A neonate at 36 weeks gestation develops hypotension on day 1 refractory to fluid boluses (40 mL/kg normal saline given). Blood gas: pH 7.28, PCO2 38, HCO3 17 mEq/L, BE -9. Echocardiography shows normal cardiac anatomy and elevated pulmonary artery pressure equal to systemic pressure with right-to-left shunting at PDA and foramen ovale. The first-line pharmacological agent recommended for persistent pulmonary hypertension of the newborn (PPHN) in this setting is:

• A Inhaled nitric oxide (iNO) at 20 ppm ✓
• B Intravenous sildenafil
• C Intravenous prostacyclin (epoprostenol)
• D High-dose dopamine (>10 mcg/kg/min)

Explanation

Inhaled nitric oxide at 20 ppm is the first-line specific pulmonary vasodilator for PPHN in term and near-term neonates; it selectively dilates pulmonary vasculature without systemic hypotension because it is rapidly inactivated by hemoglobin. iNO reduces the need for ECMO by ~40% in trials. Sildenafil is a second-line agent (oral/IV) used when iNO is unavailable. Prostacyclin is a third-line option. High-dose dopamine increases systemic vascular resistance and can worsen right-to-left shunting.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.