Respiratory Medications And Corticosteroids Flashcards
1
Q
What are the 6 types of respiratory medications?
A
Anticholinergics Adrenergic agonists Membrane stabilizer Xanthines Related drugs: tocolytics Corticosteroids
2
Q
Atropine antagonizes what on airway smooth muscle in large and medium sized airways?
A
Acetylcholine effects
- affects airways that respond to vagal stimulation
- decreases airway resistance
- Increases dead space
3
Q
This is most effective in treating bronchospasm due to beta antagonists
A
Ipratropium
- slower onset and less effective than beta agonists in treating bronchial asthma (not useful in acute attacks)
- more effective than beta agonists in chronic bronchitis or emphysema
- may use in combo with beta agonists
4
Q
Is there significant systemic absorption of ipratropim?
A
Minimal systemic absorption (1%)
Limited absorption results in prolonged local site effect
5
Q
With Ipratropium, blockade of M-2 may cause what?
A
Paradoxical bronchospasm
6
Q
T/F: tolerance to Ipratropium’s bronchodilator effect has been observed
A
FALSE
7
Q
What medications contain Ipratropium?
A
Atrovent - Ipratropium alone
Duoneb/combivent - in combo with albuterol
8
Q
This is a long-acting anticholinergic bronchodilator that blocks muscarinic receptor subtypes M1 and M3
A
Tiotropium (Spiriva)
9
Q
Tiotrepium (Spireva) does what 2 things?
A
Facilities bronchodilation
Reduces mucous secretion
10
Q
Tiotropium (Spireva) is used for what conditions?
A
Maintenance treatment of bronchospasm associated with COPD including chronic bronchitis and emphysema
11
Q
This medication is similar to Spireva except it is given twice daily and has faster onset to peak (2D vs 7D)
A
Aclidinium (Tudorza)
12
Q
List the 4 Beta agonists
A
Ephedrine
Isoproterenol
Albuterol
Terbutaline
13
Q
These 2 medications have bronchodilating effects from activation of Beta-2 receptors, and have a significant amount of non-respiratory side effects.
A
Ephedrine and Epinephrine
14
Q
This medication is a non-selective sympathomimetic (acts on Beta-1 and Beta-2 receptors), and is highly pro-arrhythmic
A
Isoproterenol
15
Q
What is the action and benefit of Beta-2 agonists?
A
Relax bronchial smooth muscle
Lack stimulating effects on the heart at therapeutic doses
16
Q
What are 4 uses of Beta-2 agonists?
A
- preferred treatment for acute episodes of asthma
- prevention of exercise-induced asthma
- improve airflow and exercise tolerance in pts with COPD
- tocolytic to stop premature uterine contractions
17
Q
What are the 2 classes of Beta-2 agonists?
A
Intermediate acting (3-6 hours)
Long acting (> 12 hours)
18
Q
What are the routes of administration for Beta-2 Agonists?
A
Inhaled - preferred
Oral
Parenteral - S.Q., IV
19
Q
What are the 4 steps to the inhalation technique for Beta-2 agonists?
A
- Deep breath in, blow it all out
- Discharge MDI with a slow deep breath in (over 5-6 seconds)
- Hold breath for 10 seconds
- Repeat
20
Q
With inhalation of Beta-2 agonists, what percentage is actually delivered to the lungs?
A
12%
The rest to the mouth, pharynx, and larynx
21
Q
How does the presence of an ETT affect the amount of inhaled Beta-2 agonist delivered?
A
The presence of an ETT decreases by 50-70% the amount of drug delivered by a MDI that reaches the trachea
*administration during mechanical ventilation increase the amount of drug that passes beyond the dismal end of the ETT
22
Q
Dose delivered by a nebulizer requires ____x that of a MDI dose to produce the same degree of bronchodilation
A
6-10x
23
Q
What are the side effects of Beta-2 agonists
A
Tremor: due to stimulation of Beta-2 receptors on skeletal muscle
Tachycardia: direct stimulation of receptors on the heart
Metabolic Response: hyperglycemia, hypokalemia, hypomagnesemia
24
Q
What is the preferred Beta-2 agonist for acute bronchospasm?
A
Albuterol
25
What are the 3 Short acting Beta agonists (SABA)?
Albuterol
Levoalbuterol (xopenex): little or no clinically significant difference in adverse effects compared to albuterol
Metaproterenol: selective Beta-2 agonist
26
This medication is used to treat asthma and is also a tocololytic
Terbutaline
27
What are the 2 long acting Beta-2 agonists (>12 hrs) (LABA)
Salmeterol (serevent): frequently administered with a steroid. What’s in Advair
Vilanterol
28
Cromolyn Sodium is a ________ ________
Membrane stabilizer
29
Cromolyn Sodium inhibits _______ release of ________ and other mediators from pulmonary mast cells during antibody mediated allergic responses
Antigen-induced
Histamine
* suppresses the secretory response NOT the Ag-Ab interaction
* does NOT relax bronchial or vascular smooth muscle
30
T/F: you can use Cromolyn Sodium in an acute asthma attack
FALSE
31
Cromolyn Sodium (Intel) is used for what?
Prophylactic treatment of bronchial asthma
32
What are the 3 methylxanthines?
Theophylline/aminomphylline
Caffeine
Therbromine
33
What are the 4 uses of methylxanthines?
1. Stimulate the CNS
2. Increase BP
3. Increase myocardial contractility and HR
4. Relax smooth muscle (airways)
34
Methylxanthines are non-selective ______________ inhibitors
Phophodiesterase
*inhibit all fraction of PDE isoenzymes
35
Methylxanthines competitively antagonize _________ receptors
Adenosine
*theophylline more active than caffeine or theobromine
36
Theophylline is used for what?
- Treatment of bronchospasm due to acute exacerbation of asthma
- CNS stimulant: treat apnea of prematurity in infants
37
What are the S/S of toxicity of theophylline at:
15-25mcg/ml
25-35:
>35
15-25: GI upset, N/V, tremor
25-35: tachycardia, PVCs
>35: Vtach, seizures
38
What are the 3 effects of caffeine
CNS stimulant
Cerebral vasoconstrictor
Secretion of gastric acid
39
What are the 3 uses of caffeine
Apnea of prematurity
Post-Duran puncture HA
Cold remedies (offset sedation from antihistamines)
40
Ritodrine works on what receptor?
It’s a Beta-2 agonist
- activates adenyl cyclase
- Some Beta-1 effects - tachycardia
41
What is Ritodrine used for?
It’s a tocolytic. Used to stop uterine contractions of premature labor
42
T/F: Ritodrine crosses the placenta
TRUE
It has cardiac and metabolic effects in both the mother and fetus
- Dose related tachycardia
- increased CO
- Increased renin secretion
- Exaggerated systemic BP decrease
- Hyperglycemia in mother may cause reactive hypoglycemia in fetus
43
This is a low molecular-weight, naturally occurring hydrophilic endogenous amine that produces a variety of physiologic and pathological responses
Histamine
-its a chemical mediator of inflammation in allergic disease
44
What cells contain large amounts of histamine?
Mast cells in the skin, lungs, GI tract and circulating basophils
45
Histamine is released in response to:
Certain drugs
| AG-AB reactions
46
T/F: histamine easily crosses the blood-brain barrier
False
47
How many histamine receptors are there?
H1
H2
H3
H4
48
Stimulation of H-1 receptors does what?
- Evokes smooth muscle contraction in the respiratory and GI tracts
- cause pruritus and sneezing by sensory nerve stimulation
- slow the HR by decreasing AV nodal conduction
- mediate epicardial coronary vasoconstriction
49
Through H-1 and H-2 receptors histamine causes:
- Increased capillary permeability
- hypotension
- tachycardia
- flushing
- HA
50
Stimulation of H-2 receptors does what?
- activates adenyl cyclase and increases intracellular cAMP
- increases myocardial contractility and HR
- with H-1 receptors increase capillary permeability vasodilation
51
What are Cardiovascular effects of H-1 and H-2 stimulation?
Dilation or arterioles and capillaries —> flushing, decreased SVR, decreased BP, increased capillary permeability leading to edema
Coronary vasodilation (H2) and vasoconstriction (H1)
Inotropic, chronotropic, andtidromic effects
52
T/F: need H1 and H2 blockers to completely block the vasodilatory effects of histamine
TRUE
53
What is the triple response?
Wheal and Flare
- Edema: due to increased permeability
- Flare: dilated arteries around the edema due to histamine stimulating nerve endings
- Pruritus: due to histamine in the superficial layers of the skin
54
H-1 receptor activation causes what in the airway?
Constricts bronchial smooth muscle
- in normal pts this action is negligible
- in pts with asthma or bronchitis, more likely to develop increases in airway resistance
55
What does H-2 receptor stimulation do to airway?
Relaxes bronchial smooth muscle
56
Does histamine increase or decrease gastric secretions?
Histamine evokes secretion of gastric fluid containing high concentrations of hydrogen ions
- can occur without enough histamine to alter BP
- due to H2 receptor stimulation
- vagal activity also increases H+ secretion
57
Do histamine receptor antagonists reversibility or irreversibly antagonized histamine receptors?
REVERSIBLE
58
Do histamine receptor antagonists work by inhibiting the release of histamine?
NO
They attach to receptors and prevent the response mediated by histamine
-stabilizes the receptor in the inactive form (inverse agonist)
59
T/F: H1 receptor antagonists are not highly selective for H1 receptors
FALSE
60
Which generation of H1 receptors antagonists are sedating and which are non-sedating?
First generation: sedating
-may also activate anti-cholinergic, serotonin, or alpha-adrenergic receptors
Second generation: non-sedating
61
Classification that combines and stabilizes the inactive form of the H1 receptor shifting the equilibrium toward the inactive state.
Inverse agonists
62
What are the side effects of 1st generation H1 histamine receptor antagonists?
CNS: somnolence, decreased alertness, slowed reaction time, and impaired cognitive function
Anticholinergic: dry mouth, blurred vision, urinary retention, and constipation
CV: tachycardia, QT prolongation, heart block, and cardiac dysrhythmias
63
Are you likely to get CNS side effects from 2nd generation H1 histamine receptor antagonists?
Unlikely
Enhancement of sedative or ETOH unlikely
64
What are the 5 clinical uses of H1 histamine receptor antagonists?
1. Prevent and relieve symptoms of allergic rhinoconjunctivitis
2. Pretreatment may provide some protection against bronchospasm induced by various stimuli
3. Antipruritic
4. Sedative
5. Antiemetic
65
What are 2 H1 histamine receptor antagonists?
Diphenhydramine (Benadryl)
Dimenhydrinate (Dramamine)
66
What is Benadryl used for?
Sedative, antipruritic, antiemetic
Type 1 allergic reactions: anaphylaxis
Anaphylactic reactions (IV contrast, blood products)
67
What is Dramamine used for?
Motion sickness and PONV
Inhibits the integrative functions of vestibular nuclei by decreasing vestibular and visual input
68
What are some 2nd generation H1 histamine receptor antagonists?
Claritin
Allegra
Xyzal
69
Glucocorticoids are produced where?
The middle layer of the adrenal cortex - zona fascicula
70
What causes the release of cortisol from the adrenal cortex?
Stimulation of the H-P-A axis due to stress
71
What series of metabolic effects are initiated by the release of cortisol?
Carbohydrate, protein, and fat metabolism
Fluid and electrolyte balance
CV, CNS, Immune, Endocrine, Renal stabile
Inhibition of inflammatory, allergic response
72
Cortisol is also called what?
Hydrocortisone
73
This is secreted secondary to increased potassium, decreased sodium, and decreased BP/fluid volume
Aldosterone
74
_______ —> _________ —> __________ —> aldosterone
Renin —> AG1 —> AG2 —-> aldosterone
75
What are the 3 effects of aldosterone?
1. Increased K excretion
2. Increased Na retention
3. Increased water retention, increased blood volume
76
When are secretory rates of CRH, ACTH, and cortisol are highest____________, and lowest___________
Highest in the early morning
Low in the late evening
*changing daily sleeping habits causes a corresponding change in the cycle
77
What is an example fo primary adrenocortical insufficiency?
Addison’s disease
Adrenals do not secrete cortisol or aldosterone
Replacement therapy must include glucocorticoid and mineralocorticoid
78
What is secondary adrenocortical insufficiency?
Chronic steroid use and suppression fo the H-P-A axis
- aldosterone secretion maintained
- replacement usually requires only glucocorticoid
79
Make slide for physiological effects after lecture
Don’t know
80
What is the glucocorticoid effect?
Anti-inflammatory response
81
What is the mineralocorticoid effect?
Evoke dismal renal tubular re-absorption of Na+ in exchange for K+
82
What are the 5 naturally occurring corticosteroids?
```
Cortisol (hydrocortisone)
Cortisone
Corticosterone
Desoxycorticosterone
Aldosterone
```
83
What are the synthetic glucocorticoids?
```
Prednisone
Prednisolone
Methylprednisolone
Betamethasone
Dexamethasone
Triamcinolone
```
84
What is the synthetic mineralocorticoid?
Fludrocortisone
85
What methods of administration are effective for steroids?
Oral
IV: Water soluble forms can be administered IV
IM: prolonged effects with IM administration
Topical or aerosol
86
Can steroids cross the placenta?
YES
87
Endocrine side effects of corticosteroids
Adrenal atrophy, HPA axis suppression/secondary adrenal insufficiency, cushing’s syndrome, diabetes/hyperglycemia
88
Cardio side effects of corticosteroids
Dyslipidemia, HTN, thrombosis, vas Ulithi summer
89
CNS side effects of corticosteroids
Cataracts, glaucoma, changes in mood/behavior/cognition/memory, HA, psychosis, cerebral atrophy
90
Immune side effects of corticosteroids
Immunosuppression, increased infection risk, latent viral activation
91
Renal side effects of corticosteroids
Increased sodium and water retention, increased K+ and H+ ion secretion, edema
92
GI side effects of corticosteroids
PUD, GI bleed, pancreatitis
93
Musculoskeletal side effects of corticosteroids
OP, osteonecrosis, atrophy, myopathy, retardation of normal bone growth
94
Skin side effects of corticosteroids
Atrophy, acne, dermatitis, delayed wound healing, erythema, ecchymosis, hirsutism, hyperpigmentation
95
GU side effects of corticosteroids
Delayed puberty, hypogonadism, fetal growth inhibition, menstrual disorders
96
Use of corticosteroids caucuses what electrolyte and metabolic changes?
Hypokalemia metabolic alkalosis
-mineralocorticoid effect of cortisol on distal renal tubules leading to enhanced absorption of Na+ and loss of K+
97
Corticosteroids inhibit or enhance glucose use in peripheral tissues?
They inhibit glucose use in peripheral tissues
Also promote hepatic gluconeogenesis
98
What changes to oral hypoglycemics or insulin may need to be made when corticosteroids are given to type II diabetics?
May need to increase dose
99
How does fat redistribute with corticosteroid use?
Buffalo hump
Moon face
Loss of fat from the extremities
100
What are the catabolic effects seen with corticosteroids?
Peripherally, they mobilize amino acids from tissues
- decreased skeletal muscles mass
- osteoporosis
- thinning of the skin
- negative nitrogen balance
101
T/F: Steroid use is associated with a decreased incidence of neurosis and psychosis
FALSE
102
Behavioral changes include __________ and ___________
Manic depression
| Suicidal tendencies
103
Cataracts can develop with _______ years of usage
> 4 years
104
Long term corticosteroids tend to increase ______ and number of _________ in blood
Hematocrit
Leukocytes
105
Single dose of cortisol decreases circulating:
Lymphocytes by
Monocytes by
Lymphocytes by 70%
Monocytes by 90%
*cells are sequestered rather than destroyed
106
How do glucocorticoids affect growth in children?
Arrest of growth can result from the administration of relatively small doses
107
Corticosteroids inhibits _______ synthesis and _______ division
DNA
Cell
108
What are some relative contraindications for corticosteroids?
```
Active systemic infection
Immunosuppression
Acute psychosis
Primary glaucoma
Hypokalemia
CHF
Cushing’s syndrome
Diabetes
HTN
Osteoporosis
Hyperthyroidism
```
109
What are 4 concerns surgeons have with intraoperative use of corticosteroids?
1. Masking infection or further complicating surgery intended to treat infection
2. Altering glucose control in diabetes
3. Aseptic necrosis of the femoral head
4. Failure of bone fusion
110
Likelihood is increased for HPA axis suppression by:
Longer the duration
| Larger the dose
111
What is associated more commonly with H-P-A axis suppression?
Prednisone or dexamethasone (even physiological doses) given as a single daily dose at bedtime is associated more commonly with HPA axis suppression
112
What therapies are unlikely to suppress HPA axis?
- Prednisone 5mg/day or less
- long term every other day dosing
- glucocorticoids, any dose < 3 weeks
113
What therapies are assumed to suppress HPA axis?
- Prednisone 20mg.day > 3 weeks within previous year
- Pt with clinical signs of Cushing syndrome from any steroid dose
*no need to the the HPA axis in these patients, just supplement with stress dose steroids
114
After cessation of therapy, how long can it take the HPA axis to recover?
12 months or longer
115
H-P function returns to normal ______ adrenal function
BEFORE
116
What test checks adrenal function?
Cosyntropin (ACTH) stimulation test
117
Goal is to __________ the plasma concentration of cortisol _______ normal during majorly surgery in pts receiving chronic treatment with corticosteroid and manifesting a subnormal response to the preoperative infusion of ACTH
Maintain
Above
118
It’s here a need for addition corticosteroid coverage for minor operations?
Minimal or no addition coverage
119
T/F: you can base dose of corticosteroid supplementation based on the magnitude of the planned surgical procedure
TRUE
120
What can exaggerate the need for exogenous corticosteroid supplementation
Burns or sepsis
121
What are some S/S of acute adrenal crisis?
- hypotension unresponsive to vasopressors
- hyperdynamic circulation
- hypoglycemia
- hyperkalemia
- hyponatremia
- hypovolemia
- metabolic acidosis
- decreased LOC
