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Structured Abstract
Objectives:
To systematically review the evidence on the use of inhaled nitric oxide (iNO) in preterm infants born at or before 34 weeks gestation age who receive respiratory support.
Data sources:
We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Studies (CENTRAL) and PsycInfo in June 2010. We also searched the proceedings of the 2009 and 2010 Pediatric Academic Societies Meeting and ClinicalTrials.gov. We identified additional studies from reference lists of eligible articles and relevant reviews, as well as from technical experts.
Review methods:
Questions were developed in collaboration with technical experts, including the chair of the upcoming National Institutes of Health Office of Medical Applications of Research Consensus Development Conference. We limited our review to randomized controlled trials (RCTs) for the question of survival or occurrence of bronchopulmonary dysplasia (BPD) and for the question on short-term risks. All study designs were considered for long-term pulmonary or neurodevelopmental outcomes, and for questions about whether outcomes varied by subpopulation or by intervention characteristics. Two investigators independently screened search results, and abstracted data from eligible articles.
Results:
We identified a total of 14 RCTs, reported in 23 articles, and eight observational studies. Mortality rates in the NICU did not differ for infants treated with iNO versus those not treated with iNO (RR 0.97 (95% CI 0.82, 1.15)). BPD at 36 weeks for iNO and control groups also did not differ (RR 0.93 (0.86, 1.003) for survivors). A small difference was found between iNO and control infants in the composite outcome of death or BPD (RR 0.93 (0.87, 0.99)). There was inconsistent evidence about the risk of brain injury from individual RCTs, but meta-analyses showed no difference between iNO and control groups. We found no evidence of differences in other short term risks. There was no evidence to suggest a difference in the incidence of cerebral palsy (RR 1.36 (0.88, 2.10)), neurodevelopmental impairment (RR 0.91 (0.77, 1.12)), or cognitive impairment (RR 0.72 (0.35, 1.45)). Evidence was limited on whether the effect of iNO varies by subpopulation or by characteristics of the therapy (timing, dose and duration, mode of delivery, or concurrent therapies).
Conclusions:
There was a seven percent reduction in the risk of the composite outcome of death or BPD at 36 weeks PMA for infants treated with iNO compared to controls, but no reduction in death or BPD alone. Further studies are needed to explore particular subgroups of infants and to assess long term outcomes including function in childhood. There is currently no evidence to support the use of iNO in preterm infants with respiratory failure outside the context of rigorously conducted randomized clinical trials.
Contents
- Preface
- Acknowledgments
- Executive Summary
- 1. Introduction
- 2. Methods
- 3. Results
- Literature Search/Abstract/Article Review
- Description of the Types of Studies Retrieved
- Risk of Bias
- Key Question 1 Does inhaled nitric oxide (iNO) therapy increase survival and/or reduce the occurrence or severity of bronchopulmonary dysplasia (BPD) among premature infants who receive respiratory support?
- Key Question 2 Are there short term risks of iNO therapy among premature infants who receive respiratory support?
- Key Question 3 Are there effects of iNO therapy on long term pulmonary and/or neurodevelopmental outcomes among premature infants who receive respiratory support?
- Key Question 4 Does the effect of iNO therapy on BPD and/or death or neurodevelopmental impairment vary across subpopulations of premature infants?
- Key Question 5 Does the effect of iNO therapy on BPD and/or death or neurodevelopmental impairment vary by timing of initiation, mode of delivery, dose and duration, or concurrent therapies?
- 4. Discussion
- 5. Future Research
- References and Included Studies
- Appendixes
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10061-I. Prepared by: The Johns Hopkins University Evidence-based Practice Center, Baltimore, MD
Suggested citation:
Allen MC, Donohue P, Gilmore M, Cristofalo E, Wilson RF, Weiner JZ, Bass EB, and Robinson K. Inhaled Nitric Oxide in Preterm Infants. Evidence Report/Technology Assessment No. 195. (Prepared by Johns Hopkins University Evidence-based Practice Center under Contract No. 290- 2007-10061-1). AHRQ Publication No. 11-E001. Rockville, MD: Agency for Healthcare Research and Quality. October 2010.
This report is based on research conducted by the Johns Hopkins University Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10061-I). The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov.
- Review Inhaled nitric oxide in preterm infants: a systematic review.[Pediatrics. 2011]Review Inhaled nitric oxide in preterm infants: a systematic review.Donohue PK, Gilmore MM, Cristofalo E, Wilson RF, Weiner JZ, Lau BD, Robinson KA, Allen MC. Pediatrics. 2011 Feb; 127(2):e414-22. Epub 2011 Jan 10.
- Review Inhaled nitric oxide for respiratory failure in preterm infants.[Cochrane Database Syst Rev. 2007]Review Inhaled nitric oxide for respiratory failure in preterm infants.Barrington KJ, Finer NN. Cochrane Database Syst Rev. 2007 Jul 18; (3):CD000509. Epub 2007 Jul 18.
- Review Inhaled nitric oxide for respiratory failure in preterm infants.[Cochrane Database Syst Rev. 2017]Review Inhaled nitric oxide for respiratory failure in preterm infants.Barrington KJ, Finer N, Pennaforte T. Cochrane Database Syst Rev. 2017 Jan 3; 1(1):CD000509. Epub 2017 Jan 3.
- Review Inhaled nitric oxide for respiratory failure in preterm infants.[Neonatology. 2012]Review Inhaled nitric oxide for respiratory failure in preterm infants.Soll RF. Neonatology. 2012; 102(4):251-3. Epub 2012 Aug 15.
- Review Inhaled nitric oxide for respiratory failure in preterm infants.[Cochrane Database Syst Rev. 2010]Review Inhaled nitric oxide for respiratory failure in preterm infants.Barrington KJ, Finer N. Cochrane Database Syst Rev. 2010 Dec 8; (12):CD000509. Epub 2010 Dec 8.
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