Per Bredmose discusses the use of inhaled nitric oxide (iNO) in retrieval medicine and critical care. He explains why iNO is useful for retrieval and transport of the critical respiratory failure patient. iNO is not a magic bullet, but rather a bridge that will help you get to where you need to go when treating a patient. Furthermore, it can be useful in both pre-hospital and in hospital care. What is nitric oxide? It is an endothelial derived potent short acting vasodilator mainly found in the pulmonary system. It also exists in other areas of the body. When nitric oxide is delivered via the inhaled route it has local effects only, with no systemic effects. Most people will be familiar with the use of iNO in persistent pulmonary hypertension of the newborn.  However, there are other uses which are more “off label”. For instance, take the case of severe ARDS lungs in pre-hospital settings. These patients present challenges in retrieval for several reasons, including the retrieval ventilation systems being inferior when compared to hospital systems. Of course, you could turn straight to ECMO. However, setting up ECMO takes time and is complex. It requires a large amount of equipment, skilled operators, and room. Nitric oxide can act as a bridge. Per stresses, iNO is a tool to get the patient to the right place. Nitric oxide is simple to use. It is an extra gas that goes into the ventilatory circuit. It is accessible, can be used in any vehicle, is easy to transport, and fast to grab and use. Much faster than a big ECMO set up or retrieval. A lot of places have stopped using iNO and it has gained something of a bad reputation. The main reason for deleterious effects appears to be kidney injury. Per posits that this may be due to an increased length of time using the drug. Therefore, he advises caution. Per concludes by explaining other conditions where iNO may be used as an adjunct to standard therapy. These situations include pulmonary hypertension, non-thrombotic pulmonary vasoconstriction, and pulmonary emboli. Join Per Bredmose as he discusses all things inhaled nitric oxide.

1. How I use inhaled nitric oxide ?
Per P. Bredmose
Air Ambulance Dept, Oslo University Hospital
Norwegian Air Ambulance Foundation
Director of Training
Consultant in Prehospital and Retrieval Medicine
Consultant Anaesthetist/Intensivist
SMACC
Dublin 2016
@VikingOne_

2. No disclosures !!

3. Bring the doctor to the patient
Bring the emergency dept into the street
Bring the hospital to the patient

4. Bring iNO to the patient
The «transporters perspective»
Transferable !!!!!

5. Wrong place at the wrong time

6. With the wrong disease

7. iNO as a bridge

8. What is this....???
Endothelial derived potent short acting
vasodilator in the pulmonary tree
Delivered via the respiratory tract as iNO there is
no systemic effect

9. Traditional use
«accepted use»
PPHN
Persistent Pulmonary Hypertension of the Newborn
iNO = drug of choice when severe
Well established use

11. Being in the wrong place

12. Why don’t you go
straight to ECMO ?

13. Me + ECMO

15. Mobile ECMO
HEMS physician
HEMS nurse/HCM
Perfusionist
Not a quick fix

16. ECMO is a Complex transformation

18. iNO
Bridge to:
Recovery
ECMO
via
Transport
For me this is a tool to get the
patient to a specialised centre
For me this is a tool to get the
patient to a specialised centre

20. Rapid deployment

21. iNO in any vehicle

22. The Rationale...
Inhaled nitric oxide for acute respiratory distress syndrome and acute lung injury in
adults and children: a systematic review with meta-analysis and trial sequential
analysis.
Anesth Analg. 2011 Jun;112(6):1411-21
We found a statistically significant but transient improvement in
oxygenation in the first 24 hours, expressed as the ratio of Po₂ to
fraction of inspired oxygen (mean difference [MD] 15.91, 95% CI 8.25 to
23.56;

25. Our goal
Our Experience
A team treating a
high volume of patients
with a particular illness
is
expected to achieve good
results compared with
units
that might treat such
severe respiratory failure
only once
or twice per year.
CESAR trial, Lancet 2009

27. Why the bad reputation....
iNO appears to increase the risk of renal
impairment among adults
(RR 1.59, 95% CI 1.17 to 2.16)

28. The specials

29. Pulmonary Hypertension
outside PPHN situations

30. Pulmonary emboli
Combination of a clot
and
Downstream vasoconstriction

31. Non thrombotic pulmonary vasoconstriction

33. Resuscitation

34. Cardiac arrest
In a patient with severe pulmonary hypertesion

36. Case time

37. Theatre
Postpartum atonic uterus
Goes to Theatre
Cardiac arrest x 2 on table when maneuvering
uterus
Amniotic fluid emboli syndrome !!
ROSC
30+ yrs old woman

38. ICU
High dose vasopressors
Adr + NA (++++++++++)
PULM HT
High ventilator settings

40. Pulm HT

41. «Saturation
is
dropping»

43. ROSC w iNO

44. Retrieved in helicopter to
University Hospital
iNO treatment
Reduce vasopressors
Survivor

48. Conclusion
Potent selective pulmonary vasodilator
iNO is a BRIDGE to....something
Mobile
Can bring your patient to right centre and might
prevent an ECMO run

49. Conclusion (short version)
iNO is underused in retrieval medicine of severe
respiratory failure
iNO is a SUPERB tool for special case resuscitation

50. Don’t ask what sildenafil can do for you
(or your partner)
Ask what iNO can do for your patient !!!

51. ?