Inhaled nitric oxide in therapy of pediatric and neonatal acute respiratory distress syndrome: the good, the bad and the ugly

Abstract

Introduction Pediatric and neonatal acute respiratory distress syndrome (PARDS/NARDS) cause significant mortality or long-term morbidity in childhood. The optimal management remains elusive, making a review of therapies like inhaled nitric oxide (iNO) timely and crucial.Areas coveredThis review elucidates the mechanisms of iNO and critically appraises its application in PARDS/NARDS. A literature search covering the period up to December 2024 was conducted in PubMed, Embase, and Web of Science. We evaluated its effects on oxygenation, inflammation, and outcomes, highlighting the inconclusive impact on survival and neurodevelopment, and the limitations posed by variable response and safety concerns.Expert opinionWhile iNO can improve oxygenation, its routine use is not recommended due to uncertain long-term benefits. Future, rigorous trials must identify predictive biomarkers and patient subgroups most likely to benefit, paving the way for personalized iNO therapy in neonatal and pediatric critical care.