Introduction:Lower Respiratory Tract

Question 1

What are diseases in the lower respiratory tract?

Answer 1

Asthma
COPD – chronic obstruction of airways
Emphysema – damage to alveoli
Chronic bronchitis – inflammation/mucus airway

Question 2

What are characteristics of lower respiratory tract infections

Answer 2

Bronchoconstriction
Inflammation, mucosal edema
Excessive mucus production

Question 3

Bronchodilators/ Antiasthmatics
What are drug classifications?

Answer 3

Long-term control (prophylactic)
Achieve and maintain control of persistent constriction

Quick relief (rescue)
Used during periods of acute symptoms and exacerbations

Question 4

what are 3 drug classes?
Bronchodilators/ Antiasthmatics

Answer 4

Xanthines
Beta-agonists
Anti-cholinergics

Question 5

What are theophylline?

Answer 5

Xanthines

Question 6

What are therapeutic actions of theophylline?

Answer 6

Xanthines
Direct effect on smooth muscles of bronchi causing dilation and decreasing swelling

Question 7

What are indications of theophylline?

Answer 7

Xanthines

Asthma; Bronchospasms
Symptomatic relief or prevention of bronchial asthma and reversible bronchospasm associated with chronic bronchitis and emphysema.

Question 8

What are pharmokinetics of theophylline?

Answer 8

Xanthines

Therapeutic levels: 10-20 mcg/mL

Question 9

What are adverse affects of theophylline?

Answer 9

Xanthines

GI upset/ nausea
Irritability/ restlessness,
Tachycardia

tremors,insomnia

severe toxicity include seizure, life threatening arrhythmias, hypertension, and coma

Question 10

What are contras of theophylline?

Answer 10

Xanthines
Allergy, pregnancy/lactation

Question 11

What are cautions of theophylline?

Answer 11

Xanthines
Cardiac disease,
hyperthyroidism due to increase stimulation

also
Gi problems, resp dysfunction
renal/hepatic

Question 12

What are drug-drug interactions theophylline?

Answer 12

MANY!!
Nicotine

Question 13

What is albuterol (Proventil)?

Answer 13

Sympathomimetics/ Beta Agonists

Question 14

What is therapeutic action of albuterol (Proventil)?

Answer 14

Sympathomimetics/ Beta Agonists

Stimulate sympathetic nervous system  quickly dilates bronchi and increases rate and depth of respirations

Question 15

What is indications action of albuterol (Proventil)?

Answer 15

Sympathomimetics/ Beta Agonists
Used during acute phase of asthmatic attacks –> often called “rescue drugs”

Question 16

What is Pharmacokinetics of albuterol (Proventil)?

Answer 16

Sympathomimetics/ Beta Agonists

Inhalants (some in oral, parenteral forms)
Inhaled —> rapidly absorbed; duration of action varies

Question 17

What is adverse effects of albuterol (Proventil)?

Answer 17

Sympathomimetics/ Beta Agonists

r/t stimulation of sympathetic nervous system
Insomnia
Restlessness
Anorexia
Vascular headache
Hyperglycemia
Tremor
Cardiac stimulation

Question 18

What is contras/cautions of albuterol (Proventil)?

Answer 18

Sympathomimetics/ Beta Agonists

Allergy
HTN, tachycardia, hyperthyroidism

Question 19

What to assess/ implement albuterol (Proventil)?

Answer 19

Sympathomimetics/ Beta Agonists

Assess lungs sounds pre/post
VS pre/post
Teach use of inhalers

Question 20

Teaching patients to self-administer medication

Answer 20

Review p.992, Box 55.5
Proper administration of inhaler
Shake canister
Exhale and bring to mouth
Compress inhaler WHILE inhaling
(over 3-5 secs)
Hold for slow 10 secs
Exhale through mouth
Spacers
Mouth care

Question 21

What is ipratropium (Atrovent)

Answer 21

Anticholinergics

Question 22

What is therapeutic action of ipratropium (Atrovent)

Answer 22

Anticholinergics
BLOCKS action of acetylcholine (ACh)

Result: bronchoconstriction is prevented, airways dilate

Question 23

What is therapeutic action of ipratropium (Atrovent)

Answer 23

Anticholinergics
BLOCKS action of acetylcholine (ACh)
Result: bronchoconstriction is prevented, airways dilate

Question 24

What are indications of ipratropium (Atrovent)

Answer 24

Anticholinergics

Prevention (NOT rescue!!)

Indications: Maintenance treatment of bronchospasm associated with COPD; as a nasal spray, treatment of seasonal allergic rhinitis.

Useful for patients unable to tolerate beta-agonists (but not as effective)
copd,asthmaexacerbation

Question 25

What are Pharmacokinetics of ipratropium (Atrovent)?

Answer 25

Anticholinergics

Inhalants
Ipratropium –> rapid onset (15 min); 1-2hr hour peak
Can be combined with albuterol —> combivent —-> dosed less frequently

Question 26

What are adverse effects of ipratropium (Atrovent)?

Answer 26

Anticholinergics
Anticholinergic effects –> dizziness, headache, fatigue, dry mouth, palpitations, urinary retention
have been reported events of hypersensitivity and paradoxical bronchospasm.

Question 27

What are contras/ cautions of ipratropium (Atrovent)?

Answer 27

r/t Anticholinergic effects
Allergy to soy products or peanuts

Question 28

What are drug-drug interactions of ipratropium (Atrovent)?

Answer 28

Anticholinergics
Increase in anticholinergic effects when combined with other anticholinergics

Question 29

Drugs affecting inflammation
What is budesonide (Pulmacort)?

Answer 29

Inhaled steroids

Question 30

What is therapeutic actions budesonide (Pulmacort)?

Answer 30

Inhaled steroids
Reduces inflammation
Increases beta-agonist activity  muscle relaxation

Decreases the inflammatory response in the airway; this action will increase airflow and facilitate respiration in an airway narrowed by inflammation.

Question 31

What is indications budesonide (Pulmacort)?

Answer 31

Inhaled steroids

Treatment of bronchospastic disorders that are not controlled by conventional bronchodilation
-Could be used for asthma patient
Used early in disease process with bronchodilator
In acute episodes corticosteroid is given IV (then orally for several days)

Question 32

What are fixed combinations of inhaled steroids?

Answer 32

Advair  fluticasone and salmeterol
Symbicort  budesonide and formoterol

Question 33

What are adverse affects of budesonide (Pulmacort)?

Answer 33

Inhaled steroids

Limited due to inhalation
Dry mouth, sore throat, hoarseness
Oral fungal infections (**oral care!!)

Question 34

What are contras affects of budesonide (Pulmacort)?

Answer 34

Not for acute attack
Pregnancy/lactation
inhaled steroids are not for emergency use and not for use during an acute asthma attack or status asthmaticus

Question 35

What are cautions affects of budesonide (Pulmacort)?

Answer 35

Active respiratory infection

These preparations should be used with caution in any patient who has an active infection of the respiratory system because depression of the inflammatory response could result in serious illness.

***Bronchodilate first…. then steroid

Question 36

What are Leukotriene Receptor Antagonists

Answer 36

Leukotrienes  substances released when a trigger starts a series of chemical reactions in the body

Leukotrienes cause inflammation, bronchoconstriction, and mucus production

Result: coughing, wheezing, shortness of breath

Question 37

What are montelukast (Singular) ?

Answer 37

Leukotriene Receptor Antagonists

Question 38

What is the therapeutic actions of montelukast (Singular)

Answer 38

Leukotriene Receptor Antagonists

Prevent leukotrienes from attaching to receptors on cells in the lungs and in circulation
Decreases vascular permeability
Decreases mucus production
Inflammation in the lungs is blocked, and asthma symptoms are relieved

Question 39

What is the indications actions of montelukast (Singular)

Answer 39

Leukotriene Receptor Antagonists

Prophylaxis and chronic treatment of asthma in adults and children (NOT meant for management of acute asthmatic attacks)

Tx of allergic rhinitis

Question 40

What is the adverse effects of montelukast (Singular)

Answer 40

Leukotriene Receptor Antagonists

HA, N/V/D
Elevated LFTs
Generalized myalgia
Long term effects not fully studied

upper respiratory infection, pharyngitis, cough, headache, dizziness, nausea, diarrhea, abdominal pain, elevated liver enzyme concentrations, vomiting, generalized pain, fever, and myalgia. Serious neuropsychiatric events (including depression, suicide, hallucinations, and aggressive behavior) have been reported in patients taking leukotriene receptor antagonists. Montelukast has a boxed warning regarding the risk of neuropsychiatric events.

Question 41

What is the Contras/Cautions: montelukast (Singular)

Answer 41

Leukotriene Receptor Antagonists

Allergy
Metabolized extensively in the liver/renal
Pregnancy/lactation – fetal toxicity in animal studies

Question 42

What is the drug-drug interactions montelukast (Singular)

Answer 42

Leukotriene Receptor Antagonists

coumadin, ASA, CCBs, cyclosporine

warfarin, theophylline, phenytoin, aspirin, and others. Check for interactions before administering these medications.

Question 43

Lower respiratory medications: Lifespan considerations

Answer 43

Leukotriene-receptor antagonists very useful in children
Acute episodes best managed by short B2 then steroid
Parent teaching important
If inhalants used for exercise asthma use 30 to 60 minutes prior to exercise
Adults – periodic review of administration technique/new drugs
Pregnancy safety not established
Older adults – assess co-morbidities, renal/hepatic function…start low!

General: Yearly flu vaccine a must!