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Interventions 3 > Specialty Gases (Mod 6) > Flashcards

Specialty Gases (Mod 6) Flashcards

Nitric Oxide and Heliox

1
Q

What functions does Nitric Oxide include?

A
  • Vasodilation (potent)
  • Neurotransmission
  • Long term memory
  • Immunologic defense
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2
Q

How could Nitric Oxide affect platelet adhesion?

A

Nitric Oxide would inhibit platelet adhesion

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3
Q

How could Nitric Oxide on the inflammatory response induced by mast cells?

A

Nitric Oxide would inhibit the inflammatory process by mast cells

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4
Q

What are expected physiological effects of Nitric Oxide?

A

Relaxation of smooth muscles

  • when inhaled = potent vasodilator
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5
Q

Why is it beneficial to inhale Nitric Oxide (NO) rather than admin percutaneously?

A

Nitric Oxide is a selective pulmonary vasodilator, it only affects ventilated alveoli. Meaning…

  • Vasodilation = Decreased PVR without decreasing SVR
  • NO increases blood flow only to ventilated alveoli by relaxing the smooth muscles of the capillaries supplying these alveoli
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6
Q

When Nitric Oxide has been admined, what does the subsequent pulmonary vasodilation result in?

A
  • Decreased intrapulmonary shunting
  • Improved oxygenation
  • Decreased PVR
  • Decreased pulmonary artery pressures
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7
Q

Why doesn’t Nitric Oxidie effect SVR?

A

The effects of NO are limited to pulmonary circulation because after diffusing into the capillaries NO immediately binds to hemoglobin

  • NO + hbg = nitrosylhemoglobin which is rapidly oxidized to methemoglobin (metHb)
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8
Q

Indications and potential uses for Nitric Oxide?

A

Look over, but don’t linger

Potential Uses
ARDS
PPHN
Primary pulmonary hypertension
Pulmonary hypertension post cardiac-Sx
Heart transplantation
Acute pulmonary embolism
COPD
Bronchodilation
Congenital diaphragmatic hernia
Congenital heart disease
Testing pulmonary vascular responsiveness

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9
Q

When would Nitric Oxide be used for Bronchodilation?

A

When bronchoconstriction results from histamine and/or methacholine challenges

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10
Q

What are the benefits of Nitric Oxide for pphn treatments?

A

NO reduces pulmonary pressure…therefore:

  • Systemic pressures > Pulmonary pressures therefore:
  • Shunting through PDA and PFO are stopped/reduced –> direct effect due to the reduced PAP (and decreased PVR)
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11
Q

Most common uses for Nitric Oxide?

A

NO is primarily used for its selective pulmonary vasodilator effects but

  1. Pulmonary Vasodilation
  2. Bronchodilation
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12
Q

When would pulmonary vasodilation be desired when using Nitric Oxide? (3)

  • what pathos?
A
  1. PPHN
  2. Congenital heart defects (maintain pfo and pda)
  3. ARDS
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13
Q

When would bronchodilation be desired when using Nitric Oxide? (3)

A

To reverse methacholine or histamine induced bronchoconstriction

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14
Q

Nitric Oxide Therapeutic dose range?

A

2-20 ppm (Neo-20ppm)

  • Beneficial effects peak at 10ppm in adult ARDS patients
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15
Q

When does the therapeutic dose of Nitric Oxide peak for adults with ARDS?

A

Around 10ppm

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16
Q

Nitric Oxide Starting dose in: Adults

A

Start at 10ppm followed by ABG 5 mins after initiation

  • optimize to the lowest dose w/favorable response
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17
Q

How is Nitric Oxide dosage optimized?

A

Wean NO by 2-4 pm while monitoring SpO2 and mean PAP

  • if SpO2 falls by >2% or mean PAP increases by > 5mmHg…return to last effective dose
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18
Q

P and P for Nitric oxide on adults

A
  1. Start at 10 ppm and do an ABG 5 min after initiation
  2. If no response (PaO2 increases <10 mmHg, SpO2 increases <2% or MPAP does not decrease by at least 5 mmHg) then increase to 20 ppm
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19
Q

After initiating Nitric Oxide for ARDS, what are the next steps if there is no response to treatment?

A

Discontinue NO (treatment failure)

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20
Q

After initiating Nitric Oxide for pulmonary hypertension, what are the next steps if there is no response to treatment?

A

10ppm (starting)–> 20 ppm–> 40ppm and assess response

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21
Q

Risk of high concentrations of Nitric Oxide?

A

NO Toxicity which can lead to acute pulmonary edema…than death

  • Most toxic effects are due to its by products: NO2, Nitric Acid, and Methemoglobin
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22
Q

What range would Nitric Oxide toxicity be a concern?

A

NO toxicity would be expected at 5000-20,000 ppm

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23
Q

What would the lower end of Nitric Oxide toxicity involve?

A

Possible direct cellular damage and impaired surfactant production

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24
Q

How is Nitrogen Dioxide [NO2] produced?

A

When NO reacts with oxygen

  • More toxic than NO
  • The higher the FiO2, the more NO2 formed
25
How is Nitric Acid produced?
Forms when NO reacts with H2O
26
What toxic effect do NO2 and Nitric have?
Both can cause the following (with increased dosage) - Cell damage - Chemical pneumonitis - Hemorrhage - Pulmonary edema - Death
27
Clinically, what is the range should NO2 be kept?
The goal is to keep NO2<2ppm
28
What treatment option is used for Nitric Oxide toxicity caused by Methemoglobin formation?
metHb > 30% can be treated with **Methylene blue** - cyanosis should resolve within the hour
29
How does Methemoglobin form?
Any NO diffusing into the capillaries immediately binds to Hb resulting in MetHb (normal) - High levels of metHb reduce the oxygen carrying capacity of the blood
30
What effect does Methemoglobin have physiologically?
MetHb reduces the oxygen carrying capacity of blood - Its a toxic effect from high concentrations of NO
31
Normal metHb level?
Normal metHb < 2%
32
Range for Methemoglobinemia?
when metHb > 2% - not commonly seen at the therapeutic dose of NO
33
How often are metHb levels assessed?
q12h at the min
34
How could Nitric Oxide result in worsening of hypoxemia (adverse effect lol)
Worsening hypoxemia thought to be due to worsened v/q when no shunt was initially present
35
What is the rebound effect of Nitric Oxide?
Worsening of hypoxemia and pulmonary hypertension then before therapy - Seen during the withdrawal of NO therapy
36
During anesthesia, why does FiO2 need to be closet to the patient?
Addition of NO during administration will reduce the FiO2 - FiO2 needs to be distal to where NO is added
37
Safety limit of NO during administration?
5 ppm - Safety limit is for workers - Extracted from the environment via scavenging system
38
Where should an oxygen analyzer be placed during Nitric Oxide administration in a ventilated patient?
Oxygen analyzer must be downstream from the T in point bc NO reduces FiO2 - NO/NO2 analyzer should accompany the O2 analyzer as well
39
How is Nitric Oxide administered in spontaneously breathing patients?
Simple circuit of corrugated tubing with NO, air, and O2 blended to get desired FiO2 and ppm of NO - Requires prior analysis for baseline
40
How can the rebound effect associated with withdrawal of Nitric Oxide therapy be prevented?
**The following doesn't apply if pt was a non responder to therapy** - Reduce NO to lowest effective dose (ideally < 5ppm) - Maintain hemodynamic status w/adequate oxygenation on FiO2 <0.4 and low level of PEEP - Pt should be hyperoxygenated (FiO2 0.6-0.7) just prior to discontinuation
41
FloLan (Caripul) function?
A prostaglandin (Epoprostenol) that: 1. Inhibits natural platelet aggregation 2. Reduces pulmonary hypertension (some systemic action as well) --> specfically Pulmonary **artery** hypertension - Sometimes refered to as Prostacyclin
42
How is FloLan (Caripul) aka Epoprostenol sodium delivered?
Delivered via aerogen (vibrating mesh) nebulizer - "T" it in to a vent circuit or attach to a mask
43
Difference between Epoprostenol and Trepostinil (glance)
Epoprostenol and treprostinil are both prostacyclin analogs used in the treatment of pulmonary arterial hypertension (PAH). Differ in route and kinetics
44
Particle size deposited in the bronchi?
6-9 microns deposit in the bronchi
45
Particle size deposited in the bronchiole?
3-6 microns deposit in the bronchioles
46
Particle size deposited in the alveoli?
1-3 microns are deposited in the alveoli
47
what device can deliver particle sizes smaller than 1 micron?
Vibrating screens/mesh - Any smaller, and must of the particles are exhaled
48
What is the primary function Heliox gas?
Low density gas (light) used to decrease WOB
49
What is a mandatory feature for Heliox gas administration?
**Must be combined with oxygen** Common mixtures are the following: - 20% O2, 80% helium - 30% O2, 70% helium
50
How does Heliox assist airflow in the upper airway?
Turbulent flow in large airways is more affected by gas density than viscosity - **Breathing a low density gas improves flow through the airways**
51
Is Heliox effective in managing issues in the lower airways?
Not as much - Lower airways have laminar flow (smooth flow), flow is affected more by viscosity than density
52
Clinical indications for Heliox use in the upper airways?
If upper airway obstruction is present, can help with: - Airway tumors - Post extubation stridor - Pediatric airway obstructions
53
Clinical indications for Heliox use in the lower airways?
- Severe COPD/Astha - Combined w/NIPPV and/or mech vent - Evidence not clear to effectiveness, but promising
54
Delivery mechanisms intricacies for Heliox (4)
55
If using a Heliox mixture (like 20% O2 + 80% He), what are some considerations that need to be met?
Use a tight fitting NRM or adequate seal for NP for peds/neos
56
If using separate oxygen and helium tanks, what are some considerations that need to be met?
Monitor FiO2 and ensure adequate FiO2 delivered to patient
57
If Helium is delivered by aerosolizing the gas, what are some considerations that need to be met?
Increase flow to ensure nebulizer power is adequate - May improve aerosol penetration
58
If Helium is given on a mechanical vent, what are some considerations that need to be met?
He could alter Vt measurement and could lead to lung injury - some vents have heliox options
59

Interventions 3 (19 decks)

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