Respiratory Medications Flashcards
What’s the role of histamines?
- involved in nerve impulse transmission from CNS
- dilatation of capillaries
- contraction of smooth muscle
- stimulation of gastric secretion
- acceleration of the HR
What releases histamines?
mast cells or basophils in response to an antigen in the blood
What are the properties of antihistamines?
- antihistaminic
- anticholinergic
- sedative (main ingredient in OTC sleep aids)
What are some traditional antihistamines?
- diphenhydramine
- dimenhydrinate
- promethazine
- brompheniramine
How do antihistamines compete with histamines?
- cannot push histamine off the receptor if it’s already bound
- can pass the blood-brain barrier
- act on the central and peripheral nervous system
When should you use antihistamines?
- Nasal allergies
- Seasonal or perennial allergic rhinitis (hay fever)
- Urticaria (hives)
- Allergic rnxs
- Motion sickness
- Parkinson’s disease (d/t anticholinergic effects)
- Vertigo
- Sleep disorders
- Symptoms r/t to the common cold
– Sneezing, runny nose
What are some contraindications of antihistamines?
- Known drug allergy
- Narrow-angle glaucoma
- Cardiac disease, HTN
- Kidney disease
- BPH
- Peptic ulcer disease
- Seizure disorders
- Pregnancy (Category B)
When should you seek caution when using antihistamines?
- Impaired liver function
- Renal insufficiency
- Lactating mothers
- Neonates
- Elderly (65+)
- Lower respiratory tract symptoms
Can you use antihistamines during an acute asthma attack?
Yes, but NOT to be used as the sole drug therapy
What are some adverse effects of antihistamines?
- EENT- blurred vision, tinnitus
- CV- hypotension, palpitations, syncope
- GI- anorexia, N/V, dry mouth, constipation
- GU- urinary retention
- Neuro- drowsiness, sedation, paradoxical excitement, restlessness, nervousness, seizures
- Resp- chest tightness, thickened bronchial secretions (not common)
What to educate patients on antihistamines?
- take medication at night before bed
- perform frequent mouth care, chew gum, or suck on hard candy (sugarless) - for dry mouth
- humidifier may be needed to liquify secretions
- intake of fluids
What is diphenhydramine used for?
- relief or prevention of histamine-related allergies
- motion sickness
- tx of Parkinson’s disease
- promotion of sleep
- management of anaphylaxis (alongside epinephrine)
How is diphenhydramine administered?
Route: PO
Onset: 15-30 mins
Duration: 4 hours
(Benadryl)
What are some nursing implications of diphenhydramine?
- encourage to chew/suck on sugar-free candy and gum (dry mouth), OTC throat lozenges
- frequent mouth care
- don’t take with other OTC cold and/or cough medications
- monitor older adults and children for paradoxical reactions
- monitor BP and other VS as ordered and PRN (if in acute care setting)
What to educate patients on diphenhydramine?
- sedating effects
– avoid activities that require mental alertness - DON’T take with other traditional antihistamines
- report any difficulty breathing, heart palpitations, or unusual adverse effects
What is some information about traditional antihistamines?
- Older
- Works both peripherally and centrally
- Crosses the BBB
- Has anticholinergic effects, making them more effective than nonsedating drugs in some cases
- Generically available, less expensive
- Rx and OTC
What is some information about non-sedating/2nd generation antihistamines?
- Newer
- Developed to eliminate unwanted adverse effects (sedation)
- Works only peripherally to block the actions of histamine (less CNS/neuro effects)
- Do not cross the BBB
- Longer duration of action (daily; better adherence)
- OTC, but more expensive
What are some non-sedating antihistamines?
- Loratadine
- Fexofenadine
- Cetirizine
What are non-sedating antihistamines used for?
- Nasal allergies
- Seasonal allergic rhinitis (hay fever)
- Urticaria (hives)
What is an adverse effect of non-sedating antihistamine?
- GI: Dry mouth, GI upset
- Cetirizine:
– Neuro: dizziness, drowsiness, fatigue
What does Loratadine react with? What happens?
- Erythromycin
- Ketoconazole
- Inhibits metabolism –> Increased Loratadine levels
What does Fexofenadine interact with? What happens?
- Erythromycin
- other CYP450 inhibitors
Inhibits metabolism –> Increased Fexofenadine levels
What does Cetirizine interact with? What happens?
- Alcohol
- MAOIs
- CNS depressants
Additive effects –> Increased CNS depression
How is Loratadine administered?
Route: PO
Onset: 1-3 hours
Duration: 24 hours
Daily dosing (at night)
(Claritin)
How is nasal congestion presented? What causes it?
- Excessive nasal secretions
- Inflamed and swollen nasal mucosa
- Primary causes of congestion: allergies & URIs
What are some decongestants?
- Adrenergics (largest group)
- Corticosteroids
What are some adrenergic decongestants?
- Pseudoephedrine (PO)
- Oxymetazoline (nasally inhaled)
How is Pseudoephedrine administered?
Route: PO
Onset: 15-30 min (ER 60 min)
Duration: 4-6 hours (ER 12 hr)
What is Pseudoephedrine used for?
Symptomatic management of nasal congestion associated with acute URI
What are some adverse effects of Pseudoephedrine?
- Neuro: nervousness, excitability, anxiety, insomnia, restlessness
- CV: palpitations
- GI: anorexia
What does Pseudoephedrine interact with?
- Additive adrenergic effects w/ other adrenergic drugs
- Concurrent use w/ beta blockers (may result in hypotension and bradycardia)
What are some nursing implications of Pseudoephedrine?
- assess congestion before and during therapy
- assess lung sounds and bronchial secretions
- maintain fluid intake to decrease viscosity of secretions
- at least 2 hours before bedtime to minimize insomnia
What to educate patients on Pseudoephedrine?
- avoid OTC cough and cold products while breastfeeding or to children younger than 4
- notify the provider if nervousness, slow or fast HR, breathing difficulty, hallucinations, or seizures occur
How should Oxymetazoline be administered?
Route: Intranasal
Onset: 10 mins
Duration: 12 hours
(Afrin)
What is Oxymetazoline used for?
- management of nasal congestion associated with allergic and infectious disorders of the UR tract
- reduce swelling of the nasal passage and facilitate visualization of the nasal or pharyngeal membranes before surgery or diagnostic procedures
What are some adverse effects of Oxymetazoline?
EENT
- burning
- stinging
- dryness of nasal mucosa
- sneezing
- rebound nasal congestion
What are some nursing implications for Oxymetazoline?
- place the spray nozzle in nostril and tilt patient’s head slightly forward
– have patient sniff briskly during administration - wipe dropper with alcohol pad after each use to prevent contamination
- administered in the morning and before bedtime
What to educate patients on Oxymetazoline?
- do NOT take this medication longer than 3 days because it can cause rebound congestion
What are some corticosteroid decongestants?
- fluticasone
- beclomethasone dipropionate
- budesonide
- triamcinolone
What are corticosteroid decongestants used for?
- Acute, chronic, or seasonal rhinitis
- Used prophylactically to prevent nasal congestion in patients with chronic UR symptoms
- Does not cause rebound congestion
When to seek caution when using corticosteroid decongestants?
- Active untreated nasal infections
- Recent nasal trauma or surgery
- Underlying immunosuppression
What are some adverse effects of corticosteroid decongestants?
EENT
- Localized to where it was applied
- Mucosal irritation and dryness
How is Fluticasone administered?
Route: Intranasal
Onset: Few days
Duration: Unknown
What is Fluticasone used for?
To prevent nasal congestion in patients with chronic URT symptoms
(not associated with rebound congestion)
How are inhaled intranasal corticosteroid decongestants administered?
- patient should clear nasal secretions
- if nasal passages are blocked use an inhaled intranasal decongestant immediately prior to use
- ensure patient’s head is upright
- have patient breathe in through the nose during administration
- have patient sniff hard for a a few minutes after administration
What to educate patients on corticosteroid decongestants?
- gently blow nose before using
- shake medication well before use
- before first-time use, prime unit by spraying 6-7x
What does cough reflex do?
- naturally removes respiratory secretions and foreign objects
~ Induces coughing and expectoration
~ Initiation by irritation of sensory receptors in the respiratory tract
What are two types of coughs?
- Productive: “wet” d/t excessive secretions
- Nonproductive: “dry” cough
What are Antitussives?
Drugs used to stop or reduce coughing
What are antitussives used for?
- enhance comfort; reduce respiratory distress
- only for nonproductive “dry” coughs
- in cases when coughing is harmful (ex: after abdomen surgery)
What are two types of antitussives?
- Opioid
- Nonopioid
What are two types of opioid antitussives?
- Codeine
- Hydrocodone
What do opioid antitussives do?
Stop the cough reflex when the cough is non-productive and/or harmful
What are some adverse effects of opioid antitussives?
- CV: hypotension
- GI: N/V, constipation
- Neuro: Sedation, confusion
- Resp: respiratory depression (including sleep apnea and sleep-related hypoxemia)
What do opioid antitussives react with?
- Opioids
- General anesthetics
- Tranquilizers
- Sedatives & Hypnotics
- Tricyclic antidepressants
- Alcohol
How is codeine administered?
Route: PO (Liquid solutions, Tablets, Capsules, Suspensions)
Onset: 15-30 mins
Duration: 4-6 hours
What are some nursing implications for codeine?
- Assess BP, HR, and RR
- Fall safety! Drowsiness or dizziness may occur
- Assess for opioid addiction, abuse, or misuse prior to administration
- For overdose, administer naloxone (reversal agent)
What are some nonopioid antitussives?
- Benzonatate
- Dextromethorphan
How is benzonatate administered?
capsules only
When is benzonatate used?
Relief of non-productive cough d/t minor throat or bronchial irritation from colds
How is dextromethorphan administered?
Route: PO
Onset: 15-30 mins
Duration: 3-6 hours
When is dextromethorphan used?
Symptomatic relief of cough caused by minor viral UR tract infection
What are some adverse effects of dextromethorphan?
GI: Nausea
In high doses- dizziness and sedation
What are expectorants?
- Drugs that aid in the expectoration (removal; coughing up and spitting out) of mucus
- Reduces the viscosity of sputum
- Disintegrate and thin secretions
- Available in a lot of OTC cold and cough preparations and provide symptom relief for many clients
- Most popular one is guaifenesin
Drug profile of guaifenesin?
- Beneficial b/c it thins the mucus in the respiratory tract
- IR guaifenesin is dosed multiple times throughout the day
- SR products are given once daily or BID
- Many PO forms available:
~ Capsules
~ Tablets
~ Solutions
~ Granules
Guaifenesin indication?
Productive cough associated w/ viral UR tract infections
Guaifenesin adverse effects?
GI: N/V, gastric irritation
Guaifenesin nursing implications?
- Administer each dose followed by a full glass of water to decrease viscosity of secretions
- Assess frequency and nature of cough, lung sounds, and amount and type of sputum produced (if any)
Guaifenesin patient education?
- Teach patient how to effectively cough
- Notify provider is cough lasts longer than 1 week or is accompanied by fever, rash, persistent headache, or sore throat
What is an example of a herbal supplement?
- Echinacea
~ Shown in clinical trials to reduce cold symptoms and recovery time when taken early
~ Immunostimulant effects
What are some common uses of echinacea?
- Stimulate the immune system
- antisepsis
- tx of viral infections and influenza-like respiratory tract infections
- promotes wound healing
Echinacea adverse effects?
- dermatitis
- GI upset
- dizziness
- headache
- unpleasant taste
Describe pediatric concerns regarding OTC cough and cold products.
- OTC cough and cold products should not be given to children younger than 2 years of age
~ Oversedation
~ Seizures
~ Tachycardia
~ Death
~ Evidence that they simply are not effective
Describe what happens when someone has asthma.
- Recurrent and reversible SOB that occurs when the airways of the lungs become narrow as a result from
~ Bronchospasms
~ Inflammation of the bronchial mucosa
~ Edema of the bronchial mucosa
~ Production of viscous mucus - Alveolar ducts & alveoli remain open, but airflow to them is obstructed
What are the four types of asthma?
- Intrinsic (no hx of allergies)
- Extrinsic (clients with known allergy exposed to the allergen)
- Exercise induced
- Drug induced
What is status asthmaticus?
- Prolonged asthma attack that does not respond to typical drug therapy
- May last several minutes to hours
- MEDICAL EMERGENCY
What are some quick relief drugs for asthma?
- Short-acting inhaled beta2 agonists (rescue agents)- SABAs
- Anticholinergic agents
- IV systemic corticosteroids
What are some long-term control/maintenance drugs for asthma?
- Long acting beta2 agonists (LABAs)
~ LABAs combined with inhaled corticosteroids - Inhaled corticosteroids
- Leukotriene receptor agonists
- Anticholinergic agents
- Mast cell stabilizers
Describe the two drugs used to treat the lower respiratory tract (LRT).
- SABAs: Used during acute phase of asthmatic attacks
~ Quickly reduce airway constriction and restore normal airflow - LABAs: Used w/ maintenance/Long-term therapy
Describe other drugs used to treat the lower respiratory tract (LRT).
- albuterol
- levalbuterol
- metaproterenol
- pirbuterol
What is the drug profile of albuterol?
- Short-acting (beta2 specific bronchodilating) beta agonist [SABA]
- Must not be used too frequently
- PO and inhalational use
- forms include metered-dose inhalers (MDIs) as well as solutions for inhalation
Albuterol indication?
Prevention or relief of acute bronchospasm r/t bronchial asthma, bronchitis, or any other pulmonary diseases like COPD
Albuterol adverse effects?
CV: chest pain, heart palpitations, HTN
Neuro: nervousness, restlessness, tremor
Albuterol drug interactions?
- Concurrent use w/ other adrenergic drugs will have an increased adrenergic side effects
- Beta-blockers may negate therapeutic effect
- Use with caffeine-containing herbs (cola nut, guarana, mate, tea, coffee) can increase stimulant effect
SABA nursing implications?
- Assess lung sounds, HR before administration
- Administer PO medication w/ meals to minimize gastric irritation
- For inhalers:
~ Shake the inhaler well
~ Prime the inhaler before first use by releasing 4 test sprays into the air (away from the face)
~ For ANY inhaler: if 2 puffs from the same inhaler, wait 1-2 minutes in between puffs; if using a 2nd inhaler wait 2-5 minutes or the Rx’d amount of time after the first inhaler
SABA patient education?
- Space doses at regular intervals
- Avoid triggers (if known)
- Provide instruction on proper use and care of devices (MDIs and dry powder inhalers)
What are some other examples of LABAs?
- Salmeterol
- Formoterol
- Arformoterol
- Vilanterol
What is the drug profile of salmeterol?
- Long-acting beta2 agonist bronchodilator- LABA
- Used for the maintenance and of asthma and COPD and is used in conjunction with an inhaled corticosteroid
- Should never be given more than twice daily, nor should the maximum daily dose (one puff BID) be exceeded
Salmeterol indication?
- Co-therapy for the treatment of asthma and the prevention of bronchospasm in patients who are concurrently taking an inhaled corticosteroid
- prevention of exercise induced bronchospasm
- maintenance treatment to prevent bronchospasm in COPD
Salmeterol adverse effects?
Neuro: headache
Salmeterol drug interactions?
- Beta-blockers may negate therapeutic effect
- Use with caffeine-containing herbs (cola nut, guarana, mate, tea, coffee) can increase stimulant effect
Salmeterol nursing implications?
- These drugs should be used alongside an inhaled corticosteroid, not as monotherapy
- Assess lung sounds, HR before administration and periodically throughout therapy
Salmeterol patient education?
- Caution patient NOT use a LABA to treat acute symptoms
- Use rescue inhaler first in an acute attack
- Educate patient on rescue vs. long-term therapy drugs
What is the drug profile of ipratropium?
- Oldest & most commonly use anticholinergic bronchodilator
- Available both as a liquid aerosol (nebulizer) for inhalation and as a multi-dose inhaler
- DuoNebs (albuterol + ipratropium)
- Usually, dosed BID
Ipratropium indication?
- maintenance therapy of reversible airway obstruction d/t COPD
- unlabeled use = adjunctive management of bronchospasm caused by asthma
Ipratropium adverse effects?
EENT: increased intraocular pressure, dry mouth, dry throat, nasal congestion
CV: heart palpitations
GU: Urinary retention
Ipratropium drug interactions?
Additive effects w/ other anticholinergics
Ipratropium nursing implications?
- Assess for allergies to other anticholinergics such as atropine
- Wait 1-2 minutes (or as Rx’d) before receiving 2nd “puff” of medication
- Rinse mouth out with water to prevent mucosal dryness and/or irritation
- When giving this concurrently w/ other inhalers, administer adrenergic bronchodilator first, followed by ipratropium, then corticosteroid
Ipratropium patient education?
- Used prophylactically to decrease the frequency and severity of asthma and taken as Rx’d
- Force fluids, unless contraindicated
- Wait 2-5 minutes (or as ordered) before using additional, different inhaler
Describe the xanthine drugs used to treat the LRT.
- Natural xanthines:
~ theophylline
~ caffeine - Synthetic xanthines:
~ aminophylline
What is the drug profile of theophylline?
- Most commonly used xanthine derivative
- Make sure you do a thorough cardiac assessment (noting BP, HR, & hx of cardiac dx)
- Therapeutic range for theophylline blood level is 10 to 20 mcg/mL
Xanthine derivatives indications?
- Dilation of airways in asthma, chronic bronchitis, and emphysema
- Mild to moderate cases of acute asthma
- Adjunct drug in the management of COPD
Xanthine derivatives adverse effects?
CV: sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias
Xanthine derivatives interactions?
- Cigarette smoking decreased blood concentrations of the xanthine derivative
- Interacting foods include charcoal-broiled, high-protein, and low-carbohydrate foods
~ These foods may reduce serum levels of xanthines through various metabolic mechanisms
~ Note client’s intake of caffeine
Xanthine derivatives nursing implications?
- If giving via IV, use infusion pump
~ Infused too fast = hypotension w/ possible syncope, tachycardia, seizures and cardiac arrest
Xanthine derivatives patient education?
- Educate patients about foods that contain caffeine (chocolate, coffee, cola, tea) because their consumption can exacerbate CNS stimulation
- Some patients may need to take their own pulse; Educate patients on proper demonstration and have them teach it back to you
List some leukotriene receptor antagonists.
- Montelukast
- Zafirlukast
- Zileuton
What is the drug profile of montelukast?
- Can be used in children 1 year old and older
- Can cause suicidal thoughts/behaviors
Montelukast indication?
- prevention and chronic treatment of asthma
- prevention of exercise induced asthma
Montelukast adverse effects?
GI: Nausea
Neuro: Headache, dizziness, insomnia, anxiety, worsening depression, suicidal thoughts/ideation
Montelukast nursing implications?
- Montelukast chewable tablets contain aspartame, assess for allergies as some clients may need to avoid it
- Emphasize that these drugs are indicated for the treatment of CHRONIC (not acute) asthma attacks
Montelukast patient education?
- Emphasize that this medication is for the prevention not treatment of an acute attack
- Take medication at night and even if symptoms improve
List the types of corticosteroids (glucocorticoids) used to treat the LRT.
- Inhaled
~ Fluticasone
~ Beclomethasone
~ Budesonide - Intravenous
~ Methylprednisolone
What is the route of administration of fluticasone propionate?
Route: inhalation
Fluticasone propionate indication?
Primary tx of bronchospastic disorders to control the inflammatory responses that are believed to be the cause of these disorders; Persistent asthma
Fluticasone propionate adverse effects?
EENT: Pharyngeal irritation, dry mouth, oral fungal infection (thrush- thick white coating on tongue)
Fluticasone propionate nursing implications?
- 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
~ Avoid excessive fatigue, heat, extremes in temperature, and caffeine
Fluticasone propionate patient education?
- 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 several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid
What is the route of administration of methylprednisolone?
Route: IV
Methylprednisolone indication?
Used systemically to decrease inflammation; acute exacerbation of asthma or COPD
Methylprednisolone adverse effects?
CV: HTN
Neuro: depression or euphoria
Methylprednisolone drug interactions?
May increase requirement for insulins or oral hypoglycemic agents
Methylprednisolone nursing implications?
Monitor serum glucose levels
Methylprednisolone patient education?
- Stopping the medication suddenly may result in adrenal insufficiency
- Avoid live vaccines
What is the drug profile of roflumilast?
- PDE4 inhibitor
- Route: PO
Roflumilast indication?
To decrease the risk of severe exacerbations in severe COPD patients that have a hx of COPD
Roflumilast adverse effects?
Neuro: headache, insomnia, anxiety, depression, suicidal thoughts/behavior
Metabolic: weight loss
Roflumilast nursing implications?
- Assess respiratory status periodically during therapy
- Monitor client’s weight regularly
- Assess for suicidal tendencies
Roflumilast patient education?
- medication is NOT for a bronchodilator and should not be used to treat sudden breathing problems
- monitor their weight regularly
- notify provider if thoughts about suicide or dying
