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Respiratory Flashcards

1
Q

Beta2 Receptor Agonists: Albuterol

A

(Proair, Ventolin, Proventil)

Selective beta2 agonists with minor beta1 activity

Short-acting

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2
Q

Beta2 Receptor Agonists: Salmeterol

A

(Serevent)

Long-acting

More selective for beta2 receptors compared with albuterol and have minor beta1 activity

12 hour half life

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3
Q

Beta2 Receptor Agonists: Precautions and Contraindications

A
  • Cardiac arrhythmias
  • Diabetes: potential drug-induced hyperglycemia
  • Long-acting beta agonists:
  • —Black box warning: the risks of salmeterol and formoterol (foradil) outweigh the benefits & should not be used singly in asthma for all ages
  • —Twofold increase in catastrophic events (asthma-related intubations & death)
  • Terbutaline pregnancy category B (Others category C)
  • Children
  • —Albuterol safe for children of all ages
  • — Salmeterol should not be used in children younger than age 4 years and never singly
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4
Q

Beta Agonsits: ADRs

A

Usually transient

Tachycardia and palpitations

Some central nervous system (CNS) excitation effects
- Tremors, dizziness, shakiness, nervousness, and restlessness

Headaches

Salmeterol and other long-acting B2RAs increase risk of exacerbation of severe asthma symptoms if patient is deteriorating

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5
Q

Beta Agonists: Drug Interactions

A

Digitalis glycosides: increased risk of dysrhythmia

Beta adrenergic blocking agents: direct competition for beta sites resulting in mutual inhibition of therapeutic effects
- Including beta blocker eye drops

Tricyclic antidepressants (TCAs) & monoamine oxidase inhibitors (MAOIs) potentiate effects of beta agonist on vascular system

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6
Q

Beta Agonists: Clinical Use

A

Bronchodilators are used primarily in the treatment of bronchospasm associated with asthma, bronchitis (acute or chronic), and COPD

Albuterol metered dose inhaler (MDI) dose is 2 puffs every 4-6 hours

  • Dose via nebulizer is 2.5 mg/dose
  • May be repeated twice after 5-10 minutes
  • May be combined with ipratropium

Levalbuterol via nebulizer every 4-6 hours

Salmeterol DISKUS: 1 puff twice a day– do not use alone for persistent asthma; combine with an inhaled corticosteroid

Exercise induced bronchospasm (EIB)

  • Albuterol 2 puffs 15 minutes before exercise
  • Salmeterol 2 puffs 30-60 minutes before exercise— do not use if already on daily dose
  • Leukotriene modifiers taken daily may decrease EIB symptoms in 50% of patients but patient will still need to use albuterol before exercise
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7
Q

Beta Agonists: Rational Drug Selection

A

The Expert Panel 3 says ay short-acting beta agonist can be used in adults

Age

  • Only albuterol and metaproterenol are approved for use in children younger than 4 years of age.
  • Albuterol is the safest to use in infants

Cost
- Albuterol is the least expensive

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8
Q

Beta Agonists: Patient Education

A

Metered-dose inhaler (MDI) use

  • Demonstrate and have patient do return demonstration
  • Check correct inhaler use if patient says the inhaler is not working
  • Use a spacer with all patients

Breath-actuated inhalers require inspiratory drive to deliver medication to lungs

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9
Q

Xanthine Derivatives: Theophylline and Caffeine Pharmacodynamics

A
  • Bronchial smooth muscle relaxation
  • CNS Stimulation
  • Cardiovascular effects
  • Increased Gastric acid production
  • Stimulation of skeletal muscle
  • Increased renal blood flow and glomerular filtration rate
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10
Q

Xanthine Derivatives- Theophylline: Pharmacokinetics

A

Absorbed rapidly and completely from GI tract

Distributed widely
- Volume of distribution altered in: premature neonates, older patients, cirrhosis, pregnant women (third trimester), and critically ill patients, probably because of altered protein-binding

Metabolized extensively in liver via CYP450 into caffeine
- Disease states and CYP inducers can influence metabolism of theophylline

Eliminated renally

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11
Q

Xanthine Derivatives- Theophylline: Precautions & Contraindications

A

Monitor patients with HTN, ischemic, heart disease, coronary insufficiency, CHF, or a hx of stroke and cardiac arrhythmias

Monitor for theophylline toxicity

Prolonged clearance and half-life in neonates and older adults

Pregnancy Category C

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12
Q

Xanthine Derivatives- Theophylline: ADRs

A
  • Toxicity with levels greater than 20 mcg/mL
  • Some patients have seizures at 15-20 mcg/mL
  • CNS effects: irritability, restlessness, seizures, insomnia
  • GI effects: reflux, worsening heartburn
  • Cardiac effects: palpitations, tachycardia, hypotension, life-threatening arrhythmias
  • Toxicity (greater than 20 mcg/mL): N/V, diarrhea, HA, insomnia, & irritability
  • Toxicity (greater than 35 mcg/mL): hyperglycemia, hypotension, cardiac arrhythmias, tachycardia, seizures, brain damage, death
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13
Q

Xanthine Derivatives- Caffeine: ADRs

A 
Cardiac arrhythmias 
Tachycardia
Insomnia
Agitation
Irritability
HA
N/V
Gastric Irritation
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14
Q

Xanthine Derivatives- Theophylline: Drug-Food Interactions

A
  • Many drug interactions are caused by metabolism via CYP450 isoenzyme CYP1A2, CYP2E1, and CYP3A3/4
  • Smoking tobacco increases clearance
  • Benzodiazepines are antagonized by theophylline
  • Beta agonists may cause additive toxicity
  • Lithium levels are reduced
  • Low-carb/high-protein diet increases clearance
  • Charcoal-broiled foods accelerate the hepatic metabolism of theophylline
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15
Q

Xanthine Derivatives- Caffeine: Drug Interactions

A

Caffeine metabolized via CYP450 isoenzyme CYP1A2, CYP2E1, and CYP3A3/4

Impaired caffeine metabolism: cimetadine, ketoconazole, fluconazole, mexiletine, and phenylpropanolamine

Caffeine elimination may be increased by co-administration of phenobarbitol and phenytoin

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16
Q

Xanthine Derivatives- Theophylline: Clinical Use & Dosing

A

Second- or third-line drug for asthma and COPD

Adults started on 6 mg/kg/24 hours and dose increased by 25% every 3 days until serum theophylline levels are 10-20 mcg/mL

Maximum dose in adults is 13 mg/kg/day

Children age 5 years or older: 16 mg/kg/day, max 400 mg/day

  • 1 to 9 years: max dose 24 mg/kg/day
  • 9 to 12 years: max dose 20 mg/kg/day
  • 12 to 16 years: max dose 18 mg/kg/day
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17
Q

Apnea of Prematurity: Treatment

A

Caffeine citrate 10-20 mg/kg
- Maintenance dose of 5 mg/kg per day

Theophylline dose

  • Loading dose of 4 mg/kg per dose
  • Maintenance dose of 4 mg/kg per day in the premature infant or newborn up to age 6 weeks
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18
Q

Xanthine Derivatives- Theophylline: Rational Drug Selection

A

Cost and Convenience

Immediate release

  • Use at beginning of therapy to determine daily dose
  • Once stabilized on immediate release, transition to extended release once the total 24-hour dose has been determined

Timed release
- Taken daily at the same time

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19
Q

Xanthine Derivatives- Theophylline: Monitoring

A

Monitor for signs of toxicity

Draw frequent levels when dose is being titrated

After steady state, draw levels every 6 to 12 months

Draw levels whenever any new drug is added or deleted from regimen

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20
Q

Xanthine Derivatives- Theophylline: Patient Education

A

Take medication exactly as prescribed

Discuss signs & symptoms of toxicity
- N/V, insomnia, jitteriness, HA, rash, severe GI pain, restlessness, convulsions, or irregular heartbeat

Avoid large amounts of caffeine containing beverages

Explain that theophylline elimination is influenced by diet

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21
Q

Inhaled Anticholinergics

A 
Ipratropium bromide (Atrovent) 
- Blocks muscarinic cholinergic receptors 
Tiotropium bromide (Spiriva) and Aclidinium bromide (Tudorza Pressair)
- Inhibits muscarinic M3 receptors in lungs

All cause bronchial smooth muscle relaxation

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22
Q

Anticholinergics: Precautions and Contraindication

A

Known hypersensitivity

Not used for acute bronchospasm

Ipratropium bromide is pregnancy category B and tiotropium is pregnancy category C

Not approved for use in children younger than age 12 years
- Expert Panel 3 guidelines state ipratropium may be used in children as an adjunct to beta agonist (albuterol) therapy in acute exacerbations of asthma

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23
Q

Inhaled Anticholinergics: ADRs

A

Cough is most common

Dry mouth

Mild anticholinergic effects in a few patients

  • Constipation
  • Urinary retention (less than 2%)

Rare allergic reaction
- Allergy to soybeans, legumes, or soy lecithin appears to be correlated with hypersensitivity to ipratropium bromide

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24
Q

Inhaled Anticholinergics: Clinical Use & Dosing for COPD

A
  • Ipratropium: 2 puffs (36 mcg) 4 times/day (max 12 puffs/day)
  • Ipratropium: 1 unit dose via nebulizer 3-4 times/day, may be mixed with albuterol
  • Ipratropium-albuterol combination (combivent): 2 puffs 4 times/day
  • Tiotropium (spiriva): 2 puffs of a single capsule once/day
  • Aclidinium bromide (Tudorza Pressair): 1 puff twice/day
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25
Inhaled Anticholinergics: Clinical Use & Dosing for Asthma
Ipratropium for asthma maintenance is 2-3 puffs 4 times/day for adults - Children age less than 12 years: 1-2 puffs every 6 hours Ipratropium-albuterol combination (Combivent) is a second-line quick relief medication in treatment of asthma Tiotropium and aclidinium are not indicated for the treatment of asthma
26
Inhaled Anticholinergic: Cost and Patient Education
Cost - Combined albuterol-ipratropium products are cheaper than the two individual drugs - -----Generic ipratropium/albuterol nebulizer solution is $32 for a month's supply - Tiotropium (Spiriva) costs $415 per month - Aclidinium bromide (Tudorza Pressair) costs $2360 per month Patient Education - Use as prescribed - Be educated on use of inhaler or handihaler - Rinse mouth after inhaling medication
27
Leukotriene Modifiers: Pharmacodynamics
- Induce numerous effects that contribute to inflammatory process - Smooth muscle contractions - Leukotriene-Receptor Agonists - ---Zafirlukast & Montelukast - 5-Lipoxygenase Pathway Inhibitors - ---- Zileuton
28
Leukotriene Modifiers: Precautions
Do not do the following: - Use for primary treatment of acute asthma attack - Abruptly substitute for inhaled or oral steroids - Prescribe for lactating women Zafirlukast: patients with hepatic dysfunction
29
Leukotriene Modifiers: Contraindications
Zafirlukast and Montelukast: hypersensitivity Chewable montelukast: patients with phenylketonuria Zileuton: patients with active liver disease
30
Leukotriene Modifiers: ADRs
Most Common: HA Less Common: - GI upset - Myalgias - Fever - Increase in respiratory infections
31
Leukotriene Modifiers: Clinical Use and Dosing
Zafirlukast - chronic asthma: 5 years Montelukast - Persistent asthma: 12+ months - Exercise induced bronchoconstriction: 15 years Zileuton - Persistent asthma: 12 years
32
Leukotriene Modifiers: Monitoring
Worsening asthma symptoms Bronchodilator use Pulmonary function New onset of neuropsychiatric symptoms
33
Leukotriene Modifiers: Patient Education
Take as prescribed Do not take if pregnant or nursing Watch for drug interactions Watch for neuropsychiatric events
34
Leukotriene Modifiers: Lifestyle Management
Self-monitor respiratory status with a peak flow meter Avoid or quit smoking Avoid environmental triggers of asthma at home, work, and school
35
Corticosteroids: Benefits
Reduced severity of asthma Increased peak flow readings Decreased airway hyperresponsiveness Safe and Well tolerated at recommended dosages
36
Inhaled Corticosteroids: Precautions
Avoid if using for: - Relief of acute bronchospasm - Substitute for oral corticosteroids Avoid if patient is is/has: - Cushing's Syndrome - Pregnancy - Herpes - TB - Nasal trauma or ulcers - Untreated respiratory infection
37
Corticosteroids: Drug Interactions
Known - Ritonavir: increases fluticasone serum concentrations - Ketoconazole: increases plasma concentration of fluticasone and budesonide Unknown - Inhaled triamcinolone, flunisolide, mometasone, beclomethasone, or ciclesonide
38
Corticosteroids: Clinical Use and Dosing
Asthma: - Persistent: Inhaled corticosteroids - Mild: low dose - Moderate: daily low- to medium-dose inhaled combined with long-acting beta agonist - Severe: daily high-dose and long-acting beta agonists Allergic Rhinitis: - Used to manage seasonal or perennial allergies - Intranasal 1-2 times daily
39
Inhaled Corticosteroids: Monitoring
Patients using normal dose - Adverse effects of the medication - Effectiveness of the medication - The asthma disease process Patients using high dose for long time - Blood glucose and potassium
40
Corticosteroids: Administration
Inhaled - Use spacers - Rinse mouth with water after each use Intranasal - Clear nasal passages of mucus - Rinse mouth with water after each use
41
Corticosteroids: ADRs
``` Xerostomia (dry mouth) Hoarseness Tongue and mouth irritation Flushing Dysgeusia (altered taste sensation) Dysmenorrhea ``` Less common- oral candidiasis; cataracts; bronchospasm; hypothalamic-pituitary-adrenal axis (HPA) suppression; pulmonary infiltrates with eosinophilia; nasal irritation, itching, sneezing, dryness; bloody nasal mucus or epistaxis
42
Corticosteroids: Lifestyle Management
Self-monitor respiratory status Avoid or quit smoking Avoid environmental triggers of asthma at home, work, and school
43
Oxygen: Precautions and Contraindications
Avoid Smoking Use lowest possible concentration: sudden increase in partial pressure of carbon dioxide (PaCO2) can stop respiration
44
Oxygen: ADRs
Dry nasal passages - Most common; can be prevented Toxicity - Occurs when oxygen concentration is greater than air - Death can occur
45
Oxygen: Clinical Use and Dosing
Clinical Use - Treats hypoxia but is not curative Dosing - Goal: Maintain oxygen saturation above 90% - Delivery: NC, mask, hood or tent
46
Oxygen: Monitoring Methods
Arterial or mixed venous blood gas sampling - provides additional information regarding patient status that assists in treatment Pulse oximetry - Measures the difference in absorption of light - Measures hemoglobin saturation and not partial pressure of oxygen (PO2)
47
Oxygen: Lifestyle Management
Avoid or quit smoking Avoid exposure to viral respiratory infections Avoid high altitudes Consult with provider before traveling by air
48
Antihistamines: Uses
Reduce or prevent physiological effects of histamine at the histamine 1 (H1) receptor site Strongly block the action of histamine Decrease the flare-and-itch response
49
Antihistamines: Generations
``` First Generations (1940s) - Diphenhydramine: still widely used ``` ``` Second Generations (1980s) - Non-sedating antihistamine: relief to allergy sufferers without drowsiness ```
50
First Generation Antihistamines: Precautions
Cautioned - Pregnancy Category B - Sedation and drowsiness; reduced mental alertness Contraindicated - Newborns and infants
51
Second-Generation Antihistamines: Precautions
Pregnancy - Pregnancy categories B and C Children - Fexofenadine: age less than 6 years - Loratadine: age 2+ years - Cetirizine and desloratadine syrup: age 6+ months
52
First-Generation Antihistamines: ADRs
Sedation or fatigue, dizziness, HA, tinnitis, lassitude, disturbed coordination, N/V, irritability/nervousness, blurred vision, diplopia, tremors, increased/decreased appetite, epigastric distress, constipation, diarrhea, dry mouth, urinary retention, dysuria
53
Second-Generation Antihistamines: ADRs
Drowsiness is greatly reduced Minimal incidence of dry mouth (5% or less) Symptoms caused by first generation antihistamines can be alleviated by switching to second generation antihistamines
54
Antihistamines: Clinical Use
Respiratory allergies Hypersensitivity reactions Urticaria and angioedema Nighttime sleep aid Motion sickness/antiemetic
55
Antihistamines: Lifestyle Management
Avoid known allergies Use environmental methods to control dust mites and other common allergens
56
Decongestants: Uses & Methods of Delivery
Uses: - Common cold - Allergic rhinitis Methods of Delivery - Liquid, tablet, capsule, nasal spray, drops
57
Decongestants: Contraindications
Patients on concurrent MAOI therapy Patients with severe HTN or CAD
58
Oral Decongestants: ADRs
More common - Restlessness and tremors Less common or rare - Transient HTN, arrhythmia, and cardiovascular collapse, with hypotension
59
Topical Decongestants: ADRs
- Transient stinging - Burning - Sneezing - Dryness - Local Irritation - Rebound congestion with prolonged use - Insomnia - Dizziness - Weakness - Tremor - Irregular heartbeat
60
Clinical Use for Nasal Congestion
Oral decongestant - Temporarily relieve nasal congestion - Promote nasal or sinus drainage - Relieve eustachian tube congestion Topical decongestant - Symptomatically relive nasal congestion - Relieve ear blockage and pressure pain
61
Decongestants: Short vs Long Acting
Short acting - Better tolerated and have fewer ADRs Long acting - Useful for patients who require all-day or all-night relief, if patient can tolerate
62
Higher Dose Decongestants: ADRs
Nervousness, dizziness, or sleeplessness
63
Decongestants: Lifestyle Management
Maintain adequate hydration Refrain from smoking when congested Avoid caffeine-containing products
64
Antitussives: Use
Used to self-treat coughs Exact mechanism of action poorly understood
65
Antitussives: Precautions
Do not use for persistent or chronic cough caused by smoking, asthma, or emphysema Do not use if you have excessive respiratory secretions Do not self-medicate for cough lasting longer than 7 days
66
Antitussives: Lifestyle Management
Increase fluid intake Refrain from or quit smoking Avoid respiratory irritants and people with respiratory infections
67
Expectorants: Guaifenesin
The only expectorant ingredient listed by the FDA panel as having scientific evidence of safety and efficacy Aids in symptomatic treatment of cough caused by the common cold and mild upper respiratory infections
68
Expectorants- Gauifenesin: Precautions
Do not use for persistent cough Do not use for cough related to heart failure or ACEI therapy Do not use for cough with high fever or lasting longer than 7 days
69
Expectorants- Gauifenesin: ADRs
Most common - GI upset, N/V Less common - Drowsiness, diarrhea, dizziness, rash, and HA
70
Expectorants- Gauifenesin: False Lab Readings
Gauifenesin may cause false readings in certain lab determinations of 5-hydroxyindoleacetic acid (5-HIAA) and vanillylmandelic acid (VMA)
71
Expectorants- Gauifenesin: Uses and Management
Use - For dry, nonproductive cough with mucus in respiratory tract Lifestyle Management - Remain well hydrated - Refrain from smoking

Pharmacology (25 decks)

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