We report a synergistic effect of the combined treatment with HFV and iNO in seven consecutive patients (age 2 hours until seven months) with hypoxemic pulmonary failure. All patients included in the analysis were non-responders to iNO applied during conventional ventilation (CV). The initial mean oxygenation index (OI) was 26 (± 15.2). Diagnoses were persistent pulmonary hypertension of the newborn (PPHN) secondary to neonatal asphyxia, meconium aspiration syndrome, lung hypoplasia, severe hypoxemia, and acute respiratory distress syndrome (ARDS). There was no favorable response to iNO during CV, all patients were classified as non-responders (OI 29 ± 18.9). Subsequently the mode of ventilation was switched to HFV, which led to an even higher OI than previously (OI 40 ± 34.1). Then iNO was restarted during HFV at concentrations between 6 and 20 ppm. Within minutes the mean OI decreased significantly to 6 (± 2.5), the paO2 was significantly higher than previously [for details see figure 1 and 2]. We conclude that a sufficient degree of lung expansion is required in order to optimize the response to iNO, our experience suggests that this is more readily achieved by the use of HFV. In cases of hypoxemic pulmonary failure in neonates and infants this therapeutic regimen should be considered.

figure 1

Figure 1 and 2