Is Inhaled Nitric Oxide Therapy in Neonates With Primary Pulmonary Hypertension in Developing Countries Like India Feasible?

Joshi, Rajan; Patil, Sheela S.; Dominic, Sili; Pratap, Usha; Rajhans, Arti P.; Devaskar, Uday P.
May 2007
Perinatology: Journal of Perinatal & Neonatal Care;May/Jun2007, Vol. 9 Issue 3, p108
Academic Journal
Primary pulmonary hypertension (PPHN) continues to be a major cause of hypoxic respiratory failure (HRF) among term and near term neonates world wide. In developed countries neonatal mortality and morbidity from PPHN and the need for extra-corporeal membrane oxygenator (ECMO) has decresed largely due to the use of inhalational Nitric Oxide (iNO). However, iNO therapy is generally not available in developing countries like India. A significant improvement in the care of the critically ill newborns has occurred in India during the last decade. However, for most neonates the cost of health care is still not paid by the government or the third party payer. As a result the family has to bear the brunt. Therefore introduction of newer medical technologies like iNO has to be cost effective. In addition, introduction of newer technologies is generally met with several obstacles, both technical and logistic in nature. Here we describe our experience with the introduction of iNO. Eighteen babies with mean B.W. 3.1 kg and G.A. 38.9 weeks were treated with iNO. The iNO delivery system was assembled. Nitric oxide (99.9% pure) supplied by a local company was used. The cost of initial investment, excluding nurse and physician education and training, was ∼ IRS 200,000. Neonates with HRF with PPHN were treated with iNO at the discretion of a neonatologist. All neonates were treated with 100% FiO2, mechanical ventilation (mean air way pressure >18, n = 15 with high frequency ventilator, and n = 3 conventional) and cardiotonic drugs prior to initiating iNO. In all babies echocardiogram was obtained to rule out the presence of a cardiac anomaly. NO and Nitrogen Dioxide (NO2) concentration were monitored. After initial investment, education and training, treatment with iNO was possible. Out of 18 babies treated with iNO, 2 babies, both transported from another hospital in a critical condition, died within an hour of initiation of iNO therapy. Three babies did not show any improvement in the oxygenation following initial 2 hours of iNO therapy. Therefore iNO was discontinued and all 3 of them died. Of the remaining 13 babies who had shown a significant improvement in oxygenation after initial 2 hours of iNO therapy, 6 (46 %) survied and 7 died (54 %). Average cost of treatment during iNO therapy was ∼ IRS 7000 / day. Most but not all parents were able to pay the cost of iNO. We conclude that even in a developing country like India, iNO therapy can be introduced. Not only it can be life saving but it can be cost effective.


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