page220
ing
nasal
intermittent
positive
pressure
ventilation.
However, occasionally when ventilatory support is con-
tra-indicated and in patients with hypercapnic respir-
atory failure who are becoming drowsy or comatose,
respiratory stimulants in the short
term may arouse
patients sufficiently to co-operate and clear their secre-
tions.
Respiratory stimulants can also be harmful
in respir-
atory failure since they stimulate non-respiratory as well
as respiratory muscles. They should only be given under
expert supervision in hospital
and must be combined
with active physiotherapy.
There is at
present no oral
respiratory stimulant
available for
long-term use in
chronic respiratory failure.
Doxapram is given by continuous intravenous infusion.
Frequent arterial
blood gas and pH measurements are
necessary during treatment to ensure correct dosage.
For the use of caffeine in the management of neonatal
apnoea,
see
BNF for Children
.
DOXAPRAM HYDROCHLORIDE
Indications
see under Dose
Cautions
give with oxygen in severe irreversible air-
ways obstruction or severely decreased lung compli-
ance (because of increased work load of breathing);
give with beta
2
agonist in bronchoconstriction;
hypertension (avoid if severe),
impaired cardiac
reserve;
phaeochromocytoma;
interactions: Appen-
dix 1 (doxapram)
Contra-indications
severe hypertension;
status asth-
maticus;
coronary artery disease; hyperthyroidism;
epilepsy and other convulsive disorders;
physical
obstruction of respiratory tract;
cerebral oedema,
cerebrovascular accident
Hepatic impairment
use with caution
Pregnancy
no evidence of harm,
but manufacturer
advises avoid unless benefit outweighs risk
Side-effects
nausea,
vomiting;
hypertension,
tachy-
cardia, bradycardia, extrasystoles,
arrhythmias,
chest
pain,
flushing; dyspnoea,
cough, bronchospasm, lar-
yngospasm; pyrexia, headache,
dizziness, hyperactiv-
ity,
confusion, hallucination,
convulsions; urinary
retention,
incontinence,
perineal warmth;
muscle
spasms
Dose
. Postoperative respiratory depression,
by intravenous
injection over at least 30 seconds,
1–1.5 mg/kg
repeated if necessary after intervals of 1 hour
or
alternatively by intravenous infusion, 2–3 mg/minute
adjusted according to response;
CHILD
not recom-
mended
. Acute respiratory failure,
by intravenous infusion,
1.5–4 mg/minute adjusted according to response
(given concurrently with oxygen and whenever pos-
sible monitor with frequent measurement of blood gas
tensions);
CHILD
not recommended
. Neonatal apnoea,
see
BNF for Children
Dopram
c
(Goldshield) A
Injection
,
doxapram hydrochloride 20 mg/mL.
Net
price 5-mL amp = £3.00
Intravenous infusion
,
doxapram hydrochloride
2 mg/mL in glucose 5%.
Net price 500-mL bottle =
£21.33
3.5.2
Pulmonary surfactants
Pulmonary surfactants are used in the management of
respiratory distress syndrome (hyaline membrane dis-
ease) in neonates and preterm neonates. They may also
be given prophylactically to those considered at risk of
developing the syndrome.
Cautions
Continuous monitoring is required to avoid
hyperoxaemia caused by rapid improvement in arterial
oxygen concentration.
Side-effects
Pulmonary haemorrhage and brady-
cardia have been rarely associated with pulmonary
surfactants;
obstruction of
the endotracheal
tube by
mucous secretions and intracranial
haemorrhage have
also been reported.
BERACTANT
Indications
treatment of respiratory distress
syndrome in preterm neonates over 700 g;
prophy-
laxis of respiratory distress syndrome in preterm
neonates less than 32 weeks post-menstrual age
Cautions
see notes above and consult product litera-
ture
Side-effects
see notes above
Dose
. By endotracheal tube,
phospholipid 100 mg/kg
equivalent to a volume of 4 mL/kg, preferably within 8
hours of birth (preferably within 15 minutes of birth
for prophylaxis);
dose may be repeated within 48
hours at intervals of at least 6 hours for up to 4 doses
Survanta
c
(Abbott) A
Suspension
,
beractant (bovine lung extract) provid-
ing phospholipid 25 mg/mL, with lipids and proteins,
net price 8-mL vial = £306.43
PORACTANT ALFA
Indications
treatment of respiratory distress
syndrome or hyaline membrane disease in neonates
over 700 g;
prophylaxis of respiratory distress
syndrome in preterm neonates 24–32 weeks post-
menstrual age
Cautions
see notes above and consult product litera-
ture
Side-effects
see notes above; also
rarely
hypotension
Dose
. By endotracheal tube,
treatment
,
100–200 mg/kg;
further doses of 100 mg/kg may be repeated at
intervals of 12 hours; max. total dose 300–400 mg/kg;
prophylaxis
,
100–200 mg/kg soon after birth (prefer-
ably within 15 minutes);
further doses of 100 mg/kg
may be repeated 6–12 hours later and after a further
12 hours if still intubated;
max.
total dose 300–
400 mg/kg
Curosurf
c
(Chiesi) A
Suspension
,
poractant alfa (porcine lung phospholi-
pid fraction) 80 mg/mL,
net price 1.5-mL vial =
£281.64;
3-mL vial = £547.40
200
3.5.2 Pulmonary surfactants
BNF 61
3
Respiratory system