Respiratory Flashcards
Diseases of the Lower Respiratory Tract? 2
What they do to the system?
Chronic obstructive pulmonary disease
Asthma (persistent and present most of the time despite treatment)
Obstruct airflow through the airways
Respiratory system:
Anatomy
Lower Respiratory Tract (trachea, bronchial tree, lungs)
URT (nose, nasopharynx, oropharynx, laryngopharynx, larynx)
4 accessory structures (oral cavity/ mouth, rib cage, muscle of ribs, and diaphragm)
Function:
gas exchange in alveoli (O2 and C02)
Filter, warm, and humidify the air
Speech, sense of smell, regualtion of pH
Bronchial Asthma
Chronic airway inflammation resulting in
bronchial constriction and hyper responsiveness to various triggers (allergen)
Recurrent and reversible shortness of breath
Occurs when the airways of the lungs become narrow
The alveolar ducts and alveoli remain open, but airflow to them is obstructed (prevents CO2 to leave and O2 in)
Bronchial Asthma occurs when the airways of the lungs become narrow as a result of: 4
Bronchospasms
Inflammation of the bronchial mucosa
Edema of the bronchial mucosa
Production of viscous mucus
Onset of asthma- before age 10 in 50% of pts and before 40 in 80% of pts
Bronchial Asthma’s alveolar ducts and alveoli remain open, but airflow to them is obstructed: What are the symptoms?5
Wheezing
Difficulty breathing
SOB
chest tightness
cough
Asthma attack
A sudden and dramatic onset
Most are short and responds to medication
status (continuing) asthmaticus
Prolonged asthma attack that does not respond to typical drug therapy
May last several minutes to hours
Medical emergency: requires hospitalization
early phase response
late phase response
mediated by antibodies already present that recognizes the antigen
Antibody for asthma- IgE
Late phase peaks 5 to 12 hours after initial response, may last for hours/ days
Chronic Obstructive Pulmonary Disease
Define& symptoms
Progressive respiratory disorder
Characterized by chronic airflow limitation, systematic manifestations, and significant comorbidities
Hypersecretion of mucus, chronic cough, and increased susceptibility to bacterial infection
Assessment of COPD
is based on symptoms, future risks of exacerbations, severity of the spirometric abnormality, and identification of comorbidities.
Chronic Bronchitis
Presence of cough and sputum for at least 3 months in each of 2 consecutive years
Separate from COPD
Focus of treatment of Lower RT
role of inflammatory cells and their mediators
Bronchodilators mechanism of action 3
Relax bronchial smooth muscle, which dilates the bronchi and bronchioles (that are narrowed)
Reduce airway constriction and restore normal airflow
Agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous system
Sympathomimetics
Bronchodilators 3 CLASSES
β-adrenergic agonists
anticholinergics
xanthine derivatives
Bronchodilators:
ß-Adrenergic Agonists [sympathomimetic bronchodilators]
- Indication
- Action
- Medication (2)
Acute phase of asthmatic attacks to reduce airway constriction and restore normal airflow
Agonists/ stimulators of adrenergic R in the sympathetic NS
B agonists imitate the effects of NE and E
Short-acting: Salbutamol (SABA)
Long-acting: Salmetarol (LABA)
Bronchodilators: ß-Adrenergic Agonists [1 medication each]
Short-acting ß-agonist (SABA) inhalers
SALBUTAMOL (Ventolin®)
Terbutaline sulphate (Bricanyl®)
Long-acting ß-agonist (LABA) inhalers
formoterol (Foradil®, Oxeze®)
SALMETEROL (Serevent®)
ß-Adrenergic Agonists
LABAs are always prescribed with?
Inhaled glucocorticoids
Bronchodilators: β-Adrenergic Agonists: Newest [1 medication]
Long-acting ß-agonist and glucocorticoid steroid combination inhaler
budesonide/formoterol fumarate dihydrate (Symbicort®)
To relieve moderate to severe asthma
Bronchodilators: β-Adrenergic Agonists: budesonide/formoterol fumarate dihydrate (Symbicort®) [Indication]
Use as a reliever or rescue treatment for moderate to severe asthma when symptoms worsen
Bronchodilators: ß-Adrenergic Agonists – Three Subtypes
Nonselective adrenergic
Nonselective ß-adrenergic
Selective ß2 drugs
Bronchodilators: ß-Adrenergic Agonists:
Nonselective adrenergic
- mechanism of action
- 1 drug
- What does this stimulate?
Stimulate ß-, ß1- (cardiac), and ß2- (respiratory) receptors
Example: epinephrine (EpiPen®)
Also, stimulate a-adrenergic receptors which cause constriction within the BVs. Vasoconstriction reduces edema and swelling.
Also stimulates B1 receptors which results in cardiovascular AEs such as increased HR, force of contraction, and BP(increased renin), nervousness, tremor
Bronchodilators: ß-Adrenergic Agonists:
Nonselective ß-adrenergics
- mechanism of action
- 1 drug
Stimulate both ß1- and ß2-receptors
Example: isoproterenol hydrochloride
Bronchodilators: ß-Adrenergic Agonists:
Selective ß2 drugs
- mechanism of action
- 1 drug
- stimulates?
- Additionally treats?
- Also causes?
Stimulate only ß2-receptors
Example: salbutamol
stimulate sodium-potassium adenosine triphosphate ion pump in cell membranes, results in a temporary decrease in potassium
B2 agonists effective in treating acute hyperkalemia
Also causes uterine relaxation
ß-Adrenergic Agonists:
TWO Mechanism of Action
Dilate airways by stimulating the B2 adrenergic receptors located in lungs
Activation of ß2-receptors activates cyclic adenosine monophosphate
Increased levels of cAMP relaxes smooth muscle in the airway and results in bronchial dilation and increased airflow.
Begins at the specific receptor-stimulated. Ends with the dilation of the airways
ß-Adrenergic Agonists: Indications
Relief of bronchospasm related to asthma, chronic obstructive pulmonary disease (COPD), and other pulmonary diseases
Used in treatment and prevention of acute attacks
Used in hypotension and shock
ß-Adrenergic Agonists: Contraindications
Known drug allergy
Uncontrolled cardiac dysrhythmias
High risk of stroke (because of the vasoconstrictive drug action)
ß-Adrenergic Agonists: Adverse Effects
Mixed α and ß (epinephrine)
Produce most AEs because they are nonselective
Mixed α and ß (epinephrine)
Insomnia
Restlessness
Anorexia
Vascular headache
Hyperglycemia
Tremor
Cardiac stimulation
ß-Adrenergic Agonists: Adverse Effects
Nonselective ß1 and ß2
Limited to B-adrenergic effects
Nonselective ß1 and ß2
Cardiac stimulation
tachycardia
Tremor
Anginal pain
Vascular headache
Overdose management
include careful admin of a B-blocker due to risk of bronshospasm
ß-Adrenergic Agonists: Adverse Effects
Selective ß2 drugs (salbutamol)
Hypotension or hypertension
Vascular headache
Tremor
ß-Adrenergic Agonists: Interactions
Diminished bronchodilation when nonselective ß-blockers are used with the ß-agonist bronchodilators
Monoamine oxidase inhibitors- HTN
Sympathomimetics - HTN
Monitor patients with diabetes; an increase in blood glucose levels can occur (esp. with epinephrine)
ß-Adrenergic Agonists:
Salbutamol Sulphate (Ventolin®)
Forms?
If used too frequently….
Short-acting ß2-specific broncho-dilating ß-agonist
Most commonly used drug in this class
Oral, parenteral, and inhalational use
Inhalational dosage forms include metered-dose inhalers as well as solutions for inhalation (aerosol nebulizers).
If used too frequently, it loses its B2 specificity: and B1 Receptors are stimulated which causes nausea, anxiety, palpitations, tremors, and increased HR
ß-Adrenergic Agonists: Salmeterol (Serevent®)
MAX DOSE
Long-acting ß2-agonist bronchodilator
Never to be used alone but in combination with an inhaled glucocorticoid steroid
Used for the maintenance treatment of asthma and COPD; salmeterol maximum daily dose (one puff twice daily) should not be exceeded
Anticholinergics [muscarinic antagonists]
Mechanism of Action
Used in the treatment of COPD
When PNS release ACh , it binds to ACh R on bronchial tree- which results in bronchial constriction and narrowing
Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways.
Anticholinergics bind to the ACh receptors (block ACh R), preventing ACh from binding. Prevents constriction- indirectly causes airway dilation.
Result: bronchoconstriction is prevented, and airways dilate
Reduce secretions
Antichollinergic indication
slow and prolonged actions- used to prevent bronchospasm associated with COPD
Antichollinergic
Contraindication 3
Intercations 1
allergy
glaucoma
prostate enlargement
other antichollinergic drugs
1 MEDICATION of Anticholinergics
ipratropium (Atrovent®),
tiotropium bromide monohydrate (Spiriva®)
Antichollinergic:
Ipratropium (Atrovent®), tiotropium bromide monohydrate (Spiriva®)
Two mechanism of action
Indirectly cause airway relaxation and dilation
Help reduce secretions in COPD patients
Indications: prevention of the bronchospasm associated with COPD; not for the management of acute symptoms
oldest and most commonly used
Anticholinergics: Adverse Effects
Dry mouth or throat
Nasal congestion
Heart palpitations
Gastrointestinal distress
Urinary retention
Increased intraocular pressure
Headache
Coughing
Anxiety
can be used during pregnancy-outweighs potential risks
Anticholinergics: Ipratropium Bromide
1._____ and ____ ________ used anticholinergic bronchodilator
- Available both as a?
- Dosing?
Oldest and most commonly used anticholinergic bronchodilator
Available both as a liquid aerosol for inhalation and as a multidose inhaler
Usually dosed twice daily
Xanthine Derivatives
Consist of plant alkaloids: caffeine, theobromine, and theophylline
Only theophylline and caffeine are currently used clinically.
Synthetic xanthines: aminophylline
Xanthine Derivatives:
Mechanism of Action
What hormone do they inhibit? so that..
Causes bronchodilation by increasing the levels of energy-producing cyclic adenosine monophosphate (cAMP)
Inhibt phosphodiesterase, the enzyme that breaks down cAMP.
cAMP- maintains open airways, increased levels of cAMP leads to smooth muscle relaxation and inhibit IgE
Result: increased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow
Xanthine Derivatives: 3Drug Effects and 1 result
Cause bronchodilation by relaxing smooth muscle in the airways
Result: relief of bronchospasm and greater airflow into and out of the lungs
Also cause central nervous system stimulation
Also cause 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
Caffeine indications
Dilation of airways in asthmas and COPD
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
Caffeine- used without a prescription as a CNS stimulant or analeptic to promote alertness/ heart stimulant for infants IN PICU
Xanthine Derivatives: Contraindications
Known drug allergy
Uncontrolled cardiac dysthymias
Seizure disorders
Hyperthyroidism
Peptic ulcers
Xanthine Derivatives: Interactions
Increased serum level: allopurinol, cimetidine, macrolide abx (erythromycin), quinolones (cipro), influenza vaccine, rifampin, and oral contraceptives
Use with sympathomimetics/ caffeine- produce additive heart and CNS stimulation
Rifampin increases the metabolism of theophylline- and decrease theophylline levels
St. John wort- increases the rate of xanthin drug metabolism
Xanthine Derivatives: Adverse Effects
Nausea, vomiting, anorexia
Gastroesophageal reflux during sleep
Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias
Transient increased urination
Hyperglycemia
Overdose and toxicity of xanthine derivatives are treated
repeated admin of activated charchoal
Xanthine Derivatives: Caffeine Indications 3
Used without prescription as a central nervous system stimulant or analeptic to promote alertness (e.g., for long-duration driving or studying)
Cardiac stimulant in infants with bradycardia
Enhancement of respiratory drive in infants in Neonatal Intensive Care Units (NICUs)
Xanthine Derivatives: Theophylline
Most commonly used xanthine derivative
Oral and injectable (as aminophylline) dosage forms
Aminophylline: PRODRUG of theophylline; intravenous (IV) treatment of patients with status asthmaticus who have not responded to fast-acting ß-agonists such as epinephrine
Therapeutic range for theophylline blood level is 55 to 100 mmol/L.
Canadian Asthma Consensus guideline recommends levels between 28 to 55 mmol/L.
Can also stimulate CNS (lesser degree than caffeine)
Stimulation of CNS has beneficial effects- enhance respiratory drive
In large doses, theophylline may stimulate the cardiac system- increased force of contraction (increases CO and BF to kidneys) and an increased HR (this plus xanthines ability to dilate BVs in kidneys- increases GFR- producing a diuretic effect)
Xanthine Derivatives: Theophylline
Canadian Asthma Consensus guideline recommends levels between?
28 to 55 mmol/L.
Nonbronchodilating Respiratory Drugs [3 medication]
Leukotriene receptor antagonists (montelukast, zafirlukast)
Corticosteroids (beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, ciclesonide, and triamcinolone)
Mast cell stabilizers
Mast cell stabilizers:
rarely used and no longer included in Canadian Asthma Management Continuum
Corticosteroids medication names
(beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, ciclesonide, and triamcinolone)
Leukotriene enzyme function in body
Three symptoms
causes inflammation
bronchoconstriction
mucus production
> results in coughing, wheezing, and SOB
Leukotriene Receptor Antagonists
- Type of medication
- Currently available drugs
Nonbronchodilating
Newer class of asthma medications
Currently available drugs
montelukast (Singulair®)
zafirlukast (Accolate®)
Leukotriene Receptor Antagonists:
Mechanism of Action
only affects which organ
LTRA Montelukast acts directly by binding to the D4 leukotriene-receptor subtype
Drug effects are limited primarily to the lungs
Prevents leukotrienes from attaching to receptors- this alleviates asthma symptoms and reduces inflammation. Prevent smooth muscle contraction of the bronchial airways, decrease mucus secretion, and reduce vascular permeability (reduces edema) through reducing leukotriene synthesis.
Reduce airway inflammation
Leukotriene Receptor Antagonists:
- What are Leukotrienes?
- Leukotrienes causes?
- Result?
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, shortnessof breath
Leukotriene receptor antagonists prevent?
Leukotriene receptor antagonists 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.
Leukotriene Receptor Antagonists:Drug Effects
What happens to blocking Leukotriene?
Prevent smooth muscle contraction of the bronchial airways
Decrease mucus secretion
Prevent vascular permeability
Decrease neutrophil and leukocyte infiltration to the lungs, preventing inflammation
Leukotriene Receptor Antagonists: Indications
- Indication
- Montelukast safe in children ____ years of age and older
- Zafirlukast safe in children ___ years of age and older
- Not meant for?
- Montelukast is also approved for?
- Improvement with their use is typically seen in about?
Prophylaxis and long-term treatment and prevention of asthma in adults and children
*Montelukast safe in children 2 years of age and older
*Zafirlukast safe in 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
Leukotriene Receptor Antagonists: Contraindications
Known drug allergy
Previous adverse drug reaction
Allergy to povidone, lactose, titanium dioxide, or cellulose derivatives—important to note because these are inactive ingredients in these drugs
Leukotriene Receptor Antagonists: Adverse Effects
Montelukast- headache, nausea, and diarrhea (nightmare in children and adults)
Both drugs (montelukast, and zafirlukast) may lead to liver dysfunction.
zafirlukast
**Headache, nausea, diarrhea
Leukotriene Receptor Antagonists: Interaction
Phenobarbital and rifampin- are enzyme inducers, that decrease montelukast concentrations.
Corticosteroids (Glucocorticoids) effects
Anti-inflammatory effects
Naturally occurring/ synthetic drugs
Corticosteroids (Glucocorticoids)
Indication 2
Anti-inflammatory properties
Pulmonary diseases
Corticosteroids (Glucocorticoids)
ROUTES
IV
Oral or inhaled forms
Inhaled forms reduce systemic effects.
Corticosteroids (Glucocorticoids) onset
May take several weeks before full effects are seen
Corticosteroids: Two Mechanism of Action
Reduce inflammation & enhance the activity of B agonists
prevent nonspecific inflammation and altered vascular permeability (antiinflammatory)
Stabilize membranes of cells that release harmful broncho-constricting substances
**These cells are called leukocytes
**WBC normally releases Inflammatory mediators
Increase responsiveness of bronchial smooth muscle to ß-adrenergic stimulation
Dual effect of both reducing inflammation and enhancing the activity of ß-agonists
Corticosteroids have also been shown to?
to restore or increase the responsiveness of bronchial smooth muscle to ß-adrenergic receptor stimulation, which results in more pronounced stimulation of the ß2-receptors by ß-agonist drugs such as salbutamol.
Inhaled Corticosteroids drugs
beclomethasone dipropionate (Qvar®)
budesonide (Pulmicort Turbuhaler®)
fluticasone propionate (Flovent Dickus®)
Other:
fluticasone furoate (Avamys®)
ciclesonide (Omnaris®)
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 ß-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 the sole therapy for acute asthma attacks
Hypersensitivity to glucocorticoids
Patients whose sputum tests are positive for Candida Albicans 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. (Increasing dose can lead to CNS effects- insomnia, nervousness, seizures, infection…)
Corticosteroids when switching from systemic to inhaled that the dose is
tapered drug doses slowly
death results if switched too quickly/ dose reduced abruptly
Pts dependent on this may need up to a year of recovery time after discontinuation
Corticosteroids:
Drug interactions are more likely to occur with?
Drug interactions are more likely to occur with systemic (versus inhaled) corticosteroids.
Inhaled Corticosteroids: Drug Interactions
May increase serum glucose levels, possibly requiring adjustments in dosages of antidiabetic drugs
May raise the blood levels of the immunosuppressants cyclosporine and tacrolimus; itraconazole may reduce clearance of the steroids
Phenytoin, phenobarbital, and rifampin
Greater risk of hypokalemia with concurrent diuretic use (e.g., furosemide, hydrochlorothiazide)
Costicosteroids: Fluticasone
Lowest dose to control asthma should be used. If good control is maintained, reduce the dose
Combined with salmeterol- Advair diskus
Phosphodiesterase Type 4 Inhibitor
1 medication
roflumilast (Daxas®)
Phosphodiesterase Type 4 Inhibitor:
roflumilast (Daxas®)
- Indication?
- Adverse effects
Indicated to prevent coughing and excess mucus from worsening and to decrease the frequency of life-threatening COPD exacerbations
Adverse effects include nausea, diarrhea, headache, insomnia, dizziness, weight loss, and psychiatric symptoms (anxiety and depression).
Monoclonal Antibody Antiasthmatic
1 medication
omalizumab (Xolair®)
Monoclonal Antibody Antiasthmatic
omalizumab (Xolair®)
- Mechanism of action
- Route?
- Adverse effect?
- Monitor closely for?
Selectively binds to immunoglobulin E, which in turn limits the release of mediators of the allergic response
Omalizumab is given by injection.
Potential for producing anaphylaxis
Monitor closely for hypersensitivity reactions.
Encourage patients to take measures that promote a generally good state of health so as to prevent, relieve, or decrease symptoms of COPD
How to prevent, relieve/ decrease symptoms of COPD? (4)
Avoiding exposure to conditions that precipitate bronchospasm (allergens, smoking, stress, air pollutants).
Maintaining an adequate fluid intake
Complying with medical treatment
Avoiding excessive fatigue, heat, extremes in temperature, and caffeine.
Perform a thorough assessment before beginning therapy, including:
Skin colour
Baseline vital signs
Respirations (should be between 12 and 20 breaths/min)
Respiratory assessment, including pulse oximetry
Sputum production
Allergies
History of respiratory problems
Other medications
Nursing Implications
Teach patients to take bronchodilators exactly as prescribed.
Ensure that patients know how to use inhalers and metered-dose inhalers, and have patients demonstrate the use of the devices.
Monitor for adverse effects.
Nursing Implications: ß-Adrenergic Agonists
- Salbutamol, if used too frequently LOSES ITS? ______ AT LARGER DOSES.
- As a result, ß1-receptors are stimulated, causing? (SYMPTOMS)
- Inform patients to report?
Salbutamol, if used too frequently, loses its ß2-specific actions at larger doses.
As a result, ß1-receptors are stimulated, causing nausea, increased anxiety, palpitations, tremors, and increased heart rate.
Inform patients to report insomnia, jitteriness, restlessness, palpitations, chest pain, or any change in symptoms.
Ensure that patients take medications exactly as prescribed, with no omissions or double doses.
Nursing Implications: Leukotriene Receptor Antagonists
- Ensure that the medication is being used for?
- Improvement should be seen in about?
Ensure that the medication is being used for long-term management of asthma, not acute asthma.
Improvement should be seen in about 1 week
Teach the patient the purpose of the therapy.
Advise patients to check with prescriber before taking over-the-counter or prescribed medications, to determine drug interactions.
Assess liver function before beginning therapy and throughout therapy.
Teach patients to take medications every night on a continuous schedule, even if symptoms improve.
Monitor for Respiratory Drugs therapeutic effects: 5
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
Nursing Implications: Xanthine Derivatives
- CONTRAINDICATIONS
2.CAUTIONS
- TIME RELEASED PREPARATIONS
Contraindications: history of peptic ulcer disease or gastrointestinal disorders
Cautious use: cardiac disease
Timed-release preparations should not be crushed or chewed (causes gastric irritation).
Nursing Implications: Xanthine Derivatives
WHAT TO REPORT TO DOCTOR?
Nausea
Vomiting
Restlessness
Insomnia
Irritability
Tremors
Nursing Implications: Xanthine Derivatives
- Be aware of drug interactions with?
- _______ enhances xanthine metabolism.
- Interacting foods include?
- These foods may reduce?
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.
Nursing Implications: Inhaled Corticosteroids
- Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the
- If a ß-agonist bronchodilator and corticosteroid inhaler are both ordered?
- Teach patients to monitor disease with a?
- Encourage the use of a ________ to ensure succesful inhalations
Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent THE development of oral fungal infections.
If a ß-agonist bronchodilator and corticosteroid inhaler are both ORDERED, the bronchodilator should be used several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid.
Teach patients to monitor disease with a peak flow meter.
Encourage the use of a spacer device to ensure successful inhalations.
Teach the patient how to keep inhalers and nebulizer equipment clean after use.
For any inhaler prescribed, ensure that the patient is able to self-administer the medication BY?
Provide a demonstration and a 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.
Hypoxia
Low oxygen
Hypercapnia
High CO2
Taking salbutamol often can cause?
beta 1 receptor defects
Tiotropium bromide/ Spiriva nursing consideration
comes in a pill form – do not swallow it; have to inhale it to breathe the powder
How often do we wash aerochamber
once a week with soap and water
Explain theophylline levels
high carb and low protein diet increase theophylline levels (too high)
low carb, high protein- decreases the level of theophylline
1st priority
Airway, breathing, circulation- 1st priority
short-acting bronchodilator
salbutamol; Short-acting ß-agonist (SABA) inhalers; Selective ß2 drugs
Opens up the bronchioles during acute phases
Types of Bronchodilators
corticosteroids, beta-adrenergic agonists, anticholinergics
Order to give inhalers?
beta-adrenergic
anticholinergic corticosteroids
When not to give anticholinergics?
glaucoma
Beclomethasone with corticosteroids (or anything to do with corticosteroids)
monitor BG, wean them off gradually- Addisonian crisis- causes mortality
Wean medications when giving?
Epileptic
Costicosteroids
Oral corticosteroids can cause
fungal infections, systemic AE
ß1 and ß2 agonists
Stimulate both heart and lungs hence AE can include cardiac effects
Xanthine Derivatives causes?
Bronchodilation
Not for management of acute asthma attack
Xanthine Derivatives: Theophylline
Aminophylline
Aminophylline- IV version of Theophylline; can be easy to get toxic
Leukotriene Receptor Antagonists action
LRA- stops inflammation from happening, asthma symptoms are relived
Corticosteroids (Glucocorticoids)
Prevent inflammation form occurring
Not for asthma attack
Enhance effects of ß-adrenergic (Enhance effects of salbutamol)
Reduce inflammation, the narrowing of airwyas
Inhaled corticosteroids instructions
Swish, gargle, and spit water out- may lead to oral fungal infection
Corticosteroid inhaled- water, swish and spit it out
Used for long term management of asthma
Leukotriene Receptor Antagonists (motelukast)
Prevent inflammation
Xanthine Derivatives
Hard on the GI system- may worsen GI upset
May increase cardiac symptoms
Metered dose inhaler
best way to use with a spacer/ aerochamber- recommend using spacer device
B agonists
xanthine derivatives
antichollinergics
LTRAs
Corticosteroids
improve airflow in airway passages
increase oxygen supply
-assess vital sigs (SPO2)
-assess for dyspnea, cough, orthopnea, or hypoxia (respiratory distress)
-assess cough for character and frequency, presence of sputum and its colour
assess for sternal retractions, cyanosis, restlessness, activity intolerance, heart irregularities, palpitations, HTN, tachycardia, or use of accessory muscles to breathe, AP diameter
-collect allergies, environmental exposures, smoking habits
-assess cardiac status- BP, HR, heart sounds, ECG, blood gas, nail beds for cyanosis/ clubbing
B agonists
contraindication: dysrhythmias, risk for stroke
assess intake of caffeine (chocolate, tea) because of its sympathomimetic effects (restlessness, tachycardia, tremor, hyperglycemia, vascular headache, hypotension, HTN)
MAOIs- increases HTN
Antichollinergics
assess history of heart palpitations, GI distress, BPH, urinary retention, or GLAUCOMA (CAN POTENTIATE THESE CONDITIONS)
Ipratropium aerosol forms- assess bronchospasms
Corticosteroids
get baseline vitals, breath sounds, and heart sounds
assess for adrenal disorders- this drug can cause adrenal suppression
the systemic impact of corticosteroids on pediatric pts- suppress growth
systemic vs inhaled corticosteroids- assess the use of antidiabetic drugs, antifungals, phenytoin, phenobarbital, rifampin, and potassium sparring diuretics.
Respiratory drugs
glucocorticoids- antiinflammatory
xanthines and B agonists- broncho-dilating effect
antichollinergic- blockage of cholinergic receptors
Xanthines derivatives
cardiovascular assessment
Hard on the GI system- may worsen GI upset
May increase cardiac symptoms
HR, BP, Hx of cardiac disease (because AE such as sinus tachycardia and palpitations may occur)
assess for GI reflux- assess bowel pattern, GERD,
assess urinary patterns- may cause urinary frequency
drug interactions- allopurinol, cimetidine, erythromycin, Cipro, oral contraceptives, caffeine, or sympathomimetics
assess diets such as high carb, low protein diets (may lead to decreased theophylline elimination and increased theophylline levels)
Low carb, high protein diet (intake of charbroiled meat)- increases theophylline elimination and decreases therapeutic serum theophylline levels
LTRAs
liver function
OAs sensitive to this drug
PDE4
not for acute bronchospams
omalizumab- monoclonal antibody; assess malignancies
Hypoxia
Hypercapnia
Hypoxia- low oxygen
Hypercapnia- high CO2
Salbutamol
too often can cause beta 1 defects
Tiotropium bromide/ Spiriva
comes in a pill form – do not swallow it; you have to inhale it to breathe the powder
Wash the spacer / aero-chamber with soap and water once a week
theophylline levels and diet relationship
theophylline levels- high carb and low protein diet increase theophylline levels (too high)
low carb, high protein- decreases the level of theophylline
THE ORDER
beta-adrenergic, anticholinergic then corticosteroids
Beclomethasone with corticosteroids
Beclomethasone with corticosteroids (or anything to do with corticosteroids)- monitor BG, wean them off gradually- Addisonian crisis- causes mortality
Epileptic meds too- wean them off gradually
Oral corticosteroids-
Oral corticosteroids- can cause fungal infections, systemic AE
Aminophylline
IV version of Theophylline; can be easy to get toxic if they don’t respond to salbutamol
LRA
stops inflammation from happening, asthma symptoms are relived
Corticosteroids (Glucocorticoids)
Prevent inflammation form occurring
Enhance effects of ß-adrenergic
Reduce inflammation, the narrowing of airways
Inhaled Corticosteroids:
Swish, gargle, and spit water out- may lead to oral fungal infection- to prevent dryness and mucosal irritation (oral candidiasis)
MDIS
10 to 40% drug delivery
if a second puff is required, wait 1 to 2 minutes between puffs
if a second type of inhaled drug is prescribed, wait 2 to 5 minutes
reduce hospitalization and improves cost savings for children
DPI- dry powder inhaler
small hand-held device that delivers a specific amount of dry micronized powder with each inhaled breaths
Nebulizer
delivers an aerosol of small amounts of misted dropletsof the drug to lungs through a small mouthpiece/ mask
increased risk of pathogen transmission
Rapid infusion of xanthine derivatives
lead to profound hypotension- syncope, tachycardia, seizures, cardiac arrest
inhaled B agonist, before inhaled glucocorticoid
to provide bronchodilation before anti-inflammatory
inhaled bronchodilator is taken 2 to 5 minutes before corticosteroid.
Peak flow meter
handheld device used to monitor pts ability to breathe out air- reading reflects airflow through bronchi; thus the degree of obstruction in the airways
PDE4
report changes in psychiatric status
theophylline level
55 and 110 micromol/L
Use of multiple inhalers
LABA (b-agonist)
antichollinergic
corticosteroid
-b agonist will open airway and allow other 2 drugs to travel deeper into the lungs for improved effects
xanthines
educate interaction between smoking and xanthines (smoking decreases blood concentrations of aminophylline and theophylline)
charcoal-broiled food- decreased serum levels of xanthine
report AEs: epigastric pain, N&V, tremor, headache
learn to take HR
antichollinergics
ipratropium is used prophylactically to decrease frequency and severity of asthma
encourage fluids to decrease the viscosity of secretions
wait 2-5 mins before other inhalers
take no more than 2 puffs
Leukotriene receptor antagonists
prevent leukotriene which prevents/decrease inflammation
corticosteroids
practice good oral hygiene
to prevent oral fungal growth
divide the number of doses in the canister by the number of puffs used per day to determine number of days it will last
intranasal dosage form
tilt head slightly forward, point spray tip toward inflamed turbinates
excess use of corticosteroids may lead to Cushings syndrome\
what causes addisonian crisis?
moon faces, acne, increased fat pads, swelling
systemic corticosteroid is abruptly discontinued, This drug requires weaning prior to discontinuation.
b agonists stimulate
b1 and b2 receptors
xanthines function
theophylline- relaxes the smooth muscles of the bronchioles by inhibiting phosphodiesterase (P-breaks down cAMP which is needed to relax smooth muscles)
corticosteroids
stabilize cells that release harmful bronchoconstricting substances
LTRAs (montelukast & zafirlukast) AEs
headache, dizziness, insomnia, dyspepsia
Omalizumab
monoclonal antibody
prevent release of mediators that lead to allergic responses. Preventative
salbutamol
immediate release
nebulizer treatment with the b agonist salbutamol; pt is feeling a little shaky with slight tremors of the hands- HR is 98/min, increased from the pretreatment rate 88/min. This is a result of?
an expected AE of the drug
Aminophylline (xanthine derivative) infusion for 24 hrs- AEs
sinus tachycardia
LTRA montelukast
reduces inflammation in the airway
corticosteroids such as fluticasone, action after the dose
rinse mouth with water
teach pts about inhaler Advair (salmeterol and fluticasone)
I will rinse my mouth with water after each dose
this medication is taken BID, q12h
I will call my doctor if I notice white patches inside my mouth
