While most of us are not neonatologists, it is still important to know that in neonatal intensive care units, there have been a number of studies looking at the role of inhaled nitric oxide (iNO) for extremely preterm infants with respiratory distress syndrome (RDS). What makes this use of iNO interesting is that its use is largely off-label when administered in the first week of an infant’s life with the goal of improving survival. So does it work? Carey et al. (10.1542/peds.2017-3108) share with us a large amount of data gathered from the Pediatrics Medical Group Clinical Data Warehouse from 2004-2014 involving infants from 22-29 weeks gestation who required mechanical ventilation for RDS, received iNO in their first week of life and were matched to patients who did not receive this gas. Both groups of infants once matched were tracked for their mortality rates prior to discharge. Almost 1000 infants who received iNO are included in this study and were matched with similar numbers of infants who did not receive this agent. The bottom line is that iNO made no difference in reducing the mortality rate compared to those who did not get the drug. Does this mean it should not be used off-label for this purpose?
We asked Dr. Roger Soll, (10.1542/peds.2017-4214) neonatologist at the University of Vermont, president of the Vermont Oxford Network and Coordinating Editor of Cochrane Neonatal to offer his perspective on these results and the ongoing usage of iNO, despite studies that suggest otherwise. Dr. Soll offers reasons why iNO is still being used despite the evidence, especially if there is a risk of persistent pulmonary hypertension (PPHN). He suggests the type of study that would need to be done to prove its effectiveness for the subgroup of babies with RDS and PPHN, and calls for such evaluation before we iNO should be used.