A Single-Center Comparison of Introducing an Inhaled Nitric Oxide Initiation and Weaning Protocol into the Neonatal Intensive Care Unit

Abstract

Background:

Inhaled nitric oxide (INO) is a selective pulmonary vasodilator used in the neonatal intensive care unit (NICU) to treat hypoxic respiratory failure associated with pulmonary hypertension. Reducing practice variation through the use of a standardized protocol when initiating and weaning INO may improve overall patient outcomes and decrease overutilization of INO. The purpose of this study was to determine the impact of an INO initiation and weaning protocol on patient outcome variables, including the average number of days exposed to INO therapy, the average number of days on ventilatory support (both invasive and noninvasive), and the length of stay in the NICU. A noted pattern of increased sildenafil use in 2018 led to the addition of milrinone and sildenafil as outcome variables in this study.

Methods:

An INO initiation and weaning protocol was adapted into a level IV NICU using the plan-do-study-act method. Retrospective data was collected from January 2016 to December 2016 to act as a control group and from January 2018 to December 2018, post protocol implementation, to act as the treatment group. Data was not collected during the calendar year of 2017 due to protocol development and education for practitioners. Comparisons were made between the two groups using t-test analysis with negative binomial regression. A P-value < .05 was considered statistically significant. This study was approved by all participating Institutional Review Boards.

Results:

The treatment year was statistically significant for INO days with a decrease in median INO usage from 23.25 to 11.14 days (P = .047). During this treatment year, there was also a statically significant increase in sildenafil usage from a median duration of 6.35 to 37 days (P = .004). The 60% decrease in INO usage post protocol implementation is clinically significant for several reasons, including decreased INO exposure, decreased drug overutilization, and the provision of standardization of care.

Conclusions:

Findings from this study suggest that applying a respiratory therapy-driven INO initiation and weaning protocol can reduce overutilization of INO in the NICU. With decreased INO usage in the treatment year, there was also a significant increase in sildenafil usage. We hypothesize that adding sildenafil to the protocol as a weaning mechanism for INO caused a substantial increase in usage after protocol initiation. Further research is needed to examine the true impact of sildenafil on INO usage.