Factors influencing decision making in neonatology: inhaled nitric oxide in preterm infants

Abstract

Objective: We studied decision-making regarding inhaled nitric oxide (iNO) in preterm infants with Pulmonary Hypertension (PH). Study Design: We asked members of the AAP-Society of Neonatal-Perinatal Medicine and Division-Chiefs to select from three management options-initiate iNO, engage parents in shared-decision-making or not consider iNO in an extremely preterm with PH followed by rating of factors influencing their decision. Results: 304 respondents (9%) completed the survey; 36.5% chose to initiate iNO, 42% to engage parents, and 21.5% did not consider iNO. Provider’s prior experience, safety, and patient-centered care were rated higher by those who initiated or offered iNO; lack of effectiveness and cost-considerations by participants who did not chose iNO. Conclusions: Most neonatologists offer or initiate iNO therapy based on their individual experience. The minority who chose not to consider iNO placed higher value on lack of effectiveness and cost. These results demonstrate a tension between evidence and pathophysiology-based-therapy/personal experience.

Inhaled Nitric Oxide at Birth Reduces Pulmonary Vascular Resistance and Improves Oxygenation in Preterm Lambs

“…The use of iNO in preterm infants with hypoxemic respiratory failure and pulmonary hypertension is controversial. [ 32 , 33 , 34 , 35 ] When used with high concentrations of oxygen, iNO can increase nitrosative stress. [ 9 ] Using iNO adds a significant risk of generating toxic nitrosative derivatives such as nitro-tyrosine, nitro-albumin and highly toxic perioynitrite.…”

The Controversy Persists: Is There a Qualification Criterion to Utilize Inhaled Nitric Oxide in Pre-term Newborns?

“…According to Manja et al a national survey showed that most neonatologists continue to prescribe iNO to pre-term newborns based on the imperative that physicians should “do something/do everything” to treat HRF on maximal ventilatory support ( 119 ). Taken together, these data make clear that clinicians remain uncertain about the possible benefits of iNO in the vulnerable population of extremely pre-term infants, mainly due to a lack of studies on its efficacy in treating specific medical conditions in this population.…”

Just Say No to iNO in Preterms—Really?

“…Physician Decision-Making at the Bedside Several studies 60,61 suggest that neonatologists do not consistently follow evidence-based clinical practice recommendations, which may be due to multiple factors. 26 A recent mixed-methods study of neonatologists to explore factors that influence bedside decision-making concerning the use of iNO in infants born extremely preterm in HRF was assessed by a vignette-based survey among neonatal members of the American Academy of Pediatrics (AAP). The AAP Perinatal Committee does not recommend the routine use of iNO in infants born extremely preterm but did not specify alternative recommendations for the management of PPHN in infants born preterm.…”

“…27 Among survey participants who responded to this case vignette of an infant born preterm with HRF, only 21% chose not to use iNO. 26 A clear majority chose to either initiate iNO therapy or engage parents in shared decision-making. Comments from participants suggested that factors other than knowledge of the evidence and of clinical practice guideline recommendations played a decisive role in clinical decision-making.…”

“…Summary of clinical practice guidelines-use of iNO in infants born preterm for PH or HRF (as modified from Manja et al26 ) …”