Chapter 11

Agents Used in Special Procedures

and of Pulmonary Importance
Special Procedures
• RCP may serve as assistant during bronchoscopy
procedure
• May be responsible for direct challenge testing to
determine airway hyperresponsiveness using
methacholine
• Must take administration and safety procedures into
account
Bronchoscopy
• Direct visualization of tracheobronchial tree by
rigid or flexible scope
• Includes:
• Continuous pulse oximetry
• End-tidal CO2 monitoring
• Electrocardiographic monitoring
• May use analgesic and sedative medications
• May cause coughing or bronchospasm
Video:
https://www.youtube.com/watch?v=0jVGv_rNJ18
(Time 4:30)
Medications Used During Bronchoscopy (1 of 2)
• Benzodiazepines preferred sedative agents
• Midazolam most commonly used
• May use opioids such as fentanyl
• Achieve conscious sedation
• Small-volume nebulizer treatment given beforehand with aerosolized
local anesthetic
• Topical lidocaine commonly used- sometimes referred to as “Hurricaine”
• Both local anesthetic and antitussive
Conscious
Sedation
Medications Used During Bronchoscopy (2 of 2)
• Epinephrine used to limit bleeding during and after procedure
• Epi causes vasoconstriction at the site to help with clotting.
• Mucolytic/mucokinetic agent may be used for therapeutic
bronchoscopy performed to remove mucous plugging from airways
• Hypertonic saline
• 10% or 20% acetylcysteine
• Dornase alfa (rarely used)- specifically beneficial for cystic fibrosis pts.
Bronchial Provocation
• The bronchial provocation test evaluates how sensitive the airways in
your lungs are. A spirometry breathing test is done before and after
you inhale a medication- methacholine or mannitol
• Provides pathophysiologic and clinical information about patient’s
pulmonary disease
• Tests for degree of airway hyperresponsiveness
• Involves direct or indirect airway stimulation
• Baseline spirometry performed before testing
• Should have bronchodilators and resuscitation equipment and
medications readily available during testing
Medications Used for Airway
Hyperresponsiveness
• Methacholine
• Direct stimulus for airway hyperresponsiveness
• Positive test may indicate asthma
• Mannitol
• Indirect stimulus for airway hyperresponsiveness
• Positive test suggests underlying airway inflammation
Methaocholine (1 of 2)
• Parasympathomimetic agent
• Used only to induce bronchoconstriction for diagnostic testing
• No therapeutic indication
• Primary effect as aerosol agent:
• Direct stimulation of bronchoconstriction
• Increased bronchial gland secretion
Methaocholine (2 of 2)
• Contraindications:
• Active wheezing
• Severe airflow limitation
• Myocardial infarction or stroke in last 3 months
• Uncontrolled hypertension
• Caution if pregnant or breastfeeding
• Adverse reactions rare
• Headache, dizziness, and throat irritation
Mannitol (1 of 2)
• Osmotic agent
• Provided in dry-powder capsules
• Positive test suggests asthma
• Should not be administered for AHR in patients with:
• Severe airflow limitation
• Uncontrolled hypertension
• Recent myocardial infarction or stroke
Mannitol (2 of 2)
• Use of bronchodilators and inhaled corticosteroids decreases airway
sensitivity
• Most common adverse effects:
• Coughing, chest tightness, headache, throat irritation, rhinorrhea, nausea,
and vomiting
Pulmonary Vasodilators
• Inhaled nitric oxide (INO) and prostacyclin epoprostenol
• Used in:
• Assessment of pulmonary hypertension
• Treatment of pulmonary hypertension and acute respiratory distress
syndrome (ARDS)
Video- see module
https://www.ajmc.com/view/prostacyclins-in-pah-selecting-among-
the-agents
Inhaled Vasodilators in Acute Hypoxemia
• Ventilation/perfusion (V/Q) mismatch diseases can cause hypoxemia,
which can cause persistent pulmonary hypertension (PPHTN)
• Using systemic vasodilators to relieve V/Q mismatch worsens clinical
condition
• Improves circulation to unventilated lung units
• Providing INO or epoprostenol matches vasodilator to ventilated lung
units
Nitric Oxide (1 of 4)
• Naturally occurring substance, colorless, odorless gas
• Promotes vasodilation
• Stimulates soluble guanylate cyclase to form cyclic guanosine monophosphate
(cGMP) – part of the pulmonary vascular smooth muscle
• Leads to pulmonary vascular smooth muscle relaxation
• Approved use primarily in neonatal intensive care unit, now used in
adults as well.
Nitric Oxide (2 of 4)
• Also used for adult patients:
• With acute lung injury/ARDS
• After lung transplantation
• With right-sided heart failure
• With sickle cell disease
• During cardiac catheterization
• Infection
Nitric Oxide (3 of 4)
• Initial starting dose is concentration of 20 parts per million (ppm)
• Clinical improvement measured by improvement in oxygenation index
(OI) or PaO2
• OI- oxygen index primary used in NICU
• Expected outcome is ability to maintain oxygenation status at reduced
FiO2
Nitric Oxide (4 of 4)
• Adverse effects and hazards:
• Rebound pulmonary hypertension
• Development of methemoglobinemia- measure every 24 hours- blood test
• Imperative to exercise great caution in handling equipment and cylinders
associated with INO therapy and INOvent
• Refractory hypoxemia when there is inadequate arterial oxygenation
despite high levels of inspired oxygen, you will need to use iNO
• Start at 20 ppm
• Wean example: 20ppm– 15 – 10 – 5 – 4 – 3 – 2 – 1 (every hour as tolerated
and monitor SPO2)
• Toxic > 40 ppm
Epoprostenol Sodium (Flolan, Veletri)
(1 of 3)

• Strong pulmonary vasodilator

• Inhibits platelet aggregation
• Used in salvage therapy for patients with ARDS who exhibit refractory
hypoxemia and increased pulmonary vascular resistance
• Also used for pulmonary hypertension, acute right heart dysfunction,
and hypoxemia related to pulmonary vasoconstriction
Epoprostenol Sodium (Flolan, Veletri)
(2 of 3)

• Provided in vials- 2 ng/kg/min via continuous IV infusion

• Quick onset of action and duration
• Administered as continuous inhalation
• Dosing based on body weight
• Nebulizers used for inhaled epoprostenol:
• Aeroneb® Solo Nebulizer System
• MiniHeart™ Nebulizer
Epoprostenol Sodium (Flolan, Veletri)
(3 of 3)

• Adverse effects:
• Accumulated solution may impair ventilator valve function
• Rebound pulmonary hypertension if abruptly stopped, wean slowly
• Flushing, GI complaints, and musculoskeletal pain may occur
• Thrombocytopenia, however, rarely seen
Iloprost (Ventavis) (1 of 3)
• Synthetic analog of prostacyclin
• Indicated for treatment of chronic pulmonary arterial hypertension
(PAH)
• Shown to:
• Improve symptoms and exercise tolerance
• Prevent deterioration of condition
• Dilates pulmonary arterial vascular beds
• Affects platelet aggregation
Iloprost (Ventavis) (2 of 3)
• Adverse effects:
• Flushing, cough, and headache most common
• May also cause jaw pain, hypotension, insomnia, chest pain,
nausea/vomiting, and dizziness
• May cause bronchospasm in patients with history of reactive airway disease
• Can cause nose bleeds and hemoptysis
Iloprost (Ventavis) (3 of 3)
• Should only be inhaled using I-neb adaptive aerosol delivery (AAD)
system
• Should not mix with other medications
Treprostinil (Tyvaso) (1 of 3)
• Prostacyclin analog
• Directly causes:
• Pulmonary and systemic arterial vasodilation
• Inhibition of platelet aggregation
• Indicated in patients with:
• Pulmonary arterial hypertension
• Idiopathic/inherited or PAH associated with connective tissue disease
Treprostinil (Tyvaso) (2 of 3)
• Use only with Tyvaso Inhalation System
• Initial dose:

Courtesy of United Therapeutics Corporation.

• Three breaths (18 µg) per treatment
• Four times daily while awake

Figure 11-2: Treprostinil (Tyvaso) ultrasonic nebulizer system.

Treprostinil (Tyvaso) (3 of 3)
• Adverse effects:
• Cough
• Throat irritation
• Headache
• Flushing
• Nausea/vomiting
• Muscle and jaw pain
• Increased risk of bleeding
Apnea of Prematurity
• Caused by undeveloped respiratory control
• Methylxanthines – example theophylline
• CNS and respiratory stimulant
• Narrow therapeutic index
• Caffeine citrate
• CNS and respiratory stimulant
• May be useful when administered intravenously
Caffeine and Theophylline in Newborns (1 of 2)
• Methylxanthines used to reduce apneic episodes of premature infants
• Improve respiratory function and decrease extubation failure
• Caffeine
• Fewer adverse events and quicker action
• Theophylline
• Metabolizes into caffeine in infants
Caffeine and Theophylline in Newborns (2 of 2)
• Signs of excess serum caffeine or theophylline:
• Tachycardia, tachypnea, tremors, nausea, vomiting, diarrhea, irritability, and
feeding intolerance
• Adverse effects of theophylline:
• Seizures, tachyarrhythmias, and feeding intolerance
Smoking Cessation Methods
• No single best method
• Medical assistance increases success rate
• Should offer patients pharmacotherapy unless pregnant,
breastfeeding, adolescents, or have other contraindications
• Key to success:
• Changing social situation and peer pressure
• Making commitment to quit
• Developing strategy that works for smoker
Pharmacologic Therapy for Smoking
Cessation
• Buproprion (Zyban)
• Nonnicotine oral tablet
• Varenicline (Chantix®)
• Blocks receptors in brain
• Interferes with pleasure from nicotine
• Social and psychological supports essential
• Quit Line available in all states
Nicotine Replacement Therapy (NRT)
(1 of 2)

• Available OTC and by prescription

• RCP should:
• Be aware of adverse effects from misuse
• Discuss effective use of these agents
• Delivers nicotine at lower concentrations and slower absorption than
cigarettes
• Formulation depends on patient preference and specific patient
factors
Nicotine Replacement Therapy (NRT)
(2 of 2)

• Consult physician if patient:

• Has cardiac issues
• Is pregnant or breastfeeding
• Patients using NRTs should not smoke.
• Common side effects:
• Dizziness, insomnia, vivid dreams, headache, nausea, and muscle aches and
stiffness
Nicotine Patches (1 of 2)

• Delivers constant nicotine dose

through skin
• Available OTC
• Doses: 21 mg, 14 mg, and 7 mg
• Recommended method:
• Initial dosage patch for 6
weeks
• Weaker patch for 2 weeks
• Final lowest dose for 2 weeks
Nicotine Patches (2 of 2)
• Place on clean, dry, hairless skin on torso
• Replace at least every 24 hours
• Never use multiple patches simultaneously
• Most common side effects:
• Skin irritation and redness
• No smoking while using patch without physician approval
Nicotine Gum (1 of 2)
• Available OTC in 2-mg and 4-mg doses
• Recommended method is to chew:
• Every 1–2 hours for 6 weeks
• 2–4 hours for 3 weeks
• 4–8 hours during final 3 weeks
• Maximum dosage:
• 24 pieces per day, 6–12 weeks
• Maximum of 6 months
Nicotine Gum (2 of 2)
• Technique:
• Chew just enough to release nicotine
• Causes tingling or peppery taste
• “Park” in cheek until sensation fades
• Repeat for 20–30 minutes
• Side effects:
• Throat irritation, dyspepsia, mouth soreness, stomatitis, hiccups, and jaw pain
Nicotine Lozenges
• Available OTC in 2-mg and 4-mg doses
• 12-week program:
• One every 1–2 hours for 6 weeks
• One every 2–4 hours weeks 7–9
• One every 4–8 hours last 3 weeks
• Allow lozenge to fully dissolve
• Side effects may include nausea, heartburn, hiccups, coughing, and
sore throat
Nicotine Inhalers
• Prescription required
• Delivery system resembles cigarette
• Nicotine vaporized and quickly absorbed
• Recommended usage:
• 6–16 cartridges daily up to 6 months
• Common side effects:
• Coughing, throat irritation, rhinitis, and GI upset
• Dispose responsibly due to residual nicotine
Nicotine Nasal Spray (Nicotrol NS) (1 of 2)
• Prescription required
• Rapidly absorbed by nasal mucosa
• Risk of dependence
• Usually prescribed for 3 months
• Should not use more than 6 months
• Dosed as one spray per nostril
• Up to 10 sprays/hour
• Maximum 80 sprays/day
Nicotine Nasal Spray (Nicotrol NS) (2 of 2)
• May cause:
• Nasal irritation and congestion
• Changes in taste and smell
• Must store and dispose of containers carefully due to residual
nicotine
• Not recommended for patients with allergies, rhinitis, sinusitis, or
nasal polyps
Varenicline Tartrate (Chantix®) (1 of 2)
• Blocks nicotine binding to brain receptors
• Prevents stimulating reinforcement and reward
• Reduces withdrawal symptoms and cravings
• Steps:
• Start 1 week before quit date
• Days 1–3: 0.5 mg once daily
• Days 4–7: 0.5 twice daily
• Starting day 8: 1 mg twice daily
Varenicline Tartrate (Chantix®) (2 of 2)
• Side effects:
• Nausea, dyspepsia, headache, sleep disturbances, depression, hostility,
agitation, and suicidal ideation
• Use with caution in:
• Elderly patients
• Patients with renal insufficiency
• Patients with cardiovascular disease
Buproprion (Zyban)
• May act as nicotine receptor antagonist
• Start 1–2 weeks before quit date
• 150-mg tablet once daily for 3 days, then twice daily for 12–24 weeks
• May cause insomnia and dry mouth
• Contraindications:
• Seizures, bipolar disorder, eating disorder, pregnancy, or recent use of MAO
inhibitor
Incidence/Prevalence

• Lung cancer- result of inhaled, repeated

exposure that cause chronic irritation or
inflammation
• Pack years x pack per day = pack years
• Example: 10 years x 3 packs per day = 30
pack year
• Risk of smoking decrease with quitting
• After 15 years – almost as a non-
smoker!
• 50,000 ex-smokers develop lung cancer
each year
Smoking + COVID-19➔ worse outcomes
General Considerations of Smoking Cessation
• During smoking cessation, smoker may experience:
• Weight gain
• Increased sputum production
• Coughing in the morning
• Coughing during or after smoking cessation program
• Beneficial changes in vital signs