Inhaled Nitric Oxide (iNO) as an Adjunct to Neonatal Resuscitation

This study hopes to determine whether nitric oxide along with oxygen during the first 20 minutes of life in infants needing help with breathing will reduce the percentage and total exposure to oxygen during that time frame. Although the use of oxygen in management of breathing is an important part of supporting baby immediately after delivery, there is more evidence that too much exposure to oxygen may lead to potential problems for your baby later. Oxygen exposure can be harmful to premature babies developing lungs.

Current Neonatal Resuscitation Program (NRP) guidelines suggest the use of supplemental oxygen up to FiO2 of 1.0 during neonatal resuscitation for both term and preterm newborns. Exposure to supplemental oxygen in preterm babies has been shown to have significant toxicity. Even minimal exposure in the first hours of life has been shown to be associated with morbidity including later onset of cancer. The transition from fetal circulation to neonatal circulation is a complex process requiring lung inflation and decrease in pulmonary vascular resistance. Endogenous nitric oxide, along with oxygen, plays a major role in facilitating this transition by decreasing pulmonary vascular resistance. It is not known whether exogenous nitric oxide would facilitate this transition. In this study, we propose a novel approach to resuscitation of preterm infants where inhaled nitric oxide (iNO) will be used as an adjunct to oxygen with the primary goal of reducing supplemental oxygen exposure. This study is designed to be a double-blind, randomized, -placebo- controlled pilot trial with strict monitoring of parameters during transition in the delivery room.

• Prematurity
• Low Birth Weight

• Drug: Inhaled Nitric Oxide
  Immediately after birth, subjects will be randomized to receive iNO (20ppm) or nitrogen (placebo gas) with blended oxygen (starting with 0.3). FiO2 will be adjusted by 0.1 increments every 15 seconds targeting pre-ductal oxygen saturation of 70-85% in the first 2 minutes of life, and then 85-93% until the end of the study period while requiring supplemental oxygen.
  Other Name: Nitrogen
• Other: Nitrogen
  Subjects will be randomized to receive iNO (20ppm) or nitrogen (placebo gas) with blended oxygen (starting with 0.3). FiO2 will be adjusted by 0.1 increments every 15 seconds targeting pre-ductal oxygen saturation of 70-85% in the first 2 minutes of life, and then 85-93% until the end of the study period while requiring supplemental oxygen.

• Placebo Comparator: Placebo
  Intervention: Other: Nitrogen
• Placebo Comparator: iNO
  Intervention: Drug: Inhaled Nitric Oxide

Inclusion Criteria:

• Infants that are 25 0/7 - 31 6/7 weeks gestation
• Infants who require CPAP or PPV during delivery room resuscitation.

Exclusion Criteria:

• Refusal of consent
• Known complex congenital anomalies of the heart or lungs
• Known major genetic defects
• Hydrops fetalis