232 Treatment of Chronic Lung Disease Associated Pulmonary Hypertension with Inhaled Nitric Oxide Administered via Nasal Cpap

Background: Pulmonary hypertension (PH) is a major complication of chronic lung disease (CLD), and its treatment is based on the use of oxygen. Inhaled nitric oxide (iNO) is a highly selective pulmonary vasodilator and it has been used in the therapy of this condition via endotrachal tube during mechanical ventilation. Its use in CLD associated PH with non-invasive delivering methods has not yet been documented to our knowledge.Methods: We report the case of a newborn born prematurely (GA 27 wks BW 475 gms) who developed CLD. At 43 wks post conceptional age oxygen need increased to FiO2=0.7 in nasal CPAP (nCPAP) to maintain O2 saturation (SaO2) within the normal range. Chest X-ray showed cardiomegaly (CTI=0.66). Echocardiography showed indirect signs of PH (hypertrophy of the right ventricle, systolic “D” shaped interventricular septum, moderate pulmonary valve insufficiency) and the value of the mean pulmonary arterial pressure (mPAP) measured through pulmonary insufficiency (PI) was 40– 45 mm Hg immediately before starting iNO. INO (INOmax-INO Therapeutics) was administered via nCPAP (Infant Flow System-EME) in conjunction with a iNO delivery system (INOvent-Datex Ohmeda) at a starting dose of 10 ppm.Results: 5 minutes after starting iNO at 10 ppm via nCPAP, echocardiography showed a decrease of mPAP to 14–15 mm Hg and a significant reduction of PI. After 30 min the oxygen need decreased to FiO2=0.5 to keep SaO2 normal. Subsequently the dose of iNO was progressively decreased with no rebounds in mPAP and stopped 13 days from the start. At the end of treatment echocardiography showed a stable mPAP of 14–15 mm Hg. Met Hb on blood and NO2 in the inspiratory line of nCPAP circuit were never beyond safety levels. On the fifth day of iNO treatment, therapy with dexamethasone was started at the dose of 0.25 mg/kg/day in two doses. Dexamethasone dose was progressively decreased and stopped the day after iNO suspension. At the end of treatment the patient was off nCPAP and oxygen was needed only during feeding. 50 days after the start of iNO treatment echocardiographic PH was absent, chest X-ray showed a reduction of cardiomegaly (CTI=0.52) and the clinical status was stable with a minimal oxygen need.Conclusion: INO administered via nCPAP has been shown to be effective and safe in reducing CLD associated PH in our patient. On the basis of this experience non-invasive iNO administration can be suggested as an alternative therapy associated with CLD.