Inhaled nitric oxide (INO) is a potent vasodilator used as a bridge in treating severe respiratory failure and transporting patients to specialized centers. Although historically associated with risks, particularly renal impairment, it has demonstrated a transient improvement in oxygenation in patients with acute respiratory distress. This presentation argues for its increased utilization in retrieval medicine, emphasizing its potential benefits over ECMO in specific cases.

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. ?