Nitric Oxide (Inhalation)

Overview

Together with other agents, nitric oxide is administered through a ventilator to newborns who have suffered respiratory failure caused by pulmonary hypertension. This is an incurable disease that occurs in the arteries of the heart and may result in hypoxemia. While it has a grim prognosis for newborns, it can be treated with timely intervention and an aggressive treatment plan that includes inhaled nitric oxide treatment. The regulated breathing of nitric oxide can help alleviate this condition by relaxing the smooth muscles in the lungs to allow easier transport of oxygen through the widened blood vessels. The gas is inhaled through the nose or mouth depending on the device that is administering it and is only given under the direct supervision of a doctor or designated medical professional. Nitric oxide is only given in the form of a gas and comes with significant occupational exposure warnings. While it is a life-saving medical therapy there are some risks of overdose from excessive exposure and this is why close medical supervision during treatment is required.

Condition treated

  • Respiratory failure

Type Of Medicine

  • Pulmonary Vasodilator

Side Effects

Nitric oxide has the chance to produce unwanted side effects in infants in addition to the desired effects that aid in breathing. While these effects will not necessarily occur in all patients they may require emergency medical assistance if they do. As the medication is administered under the close supervision of a doctor they should be able to observe and respond to them quickly. If it seems that any of these symptoms are being experienced bring them to the attention of the doctor immediately.

Some of the more common serious side effects include blurry vision, confusion, profuse sweating, vertigo, and loss of strength and coordination. These may be difficult to ascertain when they happen to a newborn so any strange behavior or distress should be reported. Other more apparent signs of less common side effects include blue lips, chest pain, difficulty breathing, and other associated respiratory problems despite the treatment.

Additionally, this medication comes with a certain risk of an overdose when it is administered excessively. Summon emergency medical help if there are any of the following symptoms of an overdose:

  • Bluish-colored lips, fingernails, or palms
  • Dark urine
  • Fever
  • Headache
  • Pale skin
  • Rapid heart rate
  • Sore throat
  • Unusual bleeding or bruising

Some side effects experienced are considered temporary and will not need additional medical treatment unless they lead to complications. These are usually the result of the body adjusting to the nitric oxide being introduced to the system and they subside with time. However, if they last longer than expected or are more intense address these concerns with the supervising physician. These temporary side effects can include a dry throat or difficulty swallowing as well as other side effects not listed above.

Dosage

Nitric oxide may only be administered under the direct supervision of a qualified medical professional such as a doctor or nurse. Infants will be treated in the hospital during the entire treatment to ensure quick medical response to any side effects or complications. The dosage is introduced with a tube or mask through the mouth or nose depending on the device used. The nitric oxide delivery system and ventilator need to be calibrated by a doctor to ensure the correct dose for the severity of the condition. It is usually given for 14 days before an infant is weaned off of the nitric oxide treatment. The recommended dose of nitric oxide for inhalation by infants suffering from pulmonary hypertension is 20 ppm and this should not normally be exceeded because of the possibility of an overdose.

Interactions

Nitric oxide may have a possibility of interacting with other drugs that are being taken while it is being inhaled. While these interactions may not be likely in the case of an infant, the possibility of interactions should be considered before making any medical decisions that may result in the prescription of other medications. In some cases, such as the treatment of multiple illnesses, it may be deemed necessary to use drugs together even if they come with an interaction warning because they represent the best chance to treat the infant. However, it is imperative that the prescribing doctor knows all other medical treatment and medications that are being given to the patient in order to eliminate the possibility of serious or fatal drug interactions. Using nitric oxide with Riociguat is not recommended, and it is likely that it will be eliminated as a treatment option due to the nitric oxide being a more vital treatment. Prilocaine use while taking nitric oxide may result in more serious side effects of one or both medications, but if it represents the best treatment option the attending physician may change doses or dosing schedules in order to prescribe this medication.

Use of nitric oxide may keep a patient from eating or drinking certain foods and beverages but since all nutrients will be provided under close supervision the chances of this happening are minimal. However, there are certain medical conditions that can cause complications with the use of nitric oxide. Heart or breathing problems not related to the primary diagnosis of pulmonary hypertension may affect the ability of this treatment option to be effective. It should not be given to a baby that is dependant on a right-to-left heart shunt and it may result in serious side effects if used on a child who is suffering from heart failure.

Warnings

The decision to use nitric oxide for the treatment of respiratory failure must be weighed carefully, as there are certain degrees of harm it may do in addition to its benefits. An infant may need to be allergy tested before treatment begins to ascertain if they have an allergy to the medication or any of the materials of the essential equipment that is used in the procedure. This may represent the biggest barrier to treatment if such allergies are discovered. Infants must be closely observed in the first few days to ensure that there are no allergic reactions, side effects, or signs of an overdose. Administration of nitric oxide will require close observation throughout the process and the baby's condition may need to be checked with multiple tests and examinations to judge the effectiveness of the treatment. These procedures will allow the doctor to determine if it is the best course of treatment or if other options need to be explored.

An infant receiving nitric oxide needs to have its breathing, oxygen levels, and other vital signs constantly monitored while receiving the treatment. It is very important that the treatment is followed until its termination date and not be stopped abruptly for any reason. Sudden cessation of treatment may greatly increase the risk of pulmonary hypertension syndrome making a quick and violent rebound. At the end of the treatment, the baby will need to be weaned off of the nitric oxide treatments as they will have become dependant on them. Symptoms of a relapse of pulmonary hypertension include bluish lips/skin, slow heartbeat, lightheadedness, dizziness, fainting, and decreased cardiac output.

Nitric oxide treatments may cause a rare but serious blood problem known as methemoglobinemia in some patients. Doctors will need to test for methemoglobin levels in the blood to rule this out while the baby is taking nitric oxide. While there is a possibility of severe repercussions from missing a dose of nitric oxide, this is not a very likely situation as the treatment is administered on a strict schedule by medical professionals during hospitalization. However, if a dose is missed for any reason summon immediate medical help to begin the treatment as soon as possible. It is very important not to administer any medications that the doctor does not know about to the infant to include vitamins, herbal remedies, or over-the-counter medication.

Storage

This medication will be stored and maintained by hospital staff and will not normally be handled at all by anyone else. It is transported in pressurized tanks and must be stored under very precise environmental conditions. Its storage temperature is designated as 25°C or 77°F although it can be briefly transported so long as the temperatures are in the range of 15'30°C or 59'“86°F. The cylinders that contain the nitric oxide must be handled and stored with care to prevent depressurization or breaches. The containers must be isolated from the possibility of damage from hazards including electric shocks, falls, oxidizing or flammable materials, moisture, and sources of heat or ignition.

Summary

Nitric oxide is a life-saving treatment for infants who are inflicted with an incurable disease and timely treatment can greatly reduce infant mortality. However, there are certain risks that come with the treatment that must be discussed with the physician. The most common concerns are allergies, side effects, and the possibility of overdose which may complicate the treatment. It is important to note that exposure to the gas may be harmful to those who are not prescribed it and if there is a leak detected in the cannister avoid breathing the fumes and contact medical personnel to deal with this hazmat situation.