1997 OPEN FORUM Abstracts
NEBULIZED PROSTACYCLIN; AN ALTERNATIVE TO NITRIC OXIDE FOR TREATING PULMONARY HYPERTENSION IN AN INFANT.
Vickie Fearing BA RRCP, Joran Flach BS RRCP. Children's Hospital Meritcare, Fargo, ND
Pulmonary hypertension is often a life threatening complication of severe bronchopulmonary dysplasia. Inhaled nitric oxide (NO) has gained acceptance as a selective pulmonary vasodilator, however, specialized equipment is required for its delivery, making its use impractical for many institutions. Prostacyclin is a more obscure vasodilator, that when inhaled, can be selective for the pulmonary vasculature due to its short half-life (3 min). We report a case of an infant with pulmonary hypertension as a complication of severe bronchopulmonary dysplasia. NO administration was unavailable at our institution at the time of his hospitalization. We administered prostacyclin via a Heart (Vortran Medical Technology, Inc. Sacramento CA) continuous nebulizer through a ventilator circuit on two separate occasions during his prolonged course. Like any nebulized medication, precise dosing is difficult to estimate. We used a medfusion syringe pump (medexinc. Duluth, GA) for prostacyclin delivery and an IV pump (Lifecare 5000, Abbott. Chicago IL) to maintain a constant level of normal saline within the nebulizer. The initial course of nebulized prostacyclin (dose: 6.5 ng/Kg/min) showed dramatic improvement. Peripheral perfusion went from poor, with cold pale extremities to an immediate improvement in color and temperature. PaO2 increased from 47 mmHg to 150mmHg within 15 minutes. Prior to prostacyclin administration, the patient was being treated with intravenous prostaglandin E1 (PGE). The combination of this medication with prostacyclin resulted in systemic hypotension, suggesting systemic effects of inhaled prostacyclin. The PGE was quickly weaned and discontinued 20 minutes after nebulization began. Ventilator (Siemens Servo 900C) settings before initiating prostacyclin nebulization were: PC rate 40, PIP 28, PEEP 8, with FIO2 variable, approximately 70%. Within 2 days of continuous nebulization, settings were weaned to: rate 28, PIP 26, PEEP 8, and FIO2 .40. The initial course of prostacyclin continued for 11 days, then was discontinued due to patients improved respiratory status. Over the next few weeks, he required increasing ventilatory support. Another course of prostacyclin was initiated without the dramatic improvement initially witnessed. He was then transferred to a center with NO and ECMO. The ability to deliver prostacyclin via continuous nebulization, using equipment found in almost any RC department makes it a viable alternative to NO for pulmonary vasodilation.