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Inhaled Epoprostenol (3.51)

Inhaled Epoprostenol (3.51) - Policies, Clinical, UWHC Clinical, Department Specific, Respiratory Care Services, Special Procedures

3.51

L 3.51 Inhaled Epoprostenol
Category: UWHC Clinical Policy
Policy Number: 3.51
Effective Date: November 16, 2015
Version: Revision
Section: Respiratory Care Services

I. PURPOSE

Inhaled epoprostenol is a naturally occurring prostaglandin with potent vasodilatory activity and inhibitory
activity of platelet aggregation. Epoprostenol causes direct vasodilatation of the pulmonary arterial beds by
binding to the cell surface prostaglandin receptor to activate adenylate cyclase. Cyclic adenosine
monophosphate (C-Amp) activates protein kinase A to decrease free cellular calcium causing vasodilatation.
It also stimulates the endothelial release of Nitric Oxide (NO).

Inhaled epoprostenol has been the most widely studied alternative to NO. It is more commonly given by
intravenous infusion and has the potential to cause systemic effects; however, current data have shown
minimal systemic effects after inhalation. This is due to the low concentrations observed in the blood following
administration by inhalation and a serum half-life of 3-6 minutes.

II. INDICATIONS

A. Pulmonary Hypertension
B. Right Heart Failure
C. Pulmonary Embolism
D. Adult Respiratory Distress Syndrome

III. CONTRAINDICATIONS

A. Patients with severe left ventricular systolic dysfunction
B. Known hypersensitivity to epoprostenol
C. Patients critically dependent on right-to-left shunting of blood
D. Active and significant bleeding
E. Thrombocytopenia (platelets < 50K)

IV. COMPLICATIONS/PRECAUTIONS

A. Abrupt withdrawl including any interruptions in nebulization may result in rebound hypoxia and
pulmonary hypertension. Nebulized epoprostenol must be weaned off slowly in patients that respond
to therapy.
B. Patients with reactive airway disease or who have increased risk for lung irritation may develop
bronchospasm due to the alkalinity of the solution.
C. The following systemic side effects may occur:
1. jaw pain
2. headache
3. flushing
4. nausea
5. diarrhea
6. vomiting
7. abdominal pain
8. hypotension




V. POLICY

A. Inhaled epoprostenol may only be used in an ICU setting.
B. The physician order for inhaled epoprostenol must be placed in Health Link before therapy will be started.
Doses of 0.01, 0.02, 0.03, 0.04 or 0.05 mcg/kg/min are available.
C. The weight, dose and mL/h are listed in the epoprostenol order and pulled from the Medication
Administration Record in Health Link. The patient’s weight is defaulted to ideal body weight (IBW). If
the patient’s actual weight is less than their IBW or less than 10.9 kg, the prescriber must enter a
specific weight when ordering epoprostenol.
D. Confirm dosing weight with pharmacist.
E. Confirmation of BodyGuard pump and circuit setup must be done by two Respiratory Therapists. This does
not apply to setups completed in the OR.
F. Recommended dosing is as follows:
1. ARDS-start at 0.05 mcg/kg/min, titrate down to 0.01 mcg/kg/min as tolerated.
2. Pulmonary hypertension and severe right heart failure-start at 0.01-0.05 mcg/kg/min, and titrate
dose to response.
F. Pharmacy will mix epoprostenol solution. The concentration will be 30 mcg/ml for patients weighing
more than or equal to 11kg and 5 mcg/ml for patients weighing less than 11kg.
G. The BodyGuard lockbox will be locked at all times to avoid inadvertent dose changes. The key must
remain with the respiratory therapist at all times and will be handed off during report.
H. A BodyGuard 575 infusion pump will be used to deliver the epoprostenol to the Aeroneb Solo
Nebulizer.
I. Entering the epoprostenol dose into the BodyGuard pump requires two RT’s to confirm that the
appropriate concentration and dose are selected. The dose options are 0.01mcg/kg/min, 0.02
mcg/kg/min, 0.03mcg/kg/min, 0.04mcg/kg/min, and 0.05 mcg/kg/min and three weight ranges are
available. Weight ranges are > 11 kg, 2 to 10.9kg, and < 2 kg.
J. The duration of therapy is dependent upon the clinical response observed. If no response is noted
within 4 hours, a rapid wean can be performed.
K. The dose of epoprostenol will be decreased by 0.01 mcg/kg/min every 2 hours as tolerated until off.
L. If there is no response to the medication, a rapid wean can be performed.
M. The respiratory therapist will manage the administration of epoprostenol by inhalation. If either the
ventilator or BodyGuard 575 pump alarm, the respiratory therapist will be paged STAT to respond to
the alarm.
N. The bag of epoprostenol will be changed every forty-eight hours at a minimum due to the instability of
the drug.
O. An additional bag of epoprostenol for inhalation will be kept in the unit refrigerator at all times.
Respiratory Therapist will order the next scheduled bag to ensure it is prepared and on the unit two
hours prior to the anticipated hang time.
P. Patients receiving inhaled epoprostenol may receive inhaled medications, CPAP or IPV therapy. High
Flow Nasal Cannula can also be performed with epoprostenol. Epoprostenol will not be paused during
respiratory treatments.
Q. Due to the acuity of the patients when receiving epoprostenol, transport to procedural areas should be
minimized.
1. The RT must stay with the patient if taken to a procedural area other than the OR.
2. RT must provide a hand off report to OR nurse and inform RN of contact cell number.
3. Patients may not be transported to MRI while on inhaled epoprostenol.

R. Ventilated patient can be weaned from inhaled NO to inhaled epoprostenol.


VI. EQUIPMENT
A. Aeroneb Pro-X Generator and Nebulizer
B. BodyGuard 575 Infusion Pump
C. Infusion tubing sets (2)
D. HEPA filters (10)
E. Blue Gummie Adapter (1)
F. 15 mm adaptor (1)
G. Orange stickers labeled Caution: Epoprostenol RT for Inhalation Only
H. Ventilator elbow adaptor (1)
I. Tracking Epoprostenol form (1)

VII. PROCEDURE

A. Acknowledge the provider's order.
B. Review the patient's chart.
C. Use the body weight listed in the medication order to program the BodyGuard 575 pump.
D. Review epoprostenol monitoring practices with RN before initiating therapy.
E. Obtain epoprostenol from the pharmacy. Epoprostenol must be used within 48 hours of product
dilution. It must be discarded after 48 hours.
F. Add ONE hydrophobic HEPA filter to the expiratory inlet side of the ventilator circuit. Change
hydrophobic HEPA filter on the ventilator circuit every four hours or as needed. Discard the
filter and replace with a new filter.
G. Administer nebulized epoprostenol utilizing the Inhaled Epoprostenol Guide as a reference. (See
Related Link).
H. The patient’s blood pressure, heart rate, and oxygen saturation should be monitored by the RN and RT
every 15 minutes for the first hour of therapy and after each dose change, then every hour
thereafter.
I. Monitoring of the patient’s cardiac index, peripheral vascular resistance, total pulmonary
resistance, mean arterial pressure, and stroke volume are recommended but not required.
J. Notify the physician immediately if an adverse reaction to therapy occurs.
K. If the patient does not respond to inhaled epoprostenol within 4 hours of the initiation of therapy,
contact the physician and discontinue the epoprostenol.
L. When weaning the dose of inhaled epoprostenol in patients that demonstrate a response to therapy,
the dose should be weaned by 0.01mcg/min every two hours as tolerated until the medication is off.
M. The RT will check the system hourly for nebulization and complete documentation on
the epoprostenol flow sheet every two hours.
N. The BodyGuard lockbox will be locked at all times. The key must remain with the RT at all times and will
be handed off during report.
O. Patients should be considered for transition to epoprostenol within 12 hours if they are not weaned off
of NO. Refer to related links for the process of weaning NO to epoprostenol

VIII. References

A. RT Inhaled Epoprostenol Guideline.
B. San Francisco General Hospital Policy 213.2 Aerosolized Prostacyclin Delivery with the Aeroneb Solo
System.
C. Kemming G, Habler O, Kleen M, Kisch-Wedel H, Weite M, Zwissler B. Searching the ideal inhaled
vasodilator: from nitric oxide to prostacyclin. Eur Surg Res. 2002;34:196-202.
D. Lowson SM. Inhaled alternatives to nitric oxide. Crit Care Med. 2005:33:S188-S195.
E. Mikhail G, Gibbs S, Richardson G, et al. An evaluation of nebulized prostacyclin in patients with primary
and secondary pulmonary hypertension. Eur Heart J. 1997;8:1499-1504.
F. Ebb S, Stott S, Van Heerden P. The use of inhaled aerosolized prostacyclin (IAP) in the treatment of
pulmonary hypertension secondary to pulmonary embolism. Intensive Care Med. 1996;22:353-55.

G. Schroeder R, Rafii A, Plotkin J, et al. Use of aerosolized inhaled epoprostenol in the treatment of Porto
pulmonary hypertension. Transplantation. 2000;70:548-550.
H. Walmrath D, Schneider T, Pilch J, et al. Aerosolized prostacyclin in adult respiratory distress syndrome.
Lancet. 1993;342:961-962.
I. Vernon van Heerden P, Barden A, Michalopoulos N, Bulsara MK, Roberts BL. Dose response to inhaled
aerosolized prostacyclin for hypoxemia due to ARDS. Chest. 2000;117:819-827.
J. Walmrath D, Schneider T, Pilch J, et al. Direct comparison of inhaled nitric oxide and aerosolized
prostacylin in acute respiratory distress syndrome. Am J Respir Crit Care Med. 1996;153:991-96.
K. Zwissler B, Kemmin G, Habler O, et al. Inhaled prostacyclin versus inhaled nitric oxide in adult
respiratory distress syndrome. Am J Respir Crit Care med. 1996;154:1671-77.
L. Wet CJ, Affleck DG, Jacobsohn E, et al. Inhaled prostacyclin is, effective, and affordable in patients with
pulmonary hypertension, right heart dysfunction, and refractory hypoxemia after cardiothoracic
surgery. J Thorac Cardovasc Surg. 2004;127:1058-67

Approved by Director and Medical Director of Respiratory Care.

The original copy of this policy and procedure is maintained by respiratory care.