Nebulized flolan for severe ARDS

meandragonbrett · Dec 1, 2009

Nope, we don't use it.

Why does you not have nitric oxide? Physician preference? Cost? Facility thing?

sunnycalifRN · Dec 1, 2009

The same reason we don't have an oscillator . . . cost. We've tried to get both INO and an oscillator but, to no avail.

dmc_rrt · Dec 5, 2009

We started using it the other day, didn't see your results. INO is expensive and seldom works in ARDS. HFO is contraindicated in pt's requiring infection control, and our pt has H1N1

Nurseboy1 · Dec 11, 2009

I have an H1N1 patient right now on HFOV. We simply close the room door and wear N-95 masks when caring for the patient.

To answer the OP no haven't seen nebulized flolan. We generally use nitric oxide.

cindage · Feb 10, 2010

how do you regulate the dosing? is there a problem w/ rebound pulmonary htn? i haven't seen flolan approved for this use. there is a prostacyclin analogue called iloprost, which can be inhaled. have your md's considered that? so interesting.

sunnycalifRN · Feb 11, 2010

the dosing of the flolan is kind of inaccurate. nursing helps the RT's set up two IV pumps, one for the flolan and one for normal saline. the two lines are Y'd together and then it feeds into a mini-Heart nebulizer with the O2 flow set to 2 L/min (and the neb is inline on the inspiratory limb). the mini-Heart is supposed to use 6 ml of fluid/hr. by regulating the mix of flolan and NS and based on the concentration of the flolan, you come up with the dose.

but, in reality, the dosing is pretty "sketchy" because the neb does not always use 6 ml / hr. RT and the ICU docs usually titrate the dose to effect.

this is an "off-label" use of flolan; flolan is approved for treatment of primary pulmonary hypertension, not ARDS; however, we've had several great "saves" using the flolan

Biffbradford · Dec 25, 2012

We have been using nebulized flolan (epoprostenol) to treat the severe hypoxemia of intractable ARDS. (Flolan is generally used to treat primary pulmonary hypertension.) RT puts a continuous nebulizer in-line and we set the IV pump to drip in the flolan. We don't have inhaled nitric oxide, which is why we're using flolan. If it's going to work, it works within the first half hour and it's amazing to watch the sat's rise up into the high 90's. Is anyone else using nebulized flolan for ARDS?

From what I've read, Flolan is ~$225/day. Inhaled Nitric Oxide is ~$125/hr.

imaginations · Dec 26, 2012

Nitric is $75/hour (AUD) or thereabouts in our unit. I haven't seen nebulised Folan but we recently had a patient on continuous infusion of epoprostenol, syringe and line changed 8th hourly, requiring an entire new box opened (i.e. drug and dilutent) -- that had to cost at least as much as nitric!

However in my unit we have HFOV and nitric on hand at all times with nil concerns about usage costs.

TraumaSurfer · Dec 27, 2012

I have seen Nitric Oxide work many times in ARDS patients. There is also no contraindications for the use of HFOV in H1N1 or other infectious diseases unless there is a pneumothorax which is unresolving. Our hospital also used HFOV (Sensormedics 3100B) several times to save H1N1 patients 2 years ag with no problems. The HFOV has filters and the patients were in isolation rooms.

The HFOV 3100A (along with nitric oxide) has also been used successfully for the past 20 years for pediatrics and neonates.

Flolan has also been accept as treatment of pulmonary hypertension for several years. It is also relatively easy to transport without special equipment or an RT and can be administered by different methods including ventilator, NIPPV and mask/neb. Some patients may already be on or be transitioned to a home med version such as Ventavis. IV Flolan can also be used. I know 2 of the best hospital in San Francisco, both associated with UCSF, use Flolan or something very similar.

The cost for Flolan is approximately $45/vial. This comes to about $180/24 hours. Nitric oxide is $95/hour. Flolan requires no special equipment so it can be instituted in even remote hospitals relatively easily.

This article has some great references and do a good overview of comparing Nitric Oxide and inhaled prostacyclin.

Aerosolized Prostacyclin vs Inhaled Nitric Oxide | The American College of Chest Physicians

all517 · Dec 27, 2012

So interesting! This is why I love coming to this site.

TraumaSurfer · Dec 27, 2012

the dosing of the flolan is kind of inaccurate. nursing helps the RT's set up two IV pumps, one for the flolan and one for normal saline. the two lines are Y'd together and then it feeds into a mini-Heart nebulizer with the O2 flow set to 2 L/min (and the neb is inline on the inspiratory limb). the mini-Heart is supposed to use 6 ml of fluid/hr. by regulating the mix of flolan and NS and based on the concentration of the flolan, you come up with the dose.
but, in reality, the dosing is pretty "sketchy" because the neb does not always use 6 ml / hr. RT and the ICU docs usually titrate the dose to effect.
this is an "off-label" use of flolan; flolan is approved for treatment of primary pulmonary hypertension, not ARDS; however, we've had several great "saves" using the flolan

The dosing of almost any aerosolized medication including Albuterol is "sketchy". A nebulizer may only deliver about 10 -20% of the medication especially when given by mask and a regular nebulizer. On a ventilator, rainout, deadspace, ETT size and flow all are variables in the actual depositon. MDIs are sometimes preferred because of the timing with the ventilator. For non intubated patients, with the use of a spacer the patient can get 60% or more of the delivered dose which makes them a good choice in a rescue situation if the patient is alert.

As far as off label, how many of your patients get "Albuterol" for just about everything regardless of age and diagnosis? Check the FDA approval for Albuterol. UCSF and MGH also did a study for use of Albuterol and ARDS. Guess what they found? They also studied IV Albuterol which had been done in other countries for several years for bronchospasm. Another somewhat surprising result.