EMCrit 273 – Inhaled Pulmonary Vasodilators & Q&A with Sara Crager

This episode continues on from last time's talk by Sara Crager on Right Ventricular Failure. This is a Q&A; session with a focus on inhaled pulmonary vasodilators.

Nitric Oxide

Sara likes it through ETT or Hi-Flo NC (can also be done through BIPAP)

Start at 20 ppm

See results within 5-10 minutes

Monitor with CVP

Problems

* Nitric Dioxide (NO2) may be formed which can lead to pulmonary edema or even alveolar hemorrhage.

* MetHb can be formed and some people do routine monitoring for this dyshemoglobinemia.

Additional Resources

* PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP?

* Review Article on Inhaled NO

Epoprostenol (Flolan)

May be more complicated to set-up

go back to marker 5

Epoprostenol @ 0.05 mcg/kg/min

Must have filters on the circuit

* Review Article on Inhaled EpoProst

Milrinone

Get the vial, you want 1 mg/ml with 15 mls in vial

5 ml (5 mg) q 6 hours (According to Dr. Crager--may be more frequent if symptoms rebound (down to q 3 hrs))

Ideally use ultrasonic nebulizer

onset ~15 minutes

Must have filters on circuit

LVOTO & RVOTO contraindication for the milrinone

respigard!!!

aeroneb pro

must have filters on vent

from Andre Denault Lecture

Additional Resources

* Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

* A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients

Intratracheal Milrinone Bolus for a Crashing Patient

50-80 mcg/kg or 5 mg (1/2 a bolus is also used by some)

onset 4-5 minutes

from the amazing Hospitalist & the Resuscitationist Lecture 2019 by Andre Denault

Nitro

Need conc. of 1 mg/ml (standard bottle is 200 mcg/ml)

Doses in studies range from 2.5-25 mcg/kg/min for 10 minutes or 50 ug/kg total given over 8 minutes (perhaps easiest to put 4-5 mg in neb and let it run)

* PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?

Photo by Valeriia Bugaiova on Unsplash

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