This multicenter trial tests whether inhaled nitric oxide will reduce death or the need for oxygen in preterm infants (less than 34 weeks gestational age) with severe lung disease.

This multicenter, randomized, double-masked, controlled clinical trial evaluates the efficacy of inhaled nitric oxide (iNO) in the treatment of the preterm infant with respiratory failure secondary to respiratory distress syndrome (RDS), sepsis/pneumonia, aspiration syndrome, idiopathic pulmonary hypertension and/or suspected pulmonary hypoplasia. Infants are followed until death or discharge to home. The trial compares iNO therapy to mock gas delivery as the control and otherwise incorporates conventional management strategies (including treatment with surfactant and high frequency ventilation as adjuncts to iNO therapy). During the initial dosing, iNO is started at 5 ppm and may be increased to 10 ppm. If the infant does not respond, study gas is discontinued. For infants who respond to study gas, a gradual weaning is initiated following a well-defined protocol. The total exposure to study gas may not exceed 336 hours (14 days). Infants are monitored for signs of toxicity. Medical and neurodevelopmental outcome of surviving infants will be assessed at 18 to 22 months corrected age by masked, certified examiners.

To demonstrate that the use of iNO is associated with a clinically significant reduction (from 75% to 60%) in the primary outcome variable (incidence of death or BPD during initial hospitalization) using a power of 0.90 and an alpha of 0.05 for a two-tailed test, a sample of 440 will be required (220 infants in each arm of the study).

Inclusion Criteria

• Any infant with a birth weight 401 - 1500 grams and < 34 weeks gestational age with an OI (mean Paw x FiO2 x 100/PaO2) > 10 on two consecutive blood gases at least 30 minutes apart, but no more than 12 hours apart.

or

• Infants > 1500 grams and < 34 weeks gestational age will be entered in the Larger Preemie Pilot Study if they have an OI greater than or equal to 15 on two consecutive blood gases at least 30 minutes apart, but no more than 12 hours apart.
• Infants requiring assisted ventilation with a diagnosis of RDS/HMD, pneumonia and/or sepsis, aspiration syndrome, idiopathic pulmonary hypertension, or suspected pulmonary hypoplasia associated with PROM and/or oligohydramnios.
• Greater than or equal to 4 hours after one dose of surfactant.
• Less than or equal to 120 hours of age.
• All infants must have an indwelling arterial line.

Exclusion Criteria

• Any infant in whom a decision has been made not to provide full treatment (e.g. chromosomal anomalies or severe birth asphyxia).
• Known structural congenital heart disease, except patent ductus arteriosus and atrial-level shunts.
• Infants with any major abnormality involving the respiratory system such as congenital diaphragmatic hernia, tracheoesophageal fistula or cystic fibrosis.
• Any bleeding diathesis considered to be clinically significant or thrombocytopenia with platelet count < 50,000.
• Prior enrollment into a conflicting clinical trial such as the Neonatal Network Surfactant CPAP trial.Inclusion Criteria