Objectives: 

To characterize contemporary use of inhaled nitric oxide in pediatric acute respiratory failure and to assess relationships between clinical variables and outcomes. We sought to study the relationship of inhaled nitric oxide response to patient characteristics including right ventricular dysfunction and clinician responsiveness to improved oxygenation. We hypothesize that prompt clinician responsiveness to minimize hyperoxia would be associated with improved outcomes.

Design: 

An observational cohort study.

Setting: 

Eight sites of the Collaborative Pediatric Critical Care Research Network.

Patients: 

One hundred fifty-one patients who received inhaled nitric oxide for a primary respiratory indication.

Measurements and Main Results: 

Clinical data were abstracted from the medical record beginning at inhaled nitric oxide initiation and continuing until the earliest of 28 days, ICU discharge, or death. Ventilator-free days, oxygenation index, and Functional Status Scale were calculated. Echocardiographic reports were abstracted assessing for pulmonary hypertension, right ventricular dysfunction, and other cardiovascular parameters. Clinician responsiveness to improved oxygenation was determined. One hundred thirty patients (86%) who received inhaled nitric oxide had improved oxygenation by 24 hours. PICU mortality was 29.8%, while a new morbidity was identified in 19.8% of survivors. Among patients who had echocardiograms, 27.9% had evidence of pulmonary hypertension, 23.1% had right ventricular systolic dysfunction, and 22.1% had an atrial communication. Moderate or severe right ventricular dysfunction was associated with higher mortality. Clinicians responded to an improvement in oxygenation by decreasing Fio₂ to less than 0.6 within 24 hours in 71% of patients. Timely clinician responsiveness to improved oxygenation with inhaled nitric oxide was associated with more ventilator-free days but not less cardiac arrests, mortality, or additional morbidity.

Conclusions: 

Clinician responsiveness to improved oxygenation was associated with less ventilator days. Algorithms to standardize ventilator management may improve signal to noise ratios in future trials enabling better assessment of the effect of inhaled nitric oxide on patient outcomes. Additionally, confining studies to more selective patient populations such as those with right ventricular dysfunction may be required.

中文翻译：

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吸入一氧化氮在小儿低氧性呼吸衰竭中的应用。

目标： 

描述当代吸入一氧化氮在儿科急性呼吸衰竭中的使用情况，并评估临床变量和结果之间的关系。我们试图研究吸入一氧化氮反应与患者特征的关系，包括右心室功能障碍和临床医生对改善氧合的反应。我们假设临床医生对减少高氧的迅速反应与改善结果有关。

设计： 

一项观察性队列研究。

环境： 

协作儿科重症监护研究网络的八个站点。

患者： 

151 名因主要呼吸道适应症而接受吸入一氧化氮的患者。

测量和主要结果： 

从开始吸入一氧化氮开始并持续到最早的 28 天、ICU 出院或死亡的医疗记录中提取临床数据。计算了无呼吸机天数、氧合指数和功能状态量表。提取超声心动图报告以评估肺动脉高压、右心室功能障碍和其他心血管参数。确定临床医生对改善氧合的反应。接受吸入一氧化氮的130 名患者 (86%) 在24 小时内改善了氧合。PICU 死亡率为 29.8%，而在 19.8% 的幸存者中发现了新的发病率。在进行超声心动图检查的患者中，27.9% 的患者有肺动脉高压，23.1% 有右心室收缩功能障碍，22.1% 有心房交通。中度或重度右心室功能障碍与较高的死亡率相关。在 71% 的患者中，临床医生通过在 24 小时内将F io ₂降至 0.6 以下来对氧合改善做出反应。临床医生对吸入一氧化氮改善氧合的及时反应与更多的无呼吸机天数相关，但并非更少的心脏骤停、死亡率或额外发病率。

结论： 

临床医生对改善氧合的反应与更少的呼吸机天数相关。标准化呼吸机管理的算法可能会在未来的试验中提高信噪比，从而更好地评估吸入一氧化氮对患者预后的影响。此外，可能需要将研究限制在更具选择性的患者群体，例如右心室功能障碍患者。