Inhaled Nitric Oxide in Right Ventricular Failure

Primary Indication and Dosing

The American Heart Association suggests using inhaled nitric oxide (iNO) at 20 ppm when right ventricular failure causes hemodynamic instability despite conventional inotropic support, with evidence supporting this approach in critically ill patients with acute right heart syndrome, where iNO significantly increases cardiac output, stroke volume, and mixed-venous oxygen saturation 2, 3
The Intensive Care Medicine consensus recommends starting at 20 ppm and titrating in 10 ppm increments based on hemodynamic response, with 5-10 ppm possibly sufficient for RV dysfunction specifically 1, 2

In post-cardiac surgery right ventricular failure, iNO has demonstrated efficacy in reducing pulmonary vascular resistance and improving cardiac output 2, 3, 4
In acute pulmonary embolism with right ventricular dysfunction, consider iNO as a bridge to definitive therapy, such as thrombolysis or thrombectomy, as it improves oxygenation and allows for successful intervention 5
When weaning iNO, rebound pulmonary hypertension can occur, so start or restart a phosphodiesterase inhibitor, such as sildenafil, before weaning 2, 3
Use iNO alongside inotropes with neutral or beneficial effects on pulmonary vascular resistance, such as dobutamine, milrinone, or epinephrine, and offset potential systemic vascular resistance drops with replacement-dose vasopressin 2, 3

Limit peak pressures to <30 cmH2O and keep positive end-expiratory pressure (PEEP) ≤10 cmH2O to minimize increases in right ventricular afterload 2
Avoid permissive hypercapnea and target SpO2 >90% to prevent increases in pulmonary vascular resistance 2
Monitor for methemoglobinemia at sustained high doses and be aware of the potential for tachyphylaxis with prolonged use 2, 3
Reserve iNO for acute hemodynamic compromise where conventional therapies have failed or as a bridge to definitive intervention, and do not use it routinely or prophylactically in right ventricular dysfunction 1