Pediatric ARDS: iNO unhelpful in retrospective analysis

  • Crit Care Med

  • curated by Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • Inhaled nitric oxide (iNO) does not improve mortality or increase ventilator-free days (VFDs) in pediatric acute respiratory distress syndrome (PARDS).
  • There is some evidence for harm from the treatment.

Why this matters

  • A suggestion to use iNO by Pediatric Acute Lung Injury Consensus Conference is based on scarce evidence; practice varies widely.
  • 1 previous trial suffered from low enrollment; another was criticized for uncontrolled confounders.

Key results 

  • Among iNO recipients, 61% (87 children) had positive oxygenation response.
  • With vs without iNO:
    • Mortality: 25.2% vs 16.3% (P=.02); 
    • Median VFDs: 10 vs 17 (P<.0001>
  • Among propensity-matched children (88 pairs), with vs without iNO:
    • Adjusting for nonconventional ventilation and extracorporeal membrane oxygenation: similar mortality (OR, 1.3; 95% CI, 0.56-3.0; P=.54);
    • In models adjusting for above plus PRISM III score: similar VFDs.
  • Some models found higher likelihood of zero VFDs with iNO treatment.

Study design

  • Observational cohort study of records from Children’s Hospital of Philadelphia and Children’s Hospital Los Angeles (CHLA) (n=499). 
  • Researchers created propensity score model for children with PARDS who received (n=143) or did not receive iNO in first 72 hours of illness.
  • Outcome: pediatric ICU mortality.
  • Funding: CHLA.

Limitations

  • Retrospective study, may have been underpowered to detect mortality benefit.

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