Does inhaled nitric oxide initiated on postnatal days 5 to 14 and continued for 24 days improve survival without bronchopulmonary dysplasia in preterm infants younger than 30 weeks’ gestation?
In this randomized clinical trial of 451 infants, no differences were observed in mortality, incidence of bronchopulmonary dysplasia, or respiratory or neurodevelopmental outcomes between the placebo and inhaled nitric oxide groups at 36 weeks’ postmenstrual age, 1 year, or 18 to 24 months’ postmenstrual age.
This study provides evidence that inhaled nitric oxide administration does not improve survival without bronchopulmonary dysplasia or neurodevelopmental outcomes in very preterm infants.
Bronchopulmonary dysplasia (BPD) occurs in approximately 40% of infants born at younger than 30 weeks’ gestation and is associated with adverse pulmonary and neurodevelopmental outcomes.
To test whether administration of inhaled nitric oxide to preterm infants requiring positive pressure respiratory support on postnatal days 5 to 14 improves the rate of survival without BPD.
Design, Setting, and Participants
This intent-to-treat study was a randomized clinical trial performed at 33 US and Canadian neonatal intensive care units. Participants included 451 neonates younger than 30 weeks’ gestation with birth weight less than 1250 g receiving mechanical ventilation or positive pressure respiratory support on postnatal days 5 to 14. Enrollment spanned from December 23, 2009, to April 23, 2012, and neurodevelopmental outcome studies were completed by April 4, 2014.
Placebo (nitrogen) or inhaled nitric oxide initiated at 20 ppm was decreased to 10 ppm between 72 and 96 hours after starting treatment and then to 5 ppm on day 10 or 11. Infants remained on the 5-ppm dose until completion of therapy (24 days).
Main Outcomes and Measures
The primary outcome was the rate of survival without BPD at 36 weeks’ postmenstrual age (PMA). Secondary outcomes included BPD severity, postnatal corticosteroid use, respiratory support, survival, and neurodevelopmental outcomes at 18 to 24 months’ PMA.
In total, 222 infants (52.3% male [n = 116]) received placebo, and 229 infants (50.2% male [n = 115]) received inhaled nitric oxide. Their mean (SD) gestation was 25.6 (1.5) vs 25.6 (1.4) weeks, and their mean (SD) birth weight was 750 (164) vs 724 (160) g. Survival without BPD at 36 weeks’ PMA was similar between the placebo and inhaled nitric oxide groups (31.5% [n = 70] vs 34.9% [n = 80]) (odds ratio, 1.17; 95% CI, 0.79-1.73). Rates for severe BPD (26.6% [55 of 207] vs 20.5% [43 of 210]) and postnatal corticosteroid use for BPD (41.0% [91 of 222] vs 41.5% [95 of 229]) and the mean (SD) days of positive pressure respiratory support (55  vs 54 ), oxygen therapy (88  vs 91 ), and hospitalization (105  vs 108 ) were equivalent between the 2 groups. No differences in the incidence of common morbidities were observed. Respiratory outcomes on discharge to home, at 1 year, and at age 18 to 24 months’ PMA and neurodevelopmental assessments at 18 to 24 months’ PMA did not differ between groups.
Conclusions and Relevance
Inhaled nitric oxide, initiated at 20 ppm on postnatal days 5 to 14 to high-risk preterm infants and continued for 24 days, appears to be safe but did not improve survival without BPD at 36 weeks’ PMA or respiratory and neurodevelopmental outcomes at 18 to 24 months’ PMA.
clinicaltrials.gov Identifier: NCT00931632
Hasan SU, Potenziano J, Konduri GG, Perez JA, Van Meurs KP, Walker MW, Yoder BA, for the Newborns Treated With Nitric Oxide (NEWNO) Trial Group. Effect of Inhaled Nitric Oxide on Survival Without Bronchopulmonary Dysplasia in Preterm InfantsA Randomized Clinical Trial. JAMA Pediatr. Published online September 25, 2017. doi:10.1001/jamapediatrics.2017.2618
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