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RSPT 2353 – Neonatal/Pediatric Respiratory Care
SPAG for administration of Ribavirin
Lecture Notes
I.
PURPOSE
a. The Small Particle Aerosol Generator (SPAG) is used for the
administration of Ribavirin.
b. Ribavirin is indicated when a patient is RSV + or has RSV
pneumonia. A nasal wash and ELISA test for RSV must be
performed before Ribavirin is prescribed.
c. Ribavirin is an antiviral agent, it is virostatic versus
virocidial. It inhibits replication of RNA and DNA viruses.
d. Brand names for Ribavirin: Rebetol, RibaPak, Virazole and
Ribasphere
II.
DOSAGE - Ribavirin can be administered in one of two ways:
a. High Dose/Short duration
1. 2g Ribavirin in 33.3 cc sterile water
2. Schedule is 2 hours on/6 hours off
3. Each dose is used for 3 daily treatments Q8
hours
4. May be repeated
b. Low dose/Long duration
1. 6g Ribavirin in 300 cc of sterile water
2. Schedule is 18 hours on/6 hours off for 3-4
days
3. May be repeated
III.
SPAG – Small Particle Aerosol Generator
a. The SPAG nebulizes Ribavirin to particles with a medial
diameter of 1.3 microns
b. Particles must be small to reach the level of alveoli and
respiratory bronchioles where RSV is causing symptoms or
pneumonia
c. It has a triple capillary tube nebulizer that creates very tiny
particles
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d. After the particles are created they are further reduced in
diameter by being passed through a drying chamber that
evaporates the particles down to about 1 micron.
e. If the SPAG is operated correctly the aerosol is should be
invisible to the naked eye at the final exit point.
f. One flowmeter controls the nebulizer flow. It should be set
as high as it can go. Because the orifice going to the triple
capillary system is so small this is generally between 6-10
lpm (usually only 7-8 lpm)
*If
this flowmeter can go higher, there is a leak upstream from the
nebulizer.
g. The second flowmeter goes to the drying chamber. It is set
at a flow rate that added to the nebulizer flow will total
15lpm. (usually 6-7 lpm)
h. This total 15 lpm goes into the croupette, aerosol mask,
trach collar, or ventilator circuit
i. For mechanically ventilated patients the nebulizer flow will
be 8 lpm with the drying chamber off.
Note: the mist will be visible.
j. Pressure manometer should be set at 26 psig to optimize the
particle size
k. When a patient has an O2 requirement > 50%, use oxygen
for the high pressure hose. If O2 requirement is less than
or equal to 50% use air hose, with supplementary oxygen.
l. The SPAG circuit can be reused for each dose for 24 hours.
Q24h, the circuit should be replaced and the dirty circuit in
a biohazard bag and disposed of properly.
IV.
PRECAUTIONS
a. ALL spontaneously breathing patients should be place under
a large HEPA filter tent while receiving Ribavirin.
Mechanically ventilated patients must have a double filter at
expiratory valve.
b. Pregnancy: Practitioner should ask family members if they
are pregnant. Pregnant or who may be pregnant
practitioners should not be assigned to these patients due to
unknown effects of Ribavirin on the fetus.
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c. All family members and practitioners will wear N95 HEPA
filter masks while Ribavirin is running.
d. Wear goggles or change to glasses if you wear contacts. The
Ribavirin will stick and absorb onto the contact.
V.
ADVERSE REACTIONS
a. Induced bronchospasm – If this occurs, stop tx immediately,
inform RN and MD. Administer Albuterol as needed.
b. Excessive coughing – When this happens, stop tx
immediately, notify RN and MD, continue to monitor and
document the situation.
VI.
TROUBLESHOOTING
a. Verifying Function of the SPAG - Turn the drying chamber
off just long enough to see the aerosol flow then return it
to the prescribed flow. When turned back on the mist should
again become invisible
b. Ventilator Malfunction
1. The ventilator MUST have two filters on the
expiratory limb of the circuit
2. Replace one filter q2h, if the ventilator is reading
inadvertent PEEP also replaces filters.
3. For volume ventilators (Servo 300, 900C, PB-840)
adjust sensitivity, VT and alarm settings as needed.
4. For pressure ventilators (Sechrist) adjust flow to
maintain original PIP.