Respiratory Therapy

Pharmacology
Week 7
Exogenous Surfactant
Administration

Indicated for surfactant deficiency,

such as in infant respiratory
distress syndrome and following
lung lavage
Exogenous Surfactant
Administration

Produced synthetically or
naturally

Administered by direct instillation

into the trachea
http://www.youtube.com/watch?v=4VwdsdOBwtQ
Exogenous Surfactant
Administration
Drug Response Administrati Preparatio Side effects
Time on n
Synthetic Slow in During CMV Reconstitute No proteins to
Colfosceril onset breath, two d stimulate immune
(Exosurf) (several divided response
hours) doses

Natural Rapid onset Four divided Refrigerated Proteins may elicit

Beractant (5 30 doses immune response
min) suspension
(Survanta)
 Surfactant
Surfactant is a complex substance containing phospholipids and a
number of apoproteins. This essential fluid is produced by the Type
II alveolar cells, and lines the alveoli and smallest bronchioles.
Surfactant reduces surface tension throughout the lung, thereby
contributing to its general compliance. It is also important because
it stabilizes the alveoli. Laplaces Law tells us that the pressure
within a spherical structure with surface tension, such as the
alveolus, is inversely proportional to the radius of the sphere. That
is, at a constant surface tension, small alveoli will generate bigger
pressures within them than will large alveoli. Smaller alveoli would
therefore be expected to empty into larger alveoli as lung volume
decreases. This does not occur, however, because surfactant
reduces surface tension, more at lower volumes and less at higher
volumes, leading to alveolar stability and reducing the likelihood
of alveolar collapse. Surfactant is formed relatively late in fetal
life; thus premature infants born without adequate amounts
experience respiratory problems associated with immature lungs
 Surfactant
The baby presents with retractions (inward
movement of intercoastals on inspiration),
grunting (an attempt to increase FRC with
back pressure), cyanosis, and tachypnea.
Babies born with insufficient surfactant are
determined to have a disease called RDS
(respiratory distress syndrome) or Hyaline
Membrane Disease. Surfactant can be
distilled into the lungs following birth
manually down an ETT.
 Surfactant
Common Surfactants Used: Infasurf (synthetic),
Survanta (modified natural bovine lung extract), Exosufr
neonatal, Curosurf (Pig extract)
Classification: Natural or synthetic surfactant used to
treat prematurely of the lung as demonstrated by RDS.
How it works: The active component colfosceril palmitate
(dipalmitoylphosphatidylcholine) is the major surface active
component of natural lung surfactant and acts by forming a
stable film that stabilizes the terminal airways by lowering
the surface tension of the pulmonary fluid lining them. The
lowered surface tension prevents alveolar collapse at end-
inspiration; the hysteresis effect equalizes the distension of
adjacent alveoli and hence prevents over distension which
might result in alveolar rupture and pulmonary air leak.
 Surfactant
Delivery Device: Through endotracheal tube, instilled
with tracheal adapter, surfactant is drawn up in syringe and
instilled down ETT directly into lungs.
Doses: A dose of 5ml/kg birth weight of reconstituted
Exosurf Neonatal, If the baby is still intubated, a second
equal dose should be given 12 hours later by the same
route. Survanta- 4cc/Kg given initially, second dose 2cc/Kg.
Curosurf- 2.5 cc/Kg, second dose is the same; third dose is
1.25 cc/kg.
Administration of exogenous surfactants rapidly improves
oxygenation and lung compliance. Following administration,
patients should be monitored so that oxygen and
ventilatory support can be modified.
Medication frequency
BID= twice a day Ad lib= as desired
TID= three times a day Q4PRN= every 4 hours as
needed
QID= four times a day Qh= every hour
QD= once a day NS= normal saline
QS= every shift m.l.= militer
Q4=every 4 hours Mg= miligrams
Q6= every 6 hours NPO= nothing per mouth
HS= At bed time
PRN= AS NEEDED

EX: Albuterol 2.5 mg and 2.5 ml NS Q4 and Q2 PRN

for wheezing. Oximeter check QS
Solutions, Concentrations, &
Medication Delivery
 Mixtures

MATTER

Pure Substance Mixture

(homogeneous) (heterogeneous or
homogeneous)

elements compounds colloids suspension

solutions
Heterogeneous mixtures

Heterogeneous colloid &

suspension
Not uniform
Large particles
Concentrations vary throughout
May settle
Can be easily separated by
physical means (filtration)
 Homogeneous mixtures
Homogeneous solution
Usually transparent
Small (invisible) particles
Will not settle
Uniform concentration throughout
Can be separated by physical means but
not easily. (evaporation)
 Mixtures
Three types:
Colloids
Suspensions
Solutions
MIXTURES - Colloid

Examples: Cellular protoplasm,

milk, fat in blood, proteins in
blood (albumin)
Heterogeneous
Large molecules
Attract and hold water
Usually uniformly dispersed
Usually do not settle
Suspended in a gel
MIXTURES - Suspension

Examples: red blood cells in

plasma
Heterogeneous
Large particles that float in the
liquid
Dispersed by agitation
Will settle if agitation stops
MIXTURES - Solution

Example: Saline (salt + water),

medications, electrolytes in body
fluids
Homogeneous
Solute evenly dispersed throughout
solvent so concentration is same
throughout
Solute smaller quantity dissolved, can be
solid, liquid or gas, active ingredient.
Solvent larger quantity, where solute is
dissolved.

Aqueous solution has water as the

Solutions - Gases in liquids

Ability of a gas to dissolve in a

liquid depends upon :
Henrys Law dissolving (into)
Grahams Law diffusion
(through)
Ficks Law - overall relationships
Surface area
Thickness
Partial pressure
Diffusion coefficient
Solutions - Solids & liquids in liquids

Ability of a solute to dissolve in

a solvent also depends upon:
Physical properties of solute &
solvent (density, solubility
coefficient)
Pressure of solute
Temperature of solute & solvent
Presence of other solutes
Concentrations of solutions

More or less solute or solvent will change the

overall concentration of the solution.
Dilute small amount of solute in solvent
Saturated maximum amount of solute in solvent
Precipitate Excess solute in solvent where some
solute settles out at bottom of solvent.

As the concentration changes, the properties

of the solution change (freezing point, boiling
point)
Examples: salt on roads, anti-freeze in radiator
 Concentrations of solutions

(A) Dilute solution

with relatively
few solute
particles.
(B)Saturated
solution where
the solvent
contains all the
solute it can
hold in the
presence of (C) Supersaturation solution - Heating
excess solute. the solution dissolves more solute
particles.
 Concentrations of
Medications
Concentration can be expressed as:
%weight/volume (g/mL) solids in
liquid (meds)
%vol/vol (mL/mL) both liquids
%solution
Ratio (weight:volume or g:mL) (meds)
Molal solution
Molar solution
Parts per million or parts per billion
(extremely dilute)
Medications (drug solutions)

Medications are solutes in solvents.

Calculations help quantify amounts
of drug (solute) in sterile water or
saline (solvent).
Calculations also help express
different concentrations:
%weight/volume (g/mL) solids in
liquid (meds)
Ratio (weight:volume or g:mL)
(meds)
Parts per million or parts per billion
(extremely dilute)
Respiratory Therapy
Medications
Preparations:
Multi dose need to be measured
and diluted
Unit dose already diluted and
ready to use

Ultimate Goal of calculating

is to know how many cc or
mL to administer.
 Treatment Demonstration
Nebulization of medication
Solute = medication
Solvent = saline or water

Order: 2.5 mg Albuterol in 2.0 mL N/S by

hand held nebulizer Q4 hours.
Medication
Drug dosage
Diluent
Method of delivery
Frequency
Weight/Volume Solutions
Weight/volume solutions are ALWAYS
expressed as a % where the percent
represents the number of grams of drug
in 100ml of solvent.
0.5% Solution = 0.5 grams per 100 mL
2.25% Solution = 2.25 grams per 100 mL

In order for us to use this, we must

convert the g/100 mL to mg/mL
0.5% = 0.5 grams per 100 mL OR 500 mg
per 100 mL
2.25% = 2.25 grams per 100 mL OR 2,250
mg per 100 mL
Weight/Volume Solutions
milligrams per ml.
0.5% solution contains . 5mg/ml
1% solution contains . 10mg/ml
2% solution contains . 20mg/ml
3% solution contains . 30mg/ml
4% solution contains 40mg/ml
1:100 solution is 1%
1:200 solution is .5%
1:1000 solution is .05%
 Example

How many milligrams are in 2 ml of a

3% solution?
30mg/ml 2ml = 60mg.

Since 3% = 30 mg/ml and the

question asks how much of this is in
2 ml, we simply multiply 30 by 2
Respiratory Therapy
Medications
Preparations:
Multi dose need to be measured
and diluted
Unit dose already diluted and
ready to use

Ultimate Goal of calculating is

to know how many cc or mL
to administer.
Treatment Demonstration
Nebulization of medication
Solute = medication
Solvent = saline or water

Order: 2.5 mg Albuterol in 2.0 mL N/S by

hand held nebulizer Q4 hours.
Medication
Drug dosage
Diluent
Method of delivery
Frequency
Medication Example

The physician order states that

you are to administer 2.5 mg of
albuterol. You have a 0.5%
albuterol solution. How much
medication (in mL) should you
draw up?

How many milligrams are in a 0.5%

solution?
 Medication Order
Isuprel 5 mg of a 1:100 mL solution
in 2mL normal saline by small
volume nebulizer Q4 hours.
Medication
Drug dosage
Diluent
Method of delivery
Frequency
 Ratio Solutions

Ratio solutions = 1 gram/??? mL

1:100 = 1 gram per 100 mL
1:200 = 1 gram per 200 mL

Convert to mg/mL
1:100 = 1000 mg per 100 mL
1:200 = 1000 mg per 200 mL
Medication Example

The physician orders 5 mg of

Isuprel. You have a 1:100
solution. Determine how much
medication (in mL) to give.

What concentration of drug do you

have?
1:100What does that mean?
Universal Drug Calculation

Need to convert the ratio to a

percentage.

1:100 = 1/100 = .01 = .01 *

100% = 1%
Universal Drug Calculation
The physician orders 5 mg of Isuprel. You have a
1:100 solution. Determine how much medication
to give (#mL).
1:100 = 1% solution
Pressures in solutions

Solutes in solvents exert a

pressure
Two kinds of pressure gradients
exist:
Diffusion
The passive movement from an area of
high concentration to one of lower
concentration
Osmotic
The movement of water from an area of
low concentration to an area of high
concentration.
 Diffusion

Solute pushing across a semi-

permeable membrane
Solute can move across membrane

The movement will continue until

there is an equilibrium in
concentrations.
 Osmotic pressure

Solvent (usually water) moving across a

semi-permeable membrane
Solute cannot move across membrane.

The movement will continue until there

is an equilibrium in concentrations.
Solvent
movement is
indicated by
arrows
through the
membranes.
 Osmotic pressure

Pressure that exists in the body because

of a solvent moving across a semi-
permeable membrane.
Solute cannot move across membrane.

Cell shrinks
Solution Cell
0.9% 0.5% Solution Cell
0.9% 0.5%
Water Movement

Attempting to have equal concentrations

on both sides of membrane.
 Tonicity
Def: The amount of osmotic
pressure in a solution.
Isotonic having the same
concentration as that of the body
fluids (such as 0.9% normal
saline)
Hypertonic higher concentration
that cause cells to shrink (crenation)
Hypotonic lower concentration
that cause cells to swell (hemolysis)
 Hypertonic
Higher concentration that cause cells
to shrink (crenation)

Fluid moves from cells into vasculature

IV 3% saline
0.9% 0.9% 0.9%

3%

Cells shrink - crenation

 Hypotonic
Lower concentration that cause cells
to swell (hemolysis)

Fluid moves into cells from vasculature

IV 0.45% saline
0.9% 0.9% 0.9%

0.45%

Cells swell - hemolysis

 Dilution Example
If you have 10cc of 20%
Mucomyst and need a 10%
solution, what do you need
to do?

Question: How many cc of

saline need to be added to
10 cc of 20% Mucomyst to
obtain 10% Mucomyst?
 Dilution
If you have 20cc of 0.9%
normal saline and need 0.3%
saline, what do you need to
do?

Question: How many cc of

sterile water need to be added
to 20 cc of 0.9% Saline to
obtain 0.3% Saline?
 Questions
When you add more solvent (water or
saline) to a medication will you be
giving more medication (solute)?
When you add more solvent (water or
saline) to a medication what will happen
to the concentration (tonicity)?
(increase, decrease or stay the same)
When you add more solvent (water or
saline) to a medication what will happen
to the time it takes to aerosolize?
(increase, decrease or stay the same)
 Pediatric calculations
Body surface area (Dubois Chart)
(Child BSA m2 / 1.73) x adult dosage
Frieds Rule
Infants < 1 year
(Infant age in months / 150 months ) x adult
dosage
Youngs Rule
Child 1 12 years
(Childs age in years/age + 12) x adult dosage
Clarks Rule
(Childs weight in pounds/150 pounds) x adult
dosage