The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts

SUCCESSFUL USE OF NEBULIZED PROSTACYCLIN IN TWO INFANTS WITH PERSISTENT PULMONARY HYPERTENSION (PPHN)

Cynthia C. White, RRT-NPS, AE-C, Samuel Addison, RRT, Santina A. Zanelli, MD
University of Virginia Hospital, CharlottesvilleVA

Introduction
We have been using nebulized Prostacyclin (PGI2) at our facility for the past 5 years as an alternative to inhaled Nitric Oxide (iNO). Its primary use has been in adult post-op cardiac patients with pulmonary hypertention. Experience in newborns is limited to a few case reports of full term infants with severe pulmonary hypertension, unresponsive to iNO. Our experience has been limited to a few patients with congenital diaphragmatic hernia in which inhaled PGI2 at 50 ng/kg/min resulted in 25-35% reduction in pulmonary pressure as well as a significant improvement in oxygenation. We now report the use of inhaled prostacyclin in 2 infants with severe pulmonary hypertension.

Case Reports
Pt. #1 was a 35 6/7 week infant with a prenatal diagnosis of primary pulmonary hypertension with premature closure of the ductus arteriosus and an enlarged RV. An echo reported supra-systemic pressures with bi-directional shunting at the PFO through multiple VSD's and poor RV function. Pt. # 2 was a 41 week, Group B Strep + infant with a history of meconium stain, and maternal pregnancy complicated by IDDM. An echo reported supra-systemic RV pressures, dilated RV, poor LV function, and right to left shunting at the PFO.

Time PGI2 ng/kg/min Mean iNO ppm FIO2 P/F Ratio Pa02 OI SIMV Rate PIP/ PEEP MAP
Patient #1
0 Baseline 52 20 1.0 54 54 19 25 25/4 10
1h 50 54 20 .90 109 98 7 23 23/4 8
4h 50 48 20 .78 110 86 7 22 22/4 8
12h 50 47 15 .58 117 68 7 20 21/4 8
24h 50 54 OFF .48 133 64 6 20 20/4 8
72h 25 60 OFF .40 158 63 5 20 20/4 8
96h OFF 59 OFF .35 306 107 3 20 17/5 9
Patient #2
0 Baseline 60 20 1.0 63 63 19 50 20/4 12
1h 50 64 20 1.0 414 414 3 48 20/4 12
4h 50 59 20 .88 408 359 3 41 20/4 12
12h 50 63 20 .78 359 280 3 35 19/4 9
24h 50 63 OFF .60 135 81 7 34 18/4 9
72 OFF 54 OFF .35 237 83 4 28 18/4 9

Discussion

In both of the above cases, inhaled PGI2 was started secondary to inability to wean FIO2 after 2-3 days despite the use of iNO and other therapies. Both patients seemed to have pure pulmonary hypertension without lung disease and failed to respond to conventional therapy. Pt. #1 failed an attempt to switch to HFOV due to right ventricular failure. As illustrated in the above chart, an immediate improvement in OI and P/F ratio was seen in both patients, following the initiation of PGI2. This allowed for FI02 to be decreased and iNO to be weaned off within 24 hours.

References:

1. Kelly L, et al. Inhaled Prostacyclin for Term Infants with persistent pulmonary hypertension Refractory to inhaled Nitric Oxide. J. Pediatr 2002; 141: 830-832.

2. Lowson S. Inhaled Alternatives to Nitric Oxide. Crit Care Med 2005; 33:188-195Discussion

In both cases, inhaled PGI2 was started secondary to inability to wean FiO2 (after days or hours?) and unresolved pulmonary HTN, despite the use of iNO and other therapies. Both patients seemed to have pure pulmonary hypertension without lung disease and failed to respond to conventional therapy. Pt. #1 failed an attempt to switch to HFOV. As illustrated in the above chart, an immediate reduction in OI was seen in both patient #1 and patient #2, following the initiation if PGI2. FiO2 was decreased and iNO was weaned off within 24hrs.

References:

1.Kelly L, et al. Inhaled Prostacyclin for Term Infants with persistent pulmonary hypertension Refractory to inhaled Nitric Oxide. J. Pediatr 2002; 141: 830-832.

1.Lowson S. Inhaled Alternatives to Nitric Oxide. Crit Care Med 2005; 33:188-195.

  1. Comments: You might want to join the two charts above and make a graph of the P/F ratio or OI. The P/F ration sends a clear picture as well and our adult counter parts might understand that better. Just a thought.

Looks great!!!!

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