CAPHC iNO Guidelines Development Process

Last modified by anshika sharma on 2022/06/05 09:17

Guideline Review

A review of hospital guidelines for administration of inhaled Nitric Oxide (iNO) was completed. Eighteen documents from eleven hospitals across Canada and a systematic review of the literature, the American Association for Respiratory Care: Evidence-Based Clinical Practice Guideline: Inhaled Nitric Oxide for Neonates With Acute Hypoxic Respiratory Failure, were analyzed. There are two documents from IWK Health Centre. The first document is a literature review and guideline from 2006 and the second is a guideline with some content based upon the first document. Two of the documents from London Health Science Centre consisted of tables used to document monitoring levels.

Two researchers extracted all the content from the documents to a platform for comparison. Due to the heterogynous nature of the documents, time was devoted to independently identify categories common among the documents. After a discussion, categories were agreed upon. Inclusion and exclusion criteria were then determined. Information was grouped using the criteria. Information within categories was summarized and standardized for ease of comparison.  The researchers compared the results for similarities and differences. A conclusion was prepared for each category highlighting key results. 

The attached document, Administration of Inhaled Nitric Oxide A Review of Canadian Hospital Guidelines and a Systematic Review of the Literature for the Canadian Association of Paediatric Health Centres (CAPHC) consists of our key results by category and is followed by summary tables. It is important to note that direct comparisons were complicated by the nature of the documents which were heterogynous in their goals and target audience. 


The evidence used to support the indication of use being HRF in term/near term newborn infants is Class 1 level A, the remaining neonatal and paediatric recommendations are rated at Class 2A or 2B, Level C.

Guideline development process

For purposes of safety and operational optimization, paediatric centres have developed, independently, iNO usage protocols/guidelines. Although these guidelines were developed via evidence based practice, as identified in the guideline review there is a degree of diversity in practice in our children’s hospitals across the country.  An approach to guideline development was taken that would:

  • Provide a focus for quality control and patient safety;
  • Reduce variations in practice; and
  • Promote efficient use of iNO.

Recognizing that there are differences in the maturity of evidence for use of iNO in neonates versus the paediatric population, two separate work groups were established.    A national inter-professional collaborative including physician, registered respiratory therapists and directors for quality improvement met monthly over a 12 month period using the evidence as well as tacit knowledge to develop recommendations for implementation in the paediatric setting.

Using the results of the guideline review as the framework for the recommendations, draft guidelines were developed under each category.   These draft guidelines were then reviewed, discussed and modified until consensus was reached by the full paediatric and neonatal guideline development groups. (see below)

Guideline management process:

This guideline was originally developed in June 2015.  A Nitric Oxide Stewardship Network is being established and will facilitate data collection, benchmarking and a guideline review process to support quality improvement.  

Data will be collected prospectively from participating network members.  Reasons for deviation from guideline will be captured as well as demographic data, indications, responses and outcome data.  A new body of evidence will be amassed to support the guideline and/or support change of the guideline.


The development of this guideline was supported in part by the Canadian Association of Paediatric Health Centres through a grant from Medbuy Corporation and the in-kind contributions of time and expertise from the iNO Collaborative members and their respective health care organizations. There are no conflicts of interest to declare

Paediatric Guideline Development Group:

Zelia DaSilva Clinical, Director NICU, Neonatal Follow-up Clinic and Respiratory Services, The Hospital For Sick ChildrenLeanne Davidson Clinical Educator Respiratory Therapy CCM The Hospital For Sick Children

Chris Devlin Respiratory Therapy PICU Program Specialist, Stollery Children’s Hospital, Edmonton AB

Jeff Dmytrowich RRT, FCSRT Respiratory Therapy Clinical Supervisor Saskatoon Health Region

Dr. Philippe Jouvet MD PhD Full professor/professeur titulaire de Clinique Director of the Pediatric Intensive Care Unit/chef de service des soins intensifs pédiatriques, CHU Sainte-Justine

Dr. Peter Laussen MB.BS.,FCICM Chief, Department of Critical Care Medicine, David and Stacey  Cynamon Chair in Critical Care Medicine, Hospital for Sick Children, Professor, Department of Anaesthesia, University of Toronto, Toronto ON

Suzanne Libbey RRT II Respiratory Therapy Clinical Lead

Jason Macartney Clinical Educator Respiratory Therapy PICU The Hospital For Sick ChildrenElaine Orrbine President and CEO CAPHC

Dr Marie-Ève Samson pédiatre intensiviste - Centre mère-enfant du CHUQ

Dr. Ram Singh Children’s Hospital London Health Sciences Centre 

Elizabeth Schurmann Improvement Consultant, Quality & Patient Safety, Strategy & Organizational Performance, IWK Health Centre

Christina Sperling RRT Clinical Manager, Respiratory Therapy The Hospital For Sick Children

Neonatal Guideline Development Group:
Cheryl Bailey RRT Clinical Team Leader, Respiratory Therapy, Janeway Child Health Centre, St. John’s NL

Karrie Beck BSc, RRT Practice Lead, Inhaled Nitric Oxide Project Critical Care Strategic Clinical Network, Alberta Health Services

Michael Finelli RRT NRCP Neonatal Respiratory Care Practitioner, NICU Hospital for Sick Children Toronto ON

Lydia Hatton RRT Clinical Leader, Respiratory Therapy IWK Health Centre Halifax, NS

Amanda Hurdowar, MSc Quality Management, SickKids Length of Stay Task Force – Standardize Care Project Lead, The Hospital For Sick Children

Dr. Robert Jankov MB BS PhD FRACP Staff Physician, Division of Neonatology, Senior Scientist, Physiology and Experimental Medicine, Hospital for Sick Children, Interim Head, University of Toronto Division of Neonatology, Senior Scientist, Physiology and Experimental Medicine, Associate Professor, Paediatrics and Physiology, University of Toronto, Toronto ON

Dr. Amish Jain Neonatologist, Assistant Professor in Paediatrics Mount Sinai Hospital Toronto ON

Dr. Faiza Kurshid NICU Kingston General Hospital, Kingston ON

Marisa Leone Respiratory Therapy Assistant Chief, Montreal Children's Hospital, Montreal QC

Linda Levesque RRT Jewish General Hospital, Montreal QC

Courtney Maguire Director of Respiratory Therapy, Mount Sinai Hospital Toronto ON

Carrie Lynn Meyer RRT BA RRT-Clinical Manager NICU, Level 2 Nursery and Neonatal Transport Team McMaster Children’s Hospital

Allison Nykolaychuk RRT PCCU McMaster Children’s Hospital Hamilton ON

Dr. Horacio Osiovich Neonatologist, British Columbia Children’s Hospital, Vancouver BCDr.

Dr. Mosarrat Qureshi MBBS, FAAP, FRCPC Staff Neonatologist, Northern Alberta Neonatal Program, Clinical Assistant Professor,  Department of Pediatrics, Stollery Children’s Hospital, Edmonton AB

Adelle Riehl Saskatoon Health Region Saskatoon SK

Gerald Spence RRT Unit Manager Respiratory Pediatric Intensive Care Unit Alberta Children’s Hospital, Calgary AB

Dr. Matthew Weiss M.D., FRCPC, FAAP Pediatric Intensivist Département de pédiatrie Centre Mère-Enfant Soleil du CHU de Québec, Quebec City, QC

Created by Lisa Stromquist on 2015/09/25 18:15

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