University Hospital of Wales Paediatric Intensive Care Unit Guideline Printed on Wed 23-jul-08
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Last updated August 17, 2017 10:37 AM

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Noah's Ark Childrens Hospital for Wales
Heath Park
Cardiff
CF14 4XW
02920 747747


Nitric Oxide

iNO
May use if known pulmonary hypertension, or severe ARDS (usually when ECMO is being considered).
A trial of <30ppm is used, and will last 4 hours maximum
Responders: Improvement in oxygenation parameters of 20% by 30 mins
If no response stop iNO: prolonged treatment can cause rebound deterioration when iNO is stopped despite apparent non-response
It takes 5 - 10 mins after dialling a change in iNO concentration to achieve steady state
Methaemoglobin levels should be checked daily (should be < 5%) while on iNO Weaning: when FiO2 < 0.50, reduce in 5ppm increments. Once at 5ppm, reduce in 1ppm increments
Sildenafil 0.3mg/kg qds may be used to aid weaning.

Setting up Nitric Oxide

1. Switch on system

2. Do a system high pressure leak test

Turn both cylinders on and off.

Then watch pressure dials and wait for 10 seconds to see if there is a decrease in pressure.

If yes change O ring if you know how or call 0800 9174024 (24 hour helpline) or use other INOvent.

3. Do a low range calibration

Go to calibration, confirm to calibrate NO, NO2, O2

If test fails-retry, if fails again call helpline or swap to other INOvent.

4. Purge the system

Set up test circuit for Purge & Performance test as below - start from WALL flowmeter and work back.

iNO


Turn oxygen to 15litres & Set the NO delivery to 40ppm

Check both cylinder gauges go down to Zero-emptiest will be 1st (if this doesn't happen check cylinders are turned off & try again)

Wait for two alarms

1/ LOW NO/N2 PRESSURE
2/ DELIVERY FAILURE

If test fails call helpline or swap to back up Inovent.

5. Check performance

Turn on the cylinder you intend to use for therapy (emptiest)

Keep 02 to 15 litres & Set the NO to 20 ppm

Wait for 30 seconds and check O2, NO, NO2, are within acceptable limits

O2 = 95% +/- 3%
NO2 less than 1.0 ppm
NO 16 ppm - 24ppm

If readings not correct do a high range calibration if someone is able to do it, if this is not possible then phone helpline or use the backup Inovent instead.

6. Check performance of manual backup system.

Turn off flowmeter. Remove green O2 tubing from wall flowmeter & connect to O2/NO outlet on back of Inovent.

Then make circuit as below (remove injection module).

iNO

Connect white O2 hose to wall.

Turn backup system flowmeter on side of Inovent to 15 litres.

Check flow indicator ball has risen inside Perspex screen on front of Inovent.

Check that delivered levels are within the following range:

O2 = 97% +/- 3%
NO2 less than 0.5 ppm
NO 5 ppm - 15ppm


If a reading is not achieved then phone helpline or use backup Inovent.

When pre-use checks are completed turn off bagging system flowmeter and change set NO level to Zero. Inovent can then be connected to ventilator circuit. Once connections are all made NO set level can be set to prescribed dose (the set level may need to be adjusted slightly to achieve desired dose on the monitor readout.)

If Inovent is not connected to ventilator or not used within 10 minutes of pre-use checks then NO2 may start to build up in tubing. In this case procedures 2 and 4 must be done again immediately prior to connecting to the ventilator.

 

Changing Cylinders

Protocol for Swapping to Spare INOmax Cylinder

1. First disconnect the spare Inomax cylinder not in use. To do this disconnect the black hose that connects the regulator to the rear of the Inovent (pull back on silver fitting on Inovent)

2. Turn on spare Inomax cylinder then turn it off again immediately. The pressure gauge at the front should rise. Make sure you have adequate pressure

3. Purge the spare Inomax cylinder to remove old gas from the tubing and regulator. To do this, take the end of the hose you have disconnected from the InoventĀ  and push it into the purge fitting. You will hear a hissing as the gas is purged out of the hoses. The pressure gauge for that cylinder will go down to zero.

4. Reconnect black hose into rear of Inovent & turn on spare Inomax cylinder.

5. Turn off empty cylinder and label it clearly as empty.

 

iNO 


Protocol for Changing to New INOmax Cylinder

1. After turning off empty Inomax cylinder purge the cylinder to remove old gas and built up pressure.
Without this step undoing the connection to the cylinder will be difficult.

2. Disconnect screw adapter from the rear of the Inomax cylinder and attach silver screwtop. This is attached to neck of cylinder

3. Open packaging of new Inomax cylinder and remove silver screwtop. Attach Screw adapter from back of INOvent trolley.
Do not connect to INOvent head at this point

4. Leaving low pressure hose disconnected to the head of the INOvent, Turn on Inomax cylinder then turn it off again immediately. The pressure gauge at the front should rise.
Make sure you have adequate pressure

5. Purge the spare Inomax cylinder to remove old gas from the tubing and regulator. To do this: take the end of the hose you have disconnected from the InoventĀ and push it into the purge fitting. You will hear a hissing as the gas is purged out of the hoses. The pressure gauge for that cylinder will go down to zero.
Reconnect black hose into rear of INOvent and keep spare cylinder turned off. Only one cylinder on at any one time.


iNO 


Julie Armstrong October 2010