly, its effects are limited to the lungs since nitric oxide doesn’t usually affect the other organs in the body.

One significant benefit of nitric oxide is that it can decrease the need for other, more invasive and risky treatments, such as extracorporeal membrane oxygenation (ECMO). Also, nitric oxide therapy has been shown to decrease a newborn’s risk of developing chronic lung disease after pulmonary hypertension and hypoxic respiratory failure.

Though most infants are good candidates for nitric oxide therapy, infants with specific conditions should not receive the treatment. Contraindications for nitric oxide therapy include:

What to ask your doctor

Hearing that your baby needs nitric oxide therapy can be scary, especially if you haven’t heard of the therapy and are unsure of the risks. Nitric oxide therapy has been in use for many years and is considered safe. Still, it’s natural that you may have questions about how it works or what to expect.

Questions for your doctor

Some questions you may consider asking your baby’s medical team include:

  • What tests will be done prior to nitric oxide therapy?
  • How long will the therapy be needed?
  • Can I stay with my baby while they receive nitric oxide therapy?
  • What side effects might my baby experience?
  • How long will the weaning process take?
  • What happens if nitric oxide therapy doesn’t work?
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Nitric oxide therapy is usually well tolerated in newborns, especially if the maximum recommended dose of 20 ppm for 14 days is adhered to. Still, some babies are sensitive to even small nitric oxide doses and can experience toxicity.

Complications of nitric oxide therapy may include:

  • increased heart failure complications
  • pulmonary vasospasm (narrowing of pulmonary arteries)
  • hypotension (low blood pressure)
  • methemoglobinemia (a serious blood disorder)

What causes pulmonary hypertension in infants?

Pulmonary hypertension can occur because of lung conditions like pneumonia or respiratory distress syndrome (RDS). It can also occur because of risk factors in the birthing parent like preeclampsia and diabetes.

Newborn congenital conditions like transposition of great arteries (TGA) or congenital diaphragmatic hernia (CDH) also increase risk.

How common is hypoxic respiratory failure (HRF)?

HRF impacts about 2% of all newborns and accounts for almost 33% of all infant deaths.

Why is abrupt weaning from nitric oxide therapy not advised?

Weaning suddenly from nitric oxide therapy can reduce oxygenation too quickly and may cause pulmonary hypertension to return.

Sometimes newborns have trouble breathing after birth and need some assistance. Although nitric oxide is an FDA-approved treatment that has been used for decades to help with respiratory issues in newborns, it’s common for parents to have concerns about its use.

If you have further questions about this treatment, contact your child’s healthcare team.