Paralytics and sedatives

A1-antitrypsin (AAT):

The primary function of AAT is to inhibit inflammatory cells such as neutrophils and prevent the breakdown of elastin

  • Elastin provides the elasticity of the lung tissue

  • Insufficient levels of AAT increase the risk of lung and liver disease

Normal AAT levels in the blood typically range from 20-53 umol/L, or 80-220 mg/dL

  • Can also be expressed as 150-350 mg/dL

A1-antitrypsin (AAT) deficiency:

An inherited genetic disorder which can lead to early onset of emphysema

Deficiency prevents the AAT from getting into the bloodstream

A1-antitrypsin (AAT) inhibitor:

IV for patients with A1-T deficiency and exhibit panacinar emphysema at a young age

The inhibitor breaks down the elastin in the lungs

Additional therapy:

  • Bronchodilators

  • Steroids

  • O2

  • Lung or liver transplant

Drug therapy:

Chronic replacement therapy for congenital API (Active Pharmacological Ingredient) deficiency with clinically demonstrable panacinar emphysema

Four agents:

  • Aralast

  • Prolastin-C liquid

  • Zemaira

  • Glassia

Medications will not reverse damage or improve lung function

Warnings and adverse reactions:

Risk of disease transmission because agents are derived from human plasma

Common reactions:

  • Fever

  • Exacerbation

  • Flulike symptoms

Aralast:

Dosage and administration:

  • 60 mg/kg body weight 1 time weekly

  • IV: 0.08 mL/kg/min or greater

    • Usually takes about 15-70 minutes for total infusion

Smoking cessation:

Goal is to allow initial replacement, then gradual withdrawal

Preventable cause of cardiovascular and lung disease

Smoking cessation is the most effective measure to decrease the rate of the FEV1 decline

Signs of strong addiction or dependence to nicotine:

  • Those who smoke more than 15 cigarettes a day

  • Those who prefer brands with nicotine levels above 0.9 mg

  • Those who inhale smoke frequently and deeply

  • Those who smoke 30 minutes after waking up

  • Those who smoke more frequently in the morning after their first cigarette

  • Those who find it hard to refrain from smoking in smoke-free environments

  • Those who smoke even when ill enough to be bedridden

Physical symptoms of withdrawal:

  • Craving nicotine

  • Nervousness

  • Irritability

  • Anxiety

  • Tiredness

  • Sleep disturbance

  • Concentration is impaired

  • Increase in appetite causing weight gain

Nicotine replacement therapy:

  • NRT aids in smoking cessation by allowing initial replacement and then gradual withdrawal of the nicotine found in tobacco

What types of NRT are there?:

  • Transdermal patch

  • Gum

  • Nasal spray

  • Lozenge (Tablet)

  • Inhaler

First line agents:

  • Bupropion (Zyban)

  • Varenicline (Chantix)

Second line agents:

  • Clonidine (Catapres)

  • Nortriptyline (Pamelor)

    • Tricyclic antidepressant; FDA approved to treat depression

    • Not FDA approved as smoking cessation aid

  • Side effects:

    • Dizziness

    • Insomnia

    • Blurry vision

E-cigarettes:

E-cigarettes may help smokers quit using tobacco; using E-cigarettes is less harmful then smoking cigarettes

Selected agents of pulmonary value:

  • Inhaled NO

  • Synthetic prostacyclins

2 FDA approved medications:

  • Iloprast (Ventavis)

  • Trepostinil (Tyvaso)

Nitric Oxide:

Natural product of endothelial cells that cause vasodilation

Reduces pulmonary vascular resistance in various disease states

  • PPHN (Persistent pulmonary hypertension)

  • ARDS (Acute respiratory distress syndrome)

Inhaled as a gas; this will produce “selective” pulmonary vasodilation

Indications for use (NO):

It is approved for the use in neonates with hypoxic respiratory failure associates with pulmonary hypertension

Uses include:

  • Reduce pulmonary vascular resistance during neonatal cardiac surgery

  • Pulmonary hypertension and hypoxemia after lung transplant

ARDS:

  • Data on effectiveness is conflicting

  • No report in the usefulness in reducing the mortality in ARDS

Pharmacology of NO:

  • Generated in vascular endothelial cells

  • Diffuses rapidly into myocytes (Cells in muscles)

  • Binds to guanylyl cyclase, creating the second signal

  • Stimulates cGMP production (Enzyme that helps regulate blood flow and nerve signals)

Pulmonary hypertension:

Normal pulmonary artery pressure (PAP) is 10-15 mmHg

Pressures greater than 20 mmHg = pulmonary hypertension

  • when pressures get to high, blood won’t flow well, this will result in a decrease in PaO2