results from release of ACH, histamine, and inflammatory mediators Vagus nerve releases ACH ACH triggers release of pulmonary secretions Treated with sympathomimetics

Metered Dose Inhalers pressurized devices that deliver a measured dose of drug with each activation with CFC or non-CFC propellant hand-mouth coordination is required

Dry-powder inhalers (DPIs) include Turbohalers and Accuhalers Drugs are in the form of dry, microionized powder no propellant breath activated, much easier to use

small machine to convert a drug solution into a mist

Drugs used to relieve bronchospasms associated with respiratory disorders Includes adrenoceptor agonists selective B2-agonists and other adrenoceptor agonists Antimuscarinic bronchodilators Xanthine derivatives

Albuterol (Proventil, Ventolin): MDI, neb Levalbuterol (Xopenex): neb only Bitolterol (Tornalate): neb only Pirbuterol (Maxair): neb only Salbutamol (oral tablet) Terbutaline (oral tablet)

Salmeterol (avialable only in combination) Formoterol (Foradil Aerolizer) : DPI

Albuterol: Tablets, extended tabs, syrup Terbutaline: Tablets

Ipratropium bromide (Atrovent) is the only anticholinergic used for respiratory disease Slow and prolonged action used to _prevent_ vasoconstriction Not used for acute asthma exacerbations Side effects dry mouth or throat distress gastrointestinal headache coughing anxiety

Test 2 Pharmacology Part 1 Flashcards by Elizabeth Danielson

Bronchoconstriction

results from release of ACH, histamine, and inflammatory mediators
Vagus nerve releases ACH
ACH triggers release of pulmonary secretions
- Treated with sympathomimetics

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Inflammatory Mediators of the Respiratory Tract

histamine
Eosinophilic chemotactic factor of anaphylaxis (ECF-A)
Prostaglandins and leukotrienes
Slow-reacting substance of anaphylaxis (SRS-A)

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Drugs that act on the respiratory system include…

bronchodilators
anticholinergics
mast cell stabilizers
corticosteroids
cromoglycates
leukotriene receptor antagonists
antihistamines
cough preparations
nasal decongestants

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MDIs

Metered Dose Inhalers

pressurized devices that deliver a measured dose of drug with each activation
with CFC or non-CFC propellant
hand-mouth coordination is required

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DPIs

Dry-powder inhalers (DPIs)

include Turbohalers and Accuhalers
Drugs are in the form of dry, microionized powder
no propellant
breath activated, much easier to use

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Nebulizers

small machine to convert a drug solution into a mist

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Bronchodilators

Drugs used to relieve bronchospasms associated with respiratory disorders
Includes
- adrenoceptor agonists
  - selective B₂-agonists and other adrenoceptor agonists
- Antimuscarinic bronchodilators
- Xanthine derivatives

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Bronchodilators: Beta-Agonists

large group, sympathomimetics
used during acute phase of asthmatic attacks
quickly reduce airway constriction and restore normal airflow
stimulate beta₂ adrenergic receptors throughout the lungs

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3 types of Beta-Agonists

nonselective adrenergics
- stimulate alpha, beta₁ (cardiac), and beta₂ (respiratory) receptors
- Example: epinephrine
Nonselective beta-adrenergics
- stimulate both beta1 and beta2 receptors
- Example: isoproterenol (Isuprel)
Selective beta₂ drugs
- stimulate only beta₂ receptors
- Example: albuterol

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Beta-Agonists Side Effects

Alpha-Beta (i.e. epinephrine)
- insomnia, restlessness, anorexia, cardiac stimulation, vascular headache
Nonselective: Beta1 and Beta 2 (i.e.: isoproterenol)
- cardiac stimulation
- hypotension
- tremor
- anginal pain
- vascular headache
Beta2 (i.e.: albuterol)
- vascular headache
- tremor

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Short Acting Agents

Albuterol (Proventil, Ventolin): MDI, neb
Levalbuterol (Xopenex): neb only
Bitolterol (Tornalate): neb only
Pirbuterol (Maxair): neb only
Salbutamol (oral tablet)
Terbutaline (oral tablet)

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Long Acting Agents

Salmeterol (avialable only in combination)
Formoterol (Foradil Aerolizer) : DPI

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Oral Agents

Albuterol: Tablets, extended tabs, syrup
Terbutaline: Tablets

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Bronchodilators: Nursing Alerts

at least one minute between puffs
inform pt that salmeterol and formoterol, and oral B-2 agonists should be taken on a fixed schedule, not PRN
instruct pt to report chest pain and changes in heart rhythm or rate, because B-2 agonists can cause cardiac stimulation
contact physician if symptoms such as nervousness, insomnia, restlessness, and tremor become sever

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Anticholinergics

Ipratropium bromide (Atrovent) is the only anticholinergic used for respiratory disease
Slow and prolonged action
used to prevent vasoconstriction
Not used for acute asthma exacerbations
Side effects
- dry mouth or throat distress
- gastrointestinal
- headache
- coughing
- anxiety

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Anticholinergics (examples)

Ipratropium (Atrovent)
- Onset 30 minutes, lasts 6 hours
- MDI, neb
- Combivent MDI: combo with albuterol
- Also available intranasally for allergic rhinitis
Tiotropium (Spiriva)
- Newer, lasts longer
- DPI (handi-haler)

Bronchodilators: Xanthine Derivatives

main xanthine used clinically is theophylline
Theophylline is a bronchodilator which relaces smooth muscle of the bronchi, it is used for reversible airway obstruction
one proposed mechanism of action is that is acts by inhibiting phosphodiesterase, thereby increasing cAMP, leading to bronchodilation
another example is aminophylline

Adverse effects of Xanthine Derivatives

toxicity is related to theophyline levels (usually 5 - 15µg/ml)
20-25 µg/ml: nausea, vomiting, diarrhea, insomnia, restlessness
>30 µg/ml: serios adrevese effects including dysrhythmias, convulsions, cardiovascular collapse which may result in death

Xanthine Derivatives: Nursing alerts

Plasma theophylline levels should be monitored to keep it in therapeutic range, usually 5 - 15 µg/ml. Dosage should be adjusted to keep theophylline levels below 20µg/ml.
If pt misses a dose, the following dose should not be doubled
Instruct the pt that sustained-release formulations should be swallowed intact
Caution patients in consuming caffeine b/c it can intesnsify the adverse effects and decrease the metabolism of theophylline

Corticosteroids

used for prophylaxis of chronic asthma
suppressing inflammation
- decrease synthesis and release of inflammatory mediators
- decrease infiltration and activity of inflammatory cells
- decrease edema of the airway mucosa
decrease airway mucus production
increase the number of bronchial beta2 receptors and ther responsiveness to beta2 agonists

Corticosteroids: Examples, Adverse Effects, Nursing Alerts

Exampels
- Beclomethasone
- Budesonide
- Fluticasone
Adverse Effects
- Inhaled corticosteroids
  - candidiasis of the mouth or throat
  - hoarseness
  - can slow growth in children
  - adrenal suppresion may occur in long-term, high-dose therapy
  - increases the risk of cataracts
Nursing Alerts
- rinse and spit after taking
- if taking bronchodilators by inhalation, use bronchodilators several minutes before the corticosteroids to enhance application of the corticosteroid into the bronchial tract

Chromoglycates

Stabilize mast cells and prevent the release of bronchoconstrictive and inflammatory substances when mast cells are confronted with allergens and other stimuli
only for prophylaxis of acute asthma attacks

Chromoglycates: examples, adverse effects, nursing alerts

Examples: Chromoglycate Na, Nedocromil Sodium
Adverse effects: transient bronchospasm, coughing, throat irritation
Nursing Alerts:
- A selective B₂ agonist such as salbutamol or terbutaline may be inhaled a few minutes before hand
- for long term prophylaxis. administer of regular schedule, full therapeutic effects may take several weeks to develop
- contraindicated in patients who are hypersensitive to the drugs

Mast Cell Stabilizers: Nursing Implications

prophylactic use only
contraindicated in acute exacerbations
not recommended for children under 5
therapeutic effects may not be seen for up to 4 weeks
teach patients to gargle and rinse mouth with water afterward to minimize irritation to throat and oral mucosa

Leukotrienes Receptor Antagonists | (aka antileukotrienes)

* act by supressing the effects of leukotrienes, compounds that promote bronchoconstriction as well as eosinophil infiltration, mucus productions, and airway edema * help to prevent acute asthma attacks induced by allergens and other stimuli * indicated for long-term treatment of asthma

Antilukotrienes: Examples, adverse effects, nursing alerts

* Examples * montelukast (Singulair) * zafirlukast (Accolate) * zileuton (Zyflo) * Adverse Effects * GI disturbances, hypersensitivity reactions, restlessness and headache, upper resp. tract infections, avoid during pregnancy and breastfeeding * Nursing Alerts * Ensure drug is being use for chronic management of asthma, not acute * Teach the patient the purpose of therapy * improvement should be seen in about 1 week * Check with physician before taking OTC or prescribed meds--many interactions * Assess liver function before beginning therapy * Meds should be taken every night ona continuous schedule, even if symptoms improve