Chap 37 Respiratory Drugs Flashcards
Overview
Main function of the respiratory system
Deliver oxygen to and remove carbon dioxide from the cells of the body
Upper respiratory tract (URT)**
Nasal Cavity
Pharynx
Larynx
Trachea
Lower respiratory tract (LRT)**
Bronchi
Alveoli: Point of gas exchange
Diseases of the Lower Respiratory Tract**
Chronic obstructive pulmonary disease (COPD)*
Asthma (persistent and present most of the time despite treatment)
Emphysema*
Chronic bronchitis*
Bronchial Asthma*
Recurrent and reversible shortness of breath**
Occurs when the airways of the lungs become narrow as a result of:
Bronchospasms*
Inflammation* of the bronchial mucosa
Edema* of the bronchial mucosa
Production of viscous mucus*
Symptoms**
Wheezing*
Difficulty breathing*
Types of Asthma
INTRINSIC IDIOPATHIC*
No history of allergy
Normal IgE*
Aspirin
Cold weather
Stress
Infection
EXTRINSIC Allergic Asthma*
History of Allergy*
Elevated IgE*
EXERCISE INDUCED*
Starts with beginning of the Exercise *
Stops when exercise is halted *
DRUG INDUCED*
NSAIDS*
Beta Blockers*
Asthma
Status asthmaticus*
Prolonged asthma attack that does not respond to typical drug therapy**
May last several minutes to hours
Medical emergency*
Asthma Disease
Chronic Bronchitis*
Continuous inflammation** and low-grade infection of the bronchi
Excessive secretion of mucus** and certain pathologic changes in the bronchial structure
Often occurs as a result of prolonged exposure to bronchial irritants
Emphysema*
No longer* used as a term but is included into COPD
Air spaces enlarge** as a result of the destruction of alveolar walls.
Caused by the effect of proteolytic enzymes* released from leukocytes* in response to alveolar inflammation
The surface area* where gas exchange* takes place is reduced.*
Effective respiration is impaired.
Pharmacologic Overview
Bronchodilator*
relax bronchial smooth muscle,
Causes bronchodilation***
Beta-adrenergic agonist
Anticholinergics
MethylXanthine derivatives
Non-Bronchodilator
Suppressing underlining causes of the respiratory illness
Steroids- Cortcosteroids
Leukotriene receptor antagonist
Mast cell stabilizer
Bronchodilators: Beta-Adrenergic Agonists
Used during acute phase of asthmatic attacks
Quickly reduce airway constriction and restore normal airflow
Agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous system
Bronchodilators: Beta-Adrenergic Agonists
Short-acting beta agonist (SABA) inhalers**
Albuterol (Ventolin, ProAir)**
Levalbuterol (Xopenex)**
Pirbuterol (Maxair)
Terbutaline (Brethine)
Metaproterenol (Alupent)
Long-acting beta agonist (LABA) inhalers**
Arformoterol (Brovana)**
Formoterol (Foradil, Perforomist)
Salmeterol* (Serevent)
Vilanterol in conjunction with fluticasone (Breo Ellipta)
Vilanterol in conjunction with the anticholinergic, umeclidinium (Anoro Ellipta)
The term Ellipta refers to a new delivery system.
Bronchodilators: Beta-Adrenergic Agonists
Three types
Nonselective adrenergics*
Stimulate alpha, beta1 (cardiac), and beta2 (respiratory) receptors**
Example: epinephrine (EpiPen)*
Nonselective beta-adrenergics*
Stimulate both beta1 and beta2 receptors*
Example: metaproterenol *
Selective beta2 drugs*
Stimulate only beta2 receptors*
Example: albuterol *
Beta-Adrenergic Agonists: Mechanism of Action
Begins at the specific receptor stimulated
Ends with dilation* of the airways
Activation of beta2 receptors activates cyclic adenosine monophosphate (cAMP), which relaxes smooth muscle in the airway and results in bronchial dilation and increased airflow.
Beta-Adrenergic Agonists: Indications*
Relief of bronchospasm* related to *asthma, bronchitis, and other pulmonary diseases**
Used in treatment and prevention of acute** attacks
Used in *hypotension and shock : Nonselective *adrenergic agonist- EpiPen
Beta-Adrenergic Agonists: Contraindications*
Known drug allergy
Uncontrolled hypertension*
Cardiac dysrhythmias**
High risk of stroke (because of the vasoconstrictive drug action)
Beta-Adrenergic Agonists: Adverse Effects*
Alpha and beta (epinephrine)*
Insomnia
Restlessness
Anorexia
Vascular headache
Hyperglycemia
Tremor*
Cardiac stimulation
Beta1 and beta2 (metaproterenol)**
Cardiac* stimulation
Tremor
Anginal pain
Vascular headache
Hypotension
Beta2 (albuterol)
Hypotension or hypertension
Vascular* headache
Tremor
Beta-Adrenergic Agonists: Interactions*
Nonselective betablockers
Monoamine oxidase inhibitors(MAOI)**
Sympathomimetics… Increases risk for hypertension
Hypoglycemics*….Monitor patients with diabetes; an increase in blood glucose levels can occur.
Beta-Adrenergic Agonists: Albuterol* (Proventil)
Short-acting beta2-specific bronchodilating beta agonist
Most commonly used drug in this class
Must not* be used too frequently*
Oral and inhalational use
Inhalational dosage forms include metered-dose inhalers (MDIs) as well as solutions for inhalation.
Beta-Adrenergic Agonists: Salmeterol* (Serevent)
Long-acting beta2 agonist bronchodilator
Never to be used for acute treatment**
Used for the maintenance treatment** of asthma and COPD** and is used in conjunction with an *inhaled corticosteroid**
Salmeterol should never be given more than twice daily, nor should the maximum daily dose (one puff twice daily) be exceeded.
Nursing Implications: Beta-Adrenergic Agonists
If 2 puffs are ordered wait 1-2 mins in between puffs**
Albuterol, if used too frequently, loses its beta2-specific actions at larger doses.
As a result, beta1 receptors are stimulated, causing nausea, increased anxiety, palpitations, tremors, and increased heart rate.
Ensure that patients take medications exactly as prescribed, with no omissions or double doses.
Inform patients to report insomnia, jitteriness, restlessness, palpitations, chest pain, or any change in symptoms
Anticholinergics: Mechanism of Action*
LAMA: Long-acting muscarinic antagonists**
Acetylcholine (ACh) causes bronchial constriction
Anticholinergics bind to the ACh receptors, preventing ACh from binding.
Result:* bronchoconstriction is prevented, indirectly* causing airways to dilate
Help reduce secretions in COPD patients
Slow and Prolonged action…management of COPD
Anticholinergics: Adverse Effects
Dry mouth or throat**
Nasal congestion
Heart palpitations**
Gastrointestinal (GI) distress
Headache
Coughing
Anxiety
Anticholinergics: Ipratropium* (Atrovent)
Oldest and most commonly used anticholinergic bronchodilator
Available both as a liquid aerosol* for inhalation and as a multidose inhaler*
Usually dosed twice daily
Others:
Tiotropium* (Spiriva)
Aclidinium* (Tudorza)
Umeclidinium* (Incruse Ellipta)
Duoneb, Combivent: ( Ipratropium + Albuterol)
Anticholinergics: Contraindications*
Drug Allergy
* Peanut and Soy allergy**
With caution in patients with *narrow angle glaucoma and prostrate enlargement**
Not* for management* of acute* symptoms
Xanthine Derivatives
Plant alkaloids: caffeine, theobromine, and theophylline
Only theophylline* is used as a bronchodilator*.
Synthetic xanthines: aminophylline* and dyphylline
Xanthine Derivatives: Mechanism of Action*
Increase levels of energy-producing cAMP**
This is done by competitively inhibiting phosphodiesterase, the enzyme that breaks down cAMP.
Result: increased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow
Xanthine Derivatives: Drug Effects
Xanthine Derivatives: Drug Effects
central nervous system (CNS) stimulation
cardiovascular stimulation: increased force of contraction and increased heart rate, resulting in increased cardiac output and increased blood flow to the kidneys (diuretic effect)
Xanthine Derivatives: Indications*
Dilation of airways in asthmas, chronic bronchitis, and emphysema
Mild to moderate cases of acute asthma
NOT for management of acute asthma attack
Adjunct drug in the management of COPD
Not used as frequently because of potential for drug interactions and variables related to drug levels in the blood
Xanthine Derivatives: Adverse Effects
Nausea, vomiting, anorexia
Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias
Transient increased urination
Hyperglycemia
Xanthine Derivatives: Theophylline*
Most commonly used xanthine derivative
Oral, rectal, injectable (as aminophylline), and topical dosage forms
Aminophylline: intravenous (IV) treatment*& of patients with status asthmaticus** who have not responded** to *fast-acting beta agonists** such as epinephrine
Therapeutic range for theophylline blood level is 10 to 20 mcg/mL*
Most clinicians now advise levels between 5 and 15 mcg/mL.
Nursing Implications: Xanthine Derivatives
Be aware of drug interactions** with cimetidine, oral contraceptives, allopurinol, certain antibiotics, influenza vaccine, and others.
Cigarette smoking enhances xanthine metabolism.***
Interacting foods** include charcoal-broiled, high-protein, and low-carbohydrate foods.
These foods may reduce serum levels of xanthines through various metabolic mechanisms.
Nonbronchodilating Respiratory Drugs**
Leukotriene receptor antagonists**
(montelukast, zafirlukast, and zileuton)
Corticosteroids**
(beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, ciclesonide, and triamcinolone)
Mast cell stabilizers:**
rarely used cromolyn and nedocromil, which are sometimes used for exercise-induced asthma
Leukotriene Receptor Antagonists (LTRAs)
Nonbronchodilating**
Newer class of asthma medications
Currently available drugs
Montelukast (Singulair)***
Zafirlukast (Accolate)
Zileuton (Zyflo)
LTRAs: Mechanism of Action
Leukotrienes are substances released when a trigger, such as cat hair or dust, starts a series of chemical reactions in the body.
Leukotrienes cause inflammation, bronchoconstriction, and mucus production.
Result: coughing, wheezing, shortness of breath
LTRAs prevent leukotrienes from attaching to receptors on cells in the lungs and in circulation.
Inflammation in the lungs is blocked, and asthma symptoms are relieved.
LTRAs: Drug Effects**
By blocking leukotrienes:
Prevent smooth muscle contraction of the
bronchial airways
Decrease mucus secretion
Prevent vascular permeability
Decrease neutrophil and leukocyte infiltration
to the lungs, preventing inflammation
LTRAs: Indications*
*Prophylaxis and long-term treatment and prevention of asthma** in adults and children 12 years of age and older
Not* meant for management* of acute* asthmatic attacks
Montelukast is also approved for treatment of allergic rhinitis
Improvement with their use is typically seen in about 1 week.
LTRAs: Contraindications
Known drug allergy
Previous adverse drug reaction
Allergy to povidone, lactose, titanium dioxide, or cellulose derivatives is also important to note because these are inactive ingredients in these drugs.
Nursing Implications: LTRAs**
Ensure that the drug is being used for chronic** management of asthma, not acute asthma.**
Teach the patient the purpose of the therapy.
Improvement should be seen in about 1 week.
Advise patients to check with prescriber before taking OTC or prescribed medications to determine drug interactions.
Assess liver function before beginning therapy and throughout.
*Teach patients to take medications every night on a continuous schedule even if symptoms improve.**
Corticosteroids* (Glucocorticoids)
Antiinflammatory* properties
Used for chronic asthma
Do not* relieve symptoms of acute** asthma attacks
May be administered IV
Oral or inhaled** forms
May take several weeks before full effects are seen
Corticosteroids: Mechanism of Action*
Stabilize membranes of cells that release harmful bronchoconstricting substances
These cells are called leukocytes, or white
blood cells.
Increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation
Dual effect of both *reducing inflammation** and enhancing the activity of beta agonists.
Restore or increase the responsiveness of bronchial smooth muscle to beta-adrenergic receptor stimulation, which results in more pronounced stimulation of the beta2 receptors by beta agonist drugs such as albuterol.
Inhaled Corticosteroids**
Beclomethasone dipropionate** (Beclovent)
Budesonide (Pulmicort Turbuhaler)
Ciclesonide (Omnaris)
Flunisolide (AeroBid)
Fluticasone (Flovent)
Mometasone (Asmanex)
Triamcinolone acetonide (Azmacort)
Inhaled Corticosteroids: Indications*
Primary treatment of bronchospastic disorders to control the inflammatory responses that are believed to be the cause of these disorders
Persistent asthma
Often used concurrently with the beta-adrenergic agonists
Systemic corticosteroids are generally used only to treat acute exacerbations, or severe asthma.
IV corticosteroids: acute exacerbation of asthma or other COPD
Inhaled Corticosteroids: Contraindications*
Drug allergy
Not intended as sole therapy for acute asthma attacks
Hypersensitivity to glucocorticoids
Patients whose sputum tests positive for Candida organisms
Patients with systemic fungal infection
Inhaled Corticosteroids: Adverse Effects**
Pharyngeal irritation**
Coughing*
Dry mouth*
Oral fungal infections*
Systemic effects are rare because low doses are used for inhalation therapy.
Inhaled Corticosteroids: Drug Interactions *
Drug interactions are more likely to occur with systemic (versus inhaled) corticosteroids.
May *increase serum glucose levels**, possibly requiring adjustments in dosages of antidiabetic drugs
Cyclosporine and tacrolimus
Itraconazole
Phenytoin, phenobarbital, and rifampin
Nursing Implications**: Inhaled Corticosteroids
Teach patients to gargle and rinse the mouth** with lukewarm water afterward to prevent the development of oral fungal infections.**
If a beta agonist bronchodilator and corticosteroid inhaler are both ordered, the bronchodilator should be used at least 5 minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid.
Encourage use of a spacer** device to ensure successful inhalations.
Teach patient how to keep inhalers and nebulizer equipment clean after use**
Monoclonal Antibody Antiasthmatic
Omalizumab (Xolair), mepolizumab* (Nucala), reslizumab (Cinqair)
Selectively binds to the immunoglobulin E, which in turn limits the release of mediators of the allergic response
Given by injection
Potential for producing anaphylaxis
Monitor closely for hypersensitivity reactions.
Nursing Implications*
Encourage patients to take measures that promote a generally good state of health to prevent, relieve, or decrease symptoms of COPD.
Avoid exposure** to conditions that precipitate bronchospasm (allergens, smoking, stress, air pollutants).
Adequate fluid intake**
Compliance* with medical treatment
Avoid excessive fatigue, heat, extremes in temperature, and caffeine.
Encourage patients to get prompt treatment for flu or other illnesses and to get vaccinated against pneumonia or flu.
Encourage patients to always check with their physicians before taking any other medication, including over-the-counter (OTC) medications
Perform a thorough assessment before beginning therapy, including:
Skin color*
Baseline vital signs*
Respirations* (should be between 12 and 24 breaths/min)
Respiratory assessment, including pulse oximetry
Sputum production
Allergies
History of respiratory problems
Other medications
Smoking history
Ensure that patients know how to use inhalers and MDIs and have patients demonstrate use of the devices.
Nursing Implications
Monitor for therapeutic effects:**
Decreased dyspnea*
Decreased wheezing, restlessness, and anxiety**
Improved respiratory** patterns with return to normal rate and quality
Improved activity tolerance**
Decreased symptoms and increased ease of breathing**
Inhalers: Patient Education**
For any inhaler prescribed, ensure that the patient can self-administer the medication.
Provide demonstration and return demonstration.**
Ensure that the patient knows the correct time intervals for inhalers.
Provide a spacer if the patient has difficulty coordinating breathing with inhaler activation.
Ensure that the patient knows how to keep track of the number of doses in the inhaler device.
