Lower Respiratory Agents Flashcards
Where do Lower Respiratory Agents work?
Where gas exchange occers
* Bronchial tree
* Alveoli
Which diseases are treated with lower respiratory drugs?
- Asthma
- COPD (Emphysema, Chronic Bronchitis)
- Pneumonia
- Respiratory Distress Syndrome (neonates)
- Adult Respiratory Distress Syndrome
What forms do lower respiratory drugs come in?
Oral, nebulizer, injection
Considerations for Lower Respiratory Tract agents
In Children
Prevention is KEY
* Avoid allergens, smoke, crowds, dusty areas
Used frequently:
* Long-Acting inhaled steroid
* Short-Acting Beta2 agonist (SABA)
* Leukotriene receptor agonist (best for prevention)
Theophylline ONLY if nothing else works
Considerations for Lower Respiratory Tract agents
In Adults
- Avoidance of aggravating factors/triggers
- Periodic review of treatment regimen
- Periodic spirometry to measure lung capacity
- Safety in pregnancy has not been established: benefit vs. risk
Considerations for Lower Respiratory Tract agents
In Older Adults
- Used frequently in this population
- More likely to experience adverse effects
- Renal and hepatic impairment can alter metabolism and excretion
- START LOW, GO SLOW
- Close monitoring
Considerations for Lower Respiratory Tract agents - Adjuvant Therapy
In Older Adults
- Pulmonary hygiene (toileting) - positioning, coughing, deep breathing, head of bed up
- Positioning
- Fluids
- Nutrition
- Humidification
- Rest
- Activity Plans
- Support for complicated drug regimen
Xanthines
Mechanism of Action
- Direct effect on the smooth muscles of the resp. tract, both in the bronchi and in the blood vessels (vasodilation)
- Exact MOA unknown
Xanthines
Indications
- Symptomatic relief or prevention of asthma and COPD
- Reversal of bronchospasm
Xanthines
Drug Names
- Caffeine
- Theophylline (most common)
Other name for Xanthines
Methylxanthines
Xanthines
Safety Considerations
- Narrow margin of safety
- Interact with MANY drugs
- Numerous adverse effects
- Reserved for when other drugs don’t work or critical situation in ICU
Xanthines
Contraindications
Absolute:
* Allergy
Cautions: (worsened with xanthines)
* GI problems
* Heart disease
* Renal or hepatic disease
* Alcoholism
* Hyperthyroidism
Xanthines
Drug Interactions
- ANY drug metabolized in the liver has the potential to interact with xanthines
- Substances in CIGARETTES => need for higher dose to be therapeutic (if pt. decreases or stops smoking, risk for toxicity with the higher dose)
Xanthines
Adverse Effects
Related to theophylline levels in blood
* GI issues: Nausea & Vomiting
* Cardiac: Tachycardia
* CNS: Tremors, Irritability, Insomnia
SEVERE TOXICITY:
* Seizures
* Life-threatening arrhythmias
* Hypotension
* Coma
Xanthines
Assessment
History:
* Allergy
* Pregnancy/lactation
* Cautions
* Smoking history
Physical:
* Respiratory
* Cardiac
* Abdomen
* ECG
Labs:
* Liver and Renal funtion tests
* Theophylline levels
Xanthines
Nursing Conclusions
- Impaired comfort (r/t adverse effects)
- Altered sensory perception (r/t adverse CNS effects)
- Knowledge deficit
Xanthines
Implementation/Patient Teaching
- Administer WITH food or milk to relieve GI upset
- Swith from IV to oral ASAP to avoid systemic effects
- Comfort measures (rest periods)
- Patient Teaching (sig. adv. effects - how to manage, report)
- Lab tests regularly
Sympathomimetics
Mechanism of Action
Bronchodilators
* Beta2 selective adrenergic agonists
* Dilates bronchi
* Increases respiratory rate
* Increases depth of respirations
* SABA (short-acting) and LABA (long-acting)
* Mimics sympathetic nervous system stimulation
Sympathomimetics
Indications
- ACUTE Asthma Attack SABA
- Bronchospasm SABA
- Prevention of exercise-induced asthma SABA
- Maintenance medication for chronic respiratory distress - LABA
Sympathomimetics
Drug Names
Epiniphrine (Drug of choice in bronchospasm)
“-terol”
* Levalbuterol
* Salmeterol
* Albuterol (rescue inhaler)
* Formoterol
“-proterenol”
* Isoproterenol
* Metaproterenol
Sympathomimetics
Contraindications
Absolute:
* Allergy
Cautions:
* Conditions that would worsen with SNS stimulation: (cardiac pts), heart disease, vasular disease, hypothyroidism
Sympathomimetics
Drug Interactions
- Beta Blockers - can block symp. drugs (if administered systemically)
- Other drugs that increase BP or HR
- Substances in cigarettes
Sympathomimetics
Adverse Effects
- Occasionally CAUSES bronchospasm
- Sympathetic Stimulation: CNS stimulation (anxiety, dizziness, headache)’; GI Upset; Cardiac (arrhythmias, hypertension, sweating, pallor, flushing)
Sympathomimetics
Assessment
History:
* Allergy
* Pregnancy/lactation
* cigarette use (affects metabolism of drug)
* conditions that require cautions
Physical:
* Respiratory
* Cardiac
* Neuro
* Vital Signs
Sympathomimetics
Nursing Conclusions
- Altered tissue perfusion
- Impaired comfort
- Anxiety or restlessness
- Knowledge deficit
Sympathomimetics
Implementation
- Proper administration
- Safety measures
- Take 30-60 minutes before exercise for exercise-induced asthma
- Comfort measures: small, frequent meals and nutritional consult
- Patient Education
Anticholinergics
MOA
Bronchodilation
* Blocks the vagal effect leading to relaxation of smooth muscle in bronchi
Anticholinergics
Indications
Maintenance treatment for COPD
For patients that cannot tolerate sympathomimetics - not as effective
Anticholinergics
Drug Names
“-tropium”
* Ipatropium
* Tiotropium
“-clidinium”
* Aclidinium
* Umeclidinium
Anticholinergics
Contraindications
Absolute
* Allergy
* Acute bronchospasm requiring imm. intervention
Cautions:
* Any condition aggravated by anticholinergic effects: Glaucoma, urinary retention
Anticholinergics
Adverse Effects
- Dry Mouth, hoarseness, sore throat
- Dizziness, headache, fatigue, nervousness, palpitations, urinary retention (from small systemic effects)
- Paradoxical bronchospasm
Anticholinergics
Drug Interactions
Other anticholinergics
Anticholinergics
Assessment
History:
* Allergy to drug, acute bronchospasm
* Pregnancy/lactation
* Conditions exacerbated by anticholinergics
Physical:
* Respiratory
* Cardiac
* Skin/mucus membranes (color, dryness, lesions)
* CNS: Orientation, affect, and reflexes
* Urinary output
* Vital Signs
Anticholinergics
Nursing Conclusions
- Impaired comfort
- Knowledge Deficit
Anticholinergics
Interventions/Patient Teaching
- Void prior to med. administration
- Safety measures for CNS effects
- Comfort measures: small, frequent meals; sugarless lozenges; humidification; adequate hydration
- Patient Teaching
Inhaled Steroids
Mechanism of Action
- Decreases the inflammatory response in the airways
- Takes 2-3 weeks to be effective
Inhaled Steroids
Indications
- Prevention and treatment of asthma
- Maintenance treatment of COPD
Inhaled Steroids
Drug Names
“-one”
* Beclomethasone (Qvar)
* Fluticasone
* Triamcinolone
“-esonide”
* Budesonide
* Ciclesonide
Inhaled Steroids
Implementation/Patient Teaching
- Comfort measures
- Safety measures
- Patient Teaching: NOT for emergencies
- Rinse mouth after using inhaler (to prevent fungal infections)
- Clean mouthpiece after every use
- Monitor for signs of respiratory infection
Inhaled Steroids
Contraindications
Absolute:
* Allergy
NOT a drug for acute asthma attack!
Caution:
* Active respiratory infection (because of suppressed immune function by steroids)
Inhaled Steroids
Adverse Effects
- Sore throat/hoarseness
- Coughing
- Dry Mouth
- Pharyngeal and laryngeal fungal infections
Inhaled Steroids
Drug Interactions
NONE/UNKNOWN
Inhaled Steroids
Assessment
History:
* Allergy
* Pregnancy/lactation
* Systemic infections
Physical:
* Respiratory
* Vital Signs (temperature) - Baselines
* CV: BP, pulse, cardiac auscultation
* Look for fungal infections
Inhaled Steroids
Nursing Conclusions
- Impaired Comfort
- Infection Risk
- Knowledge Deficit
Leukotriene Receptor Antagonists
MOA
- Block (antagonize) receptors for the production of leukotrienes
- They DO NOT have an immediate effect: 1-2 weeks for therapeutic effect
Leukotriene Receptor Antagonists
Indications
Long term treatment of Asthma
Leukotriene Receptor Antagonists
Drug Names
“-lukast”
* zafirlukast (Accolate)
* Montelukast (Singulair)
Leukotriene Receptor Antagonists
Contraindications
Absolute:
* Allergy
* Acute Asthma Attack
Caution:
* Hepatic Impairment
Leukotriene Receptor Antagonists
Adverse Effects
- Flu-like symptoms: pharyngitis, cough, generalized pain, fever, myalgia
- CNS: Headache, dizziness
- GI: nausea, diarrhea, vomiting, abdominal pain, elevated liver enzymes
Black Box Warning
* Aggressive behavior, depression & suicide, hallucinations => in children
Leukotriene Receptor Antagonists
Drug Interactions
- metabolized by p450 system along with MANY others => check drug guide before administration
Leukotriene Receptor Antagonists
Assessment
History:
* Allergy, hepatic impairment, pregnancy/lactation
Physical:
* Respiratory: rule out acute asthma attack
* Temp, resp, lung sounds
* CNS: orientation and affect
* Abdomen
Labs:
* Liver function tests (LFTs)
Leukotriene Receptor Antagonists
Nursing Conclusions
- Injury Risk (Black box warning)
- Impaired comfort
- Knowledge deficit
Leukotriene Receptor Antagonists
Implementation/Patient Teaching
- Not for use in acute asthma attack
- Monitor for infection
- Safety measures r/t adverse effects
- Patient Teaching
Lung Surfactants
MOA
- Replace the surfactant that is missing in the lungs of neonates with RDS
- Begins to work IMMEDIATELY
Lung Surfactants
Indications
Rescue treatment for infants who have developed RDS (missing surfactant)
Lung Surfactants
Contraindications
NONE
Lung Surfactants
Adverse Effects
NONE
Lung Surfactants
Drug Names
“-actant”
* Beractant (most common)
* Calfactant
* Lucinactant
* Poractant
Lung Surfactants
Assessment
History:
* Time of birth and exact weight for dosing
Physical:
for effectiveness of drug
* Respiratory assessment
* Vital Signs
* Blood gases and O2 saturation
Lung Surfactants
Nursing Conclusions
- Decreased Cardiac Output
- Injury Risk (medication through trachea)
- Knowledge deficit
Lung Surfactants
Implementation/Patient Teaching
- Monitor continuously
- Ensure tube placement before administration
- Suction before administration but wait TWO hours after administration
- Teaching and support for parents
BAM
Bronchodilators
- Beta2 Agonists (sympathomimetics)
- Anticholinergics
- Methylxanthines (xanthines)
SLM
Soothes Inflammation
- Steroids
- Leukotriene Receptor Antagonists
- Mast Cell Stabilizers (Not used anymore)
Treatment for
Acute Asthma Attack
A: Albuterol (sympathomimetic/Beta2 agonist)
I: Ipratropium (anticholinergic)
M: Methylprednisolone (steroid)
Way to remember
Anticholinergic
Side effects
Can’t see
Can’t pee
Can’t spit
Can’t shit
Block secretions, dry out
Inhaler
Patient Teaching
Multiple puffs of the same inhaler: Wait 1 minute between puffs
Sympathomimetic & Steroid Inhalers:
Sympathomimetic 1st, wait 5 minutes, then steroid
Container Inhalers: Shake it before you take it
Steroid Inhalers: Swish and spit
Clean the mouthpiece after EVERY use
