Flolan Moodles W Notes

Pulmonary Vasodilators
And
Epoprostenol (Flolan) in
Respiratory Care
Presented by Elsie Chuang, RCP, MS, RRT-NPS, RRT-ACCS
Stanford Medicine Children's Health,

3/14/2024 1
Respiratory Care, E.Chuang
Welcome! We will be learning various pulmonary vasodilators. We will cover what they
are and how they work. We will specifically focus on Epoprostenol, aka Flolan.
1
Objectives
1. Explain the pulmonary hypertension pathways.
2. Describe the different pulmonary vasodilators and list
their potential side effects and interactions.
3. Study the indications of Epoprostenol (Flolan.)
4. Understand the usage, considerations and cautions of
Flolan in LPCH.
5. Describe the policy and procedures the RCP needs to
know to correctly set-up inhaled Flolan
6. Teach the proper calculations needed to correctly set-
up inhaled Flolan and verify with the syringe pump &
MAR.
3/14/2024 2
In the following presentation, we will look at different pulmonary hypertension

pathways in our bodies. We will look at what are the pulmonary vasodilators available
to address each of the pulmonary hypertension pathways. We need to understand how
this medications interact with other medications and their side effects.
Then, we will focus on Epoprostenol, aka Flolan. We will look at the studies supporting
nebulization of Flolan. We will look at how Flolan can be used and ordered at LPCH. We
need to understand the considerations, drug interactions, potential adverse reactions
and side effects for the patients receiving nebulized Flolan. We will go into the proper
set up of Flolan delivery system and proper dosage with calculations according to the
policy and procedure.
2
3/14/2024 3
What goes into the development of Pulmonary Hypertension, as PH

Cellular and molecular mechanisms play a vital role in the development of PH. The
mechanisms include
1. Dys-regulation of vascular tone,
2. Abnormal proliferation of cells by cytokines & metabolic changes, and
3. Hypoxia-induced vasomotion & remodeling.
Pulmonary arterial hypertension (PAH) is caused by functional and structural changes in

the pulmonary vasculature, leading to increased pulmonary vascular resistance.
The process of pulmonary vascular remodeling is accompanied by endothelial

dysfunction, activation of fibroblasts and smooth muscle cells, crosstalk between cells
within the vascular wall, and recruitment of circulating progenitor cells.
Excessive cell proliferation and impaired apoptosis (death of a cell) in pulmonary

vessels leading to structural remodeling is most evident in pulmonary arterial
hypertension (PAH), and several factors have been implicated, including mitochondrial
dysfunction and mutations in bone morphogenetic protein receptor type 2.
3
3/14/2024 4
There are 3 main pathophysiologic pathways that can address pulmonary arterial
hypertension and reduce pulmonary vascular remodeling.
I. Prostacyclin cAMP pathway: vasodilation and anitproliferation function: Prostacyclin
is a powerful cardioprotective hormone released by the endothelium of all blood
vessels.
1. Prostacyclin PGI2 is an endogenous metabolite of arachnidonic acid with
potent vasodilatory effects.
2. Prostacyclin, a prostanoid metabolized from endogenous arachidonic acid
through the cyclooxygenase (COX) pathway, is a potent vasodilator that has
been identified as one of the most effective drugs for the treatment of
pulmonary arterial hypertension.
3. The prostacyclin pathway involves prostacyclin binding to the IP receptor,
which belongs to a family of prostanoid target receptors. Prostanoid binding
to the IP receptor induces adenylate cyclase activity, cAMP production and
ultimately reduction of Ca2+ concentrations, and leads to vasodilation
II. Endothelin Pathway: vasoconstriction and proliferation

1. Endothelin-1 (ET-1), which is found in high levels in PAH, is a known potent
vasoconstrictor with proliferative vascular remodeling properties. Left unchecked,
endothelin excess, along with other derangements, may contribute to the
development and perpetuation of PAH.
2. In the endothelin pathway the effects of endothelin (ET)-1 are
4
mediated via the ETA and ETB receptors. Receptor binding leads to activation of
phospholipase-C and mobilisation of calcium, resulting in vasoconstriction.
III. Nitric oxide cGMP: vasodilation and anti proliferation: elevated vascular resistance
in pulmonary arterioles
1. Nitric oxide signaling is mainly mediated by the guanylate cyclase/cyclic
guanylate monophosphate pathway. The effects of this second messenger system are
limited by enzymatic degradation through phosphodiesterases (PDEs).
2. The common pathophysiological features of PAH include pulmonary
vasoconstriction, intimal and smooth muscle proliferation, in situ thrombosis, and
pathological remodeling of pulmonary arterial circulation.
3. The nitric oxide (NO) pathway involves the production of cGMP, which leads
to inhibition of calcium entry, resulting in vasodilation.
4
Pulmonary Vasodilators
• Tyvaso (Treprostinil): Inhaled (2002)
– Prostacyclin analog
• Iloprost (Ventavis): Inhaled (2004)
– Prostacyclin analog
• Remodulin (UT-15): SC or IV
• Tracleer (Bosentan): Tablet (2001)
– Endothelial receptor antagonist
• Sildenafil (2005): Oral
– Phosphodiesterase type 5 inhibitor
• Epoprostenol (Flolan): IV & Inhaled (1995)
– Prostaglandin (prostacyclin)
Nitric Oxide: Inhaled (selective)
• 3/14/2024 Stanford Medicine Children's Health,
5
This is the list of commonly used vasodilators to treat pulmonary hypertension.

Tyvaso, Iloprost, Remodulin and Epoprostenol are targeting the Prostacyclin-cAMP
pathway. Tracleer is the only medication on the list addressing the Endothelin pathway.
Both Sildenafil and nitric oxide are targeting the Nitric oxide-cGMP pathway.
Inhaled drugs are Tyvaso, Iloprost, Epoprostenol and Nitric Oxide. Tyvaso and
Remodulin and Epoprostenol can via injection as well. Tracleer and Sildenafil are oral
medication.
5
Tyvaso (Treprostinil)
Prostacyclin Vasodilator
• Uses: PH to improve exercise tolerance
• Use only with Tyvaso Inhalation System
• Cautions: Patients with underlying lung disease
• Risk of bleeding
• Hypotension
• Hepatic or renal insufficiency patients may
receive larger systemic doses
• Sodium hydroxide and hydrochloric acid may be
added to adjust pH between 6.0 and 7.2
• Most common side effects: Headache, cough,
throat irritation, nausea, flushing, syncope
(<1%)
• Dosing: 3-12 breaths QID
• Cleaning: Daily with warm soapy water and air
dried
• LPCH: Parents to clean & administer
• RCP: Document given, premed if necessary
3/14/2024 6
While there are long-term data on use of treprostinil by other routes of administration,
nearly all controlled clinical experience with inhaled treprostinil has been on a
background of bosentan (an endothelin receptor antagonist) or sildenafil (a
phosphodiesterase type 5 inhibitor).
Tyvaso is the brand name for inhaled Treprostinil and is used only with the Tyvaso
nebulizer. The dosing is between 3 to 12 breaths and 4 times daily. The medication is
prepared once daily in the morning, general by the family or the patient. The family will
assist the administration of the medication and responsible for the cleaning of the
nebulizer at the end of the day. RCP is responsible to bring the medication, to observe
the administration and to chart on EPIC. RCP is also responsible to give pre-medication
as needed.
Be caution for patients with underlying lung disease. Watch out for bleeding and
hypotension. The dosage may need to adjusted for hepatic or renal insufficiency
patients. Common side effects are headache, cough, throuat irritation, nausea, flushing
and possible syncope.
Pregnant or plan to become pregnant. It is not known if Tyvaso will harm an unborn
baby. Women who can become pregnant should use effective birth control while taking
Tyvaso.
Patients that are breast-feeding or plan to breast-feed. It is not known if Tyvaso passes
6
into breast milk. Talk to your patients about the best way to feed their baby while taking
Tyvaso
AVAILABLE VIA SPECIAL PHARMACIES
6
Ventavis (Iloprost)
Synthetic Prostacyclin Analogue

• Special Nebulizers: I-Neb AAD System
• Dosing: 10-20 minutes Q 2hrs (not during sleep hours) but 6 sessions/day
• Monitoring: Not evaluated with patients with CLD or asthma
Watch for hypotension, syncope, pulmonary edema
• Serious side effects: CHF, Chest pain, SVT, Dyspnea
• Side effects: flushing, cough, headache, nausea, hypotension, insomnia
• Cost: $60,000-$70,000 per year
• BRONCHOSPASM HAS BEEN REPORTED IN PATIENTS WITH RAD
• LPCH: Have parents self dose & RCP documents treatment & pre med
given

3/14/2024 7
Ventavis is the brand name for Iloprost, used only by I-Neb AAD system. The AAD
system is breath actuated nebulizer. The dosing is usually 6-9 times a day. Inhaling
Ventavis gets the medication to the lungs, the site of hte disease.
Ventavis may lead to serious side effects, as CHF, chest pain, SVT or dyspnea. Common
side effects are flushing, cough, headache, nausea, hypotention and insomnia.
Bronchospasm has been reported in patients with reactive airway disease.
The same practice in LPCH as Tyvaso. The patient / family do self-administration and
RCP documents treatment and administrates pre-med when needed.
7
Remodulin (Treprostinil) Injection
Synthetic Prostacyclin
• Dose delivery: mini-infusion pump for
Subcutaneous infusion
• Continuous intravenous (IV) infusions of Remodulin delivered using an
external infusion pump, with a tube placed in a central vein within the chest,
are associated with the risk of blood stream infections and sepsis, which may
be fatal. Therefore, continuous subcutaneous (SC) infusion delivered just
beneath the skin is the preferred type of delivery.
• Serious side effects: Worsening PAH symptoms,
low blood pressure/ hypotension.
• Side effects: headaches, flushing, nausea,
diarrhea, injection site pain/irritation.

3/14/2024 8
Remodulin is the brand name for injection form of Treprostinil. There are two ways of
injection, continuous intravenous infusion or continuous subcutaneous infusion. In
LPCH, the subcutaneous infusion is more commonly used. Generally, Remodulin is used
to titrate with Epoprstenol. Watch out for serious side effects, such as worsening
hepertension symptoms or low blood pressure. Common side effects are headaches,
flushing, nausea, diarrhea and injection site pain and irritation.
8
Tracleer (Bosentan)
• Endothelium Blocker
• Tablet form
• Risks: liver toxicity, potential
harm to developing fetus
• Possible side effects: fluid
retention, swelling of ankles and legs, lower
sperm count in men, low red blood cell levels.
• Common side effects: respiratory
tract infection, headache, fainting,
flushing, low blood pressure, sinusitis,
joint pain and irregular heart beats.

3/14/2024 9
Endothelin narrows blood vessels and elevates blood pressure. Bosentan is the
medication to address the Endothelin pathway. Tracleer report improved exercise
ability, which is due to the ability of Tracleer to block a substance made by the body
known as endothelin. First oral medication to receive full FDA approval in the US.
Bosentan, sold under the brand name Tracleer, is a dual endothelin receptor
antagonist medication used in the treatment of pulmonary artery hypertension.
Bosentan is available in tablets for oral suspension.
Tracleer can cause serious side effects including liver damage and serious birth
defects. The possible side effects of Tracleer are fluid retention, swelling of
ankles and legs, lower sperm count in men, low red blood cell levels. The most
common side effects include respiratory tract infection, headache, fainting,
flushing, low blood pressure, sinusitis, joint pain and irregular heart beats.
9
Epoprostenol (Flolan)
• This is the first drug specifically approved for the treatment of pulmonary hypertension.
• Flolan is the most effective drug for the treatment of advanced disease.
• Studies have shown the drug to be effective in pulmonary arterial hypertension (PAH), as well
as pulmonary hypertension related to scleroderma, lupus, congenital heart disease, diet-pill
associated and stimulant associated pulmonary hypertension (PH).
• Flolan requires a substantial commitment from the patient. This medication is delivered by a
continuous infusion via a special intravenous catheter. The medication must be mixed on a
daily basis and kept refrigerated. Meticulous attention must be paid to catheter care to
prevent serious infections.
• Flolan can also be nebulized and deliver directly to the lungs, the target disease areas.
• Flolan will be set up as a continuous nebulization through a ventilator for an intubated
patient.
• Due to its properties, great cares are required.
• Common side effects include headache, jaw discomfort, flushing, rashes, and stomach upset.
• In patients with advanced disease, this medication improves exercise capacity and survival.
Periodic monitoring of blood counts is required.

3/14/2024 10
This is the first drug specifically approved for the treatment of pulmonary
hypertension. Flolan is the most effective drug for the treatment of advanced disease.
Studies have shown the drug to be effective in pulmonary arterial hypertension
(PAH), as well as pulmonary hypertension related to scleroderma, lupus, congenital
heart disease, diet-pill associated and stimulant associated pulmonary hypertension
(PH). Flolan requires a substantial commitment from the patient. This medication is
delivered by a continuous infusion via a special intravenous catheter. The medication
must be mixed on a daily basis and kept refrigerated. Meticulous attention must be
paid to catheter care to prevent serious infections. Flolan can also be nebulized and
deliver directly to the lungs, the target disease areas. Flolan will be set up as a
continuous nebulization through a ventilator for an intubated patient. Due to its
properties, great cares are required. Common side effects include headache, jaw
discomfort, flushing, rashes, and stomach upset. In patients with advanced disease,
this medication improves exercise capacity and survival. Periodic monitoring of
blood counts is required.
10
Epoprostenol (Flolan)
• Synthetic prostacyclin analog
• FDA approved for IV administration for PH in
adults
• Nonselective pulmonary vasodilator
• Drug is titrated to effect/improve PH
symptoms while attempting to minimize
associated side effects

3/14/2024 11
Flolan is synthetic prostacyclin analog. It is non-selective so it could affect systemic

blood pressure. Flolan is FDA approved for IV administration for pulmonary
hypertension in adults. Nebulized continuous Flolan is off label but practice widely due
to its effectiveness to target the disease area, the lungs. The medication is titrated to
improve pulmonary hypertension symptoms while attempting to minimize associated
side effects.
11
Epoprostenol in Infants
Case studies
• 4 term infants (PH refractory to iNO)
– Treated for 7-18 days @ 50ng/kg/min
– OI reduced 29±5 to 19±7
• 1 case neonate with TAPVR & acute intra-
operative PH (Zwissler et al 1995)
• 1 case preterm infant with RSV (HFOV + Flolan)
– Successful treatment 6 days (Gupta et al 2012)

3/14/2024 12
Why might the doctors want to use this? What were the evidence-based studies?
1. In one study with 4 term infants (PH refractory to iNO)
Treated for 7-18 days @ 50ng/kg/min
OI reduced from 29±5 to 19±7 within one hour of treatment
3 infants survived. The one infant died was autopsied and found to have
alveolar capillary dyskinesia.
2. In Zwissler et all 1995 study, 1 case neonate with TAPVR & acute intra-operative PH
was treated with Flolan.
3. In Gupta et al 2012 study, 1 case preterm infant with RSV (HFOV + Flolan) had
uccessful treatment for 6 days.

s
12
Epoprostenol in Infants (cont.)
Kelly et al (2002)
• 75% of infants with inadequate response to
inhaled nitric oxide demonstrated improved
OI with inhaled prostacyclin
• Risks associated with treatment
• Rebound PH
• Unexpected disruption of delivery
• Airway damage
• Condensation
• Damage to ventilator valves
3/14/2024 13
In Kelly et al 2002 study, 75% of infants with inadequate response to inhaled nitric
oxide demonstrated improved OI with inhaled prostacyclin. The risks associated with
Epoprostenol treatment included rebound PH, unexpected disruption of delivery,
airway damage, condensation and damage to ventilator valves.
13
Epoprostenol in children with PH
and Cardiac Surgery
• Data is limited
• Retrospective review (n=20)(Brown et al 2012)
– Neonates(13) in the trial revealed significant
change in OI
– Improved RV function
• Prospective trial (n=6) (Carroll et al 2005)
– Reduction in mean PA pressure
– Improvement in PaO2/FiO2 ratio without change
in cardiac index
3/14/2024 14
Data are limited for Epoprostenol in children with PH and cardiac surgeries. In a
retrospective review by Brown et al 2012, 13 out of 20 neonates in the trial revealed
significant change in OI and improved RV function. In a prospective trial by Carroll et al
2005, 6 children showed reduction in mean PA pressure and improvement in
PaO2/FiO2 ratio without change in cardiac index.
14
Where & who can order Inhaled
Epoprostenol?
• Only in critical care areas (ICUs) & OR
• Under direction of an ICU Attending,
Pulmonary Hypertension attending physician
or Anesthesiologist

3/14/2024 15
At LPCH, the continuous nebulized Flolan therapy can only be administrated in intensive
care units or operation rooms under direction of an ICU attending, pulmonary
hypertension attending or anesthesiologist.
15
Indications at LPCH
• Neonatal & Pediatric Patients
• Hypoxic respiratory failure &/or PPHN REFRACTORY to usual
therapies (iNO & HFOV)
• Cardiac Patients
• Peri-operative or post surgical patients on mechanical
ventilation who requires pulmonary vasodilation for optimal
oxygenation & hemodynamics
• Transport
• Transport of a newborn or pediatric patient currently
receiving aerosolized epoprostenol at OSH
3/14/2024 16
The indications of continuous Flolan nebulization are

1. Hypoxic respiratory failure and or PPHN regractory to usual therapies, such as iNO
and HFOV, for neonatal and pediatric patients.
2. Peri-operative or post surgical patients on mechanical ventilation wo requires
pulmonary vasodilation for optimal oxygenation and hemodynamics.
3. Transport of a newborn or pediatric patient currently receiving aerosolized
Epoprostenol at outside hospitals.
Most cases are transports into NICU already on Flolan coming here for transition to
Nitric Oxide.
16
Considerations
• “When considering aerosolized epoprostenol
for a patient being transferred, notify
respiratory therapy & pharmacy well in
advance to enable adequate medication and
equipment preparation”
• Respiratory therapy is responsible for the

administration of aerosolized epoprostenol

3/14/2024 17
Respiratory care department is responsible for the administration of aerosolized

Epoprostenol. Notify respiratory care and pharmacy well in advance to enable
adequate medication and equipment preparation when considering aerosolized
Epoprostenol for a patient in the unit or being transported into the unit.
17
Drug Interactions
• Can not be combined with any other inhaled
medication
– When absolutely needed, escalated to Respiratory management and Respiratory
medical director for exception.
• Caution should be used when combination of

other drugs can cause systemic vasodilation
&/or hypotension.
– Ca Channel blockers
– Phosphodiesterase 5 inhibitors (sildenafil, tadalafil)
– ACE inhibitors
– Nipride
– Dobutamine
– Isoprel
– Diuretics
3/14/2024 18
A lot of care is required to set up continuous Flolan and to ensure properly delivery of
the potent medication. All other nebulized treatment should be hold off during Flolan
treatment to minimize side effects from multiple drugs. Caution should be taken when
combining with other PO & IV medications for systemic vasodilation and for blood
pressure.
18
Potential Adverse Reaction or
Events
• Severe rebound pulmonary hypertension
• Airway irritation
• pH: ~12.0
• Tracheitis
• Intrinsic PEEP development
• PIP elevation
• Ventilator malfunction
• Valves
• Condensation
3/14/2024
19
Severe rebound pulmonary hypertension can occur in the event of abrupt

discontinuation of the drug. Must be weaned slowly. As highly base solution, it can
cause airway irritation which may result to tracheitis. It can cause development of
bronchospasm in the upper airway which can elevate intrinsic PEEP and PIP. In
addition, It can lead to ventilator malfunction: valves, and excessive condensation in
tubing.
19
Potential Side Effects
• Systemic hypotension
• Flushing
• Nausea
• Diarrhea
• Platelet aggregation (IV)
3/14/2024 20
Other potential side effects include systemic hypotension from Flolan non-selective
property, flushing from vasodilation, nausea from reduction in blood pressure, and
diarrhea from high dosage. There is also a concern on platelet aggregation when
administrating Flolan via IV.
20
Pharmacy Considerations
• Dosing
– Drug is dosed by ng/kg/min
– Recommended initial dose is 10ng/kg/min
– Maximum dose 50ng/kg/min
• Drug Preparation
– Must be reconstituted with Flolan diluent
– Light sensitive
– 2 syringes will be prepared when drug is initiated

3/14/2024 21
On dosing:
Drug is dosed by ng/kg/min
Recommended initial dose is 10ng/kg/min
Maximum dose 50ng/kg/min
On drug preparation:
Must be reconstitued with Flolan diluent
Light sensitive
2 syringes will be prepared when drug is initiated. (1 to be kept in the
refrigerator)
21
RCP:
Objectives
Desired effects
• An increase in oxygenation
• Improved ventilation to perfusion matching
• Improved redistribution of pulmonary blood flow
to ventilated areas of the lung
• A reduction in pulmonary artery pressure, PVR &
RV afterload
• A reduction on Oxygen Index

3/14/2024 22
For Respiratory Care, keep focus on objectives of using continuous nebulize Flolan. We
want to obtain:
•An increase in oxygenation
•Improved ventilation to perfusion matching
•Improved redistribution of pulmonary blood flow to ventilated areas of the
lung
•A reduction in pulmonary artery pressure, PVR & RV afterload
•A reduction on Oxygen Index
22
RCP:
Considerations
• The Aeroneb Solo Pro X system & syringe
pump is the system to be used at LPCH
(continuous mode ONLY.)
• ALL patients will have nitric oxide INLINE with
the ventilator as emergency back up.
• A 2nd Aerogen nebulizer & generator will be at
the bedside in case of equipment failure.
• Manual ventilation & circuit disconnect.
should be limited to true emergencies.
3/14/2024 23
These are important point when setting up continuous Flolan:

• The Aeroneb Solo Pro X system & syringe pump is the system to be used at LPCH in
continuous mode ONLY.
• ALL patients will have nitric oxide INLINE with the ventilator as emergency back
up.
• A 2nd Aerogen nebulizer & generator will be at the bedside in case of equipment
failure.
• Manual ventilation & circuit disconnect should be limited to true emergencies.
23
RCP set up process:
Medication
Epoprostenol
– Stable for 72 hrs (8 days if refrigerated)
– Syringes will be protected from light
• Brown bag covering from pharmacy
– Syringes & lines MUST be changed Q72hrs
• Remaining volume gets discarded
• Label syringe with sticker with CHANGE DUE date
– Spare syringe of drug MUST be kept on the unit AT
ALL TIMES
• Keep refrigerated
3/14/2024 24
Half life of nebulized Flolan is approximately 3-6 minutes and half life of IV Flolan is 1-2
hours. It is stable at room temperature for 72 hours and 8 days if refrigerated. Flolan is
photo-sensitive and must be protected from light. Therefore, syringe are wrapped with
brown plastic and un-used/ back up syringes are stored inside a brown bag in the
refrigerator. Syringes & tubing must be labelled with “Respiratory Med” & “Change due
___” and changed Q 72hrs.
24
RCP set up process: Maximum Pump rate
12ml/hr.
Aerogen Minimum is 0.1ml/hr.
• The Aerogen Pump must be labeled

“Inhaled Flolan Operation by RCP only”
• Delivery System is NOT MRI compatible
• Other inhaled medications will be ON HOLD
during inhaled epoprostenol delivery
• For transport generator needs to be switched
to 30-minute interval mode until patient
reaches destination and AC power is restored.
3/14/2024 25
In setting up using Aerogen nebulization system,

• The Aerogen Pump must be labeled ““Inhaled Flolan Operation by RCP only.”
• Delivery System is NOT MRI compatible.
• Other inhaled medications will be ON HOLD during inhaled Flolan delivery.
• For transport generator needs to be switched to 30-minute interval mode until
patient reaches destination and AC power is restored.
The syringe pump rate has Mmximum Pump rate 12ml/hr and minimum is 0.1ml/hr.
25
RCP on Inhaled Epoprostenol:
Confirmation & Responsibilities with delivery
2 trained RCP Initial start & Q72hrs
• Correct set up and circuit (including usage and back up, bag/mask)
• Correct & double checked the dose and MAR
• Verification of mist development
Patient’s RCP
• Check on the system Q1hr.
• Check & chart the ventilator & mechanics (PEEPi, OI & P/F) Q2hrs.
• Change filters Q2hrs.
– Monitor for intrinsic PEEP & document this!!
– If you can’t observe - document this and notify MD
• Change syringes & lines Q72hrs
• Huddle with bedside RN at start of every shift to make sure they are aware
of administration conditions/ emergency response
3/14/2024 26
When setting up continuous Flolan, follow these steps to confirm and maintain the
delivery.
2 trained RCP Initial start & Q72hrs
• Correct set up and circuit, including usage and

back up, bag/mask.
• Correct & double checked the dose and
MAR.
• Verification of mist development.
Patient’s RCP
• Check on the system Q1hr.
• Check & chart the ventilator & mechanics (PEEPi,
OI & P/F) Q2hrs.
• Change filters Q2hrs.
26
• Monitor for intrinsic PEEP & document this!!
• If you can’t observe - document this and notify MD.
• Change syringes & lines Q72hrs.
• Huddle with bedside RN at start of every shift to
make sure they are aware of administration
conditions/ emergency response.
26
RCP:
Documentation
Q2 hours Therapist time
– Set AND measured ventilator settings • 2nd RCP for
Initial set up
– Alarms per department protocol & verification
– Respiratory mechanics parameters (inc. PEEPi, OI & P/F) • Inline filter
– Level of circuit humidification changes
• Q72hr set up
– Filters change changes
• Delivery
– Route, nebulizer rate and total syringe volume
• MAR
– Dual signature required
• Charges Stanford Medicine Children's Health,
3/14/2024 27
RCP needs to document the following.

Q2 hours
• Set AND measured ventilator settings,
• Alarms per department protocol,
• Respiratory mechanics parameters (inc.
PEEPi, OI & P/F),
• Level of circuit humidification, and
• Filters change.
Delivery
• Route,
• nebulizer rate, and
• total syringe volume
MAR
Dual signature required
27
Charges
Worklist time entry
• 2nd RCP for initial set up
• Inline filter changes
• Q72hr set up changes
27
RCP:
Patient Documentation
Patient Assessment/Reassessment
• At baseline AND dose changes
• 30 minutes after initiation AND dose change
• Q2 hrs. with ventilator checks
Specific assessment criteria

• Changes in Oxygenation
– PaO2, SpO2, Pao2/FIO2 ratio, OI
• Airway related issues or resistance
• ANY COMPLICATIONS ARE TO BE DOCUMENTED &
REPORTED TO ATTENDING MD
3/14/2024 28
Additional RCP EPIC documentation includes

• Patient Assessment/Reassessment
• At baseline AND dose changes

• 30 minutes after initiation AND
dose change
• Q2 hrs. with ventilator checks
• Specific assessment criteria
• Changes in Oxygenation
• PaO2, SpO2, Pao2/FIO2 ratio, OI
• Airway related issues or resistance
• ANY COMPLICATIONS ARE TO BE
28
DOCUMENTED & REPORTED TO
ATTENDING MD
28
RCP:
Ventilator set up
Neo Mode
• Connects at the temp probe on the inspiratory
limb closest to patient (neo T)
Pediatric/Adult mode
• Wet side of heater (adult T)
HFOV
• Between the patient’s ETT and the HFOV
circuit (pedi T)
3/14/2024 29
For ventilator set up, the placement of the Aerogen T are as the following.
• Neo Mode
• Connects at the temp probe on the inspiratory limb closest to patient with
neo-T.
• Pediatric/Adult mode
• Wet side of heater with adult-T.
• HFOV
• Between the patient’s ETT and the HFOV circuit with pedi-T.
29
RCP Set up:
Other
Inline suctioning
• No routine bag suctioning will be done.
• Inline suctioning only when clinically indicated.
EtCO2
• May be assessed via spot checks IF aerosol
interferes with continuous monitoring.

3/14/2024 30
Other considers:
Inline suctioning
• No routine bag suctioning will be done.
• Inline suctioning only when clinically indicated.
EtCO2
• May be assessed via spot checks IF aerosol interferes with continuous monitoring.
30
RCP Set up:
The Calculations
1. Confirm dose (ng/kg/min or mcg/kg/min)
– Recommended initial dose 10 ng/kg/min
– Maximum dose 50 ng/kg/min
2. Confirm concentration:
– Pediatric concentration: 15mcg/ml
– Adult Concentration: 30mcg/ml
3. Confirm patients weight in Kg

3/14/2024 31
This is the calculations based on dose, concentration and patient’s weight.
1. Confirm dose (ng/kg/min or mcg/kg/min)

• Recommended initial dose 10 ng/kg/min
• Maximum dose 50 ng/kg/min
2. Confirm concentration:
• Pediatric concentration: 15mcg/ml
• Adult Concentration: 30mcg/ml
3. Confirm patients' weight in Kg.
31
RCP Set up: Example
Ordered Dose: 50ng/kg/min
The Calculations Concentration: 15mcg/ml
Patients weight: 3kg
Ng/kg/min to ml/hr.
(1) To convert ng/kg/min to mcg/kg/min
50ng/kg/min X 1mcg = 0.05mcg/kg/min
1000ng
(2) 0.05mcg X 3kg = 0.15mcg/min
kg
(3) 0.15mcg X 60 min = 9mcg/hr.
min 1hr
(4) 9mcg X 1ml = 0.6ml/hr. (Pump Rate)
3/14/2024
hr. 15mcg Respiratory Care, E.Chuang 32
This is an example with order dose of 50 ng/kg/min, concentration of 15 mcg/ml and

patient’s weight of 3kg. Follow these calculating steps to take from the ordered dose in
ng/kg/min to the syringe pump rate in ml/hr.
32
RCP Set up:
The Calculations

3/14/2024 33
The Flolan calculation sheet with an example.
33
Tip Sheets: Checklist on
• Flolan Administration Setup
 Equipment needed:
o Infusion Pump (x2)
o Aerogen Module with power source (x2)
o Aerogen 60cc syringe with tubing and Luer adaptor (x2)
o Appropriate T adaptor + solo cup (x3)
o HEPA filters (2)
 Insert Aerogen nebulizer via T adaptor into calibrated ventilator circuit.
o Neo mode –NEO T at temp probe on inspiratory limb of circuit
o Pediatric/Adult mode – ADULT T at the wet side of the heater
o HFOV – PEDI T placed between patient ETT and the HFOV wye
 Prime Aerogen syringe pump system with Epoprostenol solution and connect to Aerogen system
 Set up syringe pump at appropriate dose per hour as ordered by provider.
o Select Respiratory library>recall last settings>more> confirm ml/hr > confirm syringe size settings >
confirm calculated dose matches the order for rate > select green arrow.
o Confirm green flashing lights are moving.
 Start nebulization with Aerogen generator in the CONTINUOUS mode.
 Place 2 HEPA grade filters inline at the expiratory valve
 Obtain 2nd RCP Verification on:
o Circuit Set up
o Dose Delivery; MAR sign off
o Mist Development
3/14/2024 34
A Flolan tip sheet can be found in Respiratory SharePoint Team site. The tip sheet
covers the step by step set up checklist.
34
Tip Sheets: Checklist on
• Emergency equipment set up
 Resuscitation Bag + HEPA filter + appropriate Aerogen adaptors
 iNO system in line ventilator (Turned on, Calibration Done)
 Second Aerogen module and infusion pump bedside
• Patient’s RCP
 Q1hr: Check on system & mist development.
 Q2hrs: Check ventilator, Document, Change filters.
 Q72hrs: Change syringes & lines.
• Note:
 Spare syringe of drug MUST be kept on the unit AT ALL TIMES – keep refrigerated.
 Delivery system is NOT MRI compatible.
 Other inhaled medications will be ON HOLD during inhaled Epoprostenol delivery.
 No routine bag suctioning: inline suctioning only when clinically indicated.
 ETCO2 may be spot checked IF aerosol interferes with continuous monitoring.
 Huddle with bedside RN at start of every shift to make sure they are aware of administration
conditions/emergency response.

3/14/2024 35
The tip sheet also includes the emergency equipment, RCP’s checks and document and
more notes.
35
RCP Set up:
Equipment: Ventilator set up

3/14/2024 36
Equipment set up: see the three different Aerogen Tee’s, Adult, Pedi and Neo.
36
RCP Set up: (Aerogen neo-T)
Equipment: VN500 (Bias Flow >3.5LPM)

3/14/2024 37
This is the set up for infant dual limb circuits with Aerogen neo-T on inspiratory limb
before the wye and the filters with adaptors.
37
RCP Set up: (Aerogen Adult-T)
Equipment: V500 (Bias Flow <3.5LPM)

3/14/2024 38
This is the set up for pedi/adult dual limb circuit with the adult-T. Place the Aerogen
adult-T on the wet side of the heater.
38
RCP Set up: (Aerogen Pedi-T)
Equipment: HFOV

3/14/2024 39
This is the set up for high frequency oscillation ventilators with the pedi-T. The Aerogen
pedi-T is placed between the HFOV circuit wye and the ETT.
39
RCP Set up:
Equipment: Transport in-house
Aerogen must be set for 30minute interval during transport

Take 2 generators for in-house transports
3/14/2024 40
This is the set up for the in-house transport with Hamilton T1. The F&P dual limb
circuit is used, instead of Hamilton coaxial. Aerogen must be set for 30minute interval
during transport and take 2 generators for in-house transports. There are two locations
to place the Aerogen T, one by the vent and one before the wye. Closer to patient is
preferred.
40
RCP Set up:
Equipment: BVM set up

3/14/2024 41
This are the setups for flow-inflating bags and Ambu bags, including HEPA filter and
Aerogen T.
41
RCP Set up:
Equipment: BVM set up

3/14/2024 42
This are the set ups with flow-inflating bags and Ambu bags to be used in OR or under
drapes.
42
Tip Sheets: Pump Set Up
• Administration:
 Starting a new syringe and ensure to zero TVD
 After placing the new syringe on the pump, ensure TVD, total volume delivered is “0”. (Fig.1)
 If TVD is not zero, go to “Clear TVD” (Fig 2) and “yes” for Clear Total Volume Delivered? (Fig.3)
 Track expiration of the medication and remaining volume left in the syringe
 Use the pump to prime the line. Record the “priming volume”. (see Fig.4)
 Obtain “Change DATE” stickers (Fig.5) for the correct expiration in 72 hours. Fill in date and time due
change, priming volume and your name (Fig.6) and place the sticker on the line (Fig.7).
 Note the total syringe volume on the patient’s medication label. (Fig 8)
 Calculate the remaining volume in the syringe.
o Note total volume from patient’s label, eg. 50 mL (Fig. 8)
o Note priming volume, eg. 3.46 mL (Fig. 4)
o Note TVD, total volume delivered, on the pump (Fig.9), eg, 0.144 mL/ using 0.14 mL (Fig.9)
o Remaining Volume = (Total Volume from patient’s label) – (Priming Volume) – (TVD)
 Remaining Volume = 50 mL – 3.46 mL – 0.14 mL = 46.4 mL
 Record remaining volume in EPIC
 Request a new syringe from Pharmacy with MAR Request when the medication will expire on the
following shift or when the remaining volume is less than 6 mL (or < 2 hrs of medication left).
 Pump Alarms
 Pump will alarm when 1 hour left to the end of medication.
 Ensure to let bedside RN know to notify you if they silence the alarm.
 Pick a new syringe from Pharmacy and prepare syringe/line/filter change. (Assuming the new syringe
should have been requested earlier.)
3/14/2024 43
There is a tip sheet on continuous Flolan pump setup in the SharePoint Respiratory
website. Follow these procedures to avoid constant checking of the remaining volume
in the syringe.
43
1 4 7
2 5 8
3 6 9

3/14/2024 44
Pump set up: step by step photos.
44
10

3/14/2024 45
Using the TVD displayed on the pump, the remaining syringe volume can be calculated.
45
Tip Sheet: Pump Set Up
• MAR Charting
 Select Action “New Syringe/Cartridge” only when you start a new syringe at the
beginning of therapy or changing syringes.
 Select Action “Existing Bag/Syringe” when you chart for subsequent Q2hour
checks.
 Pump Alarms
 Pump will alarm when 1 hour left to the end of medication..
 Ensure to let bedside RN know to notify you if they silence the alarm.
 Pick a new syringe from Pharmacy and prepare syringe/line/filter change. (Assuming the
new syringe should have been requested earlier.)

3/14/2024 46
Here are the tip sheet on MAR charting and pump alarms.
46

Flolan Moodles W Notes

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Flolan Moodles W Notes

Uploaded by

Copyright:

Available Formats

Pulmonary Vasodilators

Stanford Medicine Children's Health,

In the following presentation, we will look at different pulmonary hypertension

What goes into the development of Pulmonary Hypertension, as PH

Pulmonary arterial hypertension (PAH) is caused by functional and structural changes in

The process of pulmonary vascular remodeling is accompanied by endothelial

Excessive cell proliferation and impaired apoptosis (death of a cell) in pulmonary

II. Endothelin Pathway: vasoconstriction and proliferation

This is the list of commonly used vasodilators to treat pulmonary hypertension.

AVAILABLE VIA SPECIAL PHARMACIES

Synthetic Prostacyclin Analogue

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Flolan is synthetic prostacyclin analog. It is non-selective so it could affect systemic

Stanford Medicine Children's Health,

uccessful treatment for 6 days.

Stanford Medicine Children's Health,

The indications of continuous Flolan nebulization are

• Respiratory therapy is responsible for the

Stanford Medicine Children's Health,

Respiratory care department is responsible for the administration of aerosolized

• Caution should be used when combination of

Severe rebound pulmonary hypertension can occur in the event of abrupt

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

These are important point when setting up continuous Flolan:

• The Aerogen Pump must be labeled

In setting up using Aerogen nebulization system,

2 trained RCP Initial start & Q72hrs

• Correct set up and circuit, including usage and

RCP needs to document the following.

Dual signature required

Specific assessment criteria

Additional RCP EPIC documentation includes

• At baseline AND dose changes

Stanford Medicine Children's Health,

3. Confirm patients weight in Kg

Stanford Medicine Children's Health,

This is the calculations based on dose, concentration and patient’s weight.

1. Confirm dose (ng/kg/min or mcg/kg/min)

This is an example with order dose of 50 ng/kg/min, concentration of 15 mcg/ml and

Stanford Medicine Children's Health,

The Flolan calculation sheet with an example.

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Aerogen must be set for 30minute interval during transport

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

Pump set up: step by step photos.

Stanford Medicine Children's Health,

Stanford Medicine Children's Health,

You might also like