NO means NO!

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Inhaled nitric oxide reduces the need for ECMO in term and near term infants with severe respiratory failure. Therefore, it seems reasonable to suppose that starting nitric oxide before severe respiratory failure develops might make a greater impact which might translate into improved long term outcome. In this issue of The Journal, Konduri et al report the results of a randomized trial comparing the early and late outcomes in two groups of infants: one that had nitric oxide initiated when moderate to severe hypoxic respiratory failure developed (OI>25) and one that had it initiated at an earlier threshold (OI>15 and <25). Even though early nitric oxide decreased the progression of respiratory failure, it did not alter the incidence of ECMO or mortality. Nor did it alter the incidence of long term (18 month) morbidities. Early nitric oxide had no significant negative impact on long term outcome, although there were some disturbing trends in Bayley PDI and conductive hearing loss. Different approaches will need to be developed to decrease the significant risk of neurodevelopmental and hearing abnormalities in these high risk infants.