Al Heuer, PhD, MBA, RRT, RPFT Associate Professor Rutgers-SHRP

Describe what is Flolan Review how is works and on whom it should be used Summarize the indications and contraindications Review the equipment set-up and how to administer it via a ventilator circuit. Examine some cases as to how it was introduced into the hospital and some case applications Share some additional resources on how to find out more about Flolan

Flolan ®, or epoprotenol, is an synthetic prostacyclin which relaxes smooth muscle cells induced by an increase in intracellular adenosine 3’,5’ cyclic monophosphate Results in vasodilation of the pulmonary & systemic vasculature in a dose-dependent manner Indications: Pulmonary hypertension acute right heart dysfunction Hypoxemia related to pulmonary vasoconstriction In addition, prostaglandin has an inhibitory effect on platelet aggregation Finally, prostaglandin inhibits activation of leukocytes and monocytes during the inflammatory reaction

Welte and his colleagues (1993) reported that inhaled PGI2 resulted in selective PA vasodilation in dogs Inhaled PGI2 reaches only well ventilated areas of the lungs, causing selective vasodilation in these regions than the IV route does, while not causing systemic hypotension Analog drugs: Synthetic analogs of prostacyclin (PGI 2 ).analogprostacyclin Treprostinil (marketed under the trade names Remodulin for infusion and Tyvaso for inhalation) Inhaled Iloprost (Ventavis) by Mask and nebulizer It’s NOT a medical gas like Nitric Oxide…but rather a nebulized drug!!!

 The use of Flolan ® causes marked pulmonary vasodilatation  Also does so while maintaining gas exchange and systemic arterial pressure.  There is a significant decrease in mean pulmonary artery pressures (PAPs) without noticeable change in mean arterial pressures.

 Post op for Primary Pulmonary Hypertension  Utilized in conjunction with a Ventricular Assist Device, (most commonly Right Ventricular Dysfunction).  To reduce and maintain PA pressures allowing for Heart rest, recovery, and healing.  To treat low (EF) Ejection Fraction of < 20%.  Treatment of hypoxemia secondary to ARDS, Acute Lung Injury, or V/Q mismatching.

 Comparable beneficial effects of pulmonary vasodilation without affecting systemic systems: - Reduced pulmonary artery pressure - Reduced pulmonary vascular resistance - Reduced transpulmonary gradient (Chest 1998; 114; )  Improved oxgenation.  Lack of data showing increased survival for ARDS patients.

The delivery system for Inhaled Flolan ® is relatively simple to assemble The drug is generally available in most hospitals and more available than inhaled Nitric Oxide Tends to be less expensive than inhaled Nitric Oxide. Data tend to support overall effectiveness in a clinical setting for treating: – Pulmonary Htn – Pul vasoconstriction with ARDS

CCost--~$100/hour vs ~$220/day) EEpoprostenol lacks the toxic effects/metabolites of nitric oxide and therefore does not need a complicated delivery system. EEpoprostenol can inhibit platelet aggregation. EEpoprostenol does not bind with hemoglobin (no increase in methemoglobin)

One 500-Bed NJ hospital has saved over $400K annually by supplementing their INO usage with Flolan. Other hospitals have had similar experiences. That’s equivalent to about the salary and benefits for about four FT Respiratory Therapists or Nurses.

In general, Flolan has a favorable safety (Risk to benefit) profile. Rarely can exacerbate hypotension & bleeding. – Not reported in typical dose range – Avoid aerosolized PGI2 during active pulmonary hemorrhage More common side effects include: – Flushing – Headache – Nausea & vomiting – Hypotension – Anxiety – Chest pain – Dizziness

 Limited, but growing body of evidence  Mostly case reports and small studies ◦ Some case studies ◦ Many studies had a small number of patients/subjects ◦ No control or placebo groups ◦ Not all results are attributable to inhaled PGI2 ◦ Incomplete data for some variables, such as PVR, wedge pressure, CVP

Rabinovich, et al. (2011) Chest Physician-Review Article: Inhaled PGI 2 is as effective as iNO for S/T mgt of PH and impaired oxygenation with potentially fewer side effects, lower costs, and greater ease of administration. However, further randomized, controlled studies are needed. De Wet, et al. (2004) – Prospective interventional study of 126 cardiothoracic surgical patients with pulmonary Hypertension – PGI2 decreased mean PA pressures without altering mean arterial pressure – There was a significant improvement in the PaO2/FiO2 ratio in patients with refractory hypoxemia Haché, et al. (2001) Chart review of 27 patients who received inhaled PGI2 over a one-year period – Selective pulmonary vasodilation occurred in 78% of patients – Improvement in PaO2/FiO2 ratio in 88% – Concluded that inhaled PGI2 can be useful in the treatment of patients with pulmonary hypertension & severe hypoxia

Anatomy of precapillary pulmonary arteries

◦ Though it may be used on spontaneously breathing patients ◦ Patients should in an area capable of continuous cardiac monitoring.  Post-Open Heart ICU  CCU  OR  CATH LAB

 When started in the cardiac cath. lab or OR setting, it is recommended that there be no break in delivery during transport of the patient from one area to another, (i.e. ICU/CCU). When transported from area to area there needs to be an oxygen cylinder to nebulize the Flolan ® and another cylinder to ventilate the patient.

 In general, there are 3 recommended dosages: ◦ Full strength 10mcg/ml ◦ Half strength 5mcg/ml ◦ Quarter strength 2.5mcg/ml At many hospitals, the dosing is 10mcg/ml

Flolan® will be received from pharmacy in appropriate dosages as ordered by the physician. Flolan ® will be stored in the unit medication refrigerator until needed. When initiating, or starting a subsequent treatment, always confirm that there is an additional new vial of Flolan ® available in the refrigerator in the correct dosage for the next treatment. If not, notify pharmacy and obtain the verbal or written prescription for the continuation of therapy.

Flolan ® 10mcg/ml will be the most commonly used dosage. All meds will be delivered from the pharmacy premixed.

 Flolan ® generally comes to the clinical area from pharmacy premixed, in the prescribed dosage. Any vial of medication not mixed to the physician’s prescribed dosage should generally be returned to pharmacy to be reconstituted.

Confirm prescription, typical dose is 10mcg/ml, at 8ml/hr Flolan ® will be drawn up from individual bottles when needed by use of a syringe and blunt needle. 24ml of Flolan ® will be added to a Mini Heart Nebulizer. The nebulizer will be inserted into the inspiratory limb of the circuit at the wye. – Use caution to stabilize the nebulizer to prevent spillage of the contents, due to it’s viscous nature. The Nebulizer will be covered to protect the contents from light due to a light sensitivity. The Flolan ® will be nebulized at a flow rate of 2 lpm. – At a flow of 2 lpm the contents should nebulized in approximately 3 hours.

The mechanical ventilator will be assembled with a heated circuit and humidification device. There will be an Oxygen Blender on the ventilator to generate the 2 liter per minute flow to power the Mini Heart Nebulizer at the same FiO2 as the Ventilator. The circuit will have 2 hepa filters located on the expiratory limb of the circuit. – The first filter is just after the patient wye, and the second is at the end of the circuit prior to the collection bottle. – The Hepa filters will be changed every three hours when a new Mini Heart of Flolan ® is started or as needed, if the peak airway pressures reflect an unexpected increase.

 Expired minute volume, ventilation pressures, patient-initiated triggering, FiO2, & heated humidifier settings may vary due to nebulizer flow into circuit  Glycine buffer makes aerosol sticky  Change expiratory filters Q4H or sooner to prevent sticking of expiratory valve and auto PEEP

An oxygen blender must be used to power the nebulizer to achieve the same FiO2 as the ventilator settings.

 The Mini Heart nebulizer must be shielded from light.

Note: 2 filters connected to the exhalation port on vent. The IV pump will be labeled for RT use only and will only be handled by respiratory therapy. Make sure to use only a heated wire circuit.

Miniheart nebulizer in alternate location just distal to the humidifier. Use the blender to match the patient’s set FiO2 and run the flowmeter at 2-3 lpm. On/Off switch

One common approach is to titrate medication, from full strength (10mcg/ml), to half strength (5mcg/ml), and then to quarter strength (2.5mcg/ml), prior to discontinuation. Titration of Flolan ® will be reconsidered if a patient demonstrates an increase of PA pressures within 30 minutes of titration or discontinuation If patients display a significant increase of PA pressure, the physician should be contacted to resume Flolan® at either initial or half-dose/concentration (either 10 or 5 mcg/ml.

Per Protocol, no weaning is necessary. Flolan ® effect is completely resolved within 24 minutes of termination. – After discontinuation of Flolan ®, close observation of PA pressures are required. – If a significant increase in pressures, (≥ 20%), are observed, restarting the medication is indicated. – When restarting Flolan ® a new Mini-Heart® Nebulizer should be used and a new vial of medication obtained, so that dosage and duration can be precisely determined. – When restarting the med, resume administration at full or ½ strength, (5mcg/ml), and titrate to ¼ strength, (2.5mcg/ml), at 30 minutes. If PA pressure is acceptable attempt stopping the Flolan and attempt extubation again.

 Per any Medication, an order to discontinue the medication must be obtained prior to discontinuation.  Documentation of PA pressures should be documented and followed closely for up to 30 minutes following Flolan ® termination. (All effects of Flolan ® should be resolved after 24 minutes of termination.)  In the event of elevated PA pressures Flolan ® may need to be resumed. Do not discard the Nebulizer set-up until 30 minutes has passed and Hemodynamic stability has been confirmed.  If the patient demonstrates Hemodynamic and Pulmonary Stability beyond 30 minutes, this suggests that Flolan will no longer be neeeded.

 If a patient is unable to tolerate termination of Flolan prior to extubation, there are alternatives.  Alternatives include the following:  Intravenous route Flolan ®  Oral Silendafil, (Viagra ®)  Inhaled Iloprost ® (Ventavis) by Mask and nebulizer

 At this time there are no studies documenting the safe administration of any Bronchodilator in conjunction with the use of Flolan. There is no FDA approval for any Bronchodilator to be given with Flolan running.

To Pharmaceuticals & Therapeutics Committee in December 2005 (since delivery route not HPB approved) Implemented PGI2 guidelines/policies/procedures for adult patients in April 2006 in surgical suites, ICU, & cardiac surgical unit Revised policies & procedures in March 2008 to include pediatric patients Currently reviewing case reports of PGI2 use in newborn patient population

 69 YO male with a history of cardiomyopathy is intubated and mechanically ventilated due to a severe exacerbation of CHF. He currently has Swan Ganz catheter in place and his cardiac output is 2.9 L and PAP is 52/35 torr. His FIO2 was recently raised to 65% to maintain an SPO2 of 92%.  Patient was started on Flolan, 10mcg/ml, at 8ml/hr. ◦ Within 6 hours: PAP decreased to 35/19 torr, CO 3.6 L, SPO2 95% on FIO2 50% ◦ Within 2 days, other clinical indicators (renal function) improved. ◦ Patient successfully extubated 5 days later.

 57 Yo intubated/ventilated female post-trauma patient becomes septic and develops ARDS. Her CXR has bilateral obtuse infiltrates (ground-glass appearance), she has refractory hypoxemia (P:F ratio < 150) and A/W pressures have increased to the mid-40s cm H2O.  She was switched to PCV (from volume control) and started on Flolan, 10mcg/ml, at 8ml/hr. ◦ Within one day, P:F increased to 245, FIO2 successfully weaned to 50% from 75%. ABG’s were within acceptable limits. ◦ One week later the patient was successfully extubated. 

Use of inhaled PGI2 is a promising therapy for the treatment of pulmonary hypertension & hypoxia of various origins Therapy must be based on: – Suitable patients – Proper procedures and training – Continual therapy, until intentionally withdrawn Further studies are required to determine dose- responsiveness, optimal condition of utilization, and impact on survival The pursuit of its use requires the collaborative effort of respiratory therapists, nurses, physicians, and pharmacists

 Flolan Information Center: center.com/ center.com/  US Food & Drug Administration:  "epoprostenol" at Dorland's Medical DictionaryepoprostenolDorland's Medical Dictionary